gender bias in healthcare essay

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How to attain gender equality in nursing—an essay

Read our collection on the future of nursing.

• Related content
• Peer review
• Thomas Kearns , executive director 1 ,
• Paul Mahon , operational lead 2
• 1 Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
• 2 Centre for Nursing and Midwifery Advancement, Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
• Correspondence to: P Mahon pmahon{at}rcsi.ie

Tackling stereotypes and assumptions that deter men from nursing is essential to meet the growing shortage of nurses and improve diversity, say Thomas Kearns and Paul Mahon

The covid-19 pandemic shows that where, when, how, and to whom care is delivered has never been more diverse. In today’s healthcare, the people delivering care must be similarly diverse, for the benefit of the profession, its practitioners, and patients. 1 2 3 Yet around 90% of the world’s nurses are women. 4 Calls are being made, as they have before, to examine ways to promote the profession among men to tackle this imbalance. 1 5

Nursing is an inherently human experience: it is done for humans, by humans, and as humans, and in human experience no one gender claims primacy. Men have had, and continue to have, a valuable contribution to make to nursing, not simply because they are male but because they are human. Men enter the profession for the same reason as women—to care for people.

Huge shortage

Nurses are often the first, and sometimes the only, healthcare provider that a patient sees, 6 making them well positioned to respond to healthcare challenges at every level. One of the key challenges affecting the achievement of the sustainable development goals of health and wellbeing, 7 is the worldwide shortage of nurses. Recruiting more men is essential to tackle this shortage.

The world faces a deficit of 13.5 million nurses in the next decade. 4 8 In its first report on the state of the world’s nursing, 6 the World Health Organization estimated that an additional six million nurses will be needed by 2030. This is a 20% increase from the current total global nursing stock of 27.9 million. In addition, the burden of anticipated retirement over the next decade means that 4.7 million new nurses must be recruited just to maintain current staffing levels. 4 It is too early to say what effect the covid-19 pandemic will have on intention to join the profession, but initial estimates are that at least a further 10% will leave. 9 Data to monitor the effect of covid-19 on recruitment and retention of nurses will be vital.

Recent changes in society, healthcare globally, and nursing have seen more men entering the profession. In general, their number varies across regions ( table 1 ) and remains stubbornly low in some countries and clinical specialties such as obstetrics. 10 The reasons for this are unclear but may include cultural perceptions of the role of men and women in society, the status of nursing itself, or the pay and conditions of nurses. For example, a higher proportion of male nurses in some countries may reflect societal perceptions of the role of women, and vice versa. Further research into this area may provide useful insights into gender equity for all.

Percentage of male nurses worldwide*

• View inline

Why are men under-represented?

Contrary to the common perception that male nurses are a relatively recent phenomenon, men in nursing can be traced to 1600BC ( box 1 ). 16 History speaks of military and religious orders such as the Parabalani (“those who disregard their lives”)—a group of men who cared for people with leprosy in Alexandria in AD416, or St Camillus de Lellis, who in AD1535 vowed to care for sick and dying people. 5 12 The Maltese cross, a symbol of humanitarianism worn by the Knights Hospitaller in 1099, was subsequently adopted by the Nightingale School of Nursing in London. 14

Brief history of men in nursing

250BC: First nursing school in the world started in India. Only men were considered “pure” enough to become nurses 11 12

AD416-18: The Theodosian codes refer to the Parabolani—a group of 500 poor men who cared for the lepers of Alexandria 5 12

1095: Order of the Brothers of St Anthony founded (merged with the Knights of Malta in 1775) to care for people inflicted with the medieval disease of St Anthony’s fire 13 14 15

1099: Knight Hospitallers of St John of Jerusalem founded to care for sick and injured pilgrims en route to and from the Holy Land 13 15

1119: Order of Saint Lazarus of Jerusalem founded

1180: Order of the Hospitallers of the Holy Spirit and the Brotherhood of the Holy Spirit founded

1192: Order of Brothers of the German House of Saint Mary in Jerusalem, or the Teutonic Knights, founded

1334: The Beghards (renamed Alexian Brothers after Saint Alexis in 1469) cared for the poor, the lepers, and the “morons and lunatics” of Europe 5 14 16

1535: St John of God began studying under the monks of St Jerome and cared for the ill and mistreated

1585: St Camillus de Lellis became a priest and established a religious order, vowing to care for the sick and dying even with danger to his own life

1600s–1700s: Protestant reformation led to the closure of monasteries and convents across Europe resulting in a loss of records of organized nursing activity 14 16

1780s: Nurse James Durham (or Derham) became the first African American in the United States to practise medicine 12

1850–1950s : War began to alter nursing, and the role of men within it

1859: Florence Nightingale publishes Notes on Nursing , suggesting “every woman is a nurse”

1861–65: American civil war: more women became nurses in civilian life 12

1877: St John Ambulance Association founded (derived from the Knight Hospitallers )

