0:00:00.816,0:00:03.388
We all go to doctors.

0:00:04.944,0:00:09.282
And we do so with trust and blind faith

0:00:09.306,0:00:13.164
that the test they are ordering[br]and the medications they're prescribing

0:00:13.188,0:00:16.363
are based upon evidence --

0:00:16.387,0:00:19.314
evidence that's designed to help us.

0:00:20.338,0:00:26.181
However, the reality is that that hasn't[br]always been the case for everyone.

0:00:27.086,0:00:28.381
What if I told you

0:00:28.405,0:00:32.351
that the medical science discovered[br]over the past century

0:00:32.375,0:00:36.042
has been based on only[br]half the population?

0:00:36.066,0:00:38.360
I'm an emergency medicine doctor.

0:00:38.749,0:00:42.400
I was trained to be prepared[br]in a medical emergency.

0:00:42.940,0:00:47.389
It's about saving lives. How cool is that?

0:00:48.492,0:00:51.652
OK, there's a lot of runny noses[br]and stubbed toes,

0:00:51.676,0:00:55.341
but no matter who walks[br]through the door to the ER,

0:00:55.365,0:00:57.817
we order the same tests,

0:00:57.841,0:00:59.975
we prescribe the same medication,

0:00:59.999,0:01:04.401
without ever thinking about the sex[br]or gender of our patients.

0:01:05.370,0:01:06.624
Why would we?

0:01:07.053,0:01:10.794
We were never taught that there were[br]any differences between men and women.

0:01:10.818,0:01:15.377
A recent Government Accountability study[br]revealed that 80 percent of the drugs

0:01:15.401,0:01:17.552
withdrawn from the market

0:01:17.576,0:01:19.969
are due to side effects on women.

0:01:21.080,0:01:23.391
So let's think about that for a minute.

0:01:23.415,0:01:27.289
Why are we discovering[br]side effects on women

0:01:27.313,0:01:30.599
only after a drug has been[br]released to the market?

0:01:31.496,0:01:37.156
Do you know that it takes years[br]for a drug to go from an idea

0:01:37.180,0:01:40.337
to being tested on cells in a laboratory,

0:01:40.361,0:01:42.329
to animal studies,

0:01:42.353,0:01:44.480
to then clinical trials on humans,

0:01:44.504,0:01:48.375
finally to go through[br]a regulatory approval process,

0:01:48.399,0:01:52.735
to be available for your doctor[br]to prescribe to you?

0:01:54.170,0:01:57.540
Not to mention the millions and billions[br]of dollars of funding

0:01:57.564,0:01:59.946
it takes to go through that process.

0:02:01.597,0:02:04.549
So why are we discovering[br]unacceptable side effects

0:02:04.573,0:02:09.024
on half the population[br]after that has gone through?

0:02:11.163,0:02:12.427
What's happening?

0:02:12.777,0:02:16.881
Well, it turns out that those cells[br]used in that laboratory,

0:02:16.905,0:02:18.835
they're male cells,

0:02:18.859,0:02:22.261
and the animals used[br]in the animal studies were male animals,

0:02:22.285,0:02:27.375
and the clinical trials have been[br]performed almost exclusively on men.

0:02:29.176,0:02:34.530
How is it that the male model became[br]our framework for medical research?

0:02:34.554,0:02:38.625
Let's look at an example that has been[br]popularized in the media,

0:02:38.649,0:02:41.855
and it has to do[br]with the sleep aid Ambien.

0:02:41.879,0:02:46.643
Ambien was released on the market[br]over 20 years ago,

0:02:46.667,0:02:51.480
and since then, hundreds of millions[br]of prescriptions have been written,

0:02:51.504,0:02:55.952
primarily to women, because women[br]suffer more sleep disorders than men.

0:02:57.047,0:02:59.223
But just this past year,

0:02:59.247,0:03:02.671
the Food and Drug Administration[br]recommended cutting the dose in half

0:03:02.695,0:03:05.582
for women only,

0:03:05.606,0:03:08.443
because they just realized[br]that women metabolize the drug

0:03:08.467,0:03:11.380
at a slower rate than men,

0:03:11.404,0:03:13.443
causing them to wake up in the morning

0:03:13.467,0:03:16.661
with more of the active drug[br]in their system.

0:03:16.685,0:03:20.615
And then they're drowsy and they're[br]getting behind the wheel of the car,

0:03:20.639,0:03:23.606
and they're at risk[br]for motor vehicle accidents.

