suggests that, among others, insulin resistance is a contributing factor in the association between race and poor prognosis in US women with breast cancer.

Although mortality rates have declined in some ethnic populations, the overall cancer incidence among African American and Hispanic populations continue to grow.

 The lack of data on the possible connection between race and breast cancer prognosis is what led a group of Mount Sinai researchers to conduct this new multicenter, cross-sectional study.

They used data from 10 hospitals across the country and patients included self-identified black women and white women with newly diagnosed invasive breast cancer. According to the authors, metabolic syndrome disproportionately affects more black women than white women.

The primary goal of the study was to determine if insulin resistance, determined by the homeostatic model assessment of insulin resistance (HOMA-IR), mediated the effect of race on prognosis. Researchers also included demographic data, anthropometric measurements, and fasting blood.

In total, 515 women participated (83% white, 17% black). Researchers ultimately found that MetS was more prevalent in black women than in white women (40% vs. 20%, 

The study also found that the mediation model, when adjusted for age, revealed that HOMA-IR was higher in black women than in white women (1.9± 1.2 vs. 1.3 ± 1.2, 

1. Gallagher EJ, Fei K, Feldman, SM, et al

 Insulin resistance contributes to racial disparities in breast cancer prognosis in US women. 

https://doi.org/10.1186/s13058-020-01281-y

2. Yedjou CG, Sims JN, Miele L, et al. Health and racial disparity in breast cancer. 

. 2019;1152:31‐49. doi:10.1007/978-3-030-20301-6_3

Articles

The lack of data on the possible connection between race and breast cancer prognosis is what led a group of Mount Sinai researchers to conduct this new multicenter, cross-sectional study. 

Insulin resistance contributes to racial disparities in breast cancer prognosis in US women

Below are additional resources from a peer-reviewed article, '

Gynecologic care considerations for transmasculine people

,' that appeared in this year's August issue of Contemporary OB/GYN. The following information has been provided by 

Drs. Halley Crissman, MPH and Daphna Stroumsa, MD, MPH, MSC

Guidelines for the primary and gender affirming care of transgender and nonbinary people

UCSF Transgender Care, Dept of Family and Community Medicine, University of California San Francisco; 2nd ed. Deutsch MB, ed. June 2016.

New clinical guidelines for contraceptive counseling

Society of Family Planning clinical recommendations: Contraceptive counseling for transgender and genderdiverse people. Contraception. 102(2): 70-82. August 2020.

 with Drs. Crissman and Stroumsa where they will expand upon the topics discussed in the above article. 

Find additional resources for providing high-quality sexual and reproductive healthcare to transmasculine people, transgender men, and nonbinary people, whose sex assigned at birth was female. 

Resources for transgender care 

We are in a cultural moment of awareness and change because of moral outrage by people of all colors. As was said at George Floyd’s eulogy, “What happened to Mr. Floyd happens every day in this country, in education, in health services, and in every area of American life, it’s time for us to stand up in Mr. Floyd’s name and say 

In obstetrics and gynecology, it’s way past the time to provide better and improved health care for all, not just for the haves but for the vulnerable in our communities as well.

Systematic and institutional racism result in many if not all of the 

 (SDoH) our patients face. The SDoH play a major role in numerous health disparities in our specialty and poorer outcomes that we see, whether in the death of pregnant mothers or infants or rates of cancer, heart disease, or worse outcomes in black and brown individuals with COVID-19. 

This is as a result of long-standing racism that is interpersonal, systemic, institutional, structural, and exemplary of racial bias and which adversely affects healthcare.

Physicians and healthcare workers (us) see this every day. We know racial bias and racism when we encounter it and that over the years, it leads to poorer health status and outcomes. 

The COVID-19 pandemic disproportionately affects and targets black and brown people more than whites because of racism. 

. The coronavirus has placed a bright spotlight on the long-existing poor health in black and brown people and the worse outcomes when they get COVID-19.