1884: The Male Nurses (Temperance) Cooperation founded

1892: The Male Nurses Mutual Benefit Association founded

1888−1914: Alexian Brothers and other orders built hospitals throughout Chicago, Connecticut, Massachusetts, Missouri, New York, and Pennsylvania. Increasingly, men became nurses at their own social peril, experiencing discrimination, pay inequality, role erosion, and exclusion from formal nurse education 2 17

1914–18: American men were prohibited from practising in the US Army Nursing Corps

1919: The Nurses Act in England barred men from entering the general register. 5 11 14 15 Internationally, men found it difficult to access formal training and where they did, their training was shorter and lacked the curricular content of their female counterparts 5 15

1937: Society of Registered Male Nurses founded

1950s: Men begin to be recognized in nursing in the US, Czechoslovakia, the UK, 2 14 and towards the 1970s, in Denmark and Sweden 15

1971: American Assembly for Men in Nursing founded

By the mid-1800s as men fought and died during the Crimean, American civil, and other wars, more women became nurses. In the years after the introduction of the epochal Nightingale reforms, men were increasingly excluded from formal nurse education and eventually were barred from the English general register. 2 5 11 14 15 17

Combined with the gender based division of labor, and Victorian righteousness regarding the place of women in society, 14 15 16 18 the feminization of caring within the hierarchical male dominated medical model meant men wishing to do the dirty “women’s work” were classified as deviant, undesirable, or unable to get a “real man’s” job. As caring became devalued, more men were forced to find occupations with better pay so they could provide for their families. 16

The decline of the male nurse is a complex product of cultural, historical, economic, and political factors. In modern times, the move from the hospital based apprenticeship model of education to the tertiary setting has helped establish nursing as a profession. But rising entry requirements have not been accompanied by a corresponding increase in remuneration, making nursing a less attractive career option for men and women. In addition, gendered and inaccurate representations of nursing and male nurses limit the public’s perception and affect the recruitment and retention of men. 3 19

Men in the profession have also experienced stigmatization and have been disparately positioned as being both dominant and dominated, victimized and valorized, and of benefiting from the hidden advantages of status shield and status bonus that their gender affords. 20 21

Studies show that adverse stereotypes affect male nurses’ physical and emotional wellbeing, resulting in depression, demotivation, and in some cases their exit from the profession. 19 The perpetuation of such stereotypes and gender based labels injures the profession, preserves segregation, and stifles the pursuance of gender equality for all. 1 6 22 Moreover, they compound the shortage of nurses, limit diversity in the workplace, and deny patients of both genders a holistic caring environment. 1 5 23

What can be done?

Increasing the number of men in nursing is seen as difficult because of the erroneous perception that nursing is a female-only profession, sexist stereotypes of the male nurse being less masculine, 11 13 16 and nurses’ undervalued status and pay. Solutions are as complex as the genesis of the 200 year decline of men in nursing. There is no quick fix, and change requires political, sociocultural, and professional action. Although some solutions will be universal, ultimately each country and culture will have to determine what works best for them. Nurse leaders and politicians should offer long term, strategic solutions beyond mere marketing campaigns. 3

Better public understanding

That is not to say that marketing is not needed. Indeed, given the publicity afforded to the profession during the pandemic, now is an ideal time to set aside the nostalgic view of nursing 3 and capitalize on a contemporary civic conception of caring, competence, and capability throughout clinical settings from community to critical care.

The public has seen nurses caring for ventilated patients, using tablet computers so that family members could say goodbye to loved ones, leading covid testing centres, and innovating in practice. We have heard stories of nurses’ adaptability, resilience, determination, camaraderie, and composure. We have seen them hold patients’ hands and hold governments to account while fighting for proper personal protective equipment. This has given the public a better insight into the art and science of caring in modern healthcare, which we can build on to attract more men, and women, to the profession.

Neither patients nor the public fully understand the complexity of nurses’ work. 3 Highlighting nurses’ roles across domains of practice, registration status, and stage of career could promote a more realistic understanding, not just of men in nursing but of nursing itself. 24 Campaigns such as Nursing Now have raised the status and profile of nursing, and this momentum must be maintained. As part of this, we must de-gender and revalue caring 1 by attaining a gender balance and by continuing to advocate for better pay and conditions for nurses. 25

Better recruitment

Men enter and stay in nursing for many of the same reasons as women, and ultimately, they do so to care for patients. 24 Therefore, recruitment strategies that dispel the myths surrounding the male nurse while promoting the inherent values of nursing are needed. 10 We can look to countries with higher percentages of male nurses for direction.

For men becoming nurses mid-career, graduate entry should be an option—not just in terms of access to a place on the program but also with financial support to facilitate the uptake of that place. As countries seek to increase the number of nursing graduates, consideration could also be given to a specific allocation of places to male applicants to show that men are both missing and needed in nursing. 17 Many male nurse societies were established in the mid-1800s, and such social supports, including the provision of male role models, will help retain men in the profession.

