 We are ready to start. Again welcome you to the session and we start with an interesting talk by Sophie Hildner or she told me it's actually Sarah Hildner and she will talk about the discovery of the sex in medicine. Please welcome Sarah. Wow thank you very very much for introducing me and to the curators of the session. Thank you for selecting my talk because I feel very passionate about it and I hope I can transfer some of this passion to all of you. I am blown away by how many people are here and interested in this. Since it's a tech conference I thought I'd do something techy and I know it is a venture capitalized tool but if you want to participate in parts of this presentation you can go to menti.com and insert the code 303063 and help me with doing a little bit of science on stage. I don't know if it will work. I have only done this in English once. In German it usually comes out surprisingly well but if you want to join please do. Oh I see some people are joining us. They're sending us hearts and kitty cats. That is awesome. You can continue joining. I'm going to start with the story and it is about an accident. Father and son are driving in their car and they're having an okay wait this doesn't work so I'm going to show you this so you can actually see what I'm talking about. Father and son are driving in their car and they are having an accident both are being picked up by ambulances. The son got injured at his penis and is being delivered to a specialist unit in a different hospital than his father. Once the son has been brought into the operating room the attending neurological surgeon comes in and says I cannot operate. This is my son. My question now for all of you is how are the son and the surgeon related. Type in the first thing that comes into your mind. I'm going to repeat the story really quickly. Father and son have an accident both get injured being delivered to different hospitals and the urologist that has to take care of the injury of the son says I cannot operate because it's my son. I would love to show you the results but it doesn't show on the big screen which is a pity but there's still people joining and answering questions and I'm going to give you a minute. I don't know how to I can only describe then what I can see on the on the slides and can put it up later on in the presentation. So the biggest word that pops up in a word bubble that is on this tiny screen now is the word mother and thank you for thinking this way because yes that's the possibility. When I do this experiment in German usually people think of wait a minute it's the stepfather or a father of a homosexual relationship or it's the adoptive father. So it's some kind of male person that is related to the son but they do not think about mother because German is a highly gendered language. When we say surgeon we say chirurg and we are used to apply it for male as for female surgeons but there is a distinctive word that is chirurgin which would be the female version which brings me to the point that what I've already mentioned we live in a gendered world. To give you a broad overview what you can expect in the next couple of minutes is I gonna determine what we're actually talking about what is sex what is gender because both are very very important when it comes to medicine. The next thing will be how I am trying to hack the medical system by doing the research I'm doing because that men and women and other bodies exist is a very very new idea in medicine. The major terms are gonna be discussing I will discuss is sex so the genitals and the genes and the hormones it's the gender identity which is also reproduced in society in different facets it is how we express our gender whom we are attracted to and in the end I'm gonna give you an example of the heart attack that is the best researched version of sex and gender sensitive medicine. So let's talk about sex. When I say sex I do mean the physical body I am referring to genitals I am referring to hormones I am referring to genes the hip shoulder ratio but there are not only two sexes there is the option that we now call intersex which has been there for a very long time it just has been neglected by medical research for most of the time and that means when a baby comes out the first thing people are looking for is between the legs and can we identify of what's there. If we can't identify it up until this year they had seven days to decide if this baby is supposed to be male or female and what one surgeon told me was well you know what Sarah it's easier to drill a hole than to build a pole I think you should not cut into any healthy tissue no matter how old or younger child is but particularly if it's a baby and all the exits are functioning just don't touch it leave it the baby won't mind and you will probably save it a lot of trouble once puberty hits the hormones kick in and the body will actually develop into either or or indecisive it's an option so when you're assigned a sex at birth you carry it along we are used to this tradition and it actually comes from the old Greek that they thought the male body is the ideal and the upper best expression of how a human being can be and women just lack a lot of fire to turn their penis out that's seriously what they believed and it's called the one-sex body and it has been predominantly reproduced in medicine over the time until enlightenment struck and suddenly whoa we have two bodies now everything that has been looked at under the microscope so they looked at testicles they looked at ovaries and thought whoop those are different tissues maybe it's not a penis inside out but maybe it is something entirely different and right they were but they only thought