Sex and Gender Representations of Myocardial Infarction in German Medical Books

Abstract

Mandatory teaching of sex- and gender-specific medicine (SGSM) is an essential tool to prepare future physicians for clinical care. Textbooks still play an important role for physician training in Germany. They are one of the main sources of structured and validated information.

The present study was conducted to investigate the incorporation of SGSM knowledge about myocardial infarction (MI) into the standard cardiology textbooks used for teaching by German medical faculties. Additionally, the analyzed books were screened for implicit and explicit gender bias in a qualitative manner.

Ten books were selected for analysis; they were issued in the years 2008–2012 and present in 30% or more of the 36 German academic medical libraries. Quantitative and qualitative analyses of content, language, and visual representations of the sexes in discussions of MI were conducted.

All of the analyzed books describe the symptoms present in male bodies as the norm and 7 of the 10 books describe women as “special” or “abnormal”; hence, they fail to address the unique experience of women suffering from MI. Sex and gender bias are widely present and the depiction of women in German cardiology textbooks is discriminatory.

Introduction

Cardiovascular diseases are the main cause of death in both Germany¹ and the United States.² Within the cardiovascular diseases, coronary artery disease (CAD) is the leading cause of death in Germany for both sexes. Given the importance of the impact of CAD, medical training should focus intensely on these conditions to equip future physicians for clinical practice. Myocardial infarction (MI) is one of the most thoroughly investigated cardiovascular diseases, with particular attention paid to the differences (concerning symptoms, epidemiology, treatment options, etc.) between men and women. The symptoms of myocardial infarction can vary between women and men^2,3: Women are more likely to have other symptoms than the typical chest pain experienced by men.^4,5 This notion has received wide attention in the lay press and, due to several large public campaigns in Germany—for example Hör auf Dein Herz (Listen to your Heart, 2011–2015) and Herz in Gefahr (Heart in Danger, 2012)—knowledge is increasing about women's risk for cardiovascular mortality.⁶ This rise of mainstream media attention, however, does not seem to have increased women's perception of their own vulnerability to cardiovascular disease and MI in particular.⁷

While diagnostic tests and therapeutic measures are mostly based on a consideration of biologic sex, symptom reporting, and doctor–patient communication, and coping strategies are influenced by social factors. In the medical context, teaching sex- and gender-specific medicine (SGSM)—in mandatory courses, seminars, or lectures—is an essential tool for raising awareness among medical students. While the process is complicated by structural, political, and practical issues, it can be comprehensively achieved.^8,9 Nevertheless, mandates to include SGSM in medical education are not widespread in Germany.¹⁰ Textbooks still play a relevant role for physician training as a source for structured and validated information.

According to Wiegand and Donald¹¹ libraries play a “significant role in preserving and perpetuating particular cultural forms and dominant cultural themes.” To test this assumption, the representation of the sexes in publications about MI in German medical textbooks was analyzed. SGSM knowledge about MI was widely available at the time of analysis of all analyzed books published between 2008 and 2012, and was even summarized in a freely available ad hoc publication in the German language, produced by the Robert Koch Institut¹² (the institute in charge of national public health strategies) in 2006; Even considering that books might have taken some years to be published,^13–15 the knowledge about differences was widely present, given that MI is one of the most widely researched conditions in clinical medicine and knowledge about sex and gender differences in this area is available.¹⁶ Hence, progress toward a less gender-biased representation of the sexes could be expected. This means stepping away from practices that regard the male as the norm in medical contexts¹⁷ and from the uncritical transfer of results from observations made on male subjects to women.

The findings for gender bias were analyzed according to Professor Emerita Magrit Eichler's advice on sexism-free research.¹⁸ Given that most scientific knowledge is based on male individuals, this leads to a structural skewness in identifying and portraying differences between the sexes. Eichler developed a framework centered on 3 types of sexism: (1) androcentricity/overgeneralization; (2) gender insensitivity; and (3) the double standard.¹⁹

The more-recent publications in the field of SGSM,^3,20–23 attest to the growing attention to the existence of gender bias in medical education,^8,24 and the field is generating increased interest.^3,20–23 The present study reports the analysis of German cardiology textbooks that are widely available in academic medical libraries. Apart from identifying the participation of female authors, the assessment of each sex was qualitatively measured according to Eichler's criteria. The main questions raised were:

(1) Are the unique features of each sex's experience with MI acknowledged and addressed?

