Our study sought to gain a deeper understanding of the cardiac-related angina symptoms that patients experience from a gender-centred perspective. When patients freely expressed their symptoms with minimal interview structure, two main themes emerged; 1) physical symptoms and 2) descriptors and hypotheses/analogies. Physical symptoms were subcategorised into four subthemes, including location of chest and non-chest areas of pain/discomfort, other associated symptoms and functional symptoms. We arrayed these symptoms on a ‘gender continuum’ that clarifies how women and men express symptoms in similar ways as well as differently (figure 1). We found considerable overlap in the shared symptomology between men and women. For this reason, we purport that the inflexible categorisation of symptoms according to sex does not accurately reflect the diversity among individuals, and especially within the sexes. Our new ‘gender continuum’ construct of angina symptomology demonstrates that a patient's sex can differ from their gendered expression of symptoms. More pointedly, the term ‘atypical’ angina to represent symptoms in women is challenged by this empirically grounded continuum: both men and women experience a great number of conventionally ‘atypical’ as well as ‘typical’ angina symptoms.
Not so ‘typical’
Over the past half century, the term ‘typical angina’ has come to represent the cardiac-related symptoms most commonly reported by men, while ‘atypical angina’ has come to represent the symptoms most common in women. While the historical gold-standard comparison group of ‘typical’ angina has been represented by white middle-aged males,16–27 it is not surprising that angina symptoms experienced among other groups are referred to as ‘atypical’. Further, there are inherent conceptual limitations embedded within the ‘atypical’ label itself; ‘atypical’ has connotations implying ‘abnormal, uncharacteristic, unusual and uncommon’. Presumably, one who symptomatically presents with ‘typical’ angina symptoms should receive ‘typical’ treatment; might the label ‘atypical’ be more permissive of ‘atypical’ treatment? May this, in part, explain why women are referred less than men for invasive procedures despite having severe symptoms?13 ,14 ,41–45 As the label ‘atypical’ has become a catchall phrase for anyone who does not present as a ‘typical’, white, middle-aged male, the term may perpetuate poor classification of diverse angina patients and support sloppy science. We question the continued use of this institutionalised yet imprecise, and potentially misleading term.
What does ‘gender’ have to do with it?
While ‘gender’ has been on the forefront of many cardiac symptom studies, none to our knowledge have undertaken a gender, as opposed to sex, analysis. Most studies use the term ‘sex’ and ‘gender’ interchangeably, while technically referring to sex only. We raise this issue as one that goes beyond semantics: the binary construct of ‘sex’ cannot account for the complexity of gender phenomena. Analytically, this translates to two inherent limitations when analysing cardiac symptomology according to ‘sex’: (1) it underappreciates symptoms common to both sexes and (2) it cannot capture variation of symptoms within sex. Future studies should account for the role of gender, beyond sex, by capturing the full range of experiences in women and men.
We propose the gender continuum as a new construct to evaluate angina symptoms. When we array angina along the gender continuum, two main findings emerge: (1) men and women share more symptoms in common than conventionally believed and (2) there is great variation both between and within genders in the descriptive terms patients use to describe pain/discomfort, and the reporting of other associated symptoms.
Gender is a complex and non-static social construct that interacts with other dimensions including social status, ethnicity, age, class and power.46 ,47 An individual's gendered identity is often expressed through language and narrative,32 ,46–50 such as a clinical history. It has been well described in the sociolinguistics literature that women tend to use a wider range of linguistic variation marked with a greater emotional vocabulary, conversationally using more of a ‘rapport style’ as opposed to ‘report-style’ common with men.32 ,46–48 ,50 ,51 Most men in our study described their symptoms in briefer language than women used. Women provided detailed descriptions of their pain and associated symptoms, trying to capture the exact quality of their experience, fine tuning their choice of words as the interview progressed. These differences of language may reflect men and women's' differing social roles, and language subculture of expressing pain. Nevertheless, an expressive style is not exclusive to women, and this is the strength of the gender continuum: individuals may linguistically express themselves in a gender that differs from their sex. In a sociolinguistic study of patient narratives, significant variation was found within gender groups, especially among men, denoting that higher-status men were more likely to adopt a ‘modern masculinity’ marked by an emotional vocabulary comparable with women's.52 ,53 We found this with some men in our study, particularly young men (≤50 years) and two older widowers, whose wives had succumbed to heart disease. We, like others,15 also heard more associated symptoms reported by women, perhaps, in part, due to their ‘rapport-style’.
An important component of language and gender is that linguistic usage varies according to contextual factors,31 ,32 ,46–48 ,51 ,54 such as the gender or the gendered style of the clinician. While outside the focus of the current study, our field notes included some observations related to clinician gender. Often a clinician would approach the patient with the question, ‘Can you tell me about your chest pain?’ to which patients commonly responded, ‘Well, I wouldn't call it a pain, it was more pressing’ or ‘It is more of a discomfort than a pain’. The clinician would then in his/her notes write, ‘0 CP’, which stands for ‘No chest pain’. What happened in this interaction, and is the patient experiencing pain or not? The clinician began their consult posing a question about ‘pain’. From a clinical perspective, ‘pain’ is a component of ‘typical angina’—anything not described as ‘pain’ deviates from ‘typical’. In this interaction, the clinician did not qualify the other terms used by the patient as describing ‘chest pain’. At the same time, each patient has a sensation and reference point of what they qualify as ‘pain’, and since all the patients in our study were being investigated for CAD, patients may also have preconceptions—as well as gendered ideas—of what heart pain should feel like. Like the patient, the clinician is also situated in their gender, within their roles, beliefs, norms, expectations, clinical training and experience not only about their own gender, but also of others'. Experimental studies have tested clinicians' gender bias using identical vignettes of patients that vary only by sex, and physicians consistently refer female patients less for cardiac catheterisation than their male counterparts.55 ,56 And while gender bias in patient referral for cardiac catheterisation has been reported irrespective of physician sex,57 almost 90% of cardiologists in the USA and Canada are men,58 and physician gender, to our knowledge, has never been evaluated. To fully consider gender, it is essential to understand that it is dynamic, and is happening simultaneously from the patient and clinician perspectives.
Study limitations
In order to achieve a fresh in-depth exploration of CAD symptoms less influenced by prevailing gender-biased clinical perspectives, we used an experienced interviewer who is not a clinician. Even so, it is possible that the clinical setting of the interview cued interviewers or patients to use what they considered more clinical-sounding terms or ideas. Also, a female interviewer conducted all interviews, and since patients are situated according to their gender, they may respond differently to an interviewer of their own sex versus the opposite sex. It is possible that same-gendered interviewers may elicit slightly different language or information than opposite-gendered interviewers. If this bias pertained, however, it would have favoured the female perspective, which was the under-represented voice we especially sought to understand.
We recognise that gender is a social construct that likely interacts with many other factors such as ethnicity and socioeconomic position (SEP). For example, it is plausible that a population within a certain SEP may express more shared experiences, or that cultural groups with lower expressed emotion may express their symptoms differently. The next steps in the development of the gender continuum should include a similar evaluation in populations of diverse SEP and ethnicity.