about it in a bikini model way which is a term that Marianne Legato originated a couple of years ago because it refers to the fact that everything that's covered by a bikini has been outsourced to gynecology but the rest of the body of course is not it's okay so when sex and gender sensitive medicine approach came from a long history of women's health movement so yes the ideology of feminism and bra burning and angry feminists is all in there it used to be at least because now we discovered wait a minute men are actually discriminated as well and a lot of diseases we underestimate the risk for men depression for example osteoporosis and many more that we don't even know about again sex physical body genitalia hormones pheromones all this influences your medical charter so to speak so it has differences in symptoms you as a man or as a woman also when you identify as a non-binary person your body is still genetically make up and it has hormones and so it also will react differently to medication and pharmaceuticals but also when a disease will come the prevalence of the disease for example a heart attack in women is 10 10 years later because they have astrogens that make the insides of their blood veins and vessels really smooth so a clot cannot develop there so there won't be a heart attack at least not for another 10 years because man like this hormone but there's also a bunch of similarities our job now is it as a sex and gender sensitive researchers to distinguish when does sex matter when does gender matter but in sex we have a lot of differences and similarities I've talked a lot about genes and hormones and we actually now have a way to distinguish if the genes have an impact on health or if it's the hormones so this four core genotype mouse model is a mouthful and I tried to explain it as simple as possible but it is complicated so you start out with a male and a female mouse the male mouse has an X Y minus SRI the Y minus is a natural mutation that stops this mouse from developing testes so it will not have male genitalia the SRI on the other hand is then inserted in the mouse to make it develop genitalia male genitalia and go nuts the sexual reproductive organs to then recreate appropriate with the female mouse in the offspring next generation now you have four different outcomes the female versions have the X and okay we have two female versions one is an XY minus and one is an XX the XX is it just regular female it has a genetic makeup of a female mouse and it has the hormones the XY minus mouse because it's lacking the minus it will turn out to become a female mouse on the outside but genetically it is still a male mouse in this way we can determine and distinguish if the hormones or the genes the genes have a different makeup the other way around in the male mice there we have an XX mouse which is a genetic setup of a female mouse included the SRI gene and that makes it now turn male so that's one part that you can do in research and a lot of parts in research are still done on mice and and rats so we use rodents what we underestimated in the last years is that the pheromones from the axilla steroids though all the stuff that makes your axilla smelly is having an impact on how we interact with each other and also how animals interact with us for example the 70s Barbara McClintock found out that the menstrual cycle synchronization within women that they have their period at the same time is actually leads to those or leads back to those steroids but it also influences how you perceive pain and how you are willing to express pain interesting thing is when someone now comes in with a certain steroid axillary steroid you will also react differently to your pain and express it differently in 2014 there was an experiment that looked for sex differences in the researcher and the effects on the mice and it turned out that the exposure of mice and rats to male but not female experimenters produces pain inhibition this means male research goes into a lab tries to induce pain and rats and they will show it at a certain amount of time when a female researcher reproduces these experiments the rats and the mice they admit earlier that they're in pain when we can now add one more layer and this would be when a male researcher takes off his lab coat gives it to the female researcher and she now doing the same experiment she will get the same results as the men before so the male body does not have to be present in the lab to influence these results it's sufficient if the pheromones are in the air this effect only lasts about 30 minutes but I don't know many researchers that have the time to just sit in their lab rat to calm down the rodents to then experiment on them but it is not standard to actually say in published papers with broadened experiments which sex the researcher had but it's proven that it does have an impact and we should be more aware of that when I talk about diseases and differences I want to give you one example of osteoporosis which is the loss of density in the bones which means the bones get brittle and they start breaking more easily osteoporosis was long believed to be a solely female disease but not quite we just found out that actually it's underestimated in men and once they turn 70 they increase the risk of having osteoporosis as well what the unfortunate thing is if they have a fracture in comparison to women they are more likely to die because of this fracture so they're endangered in this case and when I look for images and pictures of osteoporosis the only thing I could find were once where women is represented but I will come back later to that let's talk about gender identity gender identity is how you feel in your