Medicine Built Its Knowledge Base on Men. Women Are Still Paying for It.

Every piece of content we publish in this series — the sleep deprivation research, the female athlete nutrition review, the strength training participation data — shares a common thread. The evidence base informing care for women is systematically thinner than the evidence base informing care for men. A 2022 scoping review in Women's Health Reports (Merone et al.) makes that problem explicit across all of medicine, not just exercise science. It's worth reading directly, because the scope of the gap is larger than most practitioners appreciate — and because understanding how it was created changes how you should think about every recommendation you give to female clients.

The Scale of the Problem

The review examined 17 studies published between 2009 and 2019 that looked at sex and gender representation in medical research. Three consistent findings emerged: women remain broadly underrepresented as research participants, sex and gender are poorly analyzed and reported even in studies that include women, and a subset of contemporary medical research is outright misogynistic.

On representation: one cross-sectional analysis of 86 randomized controlled trials across nine journals found female enrollment at just 37%, with only three studies noting their lack of diversity as a limitation. In cell biology research, 60% of studies gave no information on the sex of the cells studied — and where sex was reported, 70% of cell lines were male. In animal studies for surgical research, 84% used male animals only where sex was specified. The problem runs from the bench to the bedside.

On analysis: even in studies that include women, the data is routinely not broken down by sex. Across included studies, analysis of results by sex or gender sat somewhere between 6% and 38%. A Canadian cross-sectional study found that no studies considered the influence of sex on outcomes, and only 6% performed a subgroup analysis by sex. The 1993 NIH Revitalization Act — which recommended that women be included in clinical trials based on disease prevalence — has not, according to the review, resulted in significant increases in sex-based reporting. Female participation in clinical trials actually decreased between the 1990s and the late 2000s.

The practical consequence is straightforward: most clinical guidelines are built from data that underrepresents or excludes women. When those guidelines shape how practitioners treat female patients, the mismatch between the evidence and the population has real outcomes.

The "Yentl Syndrome" Is Documented, Not Anecdotal

The review opens with a concept that deserves more recognition in health and fitness circles than it currently receives: the "Yentl syndrome," named by cardiologist Dr. Bernadette Healy. It describes how, for a woman's illness to be taken seriously, she must first demonstrate that she is as sick as a comparable male patient would need to be to receive the same level of investigation.

This isn't a fringe critique. Women wait longer than men for both diagnosis and pain relief and are more likely to be misdiagnosed or discharged during serious medical events. Six months after admission for myocardial infarction, female patients — particularly younger women — were more likely to suffer major adverse events and overall mortality. Coronary artery disease is the leading cause of death in both men and women, yet women are consistently underrepresented in cardiovascular research. Women make up 30% of the gout population but only 5.3% of gout clinical trial participants.

The review also cites the example of endometriosis, where the average time from first consultation to diagnosis in the United States is 4.4 years. Research has documented how the pain of endometriosis patients has been systematically dismissed as psychological — what the authors describe as part of a "hysterical discourse" where women who don't respond to treatment or diagnosis as expected are characterized as difficult, anxious, or mentally unwell.

The hidden curriculum of medical education compounds this. Medical students absorb attitudes and assumptions from senior clinicians that aren't part of formal training — including the implicit framing of female patients as diagnostic outliers from a male norm. Those perceptions get passed down.

What Drives Underrepresentation

The reasons for preferring male subjects in research are well-documented in the literature the review synthesizes: concern about harming fertility or pregnancy, researcher bias from predominantly male research teams, and the persistent perception of the male body as representative of the human species.

The research also makes a counterintuitive point worth highlighting: women's underrepresentation in trials is not because women are unwilling to participate. A cross-sectional study that offered patients the opportunity to volunteer for a research registry found women volunteered at slightly higher rates than their proportion of overall portal users. The gap is in trial design and recruitment, not in women's willingness to be studied.

What appears to drive representation most is perception of disease prevalence rather than actual prevalence. In diseases perceived as male-dominant — coronary disease, heart failure — women are underrepresented. In diseases perceived as female-dominant — hypertension, atrial fibrillation — they are adequately represented or over-represented. The problem is that those perceptions are often outdated. Coronary artery disease kills women and men in roughly equal numbers. The research infrastructure hasn't caught up.

Misogyny in the Literature Is Not Historical

Five of the 17 studies reviewed didn't examine the research gap — they demonstrated it in a different way, by displaying what the authors define as misogyny in medical research: research assessing the female aesthetic in terms of health without actually measuring health, or producing findings that cannot be used to improve clinical practice.

These included studies where clinicians rated the attractiveness of endometriosis patients on a Likert scale as part of a published study. Studies that proposed facial attractiveness as a proxy for health without using objective health measures. An eye-tracking study on the visual perception of female breast aesthetics, where the authors themselves acknowledged the link between gaze duration and attractiveness is unknown — raising the question, as the review puts it, of why the study was conducted.

This matters beyond the obvious ethical concerns. Studies that focus on female attractiveness perpetuate the framing of female patients as aesthetic objects rather than as people with symptoms requiring investigation. The review notes that the "beauty myth" — the use of appearance as a tool of social control — is evidenced in the contemporary medical literature, not just in cultural history. When that framing permeates clinical settings through the hidden curriculum, it contributes to delayed care, dismissal of symptoms, and the erosion of the trust female patients place in the medical system.

Limitations Worth Naming

This is a scoping review of 17 studies, all published between 2009 and 2019. The authors acknowledge that restricting to recent literature likely underestimates the historical extent of misogyny in research. Sex and gender are largely treated in binary terms, with limited literature available on gender diverse populations — a gap the authors flag for future research. The definition of misogyny applied in the review was developed by the authors themselves, since no prior framework existed for assessing it in medical literature.

The review is also predominantly US-based in its included studies, which limits generalizability across different research and healthcare systems, though the patterns are broadly consistent with what's documented internationally.

What This Means for Practitioners

For anyone working in health and fitness with female clients, this review contextualizes something that shows up constantly in practice: the evidence you're working from was often not built with your client in mind.

That's not a reason to abandon evidence-based practice. It's a reason to hold recommendations more carefully, to be explicit with clients about what the evidence does and doesn't tell us, and to treat female clients' reported experiences — particularly when they don't fit expected patterns — as data rather than noise.

When a female client reports that her symptoms were dismissed, or that she waited years for a diagnosis, or that she was told her pain was psychological — that's not anecdote. It's consistent with a documented pattern in how the medical system was built and how it continues to operate.

The practical response isn't cynicism. It's precision: know the limitations of the evidence you're using, track individual responses carefully, don't assume male-derived norms apply, and take symptoms and client self-report seriously as clinical information. The research on this is clear even if the interventions remain underdeveloped. Acting on it is a professional responsibility, not a political position.

Source: Merone L, Tsey K, Russell D, Nagle C. Sex inequalities in medical research: a systematic scoping review of the literature. Women's Health Reports. 2022;3(1):49–59. https://doi.org/10.1089/whr.2021.0083