Clearly, there are demonstrated disparities in outcomes based solely on implicit bias and racism. A midwife said to me on rounds that there is no reason for a black or brown pregnant woman to die or be very sick more so than her white counterpart other than long-standing and present racism. Think about that. She is right. There is no genetic or biological reason for this tragedy! 

We can eliminate racial disparity by eliminating racial inequity.

Racism is an insidious cultural disease with many manifestations. Privilege is one and has to be admitted. Access to healthcare and healthcare injustice are others. Not getting a deserved promotion is another. Being assigned an insurance plan that does not provide for needed services is another. And so on. You know them.

Around the country, medical students, physicians, nurses, and their families have recently knelt in remembrance of George Floyd’s death to say “yes” we know there is racism in the provision of healthcare services and “yes” we admit it and “yes” now let’s use our platforms and do something about it. 

This is a great start but that alone is not enough! Letters and events of support are meaningful, but the systemic racism continues. 

All of us providing healthcare services have a role and must speak out. What should empower you to speak out? Better outcomes for your patients.

Dr. Hill is a Maternal-Fetal Medicine specialist with CenterPlace Health and Sarasota Memorial Hospital and has been an obstetrician-gynecologist for 55 years, almost 30 in Sarasota, Fla., within the Sarasota Memorial Health Care System. He can be reached at 

Steps to advance and address racial justice and healthy equity in ob/gyn

So where do we go from here? What can you as a clinician or administrator do?

 within your organization diversity and inclusion among your learners, faculty, staff, and most importantly the leadership within your organization. Change starts from the top. Is your “med exec” group truly diverse and reflective of your medical staff or group?

Have those difficult and sometimes uncomfortable, real, open conversations about racism and racial equity at your institution and their effects locally and within policies and practices in your organization.

and teach the importance of SDoH and structural racism in health services as part of the curriculum for trainees.

 for more diversity of staff, employees, management, faculty, and leadership. These people need your help. Use your platform and speak out wherever and whenever you can.

 health equity knowledge and advocacy where you work. Remember that equality is not equity. The service may be available to all; i.e., “equality,” but are all really able to access it, i.e., “equity?”

 Examine your own group, clinic or office. Is it really diverse? Who is at the front desk and who is doing the procedures? Any blacks or Latinos?

your meetings, mouth, ears, devices, and contacts to advocate and speak out for a more accountable, diverse and inclusive “healthcare system.” Compliment when you see something done well and hold those accountable when it needs to improve.

 your leadership, staff, and employees to use their influence and push forward with diversity and inclusion initiatives. Encourage them to partner with community organizations, suppliers, businesses, and diverse communities, not just those that look like them.

questions like, “How diverse is our workforce and management?” “What do the data show?” Look at the metrics over time. You know the importance of data. Eenie, Meenie, Minie, Mo...What Do the Data Really Show?

 your own institution. Does it appear that your hospital is welcoming to all forms of promoting diversity? What more can be done? Speak up if you see an injustice committed. Your organizations should encourage and support their staff to confront overt racism and implement efforts to address the implicit biases of coworkers and senior staff members.

 We can no longer remain silent and not speak up. That’s complicity. Your voice has power!

For those of you who choose to do it, this is not easy work. There will be lots of resistance and lots of words. It will take a lot of energy, but do not become dismayed or give up. It can be very frustrating. 

We have come a ways in including diversity, inclusion, and equity in our healthcare organizations but we still have a very long way to go in really being diverse. Healthcare organizations cannot rest on their laurels. 

Your hospital should be just as proud of being one of the top diverse hospitals in your area or country as it is about being a top cardiovascular center putting in valves. Use your platform to get there.

In the past 55 years since I became a physician, progress has been made but we still have so much more to do and a long way to go. Those gatherings in front of medical schools, hospitals, and clinics kneeling to remember George Floyd in support of the Black Lives Matter movement will make sure of that. 

They are not going away nor is the community. 

 wire story, dated March 26, 1966, contains the first known published reference to Dr. Martin Luther King’s famous quotation regarding injustice in health care, “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.” 

