Women’s health: the gap in research and medical cannabis

The gap on women’s health, women and cannabis as both patients and leaders in the industry.

March 8th was International Women’s Day and this year the theme is #ChooseToChallenge, which “highlights the importance of challenging biases and misconceptions in the interest of creating a more inclusive and gender-equal world”.

At Santé Cannabis the theme resonated with us. We recognize that the medical community and the medical cannabis industry hold certain biases and misconceptions about women’s health, including medical cannabis effects, consumption habits and impacts on homelife and workplace.

We also recognize that there is important work underway by medical and research leaders to right these historical wrongs.

We know that we need to challenge ourselves to ask: are we doing enough to support women’s rights within our clinic and in our research?

Our goal will be to continue to challenge the status quo, not just through March, women’s history month, but every day.

In our post today we will explore the gap on women’s health, women and cannabis as both patients and leaders in the industry.

Knowledge gap on women’s health

In modern medical practice, women receive equal treatment as compared to men, right?

Not always.

An excellent introduction to the subject comes from Dr. Alyson J. McGregor (MD), Division Director for the first program in Sex and Gender Emergency Medicine at the Alpert Medical School of Brown University (USA), and her book, Sex Matters: How Male-Centric Medicine Endangers Women’s Health—and What We Can Do About It. The author exposes clearly the current research health disparities between men and women and the challenges women face in what she calls “the male-centric medical system”.

“The male-centric model of medicine is so pervasive in our health care systems, procedures, and philosophy that many don’t even realize it exists. In this age of medical advancement, most people assume that women’s differences are already being taken into account—yet nothing could be further from the truth.” – Dr. Alyson McGregor

Men and women differ not only in regard to their reproductive organs, but also biochemically due to sex hormones and their multisystem effects. These essential differences should have an impact on the way that medicine is practised and how research is done.

However, like Dr. McGregor’s book explains so well, there is a significant knowledge gap that results in unequal benefits for men and women from clinical research and medical care. It is a known fact that there are significant physiological differences in cardiac function between men and women (for example, susceptibility to QT interval prolongation and serious heart arrhythmias). (article) These sex differences combined to a lack of awareness translate in different diagnoses and treatment for women with a heart disease as compared to men. Outcomes for women are worse (read here more women dying than men), though there has been some recent improvement thanks to more awareness and better research. (article)

In clinical research, to protect them, women are excluded from the early phases due to their childbearing capacity. This is the norm and such exclusions originate from international work to improve research ethics (World Medical Association declaration of Helsinki; Rapport Belmont).

According to current ethics, a woman of childbearing age is not able to provide informed consent that she has no intention of having children and therefore could participate. Studies at this phase that are deemed safe for men then move subsequent trial phases where women are generally included, without consideration of whether side effects may vary by sex. To determine if there are sex-related differences in treatment efficacy and adverse events, logically data should be analyzed by sex.

Strikingly, a 2017 article reported that on 100 randomized controlled trials in Canada, 98% of studies reported sex in the sociodemographic characteristics of participants, but only 6% reported subgroup analyses across sex. Of these, only a single study commented regarding the methodological challenges of subgroup analysis or on the significance of the findings and implications for clinical practice. Clinical research needs to improve to better serve all clinical trial subjects.

Women and Cannabis

Women as medical cannabis patients

From July to November 2020, at Santé Cannabis, 64% of patients were women. Very frequently, our medical team sees patients that have tried several medications and treatments without success. They are often tired and search for something that will help them. Medical cannabis may offer relief for some; but patients also report feeling listened to and supported at our clinics, and that makes the world of a difference.

An example of a health condition that we see frequently in our clinics that disproportionately affects women is fibromyalgia. For a long time, patients with this chronic pain condition were told that the pain was in their head. Nowadays, though it is better known, the condition relies on a diagnosis of exclusion. That means that when physicians are trying to find the problem, they must exclude other probable diseases or conditions with several tests and medical imaging. As a result, even when their pain is recognized (it’s not always the case – article), patients often get shuttled around for a long time – while enduring constant pain. For those with a diagnosis, few medical treatments exist, but none are efficient to relieve the multiple symptoms.

As Fibromyalgia remains difficult to diagnose and treat, it’s important to question why this remains the situation. If we treated men and women equally in research protocols, and invested equally in women’s and men’s health, would there be more advancements? If women’s pain was treated with the same seriousness as men’s, what would the current state of diagnosis and treatment be?

Sex-related differences in medical cannabis:

In medical cannabis research as in many other clinical research fields, there is a lack of sex and gender-related analysis in studies. At this time, we barely know what sex-related differences may exist in medical cannabis efficacy and adverse events.

Nonetheless, recent research findings do show some sex-related differences:

Women are more likely to use cannabis for medical purposes to get relief from anxiety, nausea, anorexia, irritable bowel syndrome, and headache as compared to men. (article 1, article 2)
While men more frequently report inhaling medical cannabis, women more frequently ingest medical cannabis products (which provides longer effects, typically preferred for therapeutic purposes). (article)
Women are more sensitive to lower cannabis doses; they experience the same acute effects than men despite lower THC plasma concentrations. (article 1, article 2)
Women are more likely to experience anxiety/nervousness, restlessness and racing heart after THC intake as compared to men (oral or inhaled intake, dose ranging from 5 to 25 mg THC, and controlling for weight and blood concentration). (article)

Another important sex-related difference to consider is the menstrual cycle. Some progress has been made in understanding how pain perception varies according to the menstrual cycle. According to an Italian study (as well as a few previous studies), pain perception is increased in the luteal phase as compared to the follicular phase. It would be extremely interesting to investigate the impact of the menstrual cycle on pain perception in patients under medical cannabis, as estrogen directly interacts with the endocannabinoid system by modulating the expression of cannabinoid receptors. (article)

What can we do?