More financial investment

WHO recommends that nursing education be considered a science subject. 6 Therefore, nursing should be afforded the status, pay, and benefits of other science and technology professions. For example, a senior staff nurse (a nurse with over 20 years’ experience) in Ireland earns just under €50 000 (£43 000; $61 000) in base pay a year whereas a pharmacist earns the same after seven years and up to €67 000 after 13 years. 26

Adequate pay and acceptable working conditions, 6 mobility, and opportunity for personal and professional advancement must underpin and be highlighted in recruitment and retention initiatives.

Confrontation of stereotypes

Stereotypical assumptions must be challenged at school and societal level in careers guidance, mainstream and social media, and popular culture so that boys know that nursing is a valid career option. 3 19 27 28 29 This will require greater intersectoral and cross government collaboration from the early years to higher education levels, 6 and for broadcasters to consider how their programming may negatively portray nursing and male nurses. We must robustly voice our objection to any outdated overtures that disenfranchise the profession and the people within it.

We must also promote professional acceptance and challenge stereotypes and assumptions in the profession itself—such as those in relation to male nurses’ sexuality, ability to care, or reasons for entering the profession. For example, the literature often refers to the “hidden advantage” of male nurses and the over-representation of men in leadership positions without examining broadly why this is so.

Although there may be many individual and institutional reasons for this “glass elevator,” including conscious and unconscious bias, hegemonic masculinity, explicit or tacit discrimination, continuity of employment, organizational gendering practices, or the personal and professional characteristics of the individual nurse, 17 30 31 such discussion conflates the problem of attracting men to the profession with the career progression of all nurses. Indeed, examining ways to empower all nurses thorough initiatives such as the International Council of Nurses’ global nurse consultants initiative will help improve health, promote gender equality, and support economic growth. 32

Continuing men’s long history in nursing

Men have a rich and varied history in nursing, a history that is somewhat lost to the last 200 years and the often misquoted preface of Florence Nightingale’s Notes on Nursing that “every woman is a nurse.” Less well quoted, however, is her full contention that “While it has been said and written scores of times, that every woman makes a good nurse I believe, on the contrary, that the very elements of nursing are all but unknown.”

The consequences of the lack of men in nursing can be considered in terms of the effect on male nurses themselves, the profession as a whole, and on the patients that nurses serve.

To increase the number of men in nursing, it is important to highlight to men their historical past and their potential future in a rewarding, contemporary career with myriad clinical, academic, and professional development opportunities. The profession must continue to lobby governments to move beyond mere platitudes and actually provide parity of pay and esteem. We must portray to the public the true scope and complexity of our professional practice, 3 and we must build a profession for all through robust policy that focuses on education, jobs, practice, and leadership.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

Provenance and peer review: Commissioned; externally peer reviewed.

This article is part of a series commissioned by The BMJ for the World Innovation Summit for Health (WISH). The BMJ peer reviewed, edited, and made the decision to publish. The series, including open access fees, is funded by WISH.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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• Open access
• Published: 22 September 2020

Gender disparities in clinical practice: are there any solutions? Scoping review of interventions to overcome or reduce gender bias in clinical practice

• Lorena Alcalde-Rubio 1 ,
• Ildefonso Hernández-Aguado 1 , 2 ,
• Lucy Anne Parker 1 , 2 ,
• Eduardo Bueno-Vergara 1 &
• Elisa Chilet-Rosell   ORCID: orcid.org/0000-0002-9091-7255 1 , 2  

International Journal for Equity in Health volume  19 , Article number:  166 ( 2020 ) Cite this article

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Introduction

Gender, understood as “social relationships between males and females in terms of their roles, behaviours, activities, attributes and opportunities, and which are based on different levels of power”, [ 1 ] is one of the main social determinants of health [ 2 ]. The damage caused to population health by gender inequality across the globe is immense and justifies comprehensive actions addressing gender equity in health at all levels [ 3 ]. In the words of Hawkes and Buse, “Now is the time to take the call from Alma Ata in its literal sense—“Health is for All” not only for some. Embedding of gender in global health provides one promising route to attainment of the longstanding, but long-languishing, human right—the right to health” [ 4 ]. The root causes of gender inequality encompass all societal spheres and a multisectoral approach is required [ 5 ]. In fact, it has been shown that actions across multiple sectors in low and middle-income countries can improve a variety of health and development outcomes [ 6 ]. Therefore, there is no doubt that gender mainstreaming should pervade all policies. The UN Economic and Social Council embraced this approach in 1997 as “assessing the implications for women and men of any planned action, including legislation, policies, or programmes … so that women and men benefit equally, and inequality is not perpetuated” [ 7 ]. On global level, the impact of gender inequality on health was later included in the UN’s the Millennium Development Goals, and remains significant in the Sustainable Development Goals [ 8 ].

In the health domain, there has been a substantial interest in gender issues in the last two decades. Vlassof and García Montero explained why gender is key to understanding all dimensions of health including healthcare, health seeking behaviour and health status. Consequently, they proposed transformation in all areas of the health sector in order to integrate gender perspective [ 9 ]. This integral change should encompass actions on policy, research, training and programmes including interventions at the individual level. We have witnessed an appreciable increase in the consideration of gender in health plans [ 5 , 10 ] and particularly in those focused on women’s reproductive health [ 11 , 12 ]. However, more than 20 years of research from high-income, middle income and low-income countries shows that gender inequalities remain embedded in health systems [ 13 , 14 ]. Within health care systems, unconscious gender biases –based on gender stereotypes- and sexism affect patient care [ 15 , 16 ]. While policy and organisational changes are essential, the involvement of health workers can act as a catalyst of integral change in the healthcare system.