Dr. King’s remarks were made at a Chicago press conference held the day before in connection with the annual meeting of the Medical Committee for Human Rights. These words still ring true today.

I graduated from medical school in 1965 and remember marching the next summer for racial equity. It is now the summer of 2020 and people of color are still marching for racial equity. There is something wrong with that picture and many of you have pointed that out. 

—has changed. We must all do, expect, and demand better of ourselves and those in power who provide healthcare services and teach about it.

We have a lot of work and a long way to go to get the knee up and improve healthcare services for all of our patients, but we can do it if we really want to. 

A change has to come! I hope that this commentary rings clear as a clarion call touse our platforms, work together, stronger and better to eliminate racial inequity in our specialty and all of healthcare.

Racial and ethnic disparities in obstetrics and gynecology

. Committee Opinion No. 649. American College of Obstetricians and Gynecologists Obstet Gynecol 2015;126:e130–4.

Importance of social determinants of health and cultural awareness in the delivery of reproductive health care

. ACOG Committee Opinion No. 729. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e43–8.

The Joint Commission Stands for Racial Justice and Equity

SMFM Issues a Statement to its Membership on 

Reduction of Peripartum Racial/Ethnic Disparities

“In the past 55 years since I became a physician, progress has been made but we still have so much more to do and a long way to go.”

Ensuring racial justice and health equity in ob/gyn

, the 8-year-old patient presented to the defendant Emergency Department (ED) accompanied by her parents with a chief complaint of right-sided abdominal pain that started at lunchtime, and one episode of vomiting (a second episode was alluded to by the attending in her note). 

The child had constant, moderate in the right lower quadrant (RLQ) that did not radiate and had sudden onset. A similar incident had occurred the week before. The child’s medical history was non-contributory.

On examination, there was tenderness in the girl’s RLQ without guarding or rebound, no masses were palpated, and bowel sounds were normal. The child felt better while in the ED; she was well-appearing and “able to jump without difficulty.”She was sent home with instructions to return if she had fever, worsening abdominal pain, or new symptoms, and to follow up with her primary care physician (PCP) the next day. 

A computed tomography (CT) scan with contrast that was ordered initially was canceled. Discharge instructions indicated a diagnosis of “abdominal (belly) pain,” with the specific cause being unknown. It was noted that the illness did not seem dangerous or require hospitalization or emergency surgery. The instructions recommended bringing the child back in the event of increasing or persistent pain. A separate sheet of paper described diagnosis and treatment of “UTI.”

On June 10, the girl was seen for what the codefendant pediatrician described as a sick visit. His note is illegible, although the assessment appeared to be “UTI” and the plan appeared to consist of a follow-up appointment. Results of the urinalysis and urine culture done that day were normal.

Follow-up for “UTI” was done by the co-defendant pediatrician on Sept. 24, when the child was seen for fever and a cough. No mention was made of abdominal pain. 

, the child returned to the defendant hospital accompanied by her parents with a complaint of a 3-day history of RLQ abdominal pain that was severe, intermittent, and non-radiating and reported vomiting. 

The mother reported seeing the child’s PCP, who diagnosed the girl with “constipation” and gave her a laxative and enema, without improvement. Exam at that time revealed tenderness, rebound, and guarding, although no mass was felt and bowel sounds were present. Laboratory testing revealed an elevated white blood cell count.

A CT with contrast of the abdomen and pelvis was done and showed a predominantly cystic mass measuring 6.4 6.2 cm that contained internal septations. The uterus was compressed between the mass and urinary bladder. The ovaries could not be visualized. There was a small amount of free fluid in the pelvis. 

The finding was believed to be an ovarian cystic mass, mesenteric cyst or enteric duplication cyst. Pelvic ultrasound showed an enlarged right ovary that measured 7.3 4.6 4.6 cm, midline in the pelvis. A thick-walled right ovarian cystic mass with intervening thick septations was visible and there was trace fluid in the pelvis. By comparison, the left ovary was 2.2 cm in its widest diameter. 

