Victims or Vectors by Briar Bertolin 

Victims or Vectors 

Briar Bertolin

In 2019, the FDA approved a new form of PrEP, a prophylactic taken high HIV-risk populations, with the caveat that it had not been tested on cisgender women, despite them being 52% of adults living with HIV worldwide and 23% of HIV infections in the USA. This oversight is part of a long history of women being left out of research, policies, and popular representation when it comes to the treatment of AIDS, which fundamentally is due to sexist and misogynistic narratives that view women as carriers rather than victims of HIV. This fundamental characterization of women being carriers of HIV leads to a disparity between the genders as they are represented in medical research, as we see on average women only making up “ 11 percent of participants in trials investigating cures for HIV”, “19 percent of drug studies”, and “38 percent of [HIV] vaccine trial subjects.” 2 This characterization also leads to exclusions in popular narratives as the discussion switched from framing women from being immune to AIDS to women being the vectors of infection. The paradox of women being blamed for HIV/AIDS and excluded from the study of HIV/AIDS has far-reaching negative impacts in the United States as men’s infection rates drop while women’s stay stagnant. 3 In this paper, we will discuss how misogyny affects women’s representation in HIV research, healthcare, and public policy, and subsequently how this then affects the healthcare outcomes of women in the United States. 

Part 1: The Problem in Research

In December of 2019, buried beneath news of the new superflu in Wuhan, China, was the release of the new FDA approved drug named Discovy, a new form of HIV protection known as Pre-Exposure Prophylaxis (PrEP). The approval of Discovy was welcome news to people who couldn’t take Discovy’s predecessor “Truvada,” which was not recommended for those at risk of kidney issues or osteoporosis.[1] But this medical innovation was accompanied by an important caveat: the drug was only approved for people with penises. This news outraged activists against gender and sex-based discrimination because the focus of the study excluded people with vulvas. This population currently makes up 52% of those currently infected with AIDS and 49% of new infections.[2] Despite this disparity, many feminists and AIDS activists alike were unsurprised by the exclusion of people with vulvas. A recurring theme throughout the AIDS epidemic has been that treatments, research, and cures have been used primarily for people society has determined as “men,” while people that are seen as “women'' are only viewed through their reproductive and sexual utility. According to Bill Rodriguez, the former associate director of the Institute for Health and Social Justice, women initially entered discourse around AIDS as potential vectors, reservoirs of infection, sexual partners of men, and irresponsible mothers.[3] Case studies like the one referenced above illustrate that social concepts surrounding women in the United States have affected the medical and public health establishment’s treatment of people assigned female at birth (AFAB) throughout the AIDS epidemic.

Understanding how women as a social group are viewed provides useful context to understanding why AFAB people are excluded from medical research. While not all women have anatomy that is commonly associated with being “female” (ie. vulvas, uteruses, breasts, estrogen/progesterone dominance), the cisnormative construction of women as a gender informs how people who have female anatomy are treated. This is not to say that transgender women are immune to sex-based discrimination. This discussion is complicated, so the intersection between gender-based and sex-based discrimination as described in this paper can be found in the end notes.** In this paper the term “woman” will be used when social constructions of gender are discussed and the term AFAB will be used when discussing discrimination based on the variety of characteristics associated with the female sex[a][b] (breasts, vulvas, uterus, cervices, etc). This is not to say that the term AFAB is synonymous with the term woman, as not all AFAB people are women and not all women are AFAB. Rather, this emphasizes the difference in the social construction of gender versus the anatomy of those impacted. In essence, while medical misogyny is based on bigoted views surrounding women, the effect of this bigotry often impacts all AFAB people. 

By recognizing that women are primarily described through their threat to men and children, one can understand why many leading institutions prioritized controlling the participation of AFAB people. This is illustrated through the FDA’s decision to exclude “women of childbearing potential” from clinical trials, the National Institute of Health’s (NIH) exclusion of women in their regulations surrounding drug testing on human subjects, and the hyper policing of HIV positive women and their reproductive choices. These instances of public health regulations furthering medical misogyny will be discussed throughout the paper. This shows a disproportionate concern for potential fetuses rather than the people that carry them. These decisions, while seeking to protect unborn children, produce barriers that exclude AFAB people from HIV medical research and, as a result, care. 