Since the recognition of gender bias in the clinical management of cardiovascular disease, [ 17 , 18 , 19 ] several other health problems have been the target of research, which shows the extent of gender inequity in health care. Last year, Nature Communications published a study analysing health data for almost 7 million men and women in the Danish healthcare system over a 21-year period, and showing that women were diagnosed later than men in more than 700 diseases [ 20 ]. Despite demonstrated disparities in women’s health and advocacy to improve women’s health, there is still a lack of patient centred care for women.

These contributions from research on the relevance of gender inequalities in health care have not gone along with research on effective interventions that could provide health workers with practical tools that facilitate the application of gender oriented clinical interventions. In addition, the lack of patient centred care for women has been reported recently [ 21 , 22 , 23 ]. In fact, Celik et al.’s 2010 review of the available literature, [ 24 ] the authors failed to find references that contributed to the development of procedures to increase health professionals’ skills related to gender. Health systems and health providers remain largely gender unresponsive [ 13 ]. In order to move forward we need to assess the available experience in reducing gender-based inequities and, where possible, learn how to scale-up effective interventions. Our objective here is to identify available tools that can be used to overcome or reduce gender bias in clinical practice.

Material and methods

This scoping review was developed following the Arksey and O’Malley’s methodological framework, which we used to guide our reporting where possible [ 25 ]. We specifically searched for articles examining interventions to reduce or prevent gender bias in clinical practice, as long as they were provider-focused and healthcare-based.

Search strategy

The primary search was performed in Medline through PubMed, Web of Science, Scielo and Lilacs. Modifications on our search strategy in Medline through PubMed were made several times to ensure highest sensitivity. Finally, we decided to combine two individual searches to expand our search in Pubmed and we then made minor modifications to adequate the search strategy to each database. The final search strategies combined Subject headings and MeSH terms related to “gender”, “healthcare”, “bias”, “disparities”,“inequality”,“inequity” and “intervention” (Table  1 ).

In order to retrieve as many interventions studies as possible, we applied no date limitations and retrieved all results published until December 2018.

Study selection

We included empirical studies designed to prevent or decrease gender bias in clinical practice and those that were focused on other types of prejudice (such as race, age …) as long as they also evaluated gender bias. Similarly, we included studies designed to evaluate the effect on gender bias of interventions already implemented for a different primary objective (e.g. improving adherence to guidelines). These interventions should be provider-focused and healthcare-based. We only included studies that evaluated the interventions. Given the heterogeneity in the evaluation of gender bias, we included studies that assessed or measured any outcome related to clinical practice in a gender-disaggregated way (e.g. in-hospital adverse events) or the effects of interventions designed to reduce gender-based vulnerability of specific population (LGBTI+ populations, women suffering from intimate partner violence). We only included studies that were published in peer-review journals in English, Spanish and Portuguese. Exclusion criteria included non-empirical or descriptive studies, interventions focused only on patients and description of programmes or interventions without an evaluation of the impact.

All search results were first screened based on title and abstract by two researchers. The full text of potentially useful records was reviewed. We read all potentially useful texts and their reference lists were also revised for additional interventions. A detailed flow diagram of study selection is showed in Fig.  1 .

Flow diagram for identification of interventions to reduce gender bias in clinical practice

Data extraction and synthesis

We carried out the data extraction using a standardized data extraction form. Data were collected on the health issue, country, description of intervention (later categorized in clinical decision support guidelines and standardized protocols; interventions that included staff, clinic and community interventions; interventions managed by an all women team for female patients; gender sensitive improvements in data collection, and routine screening for gender violence), type of evaluation (considering the comparison group and the use of routine or non-routine-data) clinical setting (hospital, specialized care, primary health care, and others), main results and conclusions (later classified as successful or partially successful and not successful).

In order to evaluate the application of gender perspective in research reporting, we used the SAGER guidelines checklist adapted to our data extraction form [ 26 ]. In this case, we obtained information from the following items: introduction (explanation on whether sex and/or gender differences may be expected); methods (explanation on how sex and gender were taken into account in the design of the study, whether they ensured adequate representation of males and females, and justification of the reasons for any exclusion of males or females); results (in addition to sex-disaggregated data, it includes variables that facilitate gender analysis); and, discussion (implications of sex and gender on the study results and discussion of the implications of the results stratified by sex or from gender perspective).

Firstly, we performed an initial analysis of five papers by two researchers in order to homogenize data coding. Researchers agreed in four papers. After consensus on the assessment of the main variables, we proceed with the remaining articles. For the second set of articles, two researchers extracted data independently. A third research was in charge of detect discrepancies between researchers. Discrepancies were detected in four papers and were solved by consensus between the two researchers that reviewed each paper. Those discrepancies were related to minor variations on the length of text extracted to justify their answers and did not influence the interpretation of the results.