0:03:24.955,0:03:28.899
And I can't help but think,[br]as an emergency physician,

0:03:28.923,0:03:33.716
how many of my patients[br]that I've cared for over the years

0:03:33.740,0:03:36.546
were involved in a motor vehicle accident

0:03:36.570,0:03:40.022
that possibly could have been prevented

0:03:40.046,0:03:45.161
if this type of analysis was performed[br]and acted upon 20 years ago

0:03:45.185,0:03:47.193
when this drug was first released.

0:03:49.089,0:03:52.284
How many other things need[br]to be analyzed by gender?

0:03:53.197,0:03:54.879
What else are we missing?

0:03:57.555,0:04:01.231
World War II changed a lot of things,

0:04:01.255,0:04:04.136
and one of them was this need[br]to protect people

0:04:04.160,0:04:08.500
from becoming victims of medical research[br]without informed consent.

0:04:09.467,0:04:13.143
So some much-needed guidelines[br]or rules were set into place,

0:04:13.167,0:04:18.189
and part of that was this desire[br]to protect women of childbearing age

0:04:18.213,0:04:21.164
from entering into any[br]medical research studies.

0:04:22.016,0:04:26.579
There was fear: what if something[br]happened to the fetus during the study?

0:04:27.366,0:04:28.915
Who would be responsible?

0:04:29.999,0:04:32.488
And so the scientists[br]at this time actually thought

0:04:32.512,0:04:35.128
this was a blessing in disguise,

0:04:35.152,0:04:40.365
because let's face it -- men's bodies[br]are pretty homogeneous.

0:04:40.867,0:04:44.313
They don't have the constantly[br]fluctuating levels of hormones

0:04:44.337,0:04:48.081
that could disrupt clean data[br]they could get if they had only men.

0:04:49.210,0:04:51.920
It was easier. It was cheaper.

0:04:53.651,0:04:56.484
Not to mention, at this time,[br]there was a general assumption

0:04:56.508,0:05:00.733
that men and women[br]were alike in every way,

0:05:00.757,0:05:04.200
apart from their reproductive organs[br]and sex hormones.

0:05:05.211,0:05:08.028
So it was decided:

0:05:09.117,0:05:12.633
medical research was performed on men,

0:05:12.657,0:05:15.414
and the results were later[br]applied to women.

0:05:17.203,0:05:20.744
What did this do to the notion[br]of women's health?

0:05:20.768,0:05:25.024
Women's health became synonymous[br]with reproduction:

0:05:25.048,0:05:29.593
breasts, ovaries, uterus, pregnancy.

0:05:30.355,0:05:33.387
It's this term we now refer[br]to as "bikini medicine."

0:05:34.461,0:05:37.105
And this stayed this way[br]until about the 1980s,

0:05:37.129,0:05:40.614
when this concept was challenged[br]by the medical community

0:05:40.638,0:05:44.779
and by the public health policymakers[br]when they realized that

0:05:44.803,0:05:49.106
by excluding women[br]from all medical research studies

0:05:49.130,0:05:52.619
we actually did them a disservice,

0:05:52.643,0:05:54.975
in that apart from reproductive issues,

0:05:54.999,0:05:57.563
virtually nothing was known[br]about the unique needs

0:05:57.587,0:05:59.305
of the female patient.

0:06:00.999,0:06:06.513
Since that time, an overwhelming amount[br]of evidence has come to light

0:06:06.537,0:06:12.048
that shows us just how different[br]men and women are in every way.

0:06:17.297,0:06:20.050
You know, we have this saying in medicine:

0:06:20.074,0:06:23.022
children are not just little adults.

0:06:24.810,0:06:26.747
And we say that to remind ourselves

0:06:26.771,0:06:31.448
that children actually have[br]a different physiology than normal adults.

0:06:32.678,0:06:37.635
And it's because of this that the medical[br]specialty of pediatrics came to light.

0:06:37.659,0:06:43.905
And we now conduct research on children[br]in order to improve their lives.

0:06:45.039,0:06:47.936
And I know the same thing[br]can be said about women.

0:06:47.960,0:06:53.021
Women are not just men[br]with boobs and tubes.

0:06:54.561,0:06:58.117
But they have their own[br]anatomy and physiology

0:06:58.141,0:07:01.671
that deserves to be studied[br]with the same intensity.

0:07:03.381,0:07:06.312
Let's take the cardiovascular[br]system, for example.

0:07:06.999,0:07:10.706
This area in medicine has done the most[br]to try to figure out

0:07:10.730,0:07:14.879
why it seems men and women have[br]completely different heart attacks.

0:07:15.999,0:07:21.089
Heart disease is the number one killer[br]for both men and women,

0:07:21.113,0:07:25.549
but more women die within the first year[br]of having a heart attack than men.