The denied approval of Discovy for AFAB people by the FDA provides an excellent microcosm for the ongoing diversity and inclusion issues in AIDS research and public health. The FDA’s advisory board decided with a 10 to 8 vote that the drug should not be approved for AFAB people, claiming that “there is a general lack of consensus regarding this issue.” This lack of consensus stemmed from preclinical trials which only experimented on people assigned male at birth (AMAB). According to the FDA briefing document, the preclinical trials for Discovy “...enrolled 5387 cisgender men and transgender women who have sex with men and are at high risk of HIV.”[4] Instead of including cisgender women, as suggested by the FDA during the preclinical trials, Gilead (the manufacturer of both Truvada and Discovy) hoped that the FDA would approve the drug based on previous data. The study by Gilead stated that the “biology of HIV transmission is independent of gender” and that the “efficacy and safety for HIV treatment was similar to men,” in order to justify extrapolating the findings of the studies on AMAB people to AFAB people.[5] Despite these arguments, the FDA complained that “an extrapolation approach to support an indication in cisgender women is predicated upon which drug exposures are considered most relevant to PrEP efficacy, systemic or local mucosal tissue drug concentrations.”[6] In essence, because it is not well understood whether or not PrEP is efficacious in both the anus and the vagina, it is unknown whether or not PrEP will protect AFAB people from HIV infection. The egregious neglect of the physical differences between how AMAB and AFAB people have sex illustrates an apathy for sex-based differences in medical care. Overall, despite the evidence to the contrary, the FDA would not allow this medication to be prescribed to AFAB people without dedicated research on its effects.

This decision to exclude AFAB people in general is not an isolated incident in the history of AIDS research. Mary Ann Liebert, a scientific research publishing company specializing in biomedical science, performed a meta-analysis of the existing medical literature on the effects of PrEP on AFAB people compared to AMAB. The meta-analysis observed that AMAB people had slightly (but statistically insignificant) better outcomes when it came to taking the medicine, and previous studies have shown that PrEP is often more “forgiving” in AMAB people as it remains in the primary sites of infection longer.[7][8] The irony of this study was that it was difficult to observe whether or not there was an actual bias towards the efficacy of medication in men, due to only 20% of the subjects being AFAB people. This recruitment problem extends to most modern AIDS research. In 2016, a meta-analysis of all HIV research trials illustrated that only 19.2% of the participants in ARV (Anti Retroviral) trials were AFAB, 38.1% of vaccine trial participants were AFAB, and only a measly 11.1% of HIV cure study participants were AFAB.[9] So regardless of the measured efficacies, the lack of inclusion of AFAB people in research complicates its ability to determine whether they experience more negative health outcomes.

Part 2: The Precedent

Throughout the history of the United States, there have been numerous examples of malpractice on the part of pharmaceutical companies that disregarded the rights of AFAB people.  Even after the passing of the Food and Drug Act of 1906, which required accurate information to be presented on medication, many pharmaceutical companies would prey on the high expectations of cleanliness only applied to women. This would result in many cisgender women using unsafe and dangerous douches that included ingredients like Lysol as cures for normal vaginal odor.[10]

 This disregard for AFAB people led to disastrous outcomes for pregnant people in particular and the children they carried to term. For instance, the drug DES (a synthetic estrogen prescribed to prevent miscarriage and other pregnancy complications) came under fire for its unethical study design and the danger it posed to pregnant people. At the University of Chicago, every pregnant person at the Lying-In Hospital was included, without their consent, into a follow up of the initial Harvard University trial that concluded DES was a safe and effective way to prevent miscarriage. The experiment at the University of Chicago, which involved 1,646 pregnant people (half of whom received the medication without consent), found that this medication was actually linked to a 100% increase in miscarriages and a notable increase in babies who were smaller than average.[11] According to “Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume I,” this medication was still deemed safe and effective by the FDA and was utilized for another 20 years after these findings. The use of DES as a preventative measure against miscarriage continued into the 1970s, resulting in patients contracting clear-cell adenocarcinoma (a very rare cancer), and second and third generation diseases. The diseases were often genital malformations in the fetuses of pregnant people who took DES as well as their grandchildren.12 This incident resulted in the removal of this drug from the market in 1972 and illustrated the need for harsher regulation by the FDA in both the ethicality and fastidiousness of drug research. 