We performed a descriptive analysis of the information obtained from items formerly described.

After removing duplicates, we screened 3082 abstracts retrieved through database search. Additional file 1 : Appendix 1 presents detailed information of the 22 [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ] studies included in our scoping review.

When reporting the interventions, information regarding sex differences and the gender perspective: two of the studies failed to include whether sex and/or gender may be an important variant of the health outcome assessed in the introduction section (9%), three of the studies failed to report how the researchers ensured adequate representation of males and females in the sample (14%), in nine of them lacked variables/information that enabled a gender-based analysis (40%). Five studies did not discuss sex differences or apply a gender perspective (23%) and six did not discuss the implications of the results from a gender perspective (27%) (Table  2 ).

The interventions analysed were mainly focused on cardiovascular disease ( n  = 13, 59%) and, sexual and reproductive health, including one intervention focused on sexual orientation and gender identity ( n  = 5, 23%). Other themes were gender-based violence ( n  = 1), unhealthy drinking (n = 1), diabetes (n = 1) and renal failure (n = 1) (Table  3 ). Seventeen studies were conducted in USA (77%); the others were located in Brazil ( n  = 2), India (n = 1), Tanzania (n = 1) and Singapore (1).

Interventions were conducted more frequently in hospitals ( n  = 14, 64%). We found several types of intervention. Most studies included clinical decision support decision support guidelines and standardized protocols (15, 68%). These studies were aimed to reduce variability in healthcare and were not specifically designed to reduce gender bias. There was a cluster of studies (5) related to the program in the United States called Get with the Guidelines (GWTG) [ 49 ]. This initiative was focused on the redesign of hospital systems in order to improve the quality of patients care and was based on a collaborative model and Internet-based Patient Management. The GWTG included interactive learning sessions, teleconferences, and electronic communication between multidisciplinary teams from hospitals in a variety of settings to facilitate the transfer of the “how-to”, which is considered necessary to produce system-wide change. Finally, there were interventions that included activities involving staff, clinic, and community interventions (3, 14%), two studies evaluated data collection in a more gender-sensitive way, one more was an intervention managed by an all women team for female patients (2, 9%), and finally one study evaluated the implementation of gender violence screening.

The evaluations of the interventions were mostly conducted without comparison group and using routine data (7, 32%) or with a pre and post comparison and using routine data (6, 27%). The other 9 studies used non routine data (quantitative, qualitative and mixed data) and a variety of designs: randomised control group (2, 9%), non- randomised control group (2, 9%), without comparison group (3, 14%) and pre-post comparison (2, 9%).

The majority of the interventions (19, 86%) were mostly successful in narrowing the gender gap (See Annex 1 for more details). Four of them were unable to narrow this gap in all outcomes. There was no difference in cardiovascular events, quality of life, knowledge, attitudes and practices in women with cardiovascular disease after intervention [ 42 ]. A discharge tool was less used in women after acute myocardial infarction than in men [ 38 ].. Fewer women than men with heart failure received hospital discharge instructions and the length of the stay was longer for women even after implementation [ 32 ]. Additionally, the gender violence screening raised doubts in clinicians [ 39 ]. On the other hand, three studies were not successful in any outcome: two interventions in cardiovascular disease [ 36 , 43 ] and one in unhealthy drinking [ 48 ]. The latter one stated that a non-gender-specific threshold for an intervention in alcohol misuse was detrimental as may increase gender differences in receipt of brief intervention among patients.

Despite the extensive and growing evidence of gender bias in clinical practice published in scientific journals since the 90s, our scoping review has shown that few studies have tried to tackle this bias. After screening over 3082 abstracts in health sciences databases, we identified only 22 evaluated provider-focused and healthcare-based interventions. Most of the analysed studies focused on cardiovascular diseases and were strategies to improve adherence to existing guidelines in order to reduce variability in healthcare. It is noteworthy that even though the studies included in our scoping review described interventions that could reduce gender bias in clinical practice, we identified shortcomings in the reporting of the information from a gender perspective. Most of the interventions were successful in narrowing the gender gap in at least one of the outcomes even when they were not intended or seeking to reduce the gender gaps. Therefore, it is likely that future innovative interventions designed according to the theoretical bases that originate gender bias could result in higher reductions on gender bias.

There are, however, some limitations in our study. Firstly, the difficulty to find suitable articles, which we addressed by redefining our search and inclusion criteria several times in order to increase sensitivity. Secondly, the methodology of the studies was heterogeneous and could hinder the comparisons between studies. In addition, considering that some of the results of the analysed interventions were based on studies lacking a comparison group, interpretations should be cautious. Finally, interventions were conducted on few countries, which could difficult to replicate them in different contexts.

