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疼痛偏见:女性就诊是否受到不平等对待

更新时间:2018-6-6 20:04:49 来源:纽约时报中文网 作者:佚名

Pain bias: The health inequality rarely discussed
疼痛偏见:女性就诊是否受到不平等对待

In 2009, my doctor told me that, like “a lot of women”, I was paying too much attention to my body. Saying there wasn’t an issue, he suggested I just relax and try to ignore the symptoms.

2009年,我的医生告诉我,像“很多女性”那样,我过于在意自己的身体。他说没什么问题,建议我放轻松就行,尽量别理会那些不舒服症状。

The decision seemed to run counter to what my records showed. A few weeks earlier, I had ended up in the emergency room with chest pains and a heart rate hitting 220 beats per minute. The ER crew told me it was a panic attack, gave me Xanax and told me to try to sleep.

这一诊断好像和我的医疗记录很矛盾。几个星期前,因为胸痛,我去看了急诊,心率飙到220次/分。急诊医生告诉我是恐慌症发作,给我开了扑普宁,要我睡觉休息。

I’d had panic attacks before. I knew this episode was not one. So I went to my doctor.

我以前有过恐慌发作。我知道这次的症状不一样。于是我去看了我的医生。

He put me on a heart monitor overnight. Bingo: I had another episode, this time recorded. It didn’t matter. I still left his office thinking it was perhaps anxiety. And so, listening to the advice, I tried to ignore the pain.

他立刻让我上了心脏监护仪,通宵观察。猜对了:再次发作,这回检测到了。没什么大碍。从他的办公室出来,我还是觉得可能是焦虑症。这样的话,我按照医嘱,尽量不想着疼痛。

Until it happened again. And again. First every month, then every week. Over the following nine years, I would complain about it and be told again that I was having panic attacks or anxiety, that women don't feel heart pain the way I was feeling it, and that maybe I was just confused.

后来又发作了一次。然后第三次。起初是每月一次,后来每周都有。从那以后的九年里,我经常看医生,医生总告诉我是恐慌症发作或是焦虑症,还说女性的心绞痛和我的症状不是一回事,可能我给搞糊涂了。

My experience was not uncommon. Abby Norman, author of Ask Me About My Uterus, went through a similar path to discovering she had endometriosis, a painful condition where endometrial tissue grows on other organs than the uterus. Several doctors told her she had a urinary tract infection – until she went to an appointment with her boyfriend, who could vouch for her pain. Norman writes that she also struggled to be diagnosed with appendicitis; one doctor decided her symptoms were the result of childhood sexual abuse, even though Norman was clear that that never had happened.

这种体会很常见。《问问我的子宫》的作者诺曼(Abby Norman)求医的经过与我很相似,她是子宫内膜异位,子宫内膜组织长在其它器官上,而不是子宫上,症状之一是疼痛。好几个医生却告诉她是尿路感染——直到她带着男朋友一起去看了医生,男朋友证明她确实有疼痛感。诺曼写道,她的阑尾炎的诊断过程也很费劲;一位医生认为,她的症状是儿童性侵导致的,尽管诺曼很清楚,那是从来没有的事。

Both anecdotes and academic research point to a disturbing trend: in the medical industry, there’s a long history of dismissing women’s pain. More difficult to determine is whether this is due to gender bias, a lack of medical research on women, or actual differences between how the sexes interpret pain.

不论是传闻还是学术研究,都指出一种令人担忧的趋势:在医疗行业,女性的疼痛受到忽视,由来已久。更难以确定的是,对女性疼痛的忽视是因为性别偏见,或因为缺乏女性病人的医学研究,还是因为两性对疼痛的理解确有差异。

What we do know is that when it comes to pain, men and women are treated differently. One study, for example, found that women in the emergency department who report having acute pain are less likely to be given opioid painkillers (the most effective type) than men. After they are prescribed, women wait longer to receive them.

涉及到疼痛问题,男性和女性的治疗方式不一样,这是我们知道的。比如,一项研究发现,急诊科有剧痛的女性,相比男性,用鸦片类止痛药(最有疗效)的可能性小一些。而且开了药后,女性要等更久的时间才能拿到。

Another study found that women in emergency departments are less likely to be taken seriously than men. In a 2014 study from Sweden, once in the A&E women waited significantly longer to see a doctor and were less often classified as an urgent case.