Only a decade prior to the DES human rights violations, thalidomide, a common antiemetic for pregnant people, was making headlines. Thousands of children were being born with phocomelia of the limbs as well as congenital problems that led to the death of roughly 40% of babies. This resulted in roughly 8,000 children being affected.[12] These disastrous results caused an uproar from the public that demanded increased regulation.

Yet more cases of unethical medical research piled up in the press, which caused an even greater push for the regulation of pharmaceuticals. The infamous Tuskegee Syphilis experiment, reported on by the AP Press in 1972, was making waves among African American communities. This experiment, which intentionally deprived 400 African American AMAB people of treatment for syphilis. This resulted in: the deaths of 128 AMAB people from syphilis or syphilis related complications, 40 AFAB partners being infected with syphilis, and 19 children being born with congenital syphilis.[13] Additionally, the Dalkon Shield was coming under fire as it was revealed that this intrauterine device caused thousands of cases of sepsis before being recalled in 1972.[14] These disasters put pressure on the US government to more tightly regulate medical research, but perhaps more importantly it served as a pretense for enacting regulation that more tightly controlled AFAB bodies. 

This series of human rights disasters culminated in multiple different policies, such as the Federal Policy for the Protection of Human Subjects (1981). This policy would become the origin of protectionist and paternalist legislation that prevented AFAB people from being represented in research studies. This legislation notably required “additional safeguards” to be included in studies that had “subjects likely to be vulnerable to coercion or undue influence,” which included children, prisoners, mentally disabled persons, economically or educationally disadvantaged persons, and pregnant women.[15] While the decision to include people who might have an underdeveloped ability to make informed decisions for themselves (children and intellectually disabled persons) or people in desperate situations that might influence their decision making (prisoners and poor people) might warrant special consideration, it does not make much sense to include pregnant people in the category of “vulnerable to coercion or undue influence.” But this paternalistic inclusion of pregnant people largely went unchallenged by feminists as, according to Dr. Elizabeth Fee, “federal policy, being overbroad and paternalistic, at least protected women from serving as guinea pigs in ill-conceived research projects.”[16] While paternalistic and fairly sexist, it is understandable why, after the previous demonstrations of disregard for AFAB people’s consent and safety, feminist activists would not challenge federal policies that list pregnant people as “vulnerable to coercion or undue influence.”

The federal government’s response to the agitation for better drug screening practices culminated in a slew of new legislation to avenge the thousands of babies harmed. However, the inclusion of pregnant people as “vulnerable to coercion or undue influence” did not go without consequences. In 1977, the FDA released a new guideline called “General considerations for the clinical evaluation of drugs,” which explicitly prioritized the health of potential fetuses over AFAB people. The regulation barred “women of childbearing potential,” between the ages of 15 and 45, from Phase 1 and 2 of drug testing. The only exception to this rule was if there were prior tests on animal reproduction. Because this regulation was so restrictive about AFAB people’s involvement in research, research institutions were incentivised to include fewer AFAB people. Oftentimes, researchers opted to exclude AFAB people altogether because of the extra hurdles wrapped up in gender-inclusive research. 

Part 3: The application to AIDS

Aside from the ethical problems associated with pregnant people in research, the barring of “women” often means that AFAB people have negative health outcomes, particularly when it comes to the already stigmatized issue of AIDS. Bill Rodriguez, who was in 1993 a resident in Brigham and Women’s Hospital and later went on to be a leading expert in infectious disease, described this neglect in the book The Gender Politics of HIV/AIDS in Women. According to Rodriguez, “women were ignored in the earliest months of the epidemic as scientists (and the general public) cast a wide net of blame on marginalized groups and behaviors.”[17] For instance, the aforementioned 1977 ban on “women of childbearing potential” from drug testing still was a sky-high barrier for AFAB individuals to be included in medical care. This regulation, while preceding the onset of the HIV epidemic, laid the groundwork for future barriers for AFAB people participating in research due to the concerns of liability for damage to a fetus. This decision was emblematic of the FDA’s continued apathy towards AFAB people. While the FDA did make an exemption for AFAB people who had “life threatening illnesses,” they did not go out of their way to enforce this exemption. This often led to AFAB people as a whole being routinely excluded from research because of the extra roadblocks in their participation in research.

