Through the keyhole: how laparoscopic surgery has reduced the gender health gap

What is the gender health gap and why do gender health differences matter?

Men and women have different health requirements. This matters because there is evidence that women stand to be misdiagnosed, given that health datasets are often based on male outcomes. For example, research in the UK found that women are 50% more likely to be misdiagnosed following a heart attack. It wasn’t until 2011 that it was discovered that acetylsalicylic acid (aspirin), which is an effective preventative of first heart attacks in men, is not only ineffective but potentially harmful in the majority of female patients in primary prevention of cancer or heart disease. Read our article on the history of the female health gap for a more detailed discussion of the topic.

It is generally argued that, on average, women live longer than men but suffer more from chronic, nonfatal illnesses exacerbated by the gender health gap. The National Institute for Health (NIH) defines women’s health as disease or conditions that are:

• Unique to women
• More prevalent in women
• More serious among women or some subgroups of women
• For which risk factors are different for women or some subgroups of women
• For which the interventions are different for women or some subgroups of women

An example of healthcare which is specific to women is gynaecological health, i.e. female reproductive health. While it is important to note female health refers to much more than gynaecological and reproductive health, it’s the most apparently obvious way in which men and women’s medical needs differ. In one study, it was found that cis women are five times more likely to feel that their reproductive health has not been adequately addressed compared to cis men.

How has the gender health gap impacted reproductive health historically?

Reproductive health and gynaecology* have been important throughout history, largely for the reason of producing healthy heirs, with evidence of attempts to understand reproductive anatomy dating back to 1800 BC.

Illustrating this point, Hippocrates’ theory of the ‘wandering womb’ was maintained for thousands of years and was used to explain women’s hysteria – which comes from the Greek word ‘hystera’, meaning uterus – in relation to pain and other symptoms associated with reproductive issues. (Incidentally, this is also where the word ‘hysterectomy’ comes from, meaning the surgical removal of the uterus). Women are at the mercy of their biology and the fact that reproductive issues were associated with hysteria and madness is one of the reasons why women’s health has been considered a taboo topic for much of history.

Women have held different roles in midwifery, general healthcare and occasionally surgery across different cultures and societies for centuries. However, it wasn’t until the mid-1800s that women were permitted to study medicine. In many cultures across the world, the priority of women has been to conceive and nurture above education. This is important when considering the gender health gap because without women practicing medicine, male doctors and gynaecologists had to depend on patient accounts of symptoms rather than experiencing them themselves. For this reason, healthcare may not have been sufficiently empathetic to women’s reproductive health and the burdens and associated illnesses it can inflict on them.

For example, endometriosis was first officially diagnosed in 1899, but evidence suggests that women have suffered with undiagnosed chronic pain since Hippocrates in the 5th century BCE, with the cause of suffering laxly attributed to the hysteria caused by the uterus. With hysteria being used as a fast and loose gynaecological diagnosis in many instances, it is no wonder it took so long for the condition to be identified.

_{*Gynaecology is defined here as the study of menstruating women. This is the terminology used by the UN to define CIS women’s health to encompass transmen’s gynaecological needs.}

How has laparoscopic surgery advanced women’s reproductive healthcare?

Laparoscopic surgery is a minimally invasive technique used to perform surgery in the abdomen and pelvic area via small incisions or ports.

The concept of minimally invasive, endoscopic surgery using natural orifices (i.e., mouth, nose, etc.) is not new. There is evidence that medical reeds and catheters made from gold were used to conduct surgery from as early as 3,000 BC in ancient Egypt, Mesopotamia, Greece, and Rome to perform minimally invasive endoscopies. However, it wasn’t until 1901 that the first laparoscopy treatment was performed in a dog, and in 1910 when the procedure was performed diagnostically in a human by Hans Christian Jacobaeus.

Open abdomen surgery is invasive and physiologically traumatic for patients. The desire to develop laparoscopic treatments stemmed from a need to reduce infection risk, patient trauma and overall recovery time.

Between the start of the 1900s until the 1970s there were several advancements in minimally invasive investigations and operations due to technological advancements in optics and tools. Gynaecologist, Raoul Palmer, advanced laparoscopic tools through the war and post war eras and in the 1960s, along with his protégé, Kurt Semm, brought laparoscopic treatments into the modern era as a routine method to perform general and gynaecological surgeries. Although there was significant resistance to laparoscopic surgery techniques in the 1960s, Semm revolutionised the technique through his invention of ‘cold light’ laparoscopes, mitigating the risk of internal burns that could occur with the previously used electric light.

Laparoscopy revolutionised gynaecology in the 1970s because it was deemed to be a faster, safer and more discrete alternative for many gynaecological procedures, thus giving women more autonomy over their reproductive health. Laparoscopic surgeries reduced hospitalised recovery time, meaning more surgeries could be performed. This led to improved clinical understanding of reproductive health issues such as endometriosis and pelvic adhesions. Female sterilisation and IVF (In Vitro Fertilisation) are two key examples whereby laparoscopic surgery has not only advanced reproductive healthcare, but also improved the control that menstruating women have over their bodies.

Throughout the 1970s, British gynaecologist, Patrick Steptoe, adopted Palmer and Semm’s laparoscopic procedure specifically for female sterilizations in a more liberal Britain. Steptoe’s laparoscopic procedures were out-patient procedures and healing times were reduced in comparison to laparotomic sterilisation. The success of laparoscopic sterilisation in the UK paved the way for the US to begin a movement to end restrictions of female sterilizations and between 1970 and 1975 uptake of female sterilisations increased from 185,000 to 670,000 procedures per year.
Laparoscopic surgery techniques also facilitated the development of IVF, giving otherwise struggling couples a technological option for conceiving. Patrick Steptoe and Sir Robert Edwards, a pioneer in reproductive health, utilised laparoscopic techniques to extract eggs from ovaries for IVF. In a world where an unequal portion of blame associated with being childless is placed on women, IVF is liberating. In addition, laparoscopically removed eggs can be cryogenically frozen and preserved until women are ready to undergo pregnancy, enabling greater control over their reproductive health and when they choose to prioritise having children.

How can we continue to improve the gender health gap?

The World Economic Forum (WEF) benchmarks 146 countries on their progress to overall gender parity. Excitingly, the reported health and survival sub-index was found to have made the most progress in 2022, with 95.8% of the gender health gap closed. While the closing of this gap is attributed to several reasons (such as the rapid development of FemTech since 2016 and more investment in female health) laparoscopic surgery has played a big role in advancing clinical understanding of female reproductive health.

Surgical data and clinical understanding of the different health requirements of men and women is key to addressing the gender health gap. Following the advances of laparoscopic surgery, the next step is for all taboos surrounding reproductive health to be removed and for women experiencing health problems relating to reproductive health to feel confident enough to come forward. It is only through research and larger gynaecological health datasets that we can continue to build on our understanding of female reproductive health and work to reach gender health parity.