(2) How are the sexes represented?

(3) Does the gender (as sociocultural identity) of the provider and the patient play a role in diagnosis and treatment?

Materials and Methods

A questionnaire was developed, building on previous experience^25,26 and it was applied to the description of MI in German textbooks. Additionally, the books were screened to assess the presentation of sex- and gender-aspects in women and men qualitatively, according to Eichler's categories.

The first German textbook on gender medicine¹⁴ was released in 2004, a book on CAD in women was published 2 years prior,¹³ and a special issue about coronary heart disease of the German Health Report was issued by the Robert Koch Institut¹² in 2006. Assuming that a lag time of 2 years would be necessary to include new knowledge into textbooks, there was a focus on cardiology textbooks and compendiums with updated issues published in the 5-year period between 2008 and 2012.

There are 36 university libraries in Germany affiliated with medical faculties. These libraries provide a local selection of the existing literature in all fields of medicine. The most important library is the national medical library in Cologne (NMLC), which was used to select suitable books.

Entering the search term Kardiologie (German for cardiology) and limiting the publishing years to 2008–2012 in the advanced search of the online search portal of the NMLC yielded 60174 entries. Exclusion criteria were: publications other than books, language other than German, and areas other than medicine/health. The result was a sample of 1305 books from which further exclusions were made of conference reports, books for nonmedical or paramedical professions (e.g., agriculture, nursing or physical therapy), books from medical subspecialties (e.g., cardiovascular surgery), and books focused on specific skills, such as electrocardiogram interpretation. This resulted in a preliminary selection of 12 books. National dissemination of the books was validated by ascertaining their presence in all German medical libraries. Due to its presence in more than 80% of the libraries, a popular guidebook, written by a professor of medicine,²⁷ was included in this preliminary sample as well. Nine of the preliminary selected books were present in more than 50% of the libraries, 1 book was present in 36% of the libraries. Two books had only limited availability and were, hence, excluded, resulting in a final sample of 10 books.

The books were screened, building on the methods of preexisting studies,^25,26 focusing on the following questions:

• How are the epidemiologic and risk factors, symptoms, treatment options, and case studies for myocardial infarction presented?

• Are they differentiated by sex? How are the differences presented?

• Does the visual presentation represent both sexes?

For simplification purpose and reading comfort in the current publication all citations are reported solely in English.

Results

The analyzed sections of the books included knowledge about CAD in general as well as MI specifically; therefore, the following results are presented accordingly in the following sections.

General analysis

Ten books were selected for screening. Five books were cardiology textbooks focusing on basic knowledge, targeting medical students.^28–32 Four books were compendia, mainly used as quick references for practitioners and clinicians.^33–36 One was a popular guidebook in its 7th edition.²⁷ Books in the analyzed sample ranged from 7 to 225 pages, giving a total of 574 analyzed pages.

A total of 188 authors contributed to the 10 analyzed books. Of these, 25 (13%) were women, 163 were men (86%). Two of the authors (1%) could not conclusively be identified as male or female. Two women were named as coauthors on the cover of 1 of the books; all other covers named male authors and editors only. Six books were first editions, 1 was the second edition, 1 was the fourth edition, 1 was the seventh edition, and 1 was the eighth edition.

Quoting from evidence-based research does not appear to be a standard procedure in German cardiology textbooks, as only 3 of the 10 books^31,34,35 listed references for the presented facts.

Index, chapters, and subchapters concerning sex or gender

Eight of the 10 books had indices. Searching each index for information on men and women revealed three explicit mentions of pregnancy,^28,30,33 and 1 book that referred to medication and mentioned pregnancy as a subaspect.²⁹ One book included the term women in the index without referring to any pages.²⁷

A table of contents was present in each of 9 books. Two of those 9 books each contained 1 chapter about pregnancy (or about trying to conceive) in patients with heart diseases.^32,33 One of these 2 books³³ also contained subchapters about hormone treatment for women, the other book on “age and sex.” A third book also contained a subchapter about “age and sex.”³⁰ These latter 2 subchapters only described the later onset of MI in women, compared to men.