0:07:27.049,0:07:31.063
Men will complain[br]of crushing chest pain --

0:07:31.087,0:07:33.569
an elephant is sitting on their chest.

0:07:34.455,0:07:35.995
And we call this typical.

0:07:37.622,0:07:40.712
Women have chest pain, too.

0:07:40.736,0:07:47.433
But more women than men[br]will complain of "just not feeling right,"

0:07:48.898,0:07:51.767
"can't seem to get enough air in,"

0:07:51.791,0:07:53.765
"just so tired lately."

0:07:55.000,0:07:57.903
And for some reason we call this atypical,

0:07:57.927,0:08:01.854
even though, as I mentioned,[br]women do make up half the population.

0:08:03.537,0:08:09.308
And so what is some of the evidence[br]to help explain some of these differences?

0:08:09.999,0:08:12.530
If we look at the anatomy,

0:08:12.554,0:08:18.569
the blood vessels that surround the heart[br]are smaller in women compared to men,

0:08:18.593,0:08:23.073
and the way that those blood vessels[br]develop disease is different

0:08:23.097,0:08:25.152
in women compared to men.

0:08:25.875,0:08:31.027
And the test that we use to determine[br]if someone is at risk for a heart attack,

0:08:31.051,0:08:35.623
well, they were initially designed[br]and tested and perfected in men,

0:08:35.647,0:08:38.781
and so aren't as good[br]at determining that in women.

0:08:40.305,0:08:43.242
And then if we think[br]about the medications --

0:08:43.266,0:08:46.513
common medications[br]that we use, like aspirin.

0:08:47.767,0:08:52.294
We give aspirin to healthy men to help[br]prevent them from having a heart attack,

0:08:52.318,0:08:56.552
but do you know that if you[br]give aspirin to a healthy woman,

0:08:56.576,0:08:58.162
it's actually harmful?

0:09:00.376,0:09:02.758
What this is doing is merely telling us

0:09:02.782,0:09:05.534
that we are scratching the surface.

0:09:07.145,0:09:10.571
Emergency medicine[br]is a fast-paced business.

0:09:11.563,0:09:14.916
In how many life-saving areas of medicine,

0:09:14.940,0:09:18.916
like cancer and stroke,

0:09:18.940,0:09:23.073
are there important differences between[br]men and women that we could be utilizing?

0:09:24.252,0:09:29.056
Or even, why is it that some people[br]get those runny noses

0:09:29.080,0:09:31.265
more than others,

0:09:31.289,0:09:34.616
or why the pain medication that we give[br]to those stubbed toes

0:09:34.640,0:09:37.845
work in some and not in others?

0:09:41.288,0:09:46.518
The Institute of Medicine has said[br]every cell has a sex.

0:09:47.820,0:09:49.233
What does this mean?

0:09:50.532,0:09:52.930
Sex is DNA.

0:09:52.954,0:09:57.295
Gender is how someone[br]presents themselves in society.

0:09:57.883,0:10:00.423
And these two may not always match up,

0:10:00.447,0:10:03.613
as we can see with our[br]transgendered population.

0:10:04.740,0:10:09.655
But it's important to realize[br]that from the moment of conception,

0:10:09.679,0:10:11.801
every cell in our bodies --

0:10:11.825,0:10:15.126
skin, hair, heart and lungs --

0:10:15.150,0:10:18.437
contains our own unique DNA,

0:10:18.461,0:10:22.212
and that DNA contains[br]the chromosomes that determine

0:10:22.236,0:10:27.297
whether we become[br]male or female, man or woman.

0:10:28.400,0:10:29.988
It used to be thought

0:10:30.012,0:10:34.340
that those sex-determining[br]chromosomes pictured here --

0:10:34.364,0:10:37.737
XY if you're male, XX if you're female --

0:10:37.761,0:10:42.975
merely determined whether you[br]would be born with ovaries or testes,

0:10:42.999,0:10:46.740
and it was the sex hormones[br]that those organs produced

0:10:46.764,0:10:51.329
that were responsible for the differences[br]we see in the opposite sex.

0:10:52.757,0:10:57.591
But we now know that[br]that theory was wrong --

0:10:57.615,0:11:00.060
or it's at least a little incomplete.