The impression was “complex cystic right ovarian mass with thick septation.” Given the size of the mass, superimposed torsion could not be excluded. 

Progress notes indicate that “Codefendant OB/GYN [was made] aware of CT and sono findings. He will follow as outpatient.” The family was counseled as to the need for follow-up and reasons to return. 

The patient was discharged home from the ED with instructions describing a primary diagnosis of abdominal tenderness and a secondary diagnosis of right ovarian cyst. The family was also given another detailed document that described the diagnosis of ovarian cyst and included reasons for returning to the hospital.

The codefendant ob/gyn saw the patient on Sept. 27 in the office. The physician’s brief note mentions that the patient was in the ER at the defendant hospital the prior day with sudden-onset abdominal pain, she had the same pain 4 months before, and a sonogram showed a 6.4-cm cystic mass in the midline. No intervention was attempted or recommended.

, the patient then saw the defendant pediatric gynecologic surgeon.Her chief complaint was intermittent abdominal pain in the RLQ for 4 months. She reported having been seen at the defendant hospital and undergoing ultrasound and CT, which showed a right ovarian cystic mass measuring 6.4 cm, as well as a possible complex right ovarian mass, predominantly cystic. 

The family brought reports but not hard films. The girl was having less pain and was otherwise healthy, although her grandmother thought her “tummy was getting bigger.”

On exam, the child’s abdomen was full, with a lower abdomen mass palpable at midline, described as movable. The remainder of the exam was unremarkable. The impression was abdominal mass, rule out right ovarian, mesenteric, and duplicating cysts. The family was advised about possible “torsion” and the need to obtain the ultrasound and CT images from the defendant hospital. 

The child was scheduled for surgery on Oct. 4.

On October 3, the child was seen by the codefendant pediatrician for surgical clearance. Significantly, abdominal examination revealed no abnormalities. There was no pain or guarding on exam. 

Surgery went forward on Oct. 4 and the family provided the films that day, on CD. The procedure consisted of exploratory laparotomy, detorsion of twisted right adnexa, right oophorectomy, left oophorocystectomy, and peritoneal lavage. The operative report noted hemorrhagic pelvis where the mass was lodged, 3 twists of the right adnexa including infrandibulo pelvic ligament, multiple follicular cysts, involvement of the uterus in the torsion (which regained color after the torsion was reduced), and other findings that were also accompanied by a diagram drawn by the defendant surgeon.

The intraoperative log lists the time in as 11:55 a.m. The incision time was 12:25 p.m. and closure time was 2:15 p.m.Time out was listed as 2:30 p.m. The anesthesia start time was listed as 12:05 p.m., with the surgery start time listed as 12:30 p.m.Anesthesia finish time was 2:45 p.m., while surgery finish time was 2:20 or 2:30 p.m.

The operative report lists the preoperative diagnosis as abdominal mass rule out ovarian lesion with intermittent torsion, and the postoperative diagnosis was right ovarian tumor with adnexa torsion, localized peritonitis, and left ovarian follicular cyst. 

, the defendant surgeon noted that the case was “thoroughly discussed with the family” and the “possible risks and complications were explained and no guarantees were made.” A consent form for the procedure was contained in the chart.

The defendant surgeon found “serous ascitic fluid” suggestive of peritoneal reaction. A hemorrhagic mass was found in the pelvis consistent with a right ovarian tumor with 3 twists of the adnexa, including the infundibulopelvic ligament. The mass was 6 to 7 cm in diameter and “quite hemorrhagic with the violaceous discoloration of the ovarian mass.” 

The uterus was described as splayed out with torsion. Some discoloration of the uterus resolved after the torsion was reduced. The right ovary was removed and described as “replaced completely by the tumor.” The anterior wall of the rectum, the posterior bladder, and the pelvis were “quite hemorrhagic” due to the mass. They were checked for hemostasis. “Multiple follicular cysts” were drained from the left ovary. Following peritoneal lavage, the patient was closed up. 