Epidemiology, risk factors, and prevention

Epidemiologically, women are generally 10 years older, compared with men, when experiencing an MI. This is partially due to estrogen deprivation and different risk behaviors.¹⁴ The epidemiology of CAD in general was mentioned in 9 of 10 books. Concerning MI, women were mentioned in 7 (77,8%) of those 9 books, mostly in reference to the time lag in the occurrence of the first MI in women, compared with men, for example, “female sex (women suffer the first infarction 9 years later than men).”³¹ Women's significant risk for MI, particularly in the postmenopausal period, was mentioned in 50% of the books. Little other epidemiologic information was presented, although large international studies have documented gender differences in the relevance of certain risk factors, such as diabetes mellitus (DM), smoking, hypertension, and psychosocial stress.^37–39

The sex-specific relevance of these risk factors was seldom discussed, especially if they principally affected women (Fig. 1). DM increases the risk of MI for both sexes, but this association is more pronounced in women.^14,38 DM was mentioned as a general risk factor in 3 books and all 3 reported sex-segregated statistics for its prevalence.^28,30,33 Contrary to the reported background information,¹⁴ Steffel et al.²⁸ identified DM as a significantly more-relevant risk factor for men, compared to women. Erdmann³³ however, stated that “women with diabetes mellitus have a particularly negative prognosis.”

FIG. 1.

Frequency of reporting of selected risk factors.

The sex-specific impact of obesity as a risk factor for CAD was mentioned in 4 books. One book²⁷ cited figures solely about female obesity. Steffel et al.²⁸ mentioned sex-specific criteria for the diagnosis of dyslipidemia. One book²⁷ emphasized the hazard of the combination of smoking and oral contraception.

Blood pressure (BP) and its potentially different role as a risk factor in men, compared to women, were not mentioned in any of the books. Neither was the role of depression and oral birth control as separate risk factors for MI.

Discrepancies existed in the perception of the overall relevance of sex for cardiovascular risk, with 3 books emphasizing how “being a man” represents a particular risk factor^28,31,35 and 1 book³² emphasizing that “being a woman” is a risk factor.

No gender differences were reported in any of the books on the topic of preventive behavior or lifestyle measures. Five of 10 books mentioned health promotion in general^{27,29,31,33,36}; sex differences were only considered in relation to potential differences in the consumption of alcoholic beverages.

Symptoms

Chest pain radiating toward the left side of the body is the most common form of presentation of an MI in both sexes, more in males than in females. An MI can, however, also be associated with symptoms such as nausea, dizziness, shortness of breath, and exhaustion, or with no symptoms at all; these have been reported more frequently in women, especially premenopausal women.⁵

In 8 of the 10 books, the traditional symptoms, which are more prevalent in males, are described as the norm. One book presented “female” and “male” symptoms as equally important.³¹ In 7 books, less-common symptoms that typically occur more frequently in females, were labeled as special or atypical. For example, under the subheading special patients, the following description appears: “[these] are e.g. […] women, patients with renal malfunction, diabetes and anaemia.”³² If the authors mentioned potential sex-specific symptom differences, these were rarely combined with gender-sensitive preventative or therapeutic considerations.

Pharmacotherapy

A need for differentiated medication for MI was mentioned rarely (4 of the 10 books). Twice, this advice was referred to pregnancy being a contraindication for specific drugs. Pinger³¹ advised on giving weight-adjusted heparin to men and women and this advice represented the only recommendation for otherwise healthy subjects. Pinger and Erdmann also advised against unrestricted prescription of hormone-replacement therapy in postmenopausal women; if indicated, it should be given for a short time only, because side-effects generally outweigh the benefits. Erectile dysfunction is described as a specific side-effect of ß-blockers in 1 book.²⁹ In accordance with large study results,⁴⁰ Stierle and Maetzel³⁰ suggested that there is not enough research evidence for general advice on the preventive aspects of aspirin for women, while Pinger³¹ explicitly stated that aspirin is not sufficient to prevent CAD in women. Regarding Alexanderson's question: “Are reported gender differences problematized?” (meaning: if gender differences are being discussed or, for example, used as a basis for considering different treatment for the sexes),²⁶ the answer from the analyzed literature points to a clear “no.” If sex differences were mentioned (e.g., symptoms, epidemiology) they were described but not discussed, neither did they lead to differentiated treatments or diagnostic suggestions.

Example cases, visual representations, and language

Three of the 10 books contained several case studies—a total of 14 among the 3 books. Twelve of these case studies depicted male patients; 2 case studies referred to female patients.^27,29,32 In analyzing “How many pages describe men? Women? Contain gender-neutral descriptions?”²⁶ it was found that, of the 574 pages in total, 112 explicitly mentioned women and 42 referred to men, in both cases figures of speech (for examples see below) were included. Furthermore, all general descriptions of patients and physicians referred to the male individual as the norm; these were included in this current enumeration.