Although we identified few studies which sought to reduce gender bias in clinical practice, the interventions examined were mostly successful, demonstrating that narrowing gender gaps in healthcare is possible. This scoping review is a starting point, which, along with barriers and facilitators of interventions to reduce gender gap in healthcare already described in literature [ 24 ], can guide future interventions. The analysed interventions showed that gender disparities in healthcare could be reduced and even eliminated if clinician’s adherence to guidelines increased. Most of these interventions proposed the protocolization of technical procedures that aimed to reduce differences by sex and other variables without seeking specifically to reduce gender biases in health care - and may or may not result in that reduction. In contrast, interventions designed with the aim of reducing gender bias included different strategies (like programs managed by an all women team or improvement of the data collection system) and all of them were successful or partially successful in their objectives.

Most of the studies, particularly those focused on technical procedures, were based on specialized health care and hospitals. There is a lack of studies addressing this problem in primary healthcare (only two studies were based on this setting). If the narrowing of gender biases occurs in primary care, its impact could be even greater due to the volume of patients treated in these centres and because it is the patient’s first contact with the healthcare system [ 50 ].

Gender bias in clinical practice was described for the first time in the New England Journal of Medicine [ 17 , 18 , 19 ]. Almost 30 ago, Bernadine Healy used the term “Yentl syndrome” equating women with myocardial infarction to the character Yentl - a Jewish woman who dressed herself as a man to be able to study the sacred texts [ 18 ]. Healy was denouncing the fact that women have to show the same symptoms as men to receive the appropriate diagnosis and treatments, because the knowledge of cardiovascular disease was based on studies conducted on men. Since then, many studies have addressed gender bias in clinical practice, particularly in cardiovascular disease. In concordance with this, cardiovascular health was the predominant issue addressed in the analysed interventions. However, gender bias has been described in the clinical practice of a great number of diseases, [ 20 ] so it is necessary to expand the field of work to other health issues.

Importantly, physicians –and, the health system in general– have the potential to either reproduce or perpetuate disparities, or to overcome them. Even if the results of the interventions are encouraging, we need to question the theoretical framework in which these gender inequities originated. This may be why some interventions were not successful, as simply implementing instruments, while necessary, is not enough to tackle gender bias in professionals. It is important to advocate for reforms aimed to include gender aspects in the curricula of medical schools and in health research in order to advance in the field of gender- specific medicine [ 51 ].

Conclusions

In contrast to the wide research identifying gender bias in health care, few studies, so far, have described and evaluated interventions aimed to tackle this bias. However, there is some empirical evidence showing how to narrow the gender gaps in healthcare, as the reviewed literature reveals that that most of the interventions were successful at achieving at least one of the expected outcomes. Nevertheless, it is alarming that studies of interventions in primary healthcare, where the impact of narrowing of gender bias could be greater, are almost absent in the present available research.

Based on the results of our review, we consider that knowledge about the causes of gender inequities in healthcare should permeate new research on how to increase gender equity and improve quality in clinical practice.

Implications for practice and/or policy

Future clinical practice interventions should be developed with a gender perspective and should be comprehensive, long-term, experimental, evaluated with standardized methods, and specifically developed to tackle gender bias. In addition, they should address not only the women-man dichotomy, but also the gender continuum. Interventions should consider facilitators and barriers to include gender perspective in healthcare and they should always be adapted to the specific context, moment and population targeted. Finally, successful implementation is not enough, monitoring is essential. Standardized indicators and audits need to be developed for a structural embedding of gender in clinical practice.

Availability of data and materials

All available data is included in the publication.

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Home / Women's Health / Working toward gender equity in women’s health care

Working toward gender equity in women’s health care

In medical settings, women aren't always getting what they need. Find out how gender bias plays a role in health care and what you can do about it.

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It’s been more than 50 years since women in the U.S. have been publicly advocating for equal rights, opportunities and freedoms. Despite the progress of the women’s rights movement, one analysis found that almost 90% of men and women around the world are biased against women in some way.

Sadly, one place this bias can show up is in health care. If you’re a woman or femme-presenting, perhaps you’ve been at an appointment and haven’t felt heard. Maybe you felt you have no other choice than to do what your provider prescribed. No matter how this has potentially manifested in your life, you are not alone.

Learn more about spotting gender inequity in health care, promoting equality in health care and women’s health care rights.

Identifying gender inequity in health care

To spot inequity, you have to know what it is. It’s helpful to understand the difference between equity and equality:

• Equality is ensuring everyone has the same resources. In health care, this could be offering breast cancer screening to all populations.
• Equity considers the specific resources and opportunities people need to take advantage of equality. This could be ensuring that people without transportation can access cancer screening, perhaps with a mobile mammogram unit.

Unfortunately, health care all too often falls short in delivering equality and equity to marginalized populations. This is true for race and ethnicity, but also for gender.

Gender refers to culturally assigned roles associated with being a woman, man or nonbinary person. Gender can influence health care experiences:

• In an emergency. Women are less likely to receive CPR from bystanders, who cite fear of hurting the woman, or accusations related to inappropriate touching or sexual assault.
• On the way to the operating room. In a study, surgeons were 22 times more likely to recommend a knee replacement to a man with moderate knee osteoarthritis than a woman with the same disease severity.
• In a routine appointment. When women express concerns about their health, they aren’t always taken as seriously as men. One study found that health care providers estimated women to have less pain and be more likely to exaggerate it. Additionally, a review of literature on gender bias in health care found that men are more often perceived as stoic and pain-tolerant than women, who are perceived as more sensitive and likely to report pain.