The child remained at the hospital until Oct. 7. 

She was eating well and without complaints of pain prior to discharge.

Pathology revealed a right ovarian mass, marked stromal congestion, edema, and hemorrhage, as well as several cysts lined with monolayer short columnar cells with old intracystic hemorrhage. Further noted were numerous primary follicles. Findings were consistent with cystic ovary with torsion, 

When the defendant surgeon saw the child on Oct. 15, she was healing satisfactorily. Surgical pathology showed benign ovarian cystic tumor, without any indication of infarction or necrosis. The scar was described as well-healed with slight induration under the scar. 

 again with satisfactory healing and postoperative course. There was slight induration under the scar, although no unusual complaints of pain. She was eating well and having regular bowel movements. Subsequent pediatric records do not indicate any further significant medical issues.

The plaintiff alleged that the codefendant hospital departed in not admitting the patient, obtaining an immediate pediatric surgical consult, referring the patient for an immediate surgical consult or transferring the patient to an appropriate facility for surgical evaluation on Sept. 26. 

They criticized the failure of the codefendant hospital to contact the mother on Sept. 27, after the final interpretations of imaging from the day prior were made available (showing possible torsion). 

They criticized the codefendant ob/gyn’s decision

 to refer the patient to a pediatric surgeon on Sept. 27, without immediately referring her to the hospital, in light of imaging that could not rule out torsion.

The plaintiff alleged that the defendant gyn surgeon failed to timely operate on the patient, inappropriately delayed surgery by 3 days, failed to timely apprise herself of abdominal imaging done 5 days prior at the codefendant hospital, failed to order emergent imaging, improperly assessed the plaintiff, improperly examined her, failed to timely apprehend clinical and radiographic evidence of ovarian torsion, allowed ovarian cyst and torsion to worsen and ultimately caused or contributed to the loss of the plaintiff’s right ovary, due to worsening cyst and torsion. 

, decreased fertility, loss of chance of laparoscopy/laparotomy incision, abdominal adhesions/scarring, temporary incontinence, pain, and suffering.

The child’s mother testified that the girl had been having RLQ pain since June 2011, and that it began around the time of the first presentation to the co-defendant hospital that month. She didn’t recall much of the June visit, besides the diagnosis of UTI. 

When asked about the child’s pain between the June and Sept. 2011 hospital visits, the mother stated that the RLQ pain happened almost daily but she was not sure if the pain changed, as the child is “not really a vocal child in letting me know.” She did state, however, that the child’s pain from September 24 to 26 was 

The mother testified that on Sept. 27, she went to the codefendant ob/gyn, who spoke to them in his formal office, not in an examination room. He did not examine the child, stating that he was an adult gynecologist and did not examine children. 

He did, however, discuss the possibility of torsion and provided a referral to another adult gynecologist. Instead, the mother called the codefendant pediatrician, who referred her to defendant gynecologist. 

After the defendant gynecologist did a physical exam on Oct. 1, she said the child’s mass needed to be removed. Surgery was scheduled for Oct. 4. The defendant said the removal could not be laparoscopic because the mass was too large. When asked about the child’s complaints between Oct. 1 and 4, the mother stated, “I’m sure she did [have complaints] but don’t know for sure. I don’t recall.”

The defendant gynecologic surgeon went through the note from her encounter and testified that her interview and exam revealed no complaint of pain and no tenderness on palpation. Pain was described as intermittent for at least 4 months. Upon reviewing the CT and U/S reports and after assessing the patient, her impression was rule out ovarian, mesenteric, and duplicating cysts. 

She testified that she counseled the family on torsion, telling them that if the child were to have an acute attack of abdominal pain, they should contact the doctor as this would indicate a surgical emergency. 

Otherwise, the family was told that surgery would be done on Oct. 4. She was questioned intensely as to whether the child presented as a surgical emergency due to the presence or risk of torsion on Oct. 1. She insisted the child was not an “emergency” due to the absence of tenderness on palpation or active pain at the time of interview/exam. 