Table 1 exemplifies that negative discrimination only happens toward women, as they were singled out for having “special symptoms” or when the index included the term women without any page numbers. The table showed that women, as a group, deviate from the set standard that is male by default. Women were described frequently as female spouses to male partners, enforcing gender roles and stereotypes. The German language specifically reinforces several gender norms, by adding the suffix -man to formal and professional roles (the addition of a suffix -woman would be possible). There were terms such as Landsmann (translation by the authors: countryman) or Fachmann (translation by the authors: expert); yet there were no countrywomen or female experts. The general term woman, was, however, used, for example, to exemplify the intimidation of a female spouse by a bullying husband in a vignette of a stereotypical spousal relationship.²⁷

Table 1.

Selected Example from Mathes (2012)^a of the Representation of the Sexes in Language

Regarding	Topic	Women (36 mentions in total)	Men (25 mentions in total)
Sex	Pharmacology	9 × concerning hormone- substitution therapy	3 × for studies with exclusively male subjects
			2 × concerning Viagra^®
			2 × concerning preventive medication
			1 × using nicotinic acid as an additional medication for men
			1 × regarding flavonoid intake and reduction of heart failure
	Risk factors	2 × being a young female smoker	2 × regarding men with cardiac insufficiency
		2 × concerning triglycerides	1 × concerning triglycerides
		2 × regarding obesity (without figures concerning males)	1 × risk of being a man in combination with BMI >30
		1 × a study result for women only
		1 × concerning postmenopause
Gender		8 × as partner of a male spouse	5 × figures of speech
Discriminating		3 × with reference to “special symptoms”
		1 × in the index with no reference to page numbers
Comparing the sexes		7 × comparisons of men and women (intake of alcohol, symptoms, risk factors, waist circumference, daily recommendation of calorie intake, recommendation of daily cholesterol intake, & BMI)

Adapted from ref. 27.

BMI, body mass index.

Men and women were mentioned 83 times; in 9 instances (11%) women were mentioned first for women and men.

The generic masculine form for patient was used in all books, resulting in 1238 mentions of patient in the (generic) masculine form and 30 times (2.4%) explicitly using the distinctive female singular form (Patientin). This has to be taken into account when comparing the explicit mention of woman with that of man; women were specifically mentioned 112 times, all of the 1238 mentions of a patient in the texts implied a male patient.

There were no drawings of female bodies (e.g., with broad hips or breasts) in the analyzed sections; explicitly male bodies were depicted 11 times and 10 drawings were neutral (i.e., they displayed features that could be either male or female).

One-hundred and eighty-three of the 200 (91.5%) graphs did not display sex-segregated data. Four graphs/tables solely represented women, 5 represented solely men, and 8 represented both.

Androcentrism/overgeneralization

All books were written in the generic masculine form; 86% of the authors were male. Two books^30,32 each contained a remark that women are to be considered included in the generic male form. Inclusion of this remark might have been a specific decision by the editors, given that both books were released by the same publishing house that has also published Lederhuber et al.,²⁹ which also contained this remark. In reference to Alexanderson's question “Do the presented women have different positions/occupations or status than men?”²⁶ striking differences were identified. Relationships or marriages were represented in a solely heteronormative fashion (consisting of 1 male and 1 female partner). Doctors were called with the male term (126 times, 100%), as well as therapists (4 times, 100%) and directors of studies (1, 100%). Practitioners were he, and the only professional she encountered in the books was a nurse.

Dosages of medications were standardized for the male body; there was little or no differentiation, although female bodies are generally smaller and weigh less, than male ones. Furthermore, there are significant differences in some of the metabolic pathways for the same medications between the sexes.⁴¹ The only exception³¹ was the abovementioned weight-adapted heparin usage. Female specifics concerning the epidemiology, risk factors, symptoms, treatment, or pharmacotherapy were excluded, denoting a generalized androcentrism. Ninety percent of the books (9 of the 10) considered the “typically” male symptoms as the norm and labeled women as atypical or special. For example: “Atypical complaints like nausea, vomiting, diarrhea or sudden urge to defecate are particularly common in women and cases of dorsal myocardial infarction and are usually caused by a vagus activation.”³³

One book avoided this overgeneralization and presented all symptoms as possible signs of an inferior MI for both sexes.

