Sexism and the Thyroid

 

People are interesting.  That may be the blandest statement I’ve ever made on this blog.  I thought about starting with “people are unbelievable,” but that doesn’t quite capture the sentiment I’m trying to express.  They say and do things that make me shake my head – or bang it against the wall – but I expect that of my fellow humans*.  So it’s totally believable.  But I still find the way people think and express themselves fascinating, especially when it comes to how they approach their health.

Someone must have recently posted my very first piece, It’s Not Your Thyroid, to Facebook.  For several days my site traffic shot up dramatically, with a thousand people or more each day reading that piece.  One commenter left a link to a Huffington Post article called Medicine Has A Sexism Problem, And It’s Making Women Sicker.  In the nuanced discussion that follo – oh, wait, that didn’t happen.  The entire comment was simply that link.  Though there was no accompanying explanatory statement, I’m a decent surmiser.  At one end of the possibility spectrum, the commenter could be implying if a male physician declines to validate a female patient’s incorrect belief, it’s sexism.  At the other end of the spectrum, I suppose she could simply be highlighting a topic she felt was germane to the discussion.

I realize I’m about to embark on a drive down a road besieged with potholes and IEDs (improvised explosive devices, not to be confused with IUDs), but I typically roll in a reinforced Humvee, so let’s get it on.  First, the Huff Post sexism article makes some good points.  The author also makes some assertions I found overstated, but I’m not interested in critiquing her post here.  Overall, I thought her article was thought-provoking and added something useful to the conversation about women’s health and how the medical system doesn’t always do a great job addressing it.

My beef obviously isn’t with the author – it’s with anyone who attributes an Endocrinologist’s opinion they don’t want to hear to sexism.  Cultivating such knee-jerk dismissal of doctors’ advice does women a great disservice.  It reinforces the garbage that litters thyroid blogs and forums – the nonsense that claims all persistent symptoms must be due to the thyroid problem that your doctor either refuses to diagnose or refuses to treat appropriately.

The reason I feel the need to loudly counter the sexism argument is because it has the potential to be extraordinarily effective – even when it doesn’t have merit.  It’s one thing to debate someone who endorses the naturopathic/magical approach to thyroid care; it’s another animal entirely to confront someone who goes nuclear with the highly-charged claim of “sexism.”  In today’s sociopolitical climate, it is not ok to be a sexist.  Of course, it has never been ok to be a sexist, but society’s tolerance for sexism has rightly plummeted.  So when sexism is invoked, it’s the equivalent of a mic-drop.  We typically have an immediate visceral reaction.  At that point, we are so primed to hate the accused and everything for which he stands, that any reasonable discourse becomes impossible.

Can we pause for a moment and do a quick reality check?  There are implicit biases that infect everyone in a society that is, at its core, patriarchal and racist.  In a sexist and racist society, it’s unavoidable that people – even doctors – will be influenced by these biases and make problematic decisions because of them.  The best way to mitigate the influence of our ingrained biases is to be aware of them.

So, is there sexism in medicine?  Yes.  Do women disproportionately get labeled as hysterical?  Yes.  Does the medical profession need to do a better job addressing women’s health?  Yes.  If the application of an evidence-based approach to thyroid care fails to identify the thyroid as the cause of a woman’s symptoms, should the doctor’s conclusions be dismissed because he’s the product of a sexist society?  I think you know my answer to that.  My point is that we need to wield our most powerful weapons responsibly, and that includes keeping the argument about what constitutes a thyroid problem honest.

*Marcus Aurelius, one of the most successful leaders in the history of the world, had the following to say:

When you wake up in the morning, tell yourself: the people I deal with today will be meddling, ungrateful, arrogant, dishonest, jealous and surly. They are like this because they can’t tell good from evil. But I have seen the beauty of good, and the ugliness of evil, and have recognized that the wrongdoer has a nature related to my own – not of the same blood and birth, but the same mind, and possessing a share of the divine. And so none of them can hurt me. No one can implicate me in ugliness. Nor can I feel angry at my relative, or hate him. We were born to work together like feet, hands and eyes, like the two rows of teeth, upper and lower. To obstruct each other is unnatural. To feel anger at someone, to turn your back on him: these are unnatural.