She testified that a torsed ovary is capable of twisting/untwisting, and a state of torsion can be reversed and recur, intermittently. 

, there was no evidence of torsion, thus it was proper to schedule surgery 3 days out, to obtain pre-surgical clearance and give the family time to emotionally prepare for a significant procedure.

Our pathology expert believed the ovary was unsalvageable and had to be removed on Oct. 4. 

She examined slides of the specimen and found that the patient’s ovary was both completely taken over by cyst and ischemic and infarcted from torsion. The ovary was no longer viable because of both disease processes. The slides showed that the cyst had completely taken over the ovary and the two were inseparable, and thus measures such as cystectomy or drainage were unavailing. In addition, the cyst—about 7 cm in its largest dimension on Oct. 4–had grown to a point where the ovary was most likely unsalvageable by Oct. 1. 

, the ovary most likely would have been removed then as well.

Our pediatric surgery expert was supportive of the decision to remove the right ovary on Oct. 4. 

Even in the extremely unlikely event that the de-torsed ovary “pinked up,” it would have been against good medical conduct to leave the ovary and do periodic ultrasounds to check on its viability because the surgeon would then be allowing a potentially malignant tumor to remain in the child’s body. 

There was complete torsion of the right ovary, which is reflected in the operative record showing three twists of the adnexa. Finally, the expert stated that the operative pictures of the torsed and de-torsed ovary clearly showed it to be necrotic, gangrenous, and lacking any viability. In addition, the cyst had displaced any viable ovarian tissue.

After all depositions were concluded, we moved for summary judgment dismissal of the case on behalf of our client, the surgeon. We argued that the alleged 3-day delay in performing surgery was not a delay at all given the circumstances and that, regardless, the entire ovary had to come out as it was nonviable and had been that way at least since Oct. 1. 

In their opposition to all defendants’ motions

, the plaintiff’s expert had to concede that by the time the patient presented to our client, there was unlikely to have been any viable ovarian tissue remaining, and as such, it was imperative that intervention occurs prior to Sept. 26. As a result, summary judgment was granted to our client and the case was dismissed.

Sometimes medicolegal cases have so many moving parts that until they are all fleshed out, as it were, one cannot be certain as to where the focused allegations and defenses will lie. While this started out as a misdiagnosis and delay case as to all defendants, through the discovery process and expert evaluation, we were able to determine that the pathologic findings rendered any delay argument, at least as to our client, moot. 

In the face of expert testimony in support of that pathologic conclusion, the plaintiff was forced to concede that our contentions were credible and they could not mount an argument in rebuttal that would enable them to maintain the case against our client. As such, dismissal was obtained.

This case involves an eight-year-old patient who originally presented with a chief complaint of right-sided abdominal pain and one episode of vomiting.

Was loss of ovary in this pediatric case avoidable? 

know what you thought of this month’s feature stories by tagging us on 

Using Your Platform for Racial Justice & Health Equity, By Washington Clark Hill, MD, FACOG

Overcoming Racism & Unconscious Bias, By Vanessa L. Rogers, MD, & Shawna D. Nesbitt, MD, MS

Drs. Rogers and Nesbitt discuss what obstetricians and gynecologists can do to reduce racism and unconscious bias in their practice.

Equality versus Equity: What’s the difference?

By Halley Crissman, MD, MPH, and Daphna Stroumsa, MD, MPH, MSC

Transgender and non-binary people face discrimination and stigma, along with other barriers, in accessing health care.

Terminology for ob/gyns to use when treating transgender patients

Addressing inequalities in women’s health research

What did you think of this month’s feature stories? 

August issue roundup: Vol 65 No 08

Women’s health research continues to be marginalized. To address and reverse this trend requires committed, accountable leadership, inclusion of diversity of thought and critical social science issues, in addition to the more well-funded basic traditional and clinical research.

There are several areas that contribute to this marginalization, first, with respect to pregnant women. Optimizing pregnancy outcome would significantly improve world health, as babies, if born early – and often thus small – have higher risks of heart disease, diabetes, and asthma. 