The policy excluding women of childbearing potential did not change until 1993, 12 years into the epidemic, when the ACLU petitioned for AFAB inclusion. This petition, which described the 1977 policy as “discriminatory,” led to the FDA making miniscule changes in the form of the “Guideline for the Study and Evaluation of Gender Differences in the Clinical Evaluation of Drugs.”  According to Theresa McGovern, the Executive Director of the HIV Law Project, the new guideline “suggests certain by-gender analyses while stating that its recommendations need not always be followed”.[18] But, as we have seen in the Mary Ann Liebert metastudy, this suggestion is often not followed by many medical research institutions. 

Another regulation titled “Additional Protections Pertaining to Research, Development, and Related Activities Involving Fetuses, Pregnant Women, and Human in Vitro Fertilization” further excluded women from research. This policy was a recommendation from the NIH published in 1986, which stated “pregnant women or fetuses may not be involved in research unless the risk to the fetus is not greater than minimal, except when the risk to the fetus is caused solely by research designed to meet the health needs of the mother or the fetus.”[19] This regulation further disallows research institutions from including women in their research. It is also telling that fetuses are listed first in the order of protected individuals, illustrating the order of priority favoring the fetus. These discriminatory decisions resulted in women being excluded from the research done on HIV/AIDS.

The policy barrier to women entering clinical research reflects the characterization of women in most biomedical discourse. Because women are missing from discussions of HIV, aside from being labeled disease vectors that infect men and children, women are often viewed as perpetrators of the disease. According to Bill Rodriguez, while women are described as prostitutes and “sexual partners of men,” there isn’t any discussion of men as “vectors, johns, or sexual partners of women.”21 This framing of women as “victimizers rather than victims” was borne out in many accounts of people trying to treat women with AIDS during the initial outbreak. According to Dr. Kathy Anastos, a doctor at an NYC hospital in the 80s, “none of the physicians or scientists talked about the women with AIDS being sick themselves…women were discussed in perinatal and prostitute studies. Those innocent babies getting it from those irresponsible moms.”[20] Most of the research described AFAB people who were HIV positive through the lens of childbirth and as “irresponsible moms.” After reading reports of reactions to a study that found many babies testing positive for HIV, Dr. Helan Rodriquez-Trias, a doctor at Beth Israel Hospital in the late 1980s, found that “the obvious conclusion of this study didn’t hit people: “Hey, these are infected women.” 

Even when researchers ventured to study AFAB people with AIDS, they were scrutinized and ridiculed. According to Dr. Judith Cohen, a physician at the San Francisco Medical Center, her research on HIV-infected women was regarded by her male colleagues as “The Prostitute Study,” despite significantly including people who did other forms of work and were only described as “sexually active women.” Later accounts by Dr. Cohen claimed that “studies and reports on women and AIDS and then on babies and AIDS poured in…the ‘baby’ pile dwarfed the ‘woman pile.’” These attitudes massively delayed the by-gender research of AIDS and ignored the impact AIDS had on women as a social caste so severely that the CDC did not recognize women as victims until January 1st, 1993.26 This means that for 12 years, the CDC did not officially recognize women having AIDS. This level of ignorance for AFAB people’s suffering throughout the AIDS crisis is difficult to justify.

The systematic exclusion of women had impacts on all people with anatomy considered female and had dire consequences for their health and safety. Since HIV/AIDS research mostly focused on AMAB patients, (transgender women were lumped into the same group as cisgender gay men) physicians were often stifled in identifying gynecological symptoms of HIV. In fact, it took until January of 1993 for cervical cancer to be identified as a symptom of HIV infection. On top of the provider bias, insurance agencies and social services didn’t include gynecological symptoms in official HIV diagnoses–HIV positive AFAB people were denied coverage for AIDS related services. This lack of inclusion resulted in massive increases in the number of infected and dead. 

While there is not sufficient data to speculate on any differences between cisgender and transgender AFAB people, the data on cisgender women illustrates that sex based discrimination can be disastrous. In 1994, the number of women infected with HIV more than doubled from about 3 million to about 8 million worldwide. In 1995, AIDS became the primary cause of death for women in major cities and the fourth leading cause of death for women ages 25-44.[21]

One of the main justifications given for AFAB people being excluded from research, both during the inception of the epidemic and now, are the numbers. It is in fact true that in the U.S. throughout most of the epidemic, AFAB people have made up the minority of those with HIV. However, the number of AFAB people infected cannot excuse the lack of inclusion, as ample evidence pointed to the existence of female AIDS patients. According to Sex Work, Alcohol, Drugs, and AIDS by Martin A Plant, the first person who was officially recorded as infected with HIV was “contrary to popular belief, a female prostitute.”[22] Even in the present day, the discussion around the lack of inclusion in HIV trials discusses the “lack of participants,” but ignores the heavy regulations placed on AFAB people in AIDS research. They were required to “refrain from sexual activity,” use birth control, and continuously get pregnancy tested.28 These requirements and “ethical problems” place a real barrier on AFAB people that is not experienced by AMAB people in HIV research.