Gender insensitivity

In 3^28,31,35 of the 10 books, medical studies were quoted; yet, none contained detailed information about the sex of the studied subjects.

Specific forms of gender insensitivity could be detected. Concerning the incidence of an acute MI the following advice was given: “Immobilization: the patient's upper body should be elevated and supported and restricting clothes (tight shirt neck collar, neck tie) should be taken off” (translation by author).²⁹ No mention of a blouse, necklace, or brassiere was added.

Stereotypically described behavior particularly applied to the description of relationships:

According to the experience of doctors, wives are usually more able to recognize the endangerment of their partners. Although it is not rare that women tend to be intimidated by their partners' “I don't want a doctor”-attitude, which leads to missing the chance of a quick rescue.²⁷

In reporting on risk factors an interesting reverse attention was given to females. In describing obesity, one of the authors²⁷ only reported statistics for women, potentially implying that the issue only concerns this population.

Sexual dichotomy

If sex differences were mentioned at all, these were portrayed in a dichotomous fashion. All books reinforced the notion of 2 sexes who can be compared as groups with each other, ignoring all aspects of intersectionality, biologic variance, and sociocultural influences. Relevance of modifying factors was not reported.

Discussion

Sex- and gender-sensitive knowledge is essential for practicing person-centered medicine, and especially in the well-researched area of cardiology, incorporation of this knowledge into textbooks appears to be feasible and desirable. Young professionals and students need sensitization regarding questions of sex and gender. Given that most students still, at least partially, rely on textbooks as sources of knowledge, the information provided should be up to date, correct, and practice-oriented. The current authors' research showed that women were being marginalized and discriminated in almost all of the investigated textbooks in several ways, if they were considered at all. The discrimination of women happened in three distinct ways that were mostly related to androcentrism and overgeneralization.

First, the more-traditionally male symptoms of MI were described as the norm. Second, if knowledge about women was included at all, it was limited and could be found in the index unless the information was related to the topic of pregnancy. Third, women were labeled as special or atypical, and were mentioned separately; yet, the conclusions were, surprisingly, that treatment modalities should be the same for both sexes.

The male body and its symptoms, as well as its reactions to therapy, represented the norm in almost all of the analyzed books. In three books “being a man” was a distinctly mentioned risk factor—reinforcing the idea that MI is a particularly male problem. Some descriptions were clearly biased, focusing on typically male attributes (e.g., the “tight shirt collar, neck tie”) not even considering that a brassiere would restrict a woman's chest. Finally, the androcentric perspective was continued by the reproduction of gender stereotypes (e.g. the caring wife and her grumpy husband). This example was based on a heteronormative relationship with a clear distinction of the sociocultural roles of the 2 partners (i.e., the woman being responsible for recognizing and reacting to a medical emergency, while the husband resists her attempts to rescue him). Depicting women, especially married ones, in their sole role as “the caretaker” is neither timely nor appropriate. It can be said that language structures the world and our thinking; hence, it is even more important to make women explicitly visible and to portray and treat them as an independent group.⁴²

This impression is confirmed when women are mentioned separately with a label that points out their deviation from the defined norm. This premise is enhanced by the use of the generic masculine form. Only 2 books had a marginal remark that explained the use of the generic masculine form and explains that Patienten should be interpreted as inclusive of both sexes. However, the German language allows for distinction between female (Patientin) and male patients (Patienten), but this is not applied. Why these remarks are present in two books of different publishers, but not present in other books of the same publishers could be a matter of interest for further investigation.

Epidemiology was one of the subjects offering most sex-segregated information; nonetheless, this still only appeared in ∼60% of the books. Young age, especially in consideration of the increased use of oral birth control and smoking in young women,⁴³ should be mentioned selectively. In addition, depression and hypertension, which harbor a particular importance for women, were not included in these 10 books.