head how you identify and how you experience your gender also based on how much you align with what your body is so when I as a gender person I'm here I can tell you I identify as a woman and when we before talked about sex sometimes it is interesting to wonder what someone else has in their pants yes but it's just to say briefly it's very impolite to ask sorry to say like just don't if you wonder maybe they'll tell you if they're ready but if you don't intend to have sex with them on a consensual basis don't ask made that mistake so with a gender identity you also don't know people will or will not tell you if they identify with the more women this or with a more maleness but they can also identify as non-binary which means they do not identify with either or and sometimes they're even uncomfortable with what body they have if someone tells you just respect that it's awesome that they trust you so much that they do tell you so also there but the gender identity is highly influenced by society as well because there are also expectations from society to how we are supposed to behave to how women have to be kind of soft-spoken and timid and pretty and I know I'm here in a group of very privileged people and I think it's awesome that we're building this utopia here and we're living a different kind of society that I so hope will be mainstreamed but it's not in the main stream yet and this is stories to learn to read for boys and girls I let yourself choose which one switchy and you're not English speaker but I think it's quite clear the only thing I do want to point out just to mention that all the head chefs and bakers and all the famous ones are usually men so I think they made a mistake right there when we talk about expression well look at me I have to carry the microphone sender at the back of my dress because well fashion designed for women lacks pockets yes so please continue hacking that so the gender expression has a lot to do with grooming how do I style how do I carry myself how do I speak how affectionate and how do I choose my mannerisms and also there you can be you and the unicorn you are to all the way women and to all the way male everything should be okay and we should not punish anyone for not complying to that now how does gender influence our medical records well for example the assumption of the susceptibility of diseases when you're a young man and you suddenly have erectile dysfunctions you probably would not have estimated that that is something that hit you when we then add a little bit of depression to the equation it is also something that men and depression it's starting to become a subject it's starting to become a subject but so far men talk differently about their symptoms they experience their body differently and they also just as women don't think they can have a heart attack you have attached to your gender search and certain expectations of what you want know what you think you can have or develop as a disease another thing is the interaction with the doctor so I mentioned before how men and women act with other people how we describe stuff is very different can be very different on top of that comes when you're a woman and you want birth control you have to go to a gynecologist at one point of your life and once you're in the system you have to come back every year when you're a man well when you're a child male child you go to the doctor because your mom makes you and then oh wait there was a flu really sick but managed to get over it and then maybe with 35 40 you have to do the prostitute thing well till then you didn't have the time women had to practice the interaction with doctors so that's also another point when we now switch the way around your doctor also looks at you and expects a certain kind of gender and a certain kind of behavior and when you have now a urologist and the mr. floppy situation going on which might be related to actually being pressured at work having the pressure of being the single breadwinner in a family or simply because you're said and life sucks sometimes and you just don't know how to talk about it well I don't think a urologist is the first person that will point that out some do some are excellent I don't want to do dr. bashing here but it's all related to how we move about and what society is actually expecting of us and that brings me to norms and stereotypes when we say all men are like this and all women are like this that's more of a stereotype but a norm is something that is being punished by society when you divert from it so when you suddenly you're a man and you burst out in tears in the middle of public people will react in a certain way and I tell you most times it's unpleasant even as a woman bursting out in tears ugly crying all the way public can lead to some distraction but when you're a man that's a tough one and that is something we underestimate as an effect as well because everybody is judging that's how we box our worlds and we try not to I try not to but it's hard and I talked to about depression before and it is more common as a form of anxiety in women and more men are using substances to deal with the depression unfortunately men are really successful killing themselves when they're depressed so I was very very happy that Lindstrom yesterday made us all stand up to show if you have experience with depression and you're willing to talk to someone it doesn't feel like all glory sunshine out of your ass rainbows awesome thank you because it is a sincere it is a serious problem and we need to talk about how do we evaluate depression actually all the scales and measures we have are kind of related to being said and being open of admitting of being said