另一项研究表明,看急诊的女性不如男性那样受到重视。根据2014年瑞典的一项研究,以前女性去看急诊,候诊的时间明显要久一些,被列为需紧急治疗的几率则更小。

This can have lethal consequences. In May 2018 in France, a 22-year old woman called emergency services saying her abdominal pain was so acute she felt she was "going to die." "You'll definitely die one day, like everyone else," the operator replied. When the woman was taken to hospital after a five-hour wait, she had a stroke and died of multiple organ failure.

这可能带来致命的后果。2018年5月,法国一位22岁的女性拨打紧急救援电话,说她腹痛很剧烈,感觉“快要死了”。接线员这样回答,“你总有死的那一天,每个人都是这样”,等了五个小时,送到医院时,她已中风,最后死于多种器官功能衰竭。

Seeing women treated differently in the emergency department is a fairly well established phenomenon, says Esther Chen, an emergency medicine doctor at Zuckerburg San Francisco General Hospital and co-author of the study on opioid painkillers.

艾斯特·陈是扎克伯格旧金山总医院的急诊药师,也是麻醉止痛药研究的合著者。她说,女性在急诊科受到区别对待,是一个公认的现象。

But “it’s hard to tease out whether it’s simply implicit bias – which all of us have – or whether it’s the way we judge women and pain in terms of their presentation for different clinical conditions,” Chen says.

陈说,但这个现象"究竟只是固有的偏见——偏见人人都有——还是我们在评估女性患者的疼痛程度时根据的是有差异的临床诊断,这难以得知"。

Her study, for example, researched acute abdominal pain. She suspects that women who present to the emergency department with abdominal pain are often assumed to have a gynaecological problem, which many doctors believe is less likely to require opioids than an acute surgical disease.

比如,她研究的是剧烈腹痛。她认为,女性因为腹痛去看急诊,常常会诊断为妇科毛病,很多医生觉得,相比急性手术的疾病,不那么需要鸦片类麻醉药。

Meanwhile, women are more likely to receive anti-anxiety medications than men when they come to a hospital with pain – and are more often written off as psychiatric patients.

而且,女性因为疼痛去医院,和男性比起来,较有可能开一些抗焦虑的药物——当作精神病患者的几率较大。

“Women have been more often referred to psychologists or psychiatrists, whereas men are given tests to rule out actual organic conditions,” says Christin Veasley, co-founder and director at the Chronic Pain Research Alliance who helped compile the above report.

威尔斯利(Christin Veasley)说,"女性更可能会转诊到心理医生或精神病医生那里,男性则会安排检查,排除机体器官的问题", 威尔斯利是慢性疼痛研究联盟的联合创始人和董事长,参与编写上述报告。

As former executive director of the National Vulvodynia Association, Veasley saw an alarming track record of bad medical diagnoses and advice.

威尔斯利是美国国家慢性阴部疼痛研究协会的前任常务董事,她说看到的医疗务记录很令人吃惊,太多糟糕的诊断和医嘱。

“The things I heard from women… that doctors told them were completely ridiculous,” she says. “Things like, you must be having marital problems. Have a glass of wine before you have sex. It’ll be better. The list goes on and on.

她说,"我从女性患者那里听来的…医生对她们说的都很可笑。像是,你肯定婚姻出了问题。行房前最好喝杯红酒。会有好处。都是这种建议"。

“It’s hard to imagine that a medical professional who took an oath to ‘do no harm’ could say these things.”

"很难想象,曾宣誓'不可害人'的职业医师,竟会说出这些话。"

The common assumption is that women are quicker to complain of medical problems than men. Indeed, one UK study found, for example, that men consulted GPs 32% less than women. It’s possible that doctors therefore dismiss women’s reports of pain as less serious.

人们通常假设,女性比男性更爱去看病。的确,比如一项英国的研究发现,去看全科医生的男性比女性少32%。因此,女性所说的疼痛,医生可能觉得不太严重。

But other evidence suggests that it is wrong to assume that women are more likely than men to complain about the same pain. A meta-analysis of studies on two common types of pain, back pain and headache, found that men and women were equally likely to go to the doctor. The evidence that women are faster to go to the doctor is “surprisingly weak and inconsistent”, the researchers wrote. A similar study found women were no more likely to consult a GP than men with the same pain symptoms.