Second, women were not mentioned in the indices, except in relation to pregnancy. The limited visibility of women, restricted only to pregnancy and motherhood, has been reported before⁴⁴ (e.g., women could only be found in the index or in a separate chapter concerning pregnancy). The reduction of differences between men and women to the sole mention of pregnancy is, however, limiting and outdated. This approach is characterized by Marianne Legato, MD, PhD (hon. c.), FACP, with the term bikini-view,⁴⁵ which refers to the limited consideration of women's health only in relation to their reproductive organs. In one of the analyzed cases women were mentioned in the index without indication of a specific page number, suggesting that women are to be found everywhere but nowhere in particular. A specific form of myocardial dysfunction (i.e. the Tako-Tsubo syndrome), which almost exclusively affects women, was only mentioned in 2 of the 10 books. Furthermore, many risk factors that are particularly important for female patients, such as DM, hormonal birth control, and high BP, were not mentioned at all (see Fig. 1, a diagram of risk factors); yet, many of them are important regardless of sex or gender. Interestingly, the books differentiated very accurately between men and women in stereotypical domains (e.g., alcohol intake and menopause); hence, awareness appears to exist in some instances.

The third matter of discrimination involves referring to women's symptoms as atypical or special. Describing women as deviating or different is one way to raise awareness for female biology and sex specific differences, but it is an explicit kind of discrimination and continues to portray women as out of the ordinary.⁴⁶ Labeling women as a special patient subgroup is particularly discriminating when other subgroups are defined by illnesses or physiologic dysfunctions. Furthermore, although women are described as atypical in reference to their symptoms, the existing diagnostic and therapeutic approaches apparently do not need to be modified to account for being atypical. None of the analyzed books offered ideas or measures to treat or diagnose women in a specific matter; yet, much information exists in this area.¹⁶

Gender and its implications for health and disease were not reported at all in the books. Neither was the influence of the doctor's sex on their treatment patterns, nor was the influence of gender on the patient's life and interaction with physicians. Results where these aspects have been proven to matter (e.g., concerning door-to-needle-time),¹² as well as treatment differences based on sex¹² were not considered in the textbooks. Without consideration of these aspects in mainstream textbooks, there will be little-to-no motivation to address these issues in patient care in the near future.

Conclusions

Further investigation should be directed toward identifying reasons for a lack of inclusion of this information in the analyzed textbooks. The current authors assume that the limited participation of female authors helps to maintain the presented biases, because most gender-sensitive research is done and promoted by female scientists.

Trying to adapt the existing books to include both sexes equally might not be an ideal approach. A new model incorporating the recently gathered knowledge about the particularities of the sexes, possibly including a broader perspective on gender as a spectrum and on ethnicity, could be the innovation needed to improve medical education.

Introducing a holistic view on medicine that takes sex as a core variable into account could change diagnostic patterns and therapies. Medicine as a field is not focused on gender bias. The male body and its particularities is still the role model by which female bodies are measured, ignoring that lives might be at stake due to inappropriate treatments and diagnostics. Gender bias in medical textbooks is still present, although research is increasingly adapting to the idea that sex differences matter in all medical specialities.⁴⁷ More awareness of this systematic bias is needed. Guidelines to prevent bias in research and support measures for editors to improve sensitivity for the inclusion of sex differences could be developed. Finally, it is of utter importance to update books, because practitioners and teachers have argued that sex- and gender-specific differentiation is missing in textbooks; hence, it does not seem to have importance for practice.⁴⁸

Limitations

The current authors are aware that the selected sample allowed only a partial glimpse into German cardiology textbooks and do not claim to have a complete overview. The analyzed sample consisted of different types of books, and specifically the popular guidebook cannot be considered a full medical textbook, but given that it is published in its seventh edition, it seems to be very popular and widely used as a source of knowledge. Given that half of the analyzed books were first editions—and therefore brand new—they represent the current direction of publication and exemplify the application—or lack thereof—of gender mainstreaming guidelines in textbooks.

Footnotes

Acknowledgments

Prior abstract publications included the following:

• As a poster on GenPort: www.genderportal.eu/sites/default/files/resource_pool/poster_hiltner_oertelt-prigione.pdf

• As poster submissions at the 9th European Conference on Gender Equality in Higher Education and the 7th Congress of the International Society of Gender Medicine & International Congress of Gender Medicine of GIM (Institute of Gender in Medicine).

• As an abstract submission at the 51st scientific annual conference of the German Society of Social Medicine and Prevention (DGSMP) - Hiltner S, Oertelt-Prigione S. (2015). Which insights of gender medicine trickle into specialized medical literature?–Analysis of the representation of myocardial infarction in cardiology textbooks from 2008–2012 [abstr; in German]. Das Gesundheitswesen 2015;77(08/09):A219.

Author Disclosure Statement

No competing financial interests exist.

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