It’s important to note that gender and sex are distinct . Sex refers to biological status as a male, female or intersex. There are some conditions and treatments that are unique to each sex that impact organs like the ovaries or prostate . These health differences are not the same as gender inequalities.

Women’s health care disparities

When there’s a difference between specific groups in how frequent, common, deadly, or costly a disease or other health condition is, that’s a health care disparity. Where there is inequality and inequity, there are health care disparities. Disparities can arise from bias, stereotyping, prejudice and clinical uncertainty. And health care disparities are associated with worse health outcomes.

Despite awareness campaigns and public-health initiatives, women continue to experience health care disparities and disadvantages in areas such as cardiovascular and maternal health.

Cardiovascular disease

Cardiovascular disease kills women more than anything else, accounting for one in three deaths each year. However, only about half of women know that it’s their greatest threat and that most cardiovascular diseases can be prevented. Women are 20% more likely than men to develop heart failure or die within five years of a first severe heart attack.

There are many reasons why cardiovascular disease seems to impact women more severely than men, but a few stark truths stand out:

• Regardless of heart-attack severity, fewer women are prescribed medications like beta blockers or cholesterol-lowering drugs.
• Women are seen by cardiovascular specialists less often than men.

Maternal health

The number of women who die during pregnancy , childbirth or right after delivering a baby has been increasing in the U.S. Women who die during this period often experience a complication — like severe bleeding or infection — that can usually be prevented or treated.

Yet, there are factors — certainly globally, but even in the U.S. — that keep women from getting the care they need around childbirth. These factors include gender norms that de-prioritize the rights of women and girls, like a lack of quality and affordable sexual and reproductive health services.

How providers and the health care system can promote equity

Here’s some good news: Many health care organizations are aware of inequities and are working to address them. For example, the Centers for Disease Control and Prevention (CDC) has outlined a sweeping strategy to improve health equity that includes partnering with organizations to better understand how to create equity with various populations and ensuring equity in research.

Equity in research is especially important because medical research informs the development of clinical guidelines for care. There needs to be enough data available to inform how health care providers care for various groups of people.

Equity in research

Unfortunately, females haven’t been well represented in medical research. One reason for this is that the U.S. Food and Drug Administration (FDA) issued a guideline in 1977 that females of “childbearing potential” should not participate in clinical research studies, because some drugs caused serious birth defects. Although the FDA issued updated guidance in 1993 that essentially reversed this position, there is still a research gap today.

This lack of knowledge means that females aren’t getting optimal treatment in health care.

• Both sex and gender aren’t always reported demographics in clinical research, yet both factors impact how a drug might affect an individual.
• Many studies have excluded females, and instead generalize data from males.
• It’s estimated that only 39% of clinical trials include equal numbers of females and males.
• Disease prevalence among females isn’t always reflected in clinical studies and trials. For example, 30% of people with gout are female, yet only about 5% of clinical drug trial participants for gout are female.

What health care providers can do

Health care professionals sometimes use a top-down approach to delivering care, rather than seeing care as a cooperative effort with their patients.

“In training, there’s a term for patients that don’t follow your medical guidance — noncompliant. It’s a rather paternalistic approach to care that if ‘you didn’t do what I told you to do,’ you (as a health care provider) go in with the anticipation the patient is disengaged in their care or will challenge you,” says Summer Allen, M.D.

Dr. Allen is an assistant professor with the Mayo Clinic Alix School of Medicine, a physician, and a member of the Knowledge and Evaluation Research (KER) unit at Mayo Clinic. She says that care can be more cooperative. Rather than focusing on compliance, it’s important to think about what motivates patients.

She says there’s sometimes a mismatch between the values of the clinician and the patient. The patient may be making decisions based on what’s most important to their quality of life or what they can realistically achieve, while the clinician may be guided by numbers and results.

For example, a health care provider might encourage a diabetic patient to eat more fresh vegetables and fruits. However, if the patient lives in a food desert — an area with limited access to affordable and nutritious food — they might struggle to adhere to this guidance.

And even if patient and clinician are on the same page about goals of treatment, “Not everyone has the capacity or resources to do everything their clinician recommends,” says Dr. Allen.

Case in point: The American Academy of Family Physicians reports that nearly half of American women skipped a preventive health service, vaccine or recommended treatment in the last year. Why? High out-of-pocket costs, limited time to make an appointment and difficulty scheduling an appointment are a few reasons mentioned.

Even if a woman can book a needed appointment, that doesn’t guarantee she will feel empowered in her care. Busy practitioners may rely on electronic medical records to come to conclusions about care before heading into an encounter with a patient, but Dr. Allen says that conversation between clinician and patient is essential.

“You are the expert in what you’ve been living with and what you are willing to do for your care,” says Dr. Allen. “Think of each visit as a dance — how you move together through a world of uncertainty.”