但另有依据显示,对于同一痛症,要说女性比男性更有可能上医院,这是不对的。一项对两种常见痛症——背痛与头痛——的综合分析发现,男性和女性去看病的概率相同。研究人员的论文指出,说女性更急于去看医生的证据"相当薄弱,相互矛盾",一项类似的研究发现,疼痛症状一致的话,男性和女性去看全科医生的几率是相当的。

Still, many researchers and doctors point out that studies dating as far back as 1972 and as recently as 2003 show that women have a lower pain tolerance than men – something encouraged, of course, by cultural gender norms. Research also has found that women present with symptoms more closely resembling anxiety and have a higher tendency of becoming addicted to opioids, points out Karen Sibert, president of the California Society of Anesthesiologists.

而且,许多研究人员和医生指出,早自1972年,近到2003年的研究,都说明女性对于疼痛的耐受力比男性低——当然,有性别文化准则的影响。加州麻醉师协会的主席赛博特(Karen Sibert)说,研究还发现,女性的症状表现更像是焦急症,更有可能会对鸦片类药物上瘾。

As a result, it might be entirely appropriate to dole out anti-anxiety medication to women before taking the extra step of painkillers, Sibert says. “When people are anxious, their pain tolerance becomes less,” she says. “It may be best to try to get their anxiety and fear under control first and then see what the pain requirements are.”

赛博特说,这样一来,给女性自然首先开的是抗焦虑的药物,然后再额外增加止痛药,好像完全合理。"人们在焦虑的时候,对疼痛的耐受力会弱一些,最好先把焦虑和恐惧控制下来,再看需不需要止痛"。

Another complication is that oestrogen alters both the perception of pain and the response to painkillers, says Nicole Woitowich, director of science outreach and education at the Women’s Health Research Institute.

妇女健康研究所科学服务与普及部的负责人妮可·沃伊托维绮(Nicole Woitowich)说,另一个难题是雌激素会改变病人对疼痛的感知,和对止痛药物的反应。

That means there are “sex differences in the way women experience pain”, Woitowich says. So it’s imperative that women and men are treated differently in order to develop a personalised approach to the patient’s care.

沃伊托维绮说,这就是说"女性的痛感有别于男性"是真实存在,因此,女性和男性必须用不同的治疗方法,这样才能实现个性化的医疗服务。

If doctors want to focus on treating patients in a tailored, effective way, they “should at least start by treating patients based on their chromosomal makeup, either male (XY) or female (XX),” Woitowich says.

如果医生致力于一种因人而异的、行之有效的治疗方法,他们"至少应该在就诊时,考虑患者的染色体构成,男性(XY)或女性(XX)", 沃伊托维绮说。

Sex study

性别研究

But to know exactly what those differences are – and how they affect treatment – much more research is needed.

但要知道那些差异究竟是什么——以及对治疗有什么影响——还需要更多研究。

Before 1990, the year the National Institutes of Health (NIH) introduced the Office of Research on Women’s Health, clinical trials and diagnoses in the US focussed on men. (These trials often were overseen by men as well.) In Europe, women have been similarly left out of studies. Same with Canada and the UK.

在1990年美国国立卫生研究院增设妇女健康研究处之前,美国的临床试验和诊断侧重于男性。(负责监管这些试验的也是男性。)与之类似,欧洲的女性也不在临床研究的范畴之类。加拿大和英国的情况也一样。

That led to a massive body of medical evidence, including pain-focused lab studies, with a predominantly male perspective.

结果是海量的医学根据,包括探讨疼痛的实验室研究,基本上都是男性的视角。

“When the history of an ailment, including the defining of textbook cases, is largely being written by men about men, it becomes the precedent to which anyone else is held up,” Norman says.

诺曼说,"医学记载某种疾病,包括医学教科书上病例的定义,大部分都是男性医学家记载男性病人,依此先例,女性的症状就被忽略了"。

In 2015, the US’s NIH introduced a policy that requires medical investigators to take sex into consideration as a biological variable. Now, anyone who applies for grant funding from the NIH must either research both males and females, or give compelling reasoning for why only one sex should be examined. We have yet to see, though, if it will make a difference. “Since this policy is relatively new, it may take a few more years before we see if it has made an impact on how research is conducted and if it has become more inclusive,” Woitowich says.