Therefore, a baby born without complications, at the right time and weight, has the potential for a healthier life. Similarly, optimizing a woman’s health – both for a healthier pregnancy and outcome and for her long-erm health – also has the potential to improve world health. A woman’s health is known to impact her family, including both younger and older generations, thus strategies to address women’s health are essential.

Funding for women’s health research is limited. The National Institutes of Health (NIH) categorizes research funding to provide consistent and transparent information on the categories of disease, conditions, and research areas. 

The categorization uses sophisticated text data mining based on scientific experts to define a research category. Incredibly, 

2019 was the first year that federal funding for women’s health research was classified based on scientific relevance

, rather than based on the percentage of female subjects included in the studies.

The rationale for using the percentage of females enrolled in a study to count as “women’s health research” is unclear, and unfounded, as women certainly are enrolled in studies that are not focused on women’s health.In 2019, the NIH funded $4,749M in women’s health research, with the largest percent (26%) by the National Cancer Institute (Figure 1). 

As examples, the genetics, neurosciences, biotechnology, brain disorders, pediatrics, and aging research categories all had more NIH funding in 2019 than women’s health. 

Although COVID-19 has impacted research across the board, its negative impact on women’s research cannot be underestimated. 

To prevent transmission of the virus, all non-essential visits and encounters have been appropriately stopped, thus all ongoing clinical research has effectively ceased aside from that impacting clinical care. As I mentioned in my editorial in April, when there were only 51 studies

 - pregnant and breastfeeding women are yet again excluded from research, notably from participating in COVID-19 clinical trials during this pandemic. 

This is a major missed opportunity as results with therapies studied in men and nonpregnant women may not be generalizable. Furthermore, therapies are potentially not being offered to women, or if they are offered, are not being systematically studied in this population to provide needed data with which to guide therapy. 

The impact of COVID-19 on women’s health research highlights the long-standing inequities in including this population in research. Only in the last few decades were women required to be included in clinical research. 

Only in 1993, with the passage of the National Institutes of Health Revitalization Act, were women mandated to be included in NIH-funded research. 

Yet even with this mandate, subsets of women remain excluded.

Despite mandated inclusion of women in research, women’s health research remains marginalized, as are women researchers and physician-scientists. Although data suggest that women submitting NIH research project grant (RO1) applications for the first time have the same grant success rate as men

, they are half as likely to apply for those grants

, despite the fact that just as many women as men are receiving advanced degrees. 

A natural history experiment using the investigator-initiated Canadian Institutes of Health Research Grant Programmes demonstrated that gender gaps in funding were due to female principal investigators being evaluated less favorably than male principal investigators - and not related to the quality of their research proposals.

This marginalization of women researchers is rampant. As reported in numerous studies, women are less likely to be promoted, achieve tenure, or be selected for leadership roles (Supplemental figure). 

Similarly, women with equal stature are less likely to be selected to participate in “think tanks” than men. As an example, a recent article outlining a research strategy for women’s health with 17 authors included only 4 (24%) women.

Furthermore, of the nine physician authors, only one is an ob/gyn and four are pediatricians. The themes from the “think tank” neglect critical areas of research, focusing on traditional sciences and emphasize genetics, overlooking the role of racial disparities and health inequities.

As noted by the 2018 NIH Gender Inequality Task Force Report, “Sustainable change in representation of women, and of all individuals from underrepresented groups, requires committed, accountable leadership along with effective tools to accomplish this important goal.”

 It is troubling that gender diversity in leadership positions is lacking nationally. 

Using 2019 data, only 19% of department chairs (both interim and permanent) are held by women. Extrapolating the trend lines suggests another 50 years are needed to attain parity of department chairs and medical school deans by gender (Figure 2). 

This diversity is not due to a lack of qualified women, as since 2002, women have earned the majority of all doctorates

 and in 2019, women comprise the majority of enrolled US medical students.