 

It’s time to let me know your thoughts.  I know that many of you have had poor interactions with doctors; do you think that sexism is part of the problem?  If you are a doctor, think hard about this one: can you remember an instance in which your approach may have been colored by sexism?  Comment below!

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24 Replies to “Sexism and the Thyroid”

  1. I think the opinions and experiences of female physicians especially is relevant here (of which I am one). Is a female physician capable of being sexist (against females)? We may have biases, but, personally, I don’t feel mine generate from some place of degenerating a female perspective simply because it’s female. That would be rather the undoing of my own confident skills. Hence, I feel I can be “fair” to a woman in regards to her medical concerns.

    And yet, as an internist practicing primary care, I am inundated with patients refusing to believe their thyroids (and adrenals) are normal, after we’ve tested them and found them to be normal. I rather find this disturbing because what results is a refusal to confront their actual problems, such as menorrhagia/anemia, obesity, sleep apnea, poor nutrition and sleep, and the like. Their response to my response, “It’s not your thyroid,” usually is a simple decision to ignore the facts of the matter and persist in some magical belief that “mystery” enshrouds their glands… and compounded by a new-found bias against me—because I fail to “recognize” this mystery. I am now somehow limited in 1. Interest in them, and 2. Competency.

    Having thought long and hard about where this originates, and being in practice more than 20 years (and thus able to remember when it didn’t exist), I am inclined to believe this is related to the (insurance-driven) transition of medicine from that of a consultation to acquire a person’s specialized skills to one of consumerism: “I have consulted Dr. Googles, and without any context to my argument, I believe I have ‘x,’ and this need ‘y’ treatment. And you should give it to me.”

    1. Candace, I agree that the perspectives of female physicians would be germane here. Though I am not one, I would say that it is absolutely possible for a female physician to be influenced by sexism in her treatment of other females. These days it is recognized that, even if an individual is not purposely sexist or racist, the implicit biases in our society infect everyone – even the target group.

      Nonetheless, your comments are all spot on, and I agree that part of the problem is the rise of internet research, wacky blogs, and self diagnosis. There is also a greater distrust of the medical establishment, probably contributed to by the increased pressure on doctors to produce, as opposed to incentivizing us to spend more time with our patients.

      1. I’ve found my mind returning to the subject of institutionalized sexism as my morning has slowed and in between patients. I have to say, ultimately, that, regretfully, I agree with the idea that women can have sexist attitudes towards other women. I specifically recall a CV surgeon who attended when I was in ID training (and later, as a faculty member). And I must say, again, regretfully and shamefully, that I often wondered what the opinions of her male colleagues would be when we disagreed on a course of care. At the time, I truly thought it was because they had more experience, and they were easier to talk to… Retrospectively, naaaa. I just think of CV surgery as a “masculine” field. And I feel rather idiotic about this, especially being a sub specialist. I didn’t mean harm, and I don’t think it ever affected care. But I can see the subtle manner of it, just culturally in the way we think…

        All that being said, I went and read your first post on the thyroid, and Bravo! (And I’m not just saying that because you’re a male… or am I just assuming you’re a male? How would I know?!! Maybe I need counseling… 😞)
        Bravo. Brava. Whichever.

  2. A topic which I have found to be poorly addressed is a definition of what constitutes “an evidence-based approach to thyroid care “. Or, more generally, what is a “normal” value from a blood test? After having several male doctors in 2 states treat me like a hypochondriac, I was able to convince one of them to refer me to an endocrinologist who, by chance, was female. Although the test results were within the “normal” range, she considered other factors and arrived at a diagnosis of thyroid insufficiency. Supplementing with synthroid suggested she was on the right track but she changed the prescription to Armour because, as she said, it contains more than 1 kind of thyroid hormone and while most people can convert synthroid to the other one, I can’t and that’s part of my insufficiency.