having sleeping troubles but if you don't know you're not if you don't know your body that well and don't know how to talk about how don't know how to address it in front of a doctor then maybe they just missed the cues they maybe just not used to see a male version of depression because it can be the responsibilities it can be that you have to work your child is at home and you hate leaving every morning you would love to be a stay-at-home dad but you risk losing your job when you tell your boss hey I want to stay at home and that's something that's also related to the gender norms and once you're taking the little blue pills going back to erectile dysfunctions you've taken care of the symptom but not of the cause which is also something we need to talk about in medicine that a lot of those pills take care of the symptoms but not of the actual cause of diseases thank you I think I made it quite clear that sex and gender are a bit different and now we're going to go to an example of the heart attack I want to briefly address that the attraction to someone can also impact your health because for example when you're a lesbian woman and you never had to go to a gynecologist to get oral contraception well you kind of not in the system and the incidences of cervical cancer are higher in that group because they're not being screened because they have no reason to go to a gynecologist on the other hand when you're a homosexual man you're banned for life you used to be banned for life donating blood now you can donate blood but you have to practice abstinence for one year okay I need a sip of water I'm going to start with the second part of the presentation soon but before that since I'm also a physical therapist we're going to do a little breathing exercise so please stand up no no no don't stand up so sit down but come lean a bit forward move on your chair a bit to the front yes sit up straight and take a deep breath in hold it in for a second and out one more time deep breath in hold it and all the men breathe out yes for the women hold on before the women and the non-binary people can continue breathing because you're not mentioned in any of the medical textbooks anyway so far so just sorry I tried but the women are still holding yes okay okay 15 seconds fair enough continue breathing the thing is if you as a woman would have had a heart attack it would take about 15 minutes longer to reach the operating room than a man but be at ease it used to be 90 minutes it's progress in the heart attack which is one of the best researched examples we have by now and probably a lot of you have already heard of it but I'm not tired of reusing it because the data is 30 years old and I looked in medical textbooks from the newest generation and I have not found a lot of that data there but when we talk about heart attack differences in the sexes we need to talk about symptoms what I learned as a physical therapist was that when someone in front of me has chest pain pain in the left side of the body and cold sweat heart attack emergency call 112 in Germany and deliver them to the hospital as soon as possible when I started working in the Institute of gender sensitive medicine I was introduced to new facts well most women show weakness shortness of breath back pain and nausea so we put them on the couch we send them to an orthopedic and I don't know make them rest of it that's one of the reasons why women get delivered late to the hospital another one is the awareness in themselves so when you ask women what are you most afraid of dying they cancer when you ask men a lot of them will say heart attack when we look of the data at the data from 2015 in Germany then actually cancer on the what is it for you the left side is less deadly all major cancers are less deadly than cardiovascular diseases and when you look at the cardiovascular diseases it actually shows that women the light blue are more in risk than dying in dying from a cardiovascular disease than men when we now look at breast cancer and the heart attack it shows that yes less men die of breast cancer that is true but there are men that die of breast cancer but it's also that less women die of a heart attack less women die of cancer in comparison to heart attacks and when we now compare like how many people have died of a heart attack then it is 43% for female I know it's not 50 but it's just the awareness of how I think I how I think I am susceptible to a certain disease we need to campaign for cardiovascular diseases and women we need to campaign for raising awareness that the heart attack is a serious threat for women as well because in breast cancer it has worked women are now sensitized that so we can move on to the next one the acknowledgement by other people the breathing exercise when I looked at the medical textbooks I gonna refer to later I gonna refer about later you will see that there is a bias in medicine and this bias leads to delay delivering to the hospital it leads to more severe side effects in administering pharmaceuticals and one of the examples for is aspirin or ASS when someone has a heart attack one of the standard medications is to give them ASS or aspirin and that will protect the men for another heart attack for infarction but in women it will all only protect them to have a smoke stroke and we don't know quite why this is but this is what the data showed so medications can have different effects in different sexes if we know all this and I said the heart attack is something we've researched for 30 plus years now why do we actually need to talk about it why am I here because there's a bias in medical textbooks that I've looked into and one is androcentrism which means the medicine is