2015年,美国国立卫生研究院颁布一项政策,要求医学研究将性别纳入考量,作为一个生物变量。如今,要向国立卫生研究院申请拨款,就必须将男性和女性这两类都纳入研究范畴,否则就要拿出强有力的理由说明为何只研究一个性别。然而,虽有此新政,但能否有所改变,还有待观察。沃伊托维绮说,"这项政策出台不久,可能再过几年,我们才能知道对实施研究有没有影响,是不是更能兼顾男性和女性的情况"。

In 2017, the National Health Service in the UK also issued a similar dictum that the NHS must “listen to women” – though this was only meant to speed up endometriosis diagnoses. Since the early 2000s, Canada and Europe have incorporated similar policies; however, none of these have become laws or requirements, instead operating as suggestions and advice for researchers.

2017年,英国国家卫生局也发表类似的正式声明,称国家卫生服务必须"倾听女性声音"——虽然这只是为了加快女性子宫内膜异位的诊断速度。从本世纪初开始,加拿大和欧洲已纳入类似的政策;然而,这些政策没有一项成为法律或法规,至今仍只是意见或建议,供研究人员使用。

That doesn’t, however, eliminate the innate biases that physicians and other medical workers tend to have towards women’s pain.

可是,这并没有消除医生和其他医务工作者对女性疼痛的固有偏见。

Louise Pilote of Quebec’s McGill University Health Center co-authored a study showing patients with more ‘feminine’ personality traits across both genders had a higher risk of poor access to care. On the surface it may seem like that backs an implicit bias between treating men and women. But she points out that it was more complicated: the variations actually stemmed from poverty and how ‘feminine’ the personality, according to traits outlined in the Bem Sex Role Inventory, not from biological sex.

魁北克省麦吉尔大学医疗中心的皮洛特(Louise Pilote)是一项研究的合著者,她发现在两种性别中,患者"女性化"的性格特点越突出,诊疗不理想的风险就越高。表面上看,这好像是证明医疗界对于男性和女性患者的固有偏见。但她指出,实情要复杂得多:差异实际上源于贫困,以及是什么样的"女性化"性格。而这里所谓的女性化不是指生理上的性别,而是指美国社会心理学家桑德拉贝姆的性别角色量度表中列出的性外表特征和性别角色。

Pilote also has an evidence-based explanation for why my own heart issues were postponed for so long. Heart disease is less prevalent in women than men. It occurs later in life in women. And when women are seen for cardiac issues, they often focus on symptoms outside the realm of chest pain, she says.

为什么我自己的心脏病的治疗会耽搁这么久,皮洛特的解释也有根据。她说,女性患心脏病不如男性普遍,而且发病的年龄也要晚一些。因此心脏有问题的女性去看病,常常会被当作普通胸痛一类的症状。

Indeed, I was mostly concerned with how I felt as a result of my chest pain and rapid heartbeat: lightheaded, out of breath, and dizzy. I can see why a doctor might consider it to be simple anxiety.

确实,我最关心的是,胸痛和急剧心跳之后,会怎么样:眩晕、喘不过气、头晕。我知道为什么医生会误诊为焦虑症。

In January 2018, I finally found resolution in the form of a different cardiologist, a woman who listened and didn't explain away my pain as just a side effect of worrying or anxiety. I got back on a heart monitor, received an official diagnosis –and in March underwent surgery.

2018年1月,我终于在另一位心脏病专家的检测表上找到答案,她认真听了我的心脏,没有把我的痛症当成是忧虑或焦急症的副作用,搪塞了事。我又上了心脏监护仪,得到了正式的诊断——终于在三月份做了手术。

Perhaps I waited almost 10 years for treatment because heart disease is less common in women. Perhaps because my symptoms truly sounded like textbook anxiety. Or perhaps because of gender-based assumptions that women are more likely to complain of pain and less likely to have physical reasons for it.

我等了将近10年才获得治疗,也许是因为女性的心脏疾病不那么常见。也许是我的症状确实像医学教材所讲的焦急症症状。也可能是出于性别偏见的假设,认为女性动辄就抱怨这里痛那里痛,实际身体没有什么大毛病。

Even if I think my gender had everything to do with it, I’m not sure it will ever be possible to know for sure. And all that says to me is we have a long way to go before women and their pain can be fully understood.

尽管我觉得与我是女性有关,但我也不敢肯定就是如此。不过我的体会是,女性疼痛要得到充分理解前,还有很长的路要走。

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