Gender bias: a health hazard in the healthcare system?

If you’re a woman reading this, chances are you have felt dismissed at least once during your experiences with the healthcare system. This is particularly so if you have ongoing symptoms or a chronic illness. I can say that assured in the likelihood that this is so, because a recent Government Survey, found that 84% of respondents who were women (or answering on behalf of women) reported experiencing dismissal in the healthcare system in the UK [1]. They felt that they were not listened to by healthcare professionals. Can we take that in for a second?



Male doctor with stethoscope and folded arms in white medical jacket.

An overwhelming majority of women felt that their healthcare practitioners did not hear them. How could these women then trust that decisions being made about their health were in their best interest? We know that feeling heard, informed and part of the decision-making process in healthcare consultations are fundamentals to shared decision making, the gold standard of patient care. Shared decision making in healthcare is associated with increased patient satisfaction, better treatment adherence and health outcomes [2]. This all makes intuitive sense. To have a health issue that is causing you discomfort and/or pain and potentially interfering with your everyday life, is difficult enough. When you speak with a professional about this to address it, and have the experience that they understand your concerns, know why this may be happening and can offer viable solutions, is to feel safe in the hope that your situation can be alleviated. The inverse of this (that 84% of women experience), is that you have a physical issue that is causing you discomfort and/or pain and potentially interfering with your life, you consult a professional and they don’t seem to understand your experience and are then unable (or unwilling?) to offer any viable options. This is an incredibly unsafe experience. It comes with lots of fear and anxiety.


What effects do fear and anxiety have on physical symptom experience? I can tell you that they don’t make them any better. Fear and anxiety contribute to bodily hypervigilance. Which can contribute to… you guessed it… further symptoms. This is a nervous system loop which is so easy to fall into. So, healthcare experiences are fundamental to the rest of treatment and illness trajectories.


It is common knowledge that women tend to experience pain conditions (chronic pain, fibromyalgia, etc) and functional syndromes (IBS, bladder pain syndrome, chronic fatigue syndrome) at a much higher rate than men. Historically, patriarchal spheres of, typically, middle-aged, white, male physicians and academics have presumed that this is because women have a lower pain tolerance than men generally. Fortunately, research seems to be moving this notion on to a much less black and white conclusion than this. A systematic review of 10 years of research on gender differences in pain perception looked at 122 experimental studies and found that the majority of studies assessing pain intensity and unpleasantness showed no difference between genders [3]. Interestingly, there seemed to be an important role of the type of experimental pain stimuli in determining whether there were gender differences in pain tolerance or not. Females and males have comparable thresholds for pain experimentally induced using cold temperatures (e.g. using a cold pressor) and for ischemic pain (generally induced by a tourniquet around a limb interrupting blood flow with participants instructed to do particular exercises). Where gender differences in pain tolerance did seem to exist was in studies using heat as a pain or pressure as a pain stimulus. The reasons why these pain stimuli may differentially affect women compared to men may be explainable by a range of biopsychosocial factors including the role of hormones, evolutionary wiring and I’m sure much more. What is clear from these results, however, is that we cannot broadly conclude that women tolerate pain less than men. I.e. the socio-cultural gender norm of “weak women” and “strong men” does not fit the evidence. And yet this is a narrative that exists, albeit subconsciously, within the minds of physicians treating women.


This is a scary notion to confront. And yet it is necessary in order to address a very real problem that exists. Beyond the survey responses and numerous anecdotes I have myself and vicariously absorbed from women I have worked with, the research clearly demonstrates a negative bias against women. In an aptly titled systematic review, “Brave Men and Emotional Women”[4], researchers found significant gender bias in patient-professional interactions and the professionals’ treatment decisions for pain. Specifically, the study demonstrated a variety of gendered norms that were held about women versus men’s experience of pain (more sensitive), their identity (weak, emotional) and coping style (more likely to complain and need assistance). This fits with numerous other studies finding that women’s pain in more likely to be underestimated [5], which is understood to be a consequence of gendered norms.


If the stereotype is to think women are more expressive than men, perhaps ‘overly’ expressive, then the tendency will be to discount women’s pain behaviours… The flip side of this stereotype is that men are perceived to be stoic, so when a man makes an intense pain facial expression, you think, ‘Oh my, he must be dying!’” [5]

With attitudes like this, it is no wonder that women feel dismissed. But it goes beyond a negative emotional experience to having tangible and in some cases, devastating consequences. Women are half as likely to receive pain killers after surgery as men[1]. Women wait 10.6% longer than men for surgery [6]. And women are 32% more likely to die if treated by a male surgeon than a female surgeon [7].


The UK has the largest female health gap in the G20 and the 12th largest globally [1]. With The Lords 2021 Report and the Cumberlege Report [8] painting a stark picture of the nature and impact of this problem, it is clear that something has to be done. Encouragingly, these reports and surveys are recent. There appears to be an appetite for change. I continue to advocate for women in the healthcare system and conduct research shedding a spotlight on these areas. As you come to the end of this article, I wonder how you feel. Have you been a victim of this issue? Are you a bystander in a system where this issue is prevalent? Are you part of the problem? Did you meet some of this information with scepticism or with impatience? No matter what your experience of this article was, I invite you to ask, “how can I use this information to make a difference for me?”


If you are one of the many women who have felt dismissed by the healthcare system, I invite you to take this as a reminder that you are not a problem or burden. You deserve the care you seek.


References

[1] https://www.gov.uk/government/consultations/womens-health-strategy-call-for-evidence/outcome/results-of-the-womens-health-lets-talk-about-it-survey [2] Vallot S, Yana J, Moscova L, Favre J, Brossier S, Aubin-Auger I, et al. Shared decision making: what effectiveness on health outcomes? A systematic review. Exercer. 2019 Jan;(149):25–38. [3] Racine M, Tousignant-Laflamme Y, Kloda LA, Dion D, Dupuis G, Choinière M. A systematic literature review of 10years of research on sex/gender and experimental pain perception – Part 1: Are there really differences between women and men? PAIN. 2012 Mar 1;153(3):602–18. [4] Samulowitz A, Gremyr I, Eriksson E, Hensing G. “Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Pain Research and Management. 2018 Feb 25;2018:e6358624. [5] https://www.sciencedaily.com/releases/2021/04/210406164124.htm [6] Cima J, Guimarães P, Almeida Á. Explaining the Gender Gap in Waiting Times for Scheduled Surgery in the Portuguese National Health Service. PJP. 2021;39(1):3–10. [7] Wallis CJD, Jerath A, Coburn N, Klaassen Z, Luckenbaugh AN, Magee DE, et al. Association of Surgeon-Patient Sex Concordance With Postoperative Outcomes. JAMA Surgery. 2022 Feb 1;157(2):146–56. [8] https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf


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