centered around a male body so I looked at a lot of textbooks I read a lot of chapters and I brought you some pictures I don't know if you can see a pattern this is a selection they're not all when I showed all I was critiqued in practicing this talk it's just too long people will get the point trust me so all those pictures and medical textbooks only in the chapters about a heart attack that 43% I know representation of women in pictures we're not talking about like photographs it's painted pictures not one woman gender insensitivity is something when you research in on one sex and then transfer it on the other without checking if it's actually applicable so in this book it said in German special patient groups underneath it's the subgroups are older patients women patients with renal insufficiency diabetes and anemia congratulations women we all belong into the category of chronic diseases oh but although we're so special in the bottom line it says well generally you should still take the same approach as with men wait so we're really special and we are atypical but we are being treated the same great brings me to the last buyers it's the double standard same situation for the same for different sexes but they're treated differently in this case I translated a quote from a book which says in case of a heart attack immobilize the patient and remove restricting clothes tight shirt color neck tie well I think you know what I mean it's and then in in German you have usually in books this this one quote like because it's easier to read we only gonna use the male version of this word of like patient and women are implicitly meant as well well but we ignore them explicitly one book was really honest they say well RSS is good for preventing it's just for women we have insufficient data for a general recommendation so congratulations dear medical students trying to figure out with them I've talked a lot about now about in the differences between the sexes but there are also a lot of similarities and this is the big differentiation we need to make because the intersex differences and the intra sex differences need to be regarded I made an image here just one side is supposed to be the male population the other one the female population the two dashes at the top they are representing one how big the differences between the sexes in the in a general comparison are when you look at the broader picture of the actual intra sex differences so in the group of women what are the differences there and in the group of men what are the differences there they are a lot bigger the problem is we don't even look for the sexes separately so the first step is to look and separate research into men and women and again I'm very very sorry not to include binary non-binary persons to be in the binary because medicine is discovering this binary as we speak so it will be a very slow process to go to gender as a spectrum to sex as a spectrum but we need to start somewhere and we need to start looking for those two groups to then actually dissect these groups in comparison to each other why is it not mainstream yet I have interviewed a lot of gender medicine experts and I brought a quote from a Nobel Prize winner and Mr. Tim Hunt said 2015 three years ago let me tell you about my trouble with girls three things happen when they are in the lab you fall in love with them they fall in love with you and when you criticize them they cry three years ago but there's no no bias in medicine in science and some experiences of the resistance of the pioneers of gender medicine one said well they just did not see the problem they thought I was the problem shooting the messenger works everywhere I guess another one was well if you're a cardiologist for 25 years you have to learn now that you may have done things wrong with many female patients it's not nice to accept and I agree when you're a medical doctor and you have been practicing for a long time with knowledge you thought is accurate it's part of your identity and it's hard to digest it's a bitter pill to swallow to suddenly realize maybe you have overdosed maybe you have even killed someone so I know that this kind of resistance is is there and we need to address it nevertheless we need to change the system we don't come around it one last thing is there's also resistance because sometimes gender will be associated with an ideology of feminism and I say well of course I'm a feminist I really am a feminist but what I am doing now is based on the theory and not ideology of feminism but I will implement it into just practical proposals for education and daily practice so we as gender sensitive researchers are met with a lot of hostility within our own research environment and gender is being very like like maybe over there maybe the social sciences can take care of well we try I'm a sociologist working in a medical faculty trying to improve it but it's difficult because they're two different cultures we're coming now to a new problem that I've just encountered doing my current research algorithms when we are now entering the new decade of computer assisted diagnostics when we knew we want to help doctors making the right decisions we need to feed them data all the book examples I showed you were books published in 28 to 2012 so they were the most recent editions of those books and they were available in one third of all medical libraries in Germany at least in one third one of the books was actually in every library and if now this kind of knowledge is being fed to algorithms that then have to computer assist we don't get rid of the bias and I know there's a lot of research about it out there but I would also like to invite you on the one