0:11:00.084,0:11:04.862
And thankfully, scientists like Dr. Page[br]from the Whitehead Institute,

0:11:04.886,0:11:06.860
who works on the Y chromosome,

0:11:06.884,0:11:09.051
and Doctor Yang from UCLA,

0:11:09.075,0:11:14.734
they have found evidence that tells us[br]that those sex-determining chromosomes

0:11:14.758,0:11:17.355
that are in every cell in our bodies

0:11:17.379,0:11:22.738
continue to remain active[br]for our entire lives

0:11:24.517,0:11:28.092
and could be what's responsible[br]for the differences we see

0:11:28.116,0:11:30.331
in the dosing of drugs,

0:11:30.355,0:11:33.321
or why there are differences[br]between men and women

0:11:33.345,0:11:36.861
in the susceptibility[br]and severity of diseases.

0:11:39.032,0:11:41.952
This new knowledge is the game-changer,

0:11:45.425,0:11:48.799
and it's up to those scientists[br]that continue to find that evidence,

0:11:48.823,0:11:52.976
but it's up to the clinicians[br]to start translating this data

0:11:53.000,0:11:55.999
at the bedside, today.

0:11:57.168,0:11:58.324
Right now.

0:12:01.450,0:12:04.474
And to help do this, I'm a co-founder[br]of a national organization

0:12:04.498,0:12:07.481
called Sex and Gender[br]Women's Health Collaborative,

0:12:07.505,0:12:12.125
and we collect all of this data[br]so that it's available for teaching

0:12:12.149,0:12:13.554
and for patient care.

0:12:14.380,0:12:18.748
And we're working to bring together[br]the medical educators to the table.

0:12:19.756,0:12:21.224
That's a big job.

0:12:22.162,0:12:27.301
It's changing the way medical training[br]has been done since its inception.

0:12:29.039,0:12:30.882
But I believe in them.

0:12:31.882,0:12:37.479
I know they're going to see the value[br]of incorporating the gender lens

0:12:37.503,0:12:39.225
into the current curriculum.

0:12:40.598,0:12:45.216
It's about training the future[br]health care providers correctly.

0:12:48.437,0:12:49.588
And regionally,

0:12:49.612,0:12:53.473
I'm a co-creator of a division within[br]the Department of Emergency Medicine

0:12:53.497,0:12:55.217
here at Brown University,

0:12:55.241,0:12:57.851
called Sex and Gender[br]in Emergency Medicine,

0:12:57.875,0:13:02.501
and we conduct the research to determine[br]the differences between men and women

0:13:02.525,0:13:04.683
in emergent conditions,

0:13:04.707,0:13:09.975
like heart disease and stroke[br]and sepsis and substance abuse,

0:13:09.999,0:13:14.376
but we also believe[br]that education is paramount.

0:13:15.304,0:13:19.305
We've created a 360-degree[br]model of education.

0:13:19.329,0:13:25.287
We have programs for the doctors,[br]for the nurses, for the students

0:13:25.311,0:13:27.017
and for the patients.

0:13:27.511,0:13:31.569
Because this cannot just be left up[br]to the health care leaders.

0:13:32.315,0:13:35.792
We all have a role in making a difference.

0:13:36.650,0:13:40.507
But I must warn you: this is not easy.

0:13:41.840,0:13:43.432
In fact, it's hard.

0:13:45.146,0:13:49.538
It's essentially changing the way[br]we think about medicine

0:13:49.562,0:13:52.559
and health and research.

0:13:53.711,0:13:56.847
It's changing our relationship[br]to the health care system.

0:13:57.760,0:14:00.648
But there's no going back.

0:14:01.339,0:14:05.038
We now know just enough

0:14:05.062,0:14:07.418
to know that we weren't doing it right.

0:14:09.672,0:14:11.990
Martin Luther King, Jr. has said,

0:14:12.014,0:14:16.663
"Change does not roll in[br]on the wheels of inevitability,

0:14:16.687,0:14:18.861
but comes through continuous struggle."

0:14:20.314,0:14:23.044
And the first step[br]towards change is awareness.

0:14:24.116,0:14:28.194
This is not just about improving[br]medical care for women.

0:14:28.702,0:14:33.661
This is about personalized,[br]individualized health care for everyone.

0:14:35.090,0:14:41.192
This awareness has the power to transform[br]medical care for men and women.

0:14:42.827,0:14:48.515
And from now on, I want you[br]to ask your doctors

0:14:48.539,0:14:52.816
whether the treatments you are receiving[br]are specific to your sex and gender.

0:14:54.246,0:14:56.935
They may not know the answer --

0:14:56.959,0:14:58.125
yet.

0:14:59.101,0:15:02.963
But the conversation has begun,[br]and together we can all learn.

0:15:03.797,0:15:08.174
Remember, for me[br]and my colleagues in this field,

0:15:08.198,0:15:10.475
your sex and gender matter.

0:15:11.379,0:15:12.531
Thank you.

0:15:12.555,0:15:16.999
(Applause)