Underrepresentation creates a culture that perpetuates inequalities. For our patients, for ourselves, for our families, we must correct this course. This is not easy, and will require a change of culture led by a committed, accountable, proactive leadership. 

Equally important will be the inclusion of diversity and broadening of the research agenda to include critical social science issues, health disparities, and social determinants of health.

One ray of hope to address these pressing issues is the formation of the Womxn’s Health Collaborative, a group determined to identify and initiate actionable steps. 

If you are interested in participating, I encourage you to contact Dr. Michal Elovitz at 

, editor in chief, is Professor and Vice Chair in the Department of Obstetrics and Gynecology and Chief of the Division of Maternal-Fetal Medicine at UT Southwestern Medical Center in Dallas. She holds the Gillette Professorship of Obstetrics and Gynecology.

https://report.nih.gov/categorical_spending.aspx

https://www.contemporaryobgyn.net/view/heralding-new-era-timely-topics-and-guidance

Constantine MM et al. Obstetrics & Gynecology: 

Pohlhaus JR et al. Acad Med. 2011; 86(6):759-67.

https://report.nih.gov/nihdatabook/report/132?showm=Y&chartId=176&catId=

Witteman HO et al. Lancet 2019; 393:10171:531-540

Sadovsky Y et al. AJOG 2020. PMID: 32565236

https://diversity.nih.gov/sites/coswd/files/images/2018-05/Gender%20Inequality%20Task%20Force%20final%20AD%20may%2030%202018.pdf

https://ncses.nsf.gov/pubs/nsf20301/report/u-s-doctorate-awards#sex

https://www.aamc.org/news-insights/press-releases/majority-us-medical-students-are-women-new-data-show

In this month's issue, Contemporary OB/GYN Editor-in-Chief Dr. Catherine Y. Spong talks about the ways in which women's health research has and continues to be marginalized. Addressing these inequalities, Dr. Spong says, demands a change of culture led by committed and accountable leadership.

Addressing inequalities in women's health research

Transgender and nonbinary people need access to high-quality sexual and reproductive healthcare. For transmasculine people—transgender men, and nonbinary people, whose sex assigned at birth was female—ob/gyns are ideally positioned to provide such care.

Transgender and nonbinary people face disproportionate rates of stigma and discrimination in seeking healthcare—and may encounter additional unique barriers in attaining gynecologic and reproductive care.

Even in the absence of overt discrimination, transgender and nonbinary people face challenges related to structural discrimination, or cisnormativity – the assumption that all individuals are cisgender and the ways in which the social world is constructed to address the needs of cisgender people and to encourage conformity with such norms.

For example, providers and staff often make assumptions about gender identity or expression of patients in a “women’s health” clinic; many providers lack cultural competence in caring for transgender and nonbinary patients; and transgender and nonbinary people may encounter unique challenges in accessing insurance coverage.

Given the negative and traumatic experiences that many transgender and nonbinary people have had when accessing care, many avoid necessary care.

The American College of Obstetricians and Gynecologists (ACOG) has called on ob/gyns to assist gender-diverse individuals in obtaining routine treatment and screening, as well as gender-affirming care needs.

Opening the OBGYN door for sexual and gender minority patients

” in 2019, Drs. Light and Obedin-Maliver reviewed practices to ensure a welcoming environment for transgender and nonbinary people in ob/gyn clinics. 

, we will discuss ways ob/gyns can provide high quality gynecologic and reproductive health care for transgender and nonbinary people assigned female sex at birth.

Creating a structurally affirming environment

Clinics can build patient trust and reduce patient anxiety even before a patient enters an exam room. 

Several steps clinics can take to create a safe, supportive, and welcoming environment for transgender and nonbinary people include training frontline staff in cultural competency training such as pronouns and names used (“preferred”), ensuring intake forms avoid cisgender assumptions, having gender-neutral bathrooms, and posting lesbian-, gay-, bisexual-, transgender-, queer-positive friendly signage.

Transgender and nonbinary people face discrimination and stigma, along with other barriers, in accessing health care.

Vol 65 No 08