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A Conversation on the Future of Women’s Health Research with Dr. Janine Clayton, Director of the NIH Office of Research on Women’s Health

June 21, 2021

Since creating Women’s Health Research at Yale in 1998, we have been changing the landscape of medical research and practice. This change entails ensuring that women are studied, that sex-and-gender differences in health are investigated, and new findings are implemented to improve the lives of everyone. In this work, we have closely collaborated with the National Institutes of Health Office of Research on Women’s Health (ORWH), established by Congress in 1990 to ensure that NIH’s federally funded research adequately addresses persisting gaps in knowledge about the health of women.

Together, and with other partners across the country, WHRY and the ORWH have made significant progress toward advancing the health of women. Yet, challenges remain. The COVID-19 pandemic has again revealed the slim margin of resources available to women, particularly women of color, and the disproportionate social and economic burdens that affect the health of women. The need is clear to invest in the opportunities that research provides and ensure implementation of new findings to improve health outcomes and prepare us for unique challenges.

I have been fortunate in knowing ORWH Director Janine Clayton, M.D. for some years, serving on the NIH Advisory Committee for Research on Women’s Health led by ORWH, and directly seeing the accomplishments of the office. Under Dr. Clayton’s leadership and that of the inaugural director, Dr. Vivian Pinn; the ORWH is an essential driver in advancing the health of women.

In reflecting on what we know and looking ahead to next steps, I spoke with Dr. Clayton, who has led the office since 2012.

--WHRY Director Carolyn M. Mazure, Ph.D.

Dr. Mazure: In your view, what are the most urgent health care issues for women that research needs to address?

Dr. Clayton: I would point to the greatest causes of death among women — heart disease and cancer — as well as a leading cause of disability — mental health issues. Research has shown that these conditions can present differently in women and men and are often linked to one another or other diseases. The pathways that link such conditions are not fully understood. Consequently, we need scientists and clinicians to study these comorbidities using interdisciplinary approaches and a whole-person perspective. Plus, we need a health care system that is equipped to recognize the complex effects of sex and gender on a person’s health, so women are accurately diagnosed and receive the correct treatment earlier in disease progression.

Dr. Mazure: The terms “sex” and “gender” are now being increasingly integrated into our scientific work. Why is this important, and are there other related terms we could be using?

Dr. Clayton: Research has proven that biological sex matters at every level, from a single cell to the societal level. We also know the self-representation of gender can affect symptom expression, disease manifestation, and treatment efficacy. So, if both sex and gender aren’t accounted for, clinicians cannot make the best treatment decisions for all patients. As the concepts of sex and gender continue to be understood, our terminology needs to be more inclusive so the expanse of sex and gender can be studied and accurately reported. There also are a lot of domains in which to consider sex and gender. For example, we need to study the intersection of sex, gender, race, and ethnicity. Intersex and nonbinary identities need to be recognized because these too have health implications. It is important, as well, for us to work more with our social science colleagues to appropriately integrate their knowledge base as much as possible into our biomedical research questions.

Dr. Mazure: I know that your office is concerned about the mental health and emotional life of women, especially given the effects of the COVID-19 pandemic on women. What are data revealing about research directions for the ORWH regarding women and mental health?

Dr. Clayton: The bottom line is that pandemics and disasters affect men and women differently. For example, what we are seeing with the COVID-19 pandemic is unique in that women were more likely to lose their jobs because of the closure of so many service jobs populated by women and, because of their gendered caregiving roles and the fact that schools have been closed, women have taken on disproportionate responsibilities for caregiving and homeschooling. With a higher percentage of women out of paid labor positions, and the economic consequences of this situation, it is unclear how this will affect women and their mental health. Research can and should address these matters. This also is a moment in time when we can create a new way for the workforce to serve women, including women in science. The workforce of tomorrow could be better than the workforce of today if we finally take steps to make systemwide change that more fully accommodates the lives of women and men.

Dr. Mazure: Over the years that you have been focusing on the health of women, have you seen change in the research landscape as it relates to studying women and sex-and-gender differences?

Dr. Mazure: From your perspective, what are the challenges in focusing on the health needs of women of color?

Dr. Clayton: Women of color are not a monolith but rather a multidimensional group of people who have different health concerns and, indeed, different outcomes. Challenges in serving these women include structural barriers, including bias, lack of recognition of the unique needs of this diverse group, and their low rates of inclusion in biomedical research. Consequently, worse health is the outcome. For example, incidence and mortality of the most aggressive subtypes of breast cancer are significantly higher among Black women compared with all other racial/ethnic groups. Similarly, in a recent commentary, my colleagues and I discussed maternal morbidity and mortality and COVID-19 in terms of their disproportionate effects on women of color.

These examples highlight the need for more research that seeks to tackle intransigent health disparities experienced by some populations in the United States. To address this, the ORWH leads the U3 program to focus on addressing research gaps among groups of women that are understudied, underrepresented, and underreported in biomedical research. If we don’t study the problems, we can’t find solutions. Also, NIH recently established the UNITE initiative to become part of the solution by addressing structural racism and promoting equitable representation and inclusion at NIH and throughout the larger biomedical research enterprise.

Dr. Mazure: How does a center like Women’s Health Research at Yale advance the goals of the ORWH?

Dr. Clayton: Centers, in general, are a great way to focus attention on important questions. Women’s Health Research at Yale specifically addresses the concerns of women in ways that can accelerate research and foster training and mentorship on the health of women. By intentionally funding and supporting sex-and-gender-related differences research and studies that focus on important issues that affect women — ranging from heart disease to mental health — Women’s Health Research at Yale is filling the gaps in our knowledge so women can receive the best health care possible. It is a pleasure to see this center expanding, both in terms of its research and education, but also in building and maintaining close relationships with the community and its newest focus on health policy.

Submitted by Rick Harrison on June 10, 2021