hand to a conference that is happening at the Radbad University in Nijmegen on bias in artificial intelligence and neuroscience the call for papers is still open if you have something if you know something please contribute it will be very interesting and I would also like to give you the opportunity to go back to Menti and help with any ideas you have I will read through those if I can manage to switch this slide yes there we go okay I would love to show you I can't I don't know why it's not working but the first one was get rid of AI I like that well I hope I could enlighten you a little bit I thank you very much for listening and participating in my presentation and please reach out on Twitter or contact me via email if you have any questions or ideas that we cannot address in the Q&A that's now following but yeah Q&A starts now I guess thank you thank you thank you Sarah for a wonderful talk and the paper the talk is open for discussion and open for questions are there any questions I see no urgent ones so I will start with one or is somebody running to microphone two okay it's your question yeah I have microphone two hello I have just a very brief question those quotes from women who are identified with names of colors I was wondering did you gather those as part of your research were they anonymized can you tell me the story behind that study yeah it was my master thesis and I interviewed 20 experts of sex and gender sensitive medicine in Europe and I asked them about how and if they have managed to implement it at their respective universities and that's why I interviewed them all myself and transcribed it and then analyzed it why we have so much resistance and why it's not moving on because it is such a broad subject that it's actually going across all the specialties in medicine but now it's established as like a site specialty which is conflicting as well but it's it's work in progress I mean the discipline of sex and gender sensitive medicine is like 20 years old so we're talking about cutting-edge new medicine I know 20 years is a long time for you and your experience is a work field but in medicine everything turns a lot slower thank you for the question oh we continue with the microphone too yeah hi so as a woman this was the first time that I heard that there's a difference between you know heart attacks for men and women in terms of symptoms and I'm not asking you to list all the different symptoms in other things but are there any other major things that we should be aware of the where there are known differences well metabolization of medication is a big big influence and usually women need less medicine but more often so the amount but it's something you need to discuss with your doctor and I was quite surprised that most of the medications that are handed out are not weight adapted at least because usually women are also a little bit lighter in weight but I'm so sorry to say I'm also not a medical doctor I'm a sociologist so I'm trying to cover it but ask your doctor about it make them do the research because they are the experts and they should come back to you with an answer we continue with the microphone too um you also talked about um intersex people yes did you come across any research um where it's yeah where where diseases and intersex people are dealt with or like how the male and female thingy is coming you know it's kind of connected to that I personally have not and I think the research in that area is very very marginal it's because there are still a lot of doctors that are experts in that area and that do misgendering that address the people with the wrong pronouns and it's I think they I'm very sorry to say but trans and intersex people have the longest way to go and ahead of them but it's it's just I yeah we need to do it ourselves otherwise nobody will actually take care of it I guess sorry to say okay I see a question at microphone four or are you guys just standing there no question no I have a question okay thank you um yeah thank you for the talk um I'm a doctor so I'm very interested in your opinion um towards the development considering why we are all here so considering the digital transformation of health and do you have the progression from a sociologist perspective that it's getting better or the just young white man now replace the old white man and all the apps out there are very very gender insensitive and stuff the second part yes all the apps out there are still very very gender insensitive because the knowledge that needs to be inserted is still being researched I fear the old white men are not replaced by old all by young white men but also by young white women that act like white old men we're talking about medicine it's as a sociologist it's one of the most hierarchical and most traditional cultures within our system so there it is moving really slowly and those power relations are replaced very very slowly so I don't think I'm going to benefit from my research to be honest so sorry but that's also a burden I have to live with but I still do my job for you and your children so okay microphone one please hello thank you for your talks and hopes in seeing that um most well not most but about 60 percent of medical students nowadays are female it does bring forth change but slowly but I do have to say I have a lot of hope for the younger generation in general like with each younger generation we do have people that are energized that are more open that have lived with the series is like I don't know sense it with representations of people of color with trans people with intersex people that have been more in touch with it so it feels more natural to them so there's less resistance which is a good