    My current endocrinologist considers both test results and other symptoms and we “tweak” the dosage as appropriate. It’s tough when you’re not “normal”.

  3. The previous two comments combined provide a striking illustration of the problem:
    Physician commenter: Why don’t patients believe me when their test results are “normal,” and I tell them they don’t have a thyroid problem?
    Patient commenter: Several doctors told me I didn’t have a thyroid problem because the test results were “normal,” and it turned out that I actually do have a thyroid problem, but it took a lot of persistence on my part and a doctor who was willing to dig deeper to finally figure that out.
    Sometimes it is related to sexism (yes, even from other women), but I also think women encounter it more often because they are more likely to persist in seeking help for a medical issue than men are after a doctor tells them there is nothing wrong.
    There is one simple explanation for the change over the past 20 years that the doctor above commented on, and it is this: access to information. Patients did not have the access to medical information (good and bad) 20 years ago that they have today. They also had very limited ability to find out about the existence of others like themselves who had real medical issues that doctors had difficulty diagnosing. Patients used to have to take everything their doctors told them at face value. Now, patients have more information than ever before so they’re more likely to question their doctors because they know there is very little consensus about most medicine and a demonstrated resistance on the part of doctors to change their practices even in the face of scientific data. The problem now is how do you know when your doctor is right, and how do you know when you must persist to get help? It’s a tough call for a patient, and examples like the patient who commented above make people much less inclined to just say “OK” when their doctor tells them there’s nothing wrong when they know they feel like crap or something has changed in their body.

    1. Patients who haven’t had some exposure to academic research can find it difficult to discern between trusted sources, testimonial, evidence based medicine, opinions, etc. Often, people can tend to call all the results of their internet search “research”, which reinforces the clinician’s response to dismiss any information the patient has found. This then reinforces the patient’s feeling that they, as a person, are being dismissed. I don’t understand where the harm in testing free T3, free T4 and reverse T3 and discussing the results lies; if the results are optimal it can support the “its not thyroid” argument and open the door for other discussion. If the results are off, then the physician and patient have a basis for discussion beyond TSH.

      1. I do address the harm of unnecessary/excessive testing in: Endocrinology vs. Naturopathy – Steel Cage Death Match.

        I also go over the utility of the various thyroid function tests in: The Ultimate Guide to Thyroid Function Testing – Hypothyroidism Edition

        In most cases of treating existing hypothyroidism, I do not think that T4, T3, or rT3 levels will help, and they may actually muddy the waters even further. For example, the T3 level is often “low,” but that is not clinically relevant as it does not correlate with symptoms or tissue levels of T3 (which can’t be measured). I can easily explain that to a patient, and I’m happy to if they ask for a T3 level. But once the T3 number is on paper, people tend to put a lot of faith in it, even when I try to counsel them it doesn’t mean what they think it means.

    2. …I also think women encounter it more often because they are more likely to persist in seeking help for a medical issue than men are after a doctor tells them there is nothing wrong.

      That is an interesting theory and I suspect there may be something to it. The problem with having all this access to all this information is that non-physicians are generally not skilled at separating the good from the bad. Often, this is because bad information sounds mechanistically plausible and “makes sense” to people, intuitively. I think part of the reason why people like Ellen feel as if the definition of evidence-based medicine is unclear is that they are not actually reading clinical guideline papers, original research articles, etc. They are reading cursory summaries from WebMD, quacky blogs, or other sources that need to be taken with a grain (or more) of salt.

      Another issue here is that many folks are correctly diagnosed with a “normal” thyroid, but they keep going back to different healthcare providers until someone tells them what they want to hear. I’m not saying Ellen doesn’t have a thyroid problem, but when I hear that a doctor is telling a patient she doesn’t convert T4 to T3, that is usually a red flag for quackery.