Currently, AFAB people continue to be subject to more regulation. Dr. Elizabeth Connick, a prominent researcher in HIV studies wrote in a 2020 article that “It is understandable in some instances not to want to recruit participants who will become pregnant, to avoid possible harm to a fetus. Nevertheless, there are ways to include women that overcome this hurdle, for example, by requiring use of contraception.”[23] This statement illustrates the idea that the possibility of a fetus outweighs the inclusion of AFAB people, as well as tacitly justifies the barriers. By putting the responsibility on AFAB people to undergo medical procedures that affect their fertility in order to be included in research, researchers are putting an undue burden that selects out AFAB people from being included in science. 

These policies by the FDA, which clearly prioritize fetuses over real AFAB people’s bodies, led to justifications of state regulation of the sexual activity of people who are HIV positive. According to Gena Correa, who is the associate director of the Institute on Women and Technology, “the primacy of the fetus and the unimportance of the woman in governmental and scientific thinking on AIDS led to a series of concerns for those who did consider women valuable.”[24] In totality, these policies serve to remove the right of AFAB people suspected of having HIV from giving birth. For instance, a testing policy that was recommended by national groups “[offered] testing to all pregnant women or to all pregnant women in ‘high risk’ groups.”[25] A result of this recommendation was the CDC misleading many HIV positive AFAB people into delaying childbirth by stating the rate of perinatal infection was as high as 70-80 percent, despite it actually being 30 percent.  Additionally, twenty-two US states made knowingly exposing or transmitting HIV a “felony or misdemeanor,” actively criminalizing the sex lives of those with HIV. Intergovernmental AIDS Reports observed that “while no state had prosecuted a woman for knowingly transmitting the virus perinatally, the omission of specific exemptions for HIV-infected women makes the potential for criminal action possible.”[26]

Given this background of HIV/AIDS restrictions on AFAB people entering research, it is not terribly surprising that Gilead opted to exclude all AFAB people from their clinical trial. But even outside of the legal restrictions, there are other factors present that may reduce AFAB people’s involvement in research. According to the justifications presented by Gilead, the researchers had trouble recruiting AFAB people and retaining them in the study. This does have some validity. In a recent study investigating the rationale as to why researchers have trouble recruiting and retaining AFAB people in HIV research, the participants purportedly had a “distrust of researchers, competing family responsibilities, low education and linguistic barriers, HIV-related stigma and perceived discrimination, and transportation difficulties.”

Additionally, there are other concerns that would have led to Gilead entirely neglecting AFAB people in their study. In an opinion piece published by the prominent health and medicine website STAT, Dr. Oni Blackstone, a primary care and HIV physician, founder of Health Justice, and former assistant commissioner of the Bureau of HIV in New York, theorized “As men who have sex with men currently constitute the majority of the market share for PrEP in the U.S., Gilead’s decision to exclude cisgender women from its clinical trials for Discovy appears nothing short of profit-driven.”[27] The user demographic data supports this conclusion, as only 4.7% of people who filled prescriptions for any sort of PrEP were women.[28] This data illustrates how the sex-based discrimination can feed into itself cyclically. Because the policy environment discourages gender and sex-inclusive research due to the aforementioned policies, fewer AFAB people get medicine that is appropriate for their bodies. This same policy also perpetuates distrust of the medical establishment when it comes to treating AFAB people. With this stigma, the beneficiaries of research become more male-centric, and thus companies are incentivised to continue this cycle.  

The public policy environment is fundamentally informed by sexist gender constructs that define women foremost through their childbearing ability. This idea is illustrated through the language of legislation, which often frames the mistreatment of AFAB people in medical research through its effects on children. These legal constructions then incentivized medical institutions to exclude AFAB people due to the extra legislation surrounding them, leading to medical research that does not serve AFAB people. Exclusionary policies by the FDA and NIH played into and furthered narratives that view women, as a social construct, as vectors of disease who infect children and men through motherhood or prostitution. These narratives are incredibly harmful to the efficacy of research and until this exclusion is remedied, we may not even know the full extent to which this gap has affected the health of HIV+ AFAB people. The exclusion of AFAB people (due to systemic misogynistic bias) from research disproportionately harms AFAB people. To mitigate these effects, serious public health legislation needs to be enforced to further promote gender and sex-inclusive research.

