The Evolution of the National Centers of Excellence in Women's Health: The Time for Gender and Health Equity Has Arrived

Women's health has evolved over the past century from an emphasis on reproductive and breast health care, or “bikini medicine,” to a field that is comprehensive in treating the whole patient and inclusive of sex and gender identities across the spectrum. Created by the Department of Health and Human Services' Office on Women's Health (OWH) in 1996, the National Centers of Excellence in Women's Health (CoEs) developed and accelerated a multidisciplinary model of women's health by uniting clinical care, sex- and gender-specific research, professional and public education, leadership, and community outreach under one mission: to enhance women's well-being across the lifespan. ^1,2 From these efforts, the CoEs transformed the healthcare landscape by advocating for interdisciplinary services defined by intersectionality and interprofessional care, and the importance of sex and gender differences in medical research, health education, and clinical practice.

The National Academy of Sciences refers to sex as a biological construct based on physiological and anatomical traits, and to gender as one's societal identity.” ³ These overlapping concepts exist on wide spectra. In this commentary, the terms “women” and “women's health” refer to all who identify as women and/or have medical needs related to having been assigned a female gender at birth.

Over the course of a decade, academic facilities, affiliated medical centers, and community centers competed to receive federal funds and the designation as a National Center of Excellence in Women's Health. ⁴ The CoEs were essential to the incorporation of women's health courses into national medical, dental, pharmacy, nursing and allied health curricula, educating the public and health professionals on women's health and sex- and gender-related issues, in advancing research to include women and underrepresented minorities into medical research, and in providing outstanding, integrated interprofessional health care to diverse populations. ⁵ Multiplying the OWH investments by more than 1000-fold in several instances, the CoE model created an integrated network of 48 centers offering comprehensive health services to women in 40 states and Puerto Rico. ⁶

The CoEs maintained a common purpose: namely, to offer a “one-stop shop” model for the provision of clinical health care services to women with specific efforts to include those who are underrepresented in the health care system. The transformation from a traditional reproductive based women's health model necessitated institutional commitment, which the CoEs fostered by unifying dedicated leaders behind the goal of advancing multidisciplinary women's health. ⁷

The CoE program activated and mobilized a massive national and international collaboration of governmental, private foundational, industrial, health care organizations and agencies. The competition for the awarding of the CoE designations energized academic institutions to designate women's health a priority and to foster collaboration among institutions, departments, health care disciplines, and health care professionals. ⁶ Studies of the CoE program demonstrated a causal relationship between the sex- and gender-specific practices at institutions with a CoE designation and increased patient satisfaction. ^8,9 The CoE program was officially defunded in 2007. Unfortunately, while many academic institutions and community organizations supported the maintenance of the CoE at their site by leveraging institutional and private support, other CoEs ceased to exist.

In February 2022, a focus group of past and present CoE leaders, convened by Dr. Saralyn Mark, former Senior Medical Advisor to the OWH, was held to discuss the overall lessons learned from the Women's Health CoE program, and to advise federal agencies on future directions for the CoE model. During the meeting, members expressed grave concern that the lack of federal funding had led to the elimination of vital women-focused, women-relevant services at their institutions and that the CoE's success in legitimizing women's health as an interdisciplinary field of study had eroded.

The leaders concluded that there was a need for the CoE program to evolve and align with the changing landscape, to include sex- and gender-based women's health in research, education, and clinical care, and to garner renewed national attention and funding to accomplish these goals. The need to characterize women's health care as a service line and to support leaders in the women's health field nationally and within academic institutions were determined to be essential components of a successful CoE program.

By characterizing women's health as a service line rather than a traditional unit-based departmental system, the former CoEs fostered interdepartmental cooperation and improved patient care: the patient's clinical journey was arranged across multidisciplinary services tailored to their needs, minimizing variance in care and enhancing patient experiences. ¹⁰ As academic centers evolved and partnered with community hospitals and larger systems, a challenge remained to incorporate the visionary idea of an integrated system across the current dichotomy of academic versus community models of medicine.

Leadership turnover and a lack of institutional support had been a challenge for the former CoEs over the years. The CoE program had originally funded a position of “Center Director” at each site, opening the door for women and those who promote women's health to be at the forefront of leadership. ¹¹ When the CoE program was defunded, many of these opportunities quickly vanished, and female leaders at existing centers lost their positions. Without a “Center Director’’ or senior leader to advocate for women's health within an institution, competing priorities led to the atrophy rather than advancement of existing women's health efforts. Ultimately, the termination of the CoE program meant the loss of an entity that had united women's health and interdisciplinary clinical care in many institutions and across the country for over a decade.

Going forward, although the CoE program's emphasis on women proved transformative in establishing an inclusive health care landscape, further work must be done to address the new landscape in health care, which acknowledges and strives for equitable health care for patients of all sex and gender identities. In response to this need, we support the proposal to create National Centers for Gender and Health Equity developed by Saralyn Mark, MD. ¹² These new centers should not only expand on previous accomplishments of the CoE program but also represent a transformation to address the current climate. Moving forward, an egalitarian lens must be adopted where women, men, and nonbinary individuals are at the forefront as leaders and patients of this initiative.

A sex- and gender-based lens will set the foundation of the program, and the intersectionality of all human factors will serve to define and refine the new model. Centers should ensure that they follow the guiding principles of patient-centeredness and sex- and-gender-based medicine by informing patients with accurate, honest information regarding individualized treatment options, while respecting their bodily autonomy and decisions. ² As personalized, precision medicine becomes standard, the creation of these new centers would foster collaboration between the sexes and ensure that a nonbinary approach is taken to be reflective of where we are in our world today.

In conclusion, the former CoE program in Women's Health advanced and ensconced women's health as a national priority and encouraged health care institutions to promote women's health by adopting a multidisciplinary model. The program's success in spurring comprehensive clinical care and innovation demonstrated how a collaborative effort, backed by the funding and the support of a federal mandate, can be transformational. The CoE program catalyzed high-quality women's health care and ignited a revolution of sex- and gender-informed health care for people of all backgrounds.

As leaders in Women's Health and Sex and Gender Medicine look to the future, the proposed National Centers for Gender and Health Equity have the potential to galvanize and energize the continued evolution of true health care equity by using the CoE model and incorporating a sex- and gender-based lens, ensuring that the health needs of all people across the gender spectrum are addressed comprehensively, cost-effectively, and most importantly, compassionately.