      JoDi, you ask “how do you know when your doctor is right?” Sadly, you don’t. That’s why really good communication is paramount, which means the doctor needs to explain, in lay terms, exactly how she reached her diagnosis. I find that most people accept it when I explain why I don’t think the thyroid is the answer. They may be frustrated that I don’t have the answer, but at least they believe me about the thyroid.

      1. Not converting – ouch. As I understand from my reading (I can provide citations but have a lot of archive to go through) there are three circumstances where we might see an elevated reverse T3: excessively high dose of T4 without a corresponding drop in TSH, inhibiting conversion to free T3; illnesss/inflammation where the body’s response is to inhibit conversion to T3; a specific but rare gene mutation which inhibits conversion.
        I had labs run just as I was acquiring the flu but not yet aware I was ill – my reverse T3 had jumped up (normally near zero) and my free T3 had dropped substantially. med based on this result. I certainly wouldn’t make any med changes based on this single odd point in time but would recheck levels when not ill.
        The possibility of a genetic mutation can be confirmed by (probably expensive) genetic testing.
        A cancer patient on high dose Levo but not suppressed can easily be trialed on a lower T4 dose plus some T3.
        “Reverse” T3 likely shouldn’t be used diagnostically but can be valuable to confirm something’s not right. It can be quackery when used by a quack but can be a useful tool when viewed in the appropriate context.

        1. The bottom line is that you are right – rT3 has almost no diagnostic utility. In extremely rare clinical scenarios, it could help to clarify a confusing picture, perhaps in a critically ill patient. But it is pretty much never used in that context. It is used almost exclusively by quacks in people who may or may not have hypothyroidism, and it is interpreted incorrectly almost every time.

  4. I have to add my support to Ms. Monroe. I am involved in a thyroid cancer forum where “woo” is discouraged and science based discussion is encouraged. The number of people (both men and women) who join the forum after being misinformed or disparaged by their physicians is astonishing. It often goes along the line of “we’ll remove the thyroid and you’ll get RAI then you’ll be fine with a little pill.”
    They leave out the potential for surgery to become extensive, the preparation needed for RAI ablation, an explanation of why ablation is recommended, isolation after RAI (think of the difficulty for a single Mom), possible side effects from RAI and how to deal with them. Only one person who responded to the question of being referred for a DXA and nutritional counseling (by a certified RD) to help avoid potential bone loss from suppressive T4 levels. I had no idea that I should have had genetic testing as part of the treatment for medullary thyroid cancer until I went to an online MTC group – three different endocrinologists failed to mention this to me.
    For many people who have been prescribed liothyronine or dessicated thyroid, it’s often done based on a subjective “it will make you feel better” rather than objective observations (prior to thyroidectomy I could walk/run xx miles, since TT I’m having difficulty keeping up with my department’s minimum physical requirements”.) This was a real statement from a young, buff male firefighter who was In danger of losing his job. On the online forum we encourage people to keep daily logs of their symptoms and to quantify them so they are presenting objective observations instead of vague complaints when they see their physician.
    The speaker at a recent support group meeting described advantages of a fellowship trained thyroid cancer specialist for ongoing thyroid cancer follow up as having a physician who understands the “disease of thyroid cancer”. We hear patients receiving their care from centers like MD Anderson or by physicians trained at similar specialized thyroid cancer centers expressing a more holistic level of care, are better informed, are encouraged to discuss current research with their doctors and less likely to feel their incidental symptoms have been brushed off. There is hardly any body process which is not affected by our thyroid status. I can’t speak to how it might affect someone with a dysfunctional thyroid, but for someone experiencing significant changes from their pre-TT status, a one size fits all weight based or TSH response T4 dose plus being told that any symptoms of fatigue, weight gain, etc. must be because of depression, poor lifestyle, etc. is uncalled for. I don’t think that experiencing a TT should be a requirement to practice endocrinology (in our ICU we used to joke that all the docs should be intubated and paralyzed for 24 hours) but there is more to the disappearing art of medicine than blind adherence to guidelines. They are guidelines – discovery and progress is made by those who color outside the lines.