Unfortunately, as a self-identifying woman, you may be left in a position of needing to advocate for yourself when interacting with your healthcare team. To ensure that sex-related differences are taken into consideration, the first thing is to communicate with your healthcare provider and ask if that treatment was tested and specifically analyzed in the female population; ask what dosage is adequate for a woman and if there are drug interactions with, for example, hormonal contraceptives.

As healthcare professionals, it behooves us to acknowledge the knowledge gap when working with diverse patient groups, and to continually check and guide regarding any treatment that may have special considerations for women. If this is already part of your standard practice, consider sharing information regarding the disparity with colleagues as continual education, advocacy and awareness building will support your patients. Ideally, a woman should not have to raise these issues on behalf of her care provider, and instead have the care provider advocate for her.

Medical cannabis has been available legally for 20 years now; and while we’ve advanced, there is still work to be accomplished. As stated above, we don’t have clear information about how and why women may experience different outcomes, and adverse events. As researchers, we are asking ourselves if we are doing the work to advance women’s health, particularly in regards to medical cannabis.

Representation in medicine and health research

Women as medical cannabis leaders

We believe firmly that change will continue to happen with commitment as gender representation in the workforce is improved. There have been many advancements in recent decades, and now the majority of organizations and employees identify diversity as a priority.

In Canada, recent data indicates women make up a large majority (78.7%) of post-secondary graduates in health and related fields. In 2018, women earned more than half (54.5%) of the medical doctorates in Canada. Growth in female representation in healthcare is expected to continue with one estimate of 33% growth rate to the year 2030.

However, representation in leadership and executive roles within the health and research sectors is required to change the system contributing to inherent gender biases in medicine and clinical research. There have been some notable gains in recent years but women, especially women of colour, are still severely underrepresented. (article)

Find the original graphic and article here

The World Health Organization suggests some initiatives to close gender representation gaps and the well-documented gender pay gaps with the global healthcare workforce in their document Global strategy on human resources for health: Workforce 2030 which is available for download in English, French, Chinese and Russian.

In the medical cannabis industry, historical prohibition of cannabis (or marijuana) and associated stigma affect both consumption habits and professional decisions. As a result, the burgeoning cannabis industry is severely male-dominated, which may contribute to the lack of cannabis programs and studies dedicated to women’s experiences with cannabis. There are some initiatives underway to address gender diversity in the cannabis industry, including a study to collect data about women’s experiences working in the cannabis industry.

Representation matters, and when our board rooms, clinics, and producers have diversity in their workforce we know it is more likely that diversity will be considered in planning, programs, and projects.

Santé Cannabis is proud to be a female-led organization with five of our seven directors and executive positions filled by women. We strive to acknowledge and address challenges of representation inside our organization and among our partners and collaborators in the healthcare and research fields.

Sex, Gender and Identity

Science has a long history of normalizing the general. We recognize that this post has defined “women’s” health and “men’s” health very narrowly, and does not address a full representation of gender and sex. Gender is a social construct, whereas sex is biological, and neither the term “woman” nor “female” fully encompasses all the differences and similarities of people who may identify as women, female, or as nonbinary.

Sex is a set of biological markers and using the term “female” often includes, but is not limited to, chromosomes, gene expression, reproductive anatomy, and hormones.
Gender is a person’s self-identity and is open to wide ranges of understanding, behaviours, expressions, roles and identities. Gender’s role in society shapes expectations, experiences and influences self-perception and distribution of resources.

A person’s sex and gender are not necessarily related. (reference)

In 2021 Santé Cannabis is committing to further exploration and writing on these topics, from both a medical and public health perspective.

#ChooseToChallenge:

For a long time, Santé Cannabis clinics only recorded the patients’ sex (as assigned by the Quebec healthcare number), but amendments to the research protocol now allow for the collection of patients’ gender identity as well. One step at a time, we are working to improve the collective knowledge on medical cannabis treatments by continuous refinement of the data collection process.

In June 2021, Santé Cannabis will host two workshops, one in English and one in French, in order to support our staff to better understand the complexity and importance of gender in the workplace. An outcome of this training will be to ensure our sex and gender language is inclusive, with a focus on creating a safe space for patients accessing healthcare using a neutral language and to avoid any misunderstandings that can lead to potential medical errors or harm.

We aim to be inclusive for every person who comes to our clinic, as patient, partner or staff, so investing in training on diversity is a priority. The Santé Cannabis Employee Training Program will add different Diversity and Inclusion topics throughout 2021. This investment in diversity training is fundamental to the service we offer our patients and the way we interact as colleagues.

Conclusion:

It’s clear that there is a significant gap in men’s and women’s health, even in 2021. Research is not always designed to consider the differences between men and women’s health and outcomes, which means that in clinical practice men and women may not receive the same level of care, as treatment plans may be created without considering women’s unique health characteristics. While over half of our patients are women, we do not have a detailed understanding of how cannabis impacts men and women differently. In the healthcare profession, women are making large strides, but in leadership roles they still trail their male counterparts.

We have work to do.

The good news is that work is being done. By raising awareness of these issues we will help to overcome them, particularly if you are a healthcare provider, researcher or patient. Improving our collection of data, training our staff to be more aware and inclusive will make a difference. We are proud of our female leadership team and the creative and inclusive ideas they are constantly developing.

How will you choose to challenge yourself to build a more inclusive world this year?

Authors: Charlotte Bastin, Eva McMillan

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.