Challenges to conquer from the gender perspective in medicine: The case of spondyloarthritis

Abstract

BackgroundDiagnostic delay is well-known in spondyloarthritis and studies have demonstrated a longer deferral in women. The aim of this study was to explore whether diagnostic delay of spondyloarthritis depends on clinical manifestations expressed by patients according to sex or whether it is related to a doctor’s misdiagnosis bias.MethodsA cross-sectional study of 96 men and 54 women with spondyloarthritis was performed at Alicante University General Hospital in Spain using a semistructured interview and clinical records. Comparative sex analysis were done via Student’s T and Mann-Whitney U tests for parametric and nonparametric continuous variables, chi-square and Fisher’s exact tests for unpaired categorical variables, and McNemar’s test for paired ones.FindingsThe median diagnostic delay in women 7.5 (11.5) years is higher than men 4 (11) years, with a difference close to statistical significance (p = 0.053). A total of 30.2% of men received a first correct diagnosis of spondyloarthritis versus 11.1% of women (p = 0.016), indicating that men have higher probability of not having a misdiagnosis of spondyloarthritis (odds ratio = 3.5; 1.3–9). Eleven different health services referred male patients to the rheumatology clinic but only six in the case of female. No sex differences were detected in patients’ manifestations of back pain at onset. However, medical records registered differences (women 44.4%, men 82.1%; p < 0.001). There were differences between patients (women 57.7%, men 35.2%; p = 0.008) and medical records in peripheral signs/symptoms at onset (women 55.6%, men 17.9%; p < 0.001).ConclusionThe few differences of self-reported manifestations between both sexes with spondyloarthritis as compared with their clinical records (more axial pain in men and more peripheral pain in women) suggests that the professionals’ annotations reflect what they expect according to Literature, which could explain the higher misdiagnosis and diagnostic delay in women with spondyloarthritis.

Gender differences in patient journey to diagnosis and disease outcomes: results from the European Map of Axial Spondyloarthritis (EMAS)

“…The greatest gender difference was observed in physiotherapist visits prior to diagnosis, with half of females attending physiotherapists as compared with a third of males. As suggested in previous studies [ 4 ], gender differences in diagnosis of axSpA could be due to physicians underestimating women’s symptoms, resulting in inappropriate referrals to physicians other than a rheumatologist. Another potential reason for the longer delay in diagnosis could be lower frequency of HLA-B27 carriership among female participants.…”

“…The reasons for this difference are not completely understood. However, results from a Spanish study carried out at Alicante University General Hospital on 150 people with spondyloarthritis showed that despite men and women reporting the same symptoms for chronic back pain; in two thirds of the healthcare centres, only men were referred to a rheumatology unit [ 4 ]. The results from this research seem to suggest a possible bias among physicians, who may think of axSpA only in male patients.…”

A Benchmarking Study Evaluating Axial Spondyloarthritis Burden in Spain and Other European Countries. Results from the Spanish Atlas and the European Map of Axial Spondyloarthritis (EMAS) Studies

“…Comparison of the Atlas and EMAS studies showed that the diagnostic delay in Spain was significantly longer than in the OEC, with an average of more than 18 months. This difference is even more significant when considering there is a higher percentage of HLA‐B27 positive patients and a lower proportion of women in the Spanish sample, as these 2 characteristics have been associated with a shorter diagnostic delay in other studies 29 . In fact, a meta‐analysis conducted on the Spanish population finds that women with axSpA are diagnosed later 30 …”

Rheum to Diagnosis: A Mixed Methods Study to Uncover Impediments to Accurate Diagnosis of Nonradiographic Axial Spondyloarthritis in the United States

“…These ndings are consistent with a study demonstrating striking sex-speci c differences in how rheumatologists documented symptoms of patients with axSpA and showing that men were 3 times more likely to receive an axSpA diagnosis at their rst rheumatology visit. (24) The authors concluded that HCPs held gender biases that in uenced their clinical assessment, thereby affecting time to diagnosis at multiple time points.…”