      1. You’re welcome to explore the physician supported “thyroid cancer organization” that sponsors the forum and support groups. (It’s not appropriate to list the link unless this blog author OK’s it.) Many of the issues experienced by thyroid cancer survivors are shared by others who have had total thyroidectomies or ablation.

        1. Feel free to share the link, as I’m pretty sure I know to which organization you’re referring, and it is legit. Thanks for asking first.

          1. Thank you.
            The organization is http://www.thyca.org/.
            They sponsor thyroid cancer research, hold a yearly conference at different sites in the US, sponsor the ThyCa online support forum at https://www.inspire.com/groups/thyca-thyroid-cancer-survivors-association/ and sponsor local support groups around the country (plus a few contacts in the U.K., CA and Europe). The forum is an open format though some posts are “members only” when they contain more personal information. We try to avoid giving medical advice but do offer topics to discuss with your physician.
            The support group I co-facilitate with one of the cancer center social workers has been informative for me and also for cancer center clinicians and med students.
            Patti in AZ

  5. I don’t have a thyroid.

    I was hypothyroid for many years before my thyroidectomy and took my thyroxine quite happily and did fairly well on it.

    The problem we have here in the UK is a rigorous testing of TSH only unless it is out of range (NHS cost saving I guess). I had a dose increase in December and presented with symptoms of being over medicated. My GP won’t touch my medication as I am under an endocrinologist for my hypoparathyroidism (people with an under active or no thyroid don’t usually get to see an endocrinologist here) and the endocrine nurse parrotted the “you are in the lower third of the range which is fab” at me. If they had done my fT4 I would undoubtedly have been proven to be over medicated as it was fairly high in December despite a high TSH.

    I confess to messing with my medication myself. I did tell my endo when I next saw him (and he is a lovely man and treats me with compassion) and I am doing a lot better. For a start, I’ve stopped losing weight that I cannot afford to lose.

    The point is, there are a lot of people who are either convinced they have a thyroid problem and don’t or believe they aren’t being treated adequately. Occasionally we aren’t listened to. Being over medicated could have had implications for me. Maybe it’s because of all these people who want stuff tested that they’ve read on some blog or Facebook group. I just needed a fT4 test.

  6. Some people are hyper aware of gender issues and race. But generalizations based on these variables exist because the medical community looks for trends and patterns. A doctor isn’t sexist because one is more aware of a woman’s risk for breast cancer and gallstones, nor racist to be more aware of an african american’s risk for prostate cancer and hypertension.

    1. I’m pretty sure they mean like sexist because the patients are mostly women dealing with thyroid problems, and are being questioned because of their gender. Like dr patient relationships, not the patterns or numbers of certain illnesses affecting certain genders and races.

  7. I am not sure that I was subjected to individual acts of sexism by my doctors, but I do feel that the reaction of my doctors (as well as my family) to my distress when I was diagnosed had some sexist elements. Women’s pain is downplayed; their fatigue and depression, even more so. We don’t treat these as physical issues; we treat them as weaknesses of character. It’s intensely invalidating to feel unwell and unable to cope with daily life, and perceive that this only irritates the people around you. After going on medication, I felt a lot of pressure to answer people who asked me how I was doing that I was all better now– but I wasn’t.

    I do think that the testing process encourages this. After I started on thyroid medication, I returned to my doctor several times and asked to be re-tested because I was having a lot of problems– muscle fatigue, a deep feeling of pain (that turned out to be bone pain), disturbed sleep. They would run a thyroid test (and there were several adjustments to my medication– I started on 50mcg and within two years was taking 125mcg), but if the results were normal, they just sort of shrugged and looked at me as if to say, “Well, what are you here for?” I felt so frustrated that they gave me absolutely no advice. I finally requested a vitamin D test and was shown to be seriously deficient– doctors had not tested me because I was already supplementing 2000IU per day. I took one prescription-strength dose (35000IU per week) and within 36 hours, I was pain-free and my energy had returned. But I had to ask, and yes, that ruined my trust in doctors. Every visit, I felt like I was bothering them and that they did not take my problem seriously in the least– especially because I had accepted an early offer to take an antidepressant (feeling awful is a real bummer), and they seemed more than happy to chalk my fatigue up to depression–even though I was describing my fatigue as reaching muscle failure with the most mild activities, such as putting on makeup or chewing. There was never a point at which I felt that my doctors were on my team to help me feel well again– I felt that I was falling off a flow chart, or that they simply didn’t believe me.