Addendum:

** When referring to the intersections between sex-based and gender-based discrimination, the key issues that come into play are the differences between the assumption of biology and the actual biology that is at play. For instance, because the terminology of “women of childbearing potential” is cisnormative and medically vague, it leaves transgender people in an HIV gray zone. Because this description describes women from the ages of 15-45 (whether or not they are actually able to get pregnant), the exclusion seems to be more on a perceived gender basis.  For instance, a cisgender woman would be excluded from medical research even if she were to be not able to get pregnant for one reason or another.  

The treatment of transgender people varies from person to person when it comes to the application of these policies and also their inclusion in research would depend upon the personal views of the doctor as well as the presentation of the transgender person. For instance, a transgender woman who has gone “stealth” (which means that, often in the pursuit of protecting themselves from discrimination, a trans woman has not revealed her transgender status to anyone) would most likely be barred from medical research under this law because she is assumed to have childbearing status. However, transgender women who do not have the ability or wish to go entirely stealth in their transition may have a different experience. Additionally, due to the false belief that transgender women are synonymous with gay men, transgender women may be assessed due to the assumption that they are men. Another factor is that some researchers view hormonal cycles in estrogen-dominant people (which includes transgender women on HRT) as a confounding variable that might mess with data, which is also predicated on a sex-based bias that excludes women as deviations from the ideal male standard. 

The converse situations often apply to transgender men. Many transgender men are able to go stealth as well and are thus assessed as men in medical research. An additional variable is that transgender men are often assumed erroneously to be unable to get pregnant due to various gender affirming procedures. This is not entirely true as while testosterone, which is the most common form of gender affirming care, often decreases the likelihood of conception, it is not a good contraceptive. There are other techniques in gender affirming care for transmasculine people (people who are trying to achieve a more masculine presentation) that do serve as effective forms of contraception like hysterectomies, ovariectomies, and phalloplasties through one way or another. 

Additionally, while this paper opens with an example of transgender women being excluded from sex-based discrimination, this does not mean that transgender women are not negatively affected by sex based discrimination. Rather, it means that the degree of discrimination is often not known because of a lack of research, which feeds into earlier discussions of sex based discrimination. The case of HIV research is a rather unique case when discussing the role of transgender women in medical research. Because the incorrect social conception of transgender women being synonymous with gay men combined with transgender women often having similar rates of HIV as gay men in the US, transgender women have been studied as a subset of homosexual men. 

While the inclusion of transgender women is common in discussions of HIV, this inclusion does not mean that transgender women aren’t largely harmed by medical sex-based discrimination. The research into this topic is actually incredibly weak because of the systemic exclusion of transgender-inclusive analyses in by-gender studies, so the extent of the medical sexism is simply not known. Additionally, transgender women often have similar sex characteristics as cisgender women depending on the forms of gender affirming care and thus it can be extrapolated suffer from similar disparities in health care. A good example is the research on the mortality rates of cardiovascular disease in cardiovascular disease (CVD) between genders and sexes. Estrogen and gender discrimination have both been positively correlated with an increased CVD mortality rate. Cisgender women have a significantly higher mortality rate due to CVD compared to cisgender men. This has a variety of risk factors ranging that have been theorized to account for this. For instance, cisgender women present different symptoms for myocardial infarction (heart attack).[29] This has been often theorized to be the reason behind cisgender women’s higher rate of misdiagnosis.[30] There is also an increase in the mortality of transgender women due to heart attacks as well as an increase in the incidence of heart attacks in transgender women that makes the incidence closer to that of cisgender women. To the frustration of this author, there is no survey of the symptomatology of transgender women as of date nor is there any research that would prove or disprove the link between the gender identity of transgender women and their increased mortality of heart attacks. Rather, this example brings up a gap in the literature surrounding gender and sex based issues that illustrates how analyses of sex-based disparities should also be analyzed through a trans inclusive lens. This addendum serves to refute the argument that many people make that transgender women benefit from sex-based discrimination because of some facets of their biology, and rather illustrates the necessity of more research into this field.  

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