thing and that will bring change as well because you can't underestimate the influence of pop culture so I wouldn't say it's the hope that more women are coming in the research but it's that the general we as a society get more open and more aware microphone to please hi thank you very much was very interesting my question is if we could see AI as a chance rather than a threat because I'm also working in field related to medical IT and I think most efforts go into analyzing a lot of data from patients with the attributes where sex is one attribute and not in learning textbook knowledge which just repeats the bias I totally agree I think actually AI and new way of of analyzing data and in compiling data is very very interesting and important to to feed that but we still have to consider and be aware that there might be a gender bias in the assumption and that's my research is on finding out how we can operationalize gender and make that one of the variables in the equation to see if that has an influence as well okay number four please hi thanks for your talk we you had some very good examples in there there's just one example where I'm not sure it's the menstrual synchrony thing I'm pretty sure this is not state of the art anymore to say there's menstrual synchrony in women sorry I didn't understand that the menstrual synchrony thing yeah okay I'm pretty sure that science doesn't say that anymore okay well um then I gotta do my research on that thank you for the for the for the input okay number two hi um I was wondering if in some questions it could be useful to skip the gender question and just go to genes right away because medicine is getting very complex with genes which are factors going into the equation so maybe this could be easier for many questions sociologists think about that I can't say I have but maybe if you have time that sounds very interesting to to talk more elaborate more on that just like neuroscience you have you know you have the genes in the brain and depending on which gene you have you are more susceptible to like nicotine addiction smoking which is a factor which leads to heart attack and stuff as well so this is as well as the sex you have this influence but you have the genes as well so this is very interesting too and maybe at some point six is just one factor which goes into that but it's not the only one no no of course it's not the only one but we have to start looking for it because so far it hasn't it's not systematically integrated in research like when sometimes they um um sometimes they they do have a group of male and female mice red humans um and then they kind of divide those groups but sometimes they even miss that step so it's not systematically integrated yet as a variable in the the research and I think I don't I want to advocate to do that like it is yes that like we need to start with that actually acknowledging that we have to look for sex differences and if they are not awesome then we can move to look for other differences but we need to know yeah microphone for please thank you thank you for the talk I really like the part where you showed that the research itself is gender influenced with the mice and the lab code um thinking to the issue about data for intersex people is there is there some research in how often we actually do have data for intersex people in the samples we do for the research or are they is there enough data for intersex people to represent it or do we need other ways of researching this issue I think most trials will ask for male or female and if you're intersex you can participate it would be an exclusion criteria because the sample group would be too small so you'd have to kick them out anyway for statistical reasons sorry um I guess there is one more question at number two so as far I understand there is a huge gap in time when it comes to pain so women most likely will wait longer for treatment when it comes to pain so my question is do you have any ideas how we could address that well that's a complex issue and the research I've read about is that women are trained to do their care and put their care work first so I just have to finish the dishes or wait I need to pick up the kids or I know there's also kind of stereotypes I'm now referring to in their old fashion but they're still present and they're still harming people because when you're trained to do this all your life you are less likely to actually take care of yourself and take yourself seriously number four please I had a question about heart attack rates in women so with this 43% do women actually have less often heart attacks or can it still be the case that the cause of death is not recognized as a heart attack that's an excellent question well it's hard to to to know um but we need to to look more for that and it's also that men can have this female version of a heart attack which can then be misdiagnosed and not not be the life cannot be saved because people just don't react on on those triggers on those symptoms but we need to we need to look into it of why people have died of course but in autopsy you wouldn't do when someone is old and it looks like something so I guess there are a couple missed yes number two please hi thank you I was wondering if you've come across any examples of perhaps people doing quantified self stuff contributing to these issues or perhaps providing data or research that traditional medicine hasn't been doing I'm sorry to say I have not no but also good to look into yeah please reach out let me know if you do okay I think there are no more questions so thank thanks to you for the for the discussion and the questions but most of all of course thanks Sarah for the wonderful talk