    I eventually developed a good rapport with my (male) endocrinologist, but I still went into each visit terrified that I would say something that made me look crazy, or like a whiner, or like some middle-aged frumpy woman who read crazy stuff from the Internet. I can’t blame him for that, but I do put some blame for that on systemic sexism.

    1. Sadie – you have no idea how many women you are speaking for.
      In the series “Manhattan Project” there is a scene where the doctor and husband are discussing the wife as if she is not in the room and she is prescribed a tranquilizer to tamp down her unwifely behavior (continuing her botany research and the effects of radiation). Physicians from that era trained future physicians and that type of sexism can still be seen. You think med students don’t still giggle and nod knowingly at the “hyster” in hysterectomy?
      We have seen dramatically in recent months how persistent this type of sexism is in everyday life. It’s naive to think it doesn’t exist in medicine.

    2. Sadie, your comment should be a must-read for all doctors. Rarely do we hear such an honest AND measured description of what it’s like to deal with chronic pain/illness. Thank you for this.

  8. I cannot resist leaving my two cents because this thread contains topics that are very relevant to my own health – thyroid health, endocrinologists, and naturopaths. Four years ago, I was misdiagnosed with a thyroid problem by a very respected DO who was my concerierge doctor. My TSH was elevated, and had been increasing over time. After running blood tests that required more than 18 different vials of blood, the DO called and said, “I found it, I’m calling in a prescription now. You are hypothyroid.” I felt so bad and trusted this doctor, so I filled his prescription for NatureThroid medication, which I learned is both T3 and T4. After one dose, I knew something was wrong, and called the doctor to report that I felt like I was going a million miles per hour, could not sit still, could not eat, and felt like my heart was going too fast. I asked if we needed to have an endocrinologist review the tests, to which I was scolded, “You have to take the medication! It takes 6 weeks to take effect.” I took the medication for a total of 5 days and stopped taking it as I was starting to lose weight, and I started at 105 pounds. Over the next two weeks I continued to lose weight, going as low as 90 pounds. My husband took me to see another doctor, who looked at the test results, and she said that the DO “Did the worst thing possible for you, because you do not have a thyroid problem.” She worked with me to repair the all-systems failure that I was experiencing. I want to point out that “non Naturopathic doctors” are guilty of thinking they are endocrinologists. My trusted DO put me into a medically-induced overactive thyroid state and refused to accept that the medication created a worse state. He wanted to send me for all kinds of additional “zebra-hunting” tests, to which I refused. I experienced the worst kind of anxiety, insomnia, and muscle wasting all due to a traditionally trained doctor thinking he knew everything. I have had several other doctors look at those same blood tests who agreed I was actually overactive thyroid at the time when you look at the other thyroid tests, not just the TSH. I also want to point out that this doctor failed not just once in his misdiagnosis, he refused to listen to the bad reaction I experienced after just one dose, and instead of rerunning the tests, he told me it was not possible to have a bad reaction because it would take 6 weeks for the medication to take effect. I am not embarrassed to say that I was extremely suicidual during the month I was overactive thyroid due to unnecessary medication. A lot of people will claim they have insomnia, but when you are overactive thyroid, you cannot sleep, which really messes with your brain and neurotransmitters. It is important for people to know that thyroid medication is powerful and there are doctors that claim competence in this area which they really should not be prescribing.

    1. That sounds like a truly awful experience – I’m sorry you had to go through that. I agree that there are practitioners of all stripes who think they know how to treat thyroid conditions, but they do not.

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