Your health care rights as a woman: What you should know

Whether you have a routine screening or specialized appointment, Dr. Allen says it’s important to participate in the conversation with your health care clinician. Specifically, here’s what Dr. Allen says you can do to exercise your rights and be engaged in your health care:

Make a list

Formulate questions, write them down and rank them. This allows your priorities to come through in the conversation. For example, if you come into a visit with knee pain, and mention that you’ve had some chest pain and depression, the knee pain might be your priority, but your health care clinician will likely want to explore the other issues. Having a list helps you ensure you don’t forget anything that’s important to you.

Ask what information a test or procedure will provide

Doing this helps give you visibility into where your care might go next. When you know how the outcome of the test or procedure will be used, you can make better decisions about whether the test or procedure is necessary. For example, if a procedure is designed to determine the viability of surgery, and you aren’t willing to have surgery, it’s not necessarily valuable to have the procedure done.

Request additional support when you need it

It’s OK to ask specifically about what will happen during a test or procedure — what you will experience, steps the practitioner will take and who will be involved.

“Some gynecological procedures will involve additional examination while under anesthesia and require patients to sign a consent form for the additional examination (i.e., pelvic exam). You have the choice to not consent, and you can ask questions about exactly what will happen during the procedure,” says Dr. Allen.

If you’re not comfortable undergoing a test or procedure alone, you can ask for help. For example, you can ask to have a chaperone during a test or procedure done in an OR setting. A nurse or other health care professional can attend and act as an advocate while you are under anesthesia.

Find a health care professional that you connect with

It’s possible that your personality might not match well with a specific practitioner, and you don’t have to stick it out if that’s the case. Consider asking friends and family members for recommendations, do your research, and let your clinician know.

“I tell patients up front, if it’s not working, tell me so that I can advocate for you to find the right match,” says Dr. Allen.

Exercising your health care rights isn’t a topic just for women. These same concepts apply to everyone. Your values matter, you have unique needs, and you can play an active and engaged role in supporting your health.

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• Introduction
• Conclusions
• Article Information

For the Gender-Career IAT, implicit measures include 34 662 women and 7624 men; explicit measures, 34 835 women and 7675 men. For the Gender-Specialty IAT, implicit and explicit measures included 45 women and 85 men. Error bars represent SE. Standard errors for the Gender-Career IAT data are so small that they are not visible on the graph.

Explicit bias scores are calculated as the difference between the responses to 2 self-reported items about participants’ associations of gender with career and family (Gender-Career Implicit Association Test [IAT]) or with surgery and family medicine (Gender-Specialty IAT).

eTable 1. IAT Design for Gender and Surgery vs Family Medicine

eTable 2. Regression Analysis Predicting Implicit and Explicit Bias From the Gender-Specialty IAT

• Implicit Bias in Surgery JAMA Network Open Invited Commentary July 5, 2019 Fahima Dossa, MD; Nancy N. Baxter, MD, PhD

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Salles A , Awad M , Goldin L, et al. Estimating Implicit and Explicit Gender Bias Among Health Care Professionals and Surgeons. JAMA Netw Open. 2019;2(7):e196545. doi:10.1001/jamanetworkopen.2019.6545

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Estimating Implicit and Explicit Gender Bias Among Health Care Professionals and Surgeons

• 1 Section of Minimally Invasive Surgery, Department of Surgery, Washington University in St Louis, St Louis, Missouri
• 2 Medical student, School of Medicine, Washington University in St Louis, St Louis, Missouri
• 3 Department of Psychological and Brain Sciences, Washington University in St Louis, St Louis, Missouri
• Invited Commentary Implicit Bias in Surgery Fahima Dossa, MD; Nancy N. Baxter, MD, PhD JAMA Network Open

Question   Do surgeons and health care professionals hold implicit or explicit biases regarding gender and career roles?

Findings   A review of 42 991 Implicit Association Test records and a cross-sectional study of 131 surgeons provided evidence of implicit and explicit gender bias. Data suggest that health care professionals and surgeons hold implicit and explicit biases associating men with careers and surgery and women with family and family medicine.

Meaning   This work contributes an estimate of the extent of implicit gender bias within medicine; awareness of bias, such as through an Implicit Association Test, is an important first step toward minimizing its potential effect.

Importance   The Implicit Association Test (IAT) is a validated tool used to measure implicit biases, which are mental associations shaped by one’s environment that influence interactions with others. Direct evidence of implicit gender biases about women in medicine has yet not been reported, but existing evidence is suggestive of subtle or hidden biases that affect women in medicine.

Objectives   To use data from IATs to assess (1) how health care professionals associate men and women with career and family and (2) how surgeons associate men and women with surgery and family medicine.

Design, Setting, and Participants   This data review and cross-sectional study collected data from January 1, 2006, through December 31, 2017, from self-identified health care professionals taking the Gender-Career IAT hosted by Project Implicit to explore bias among self-identified health care professionals. A novel Gender-Specialty IAT was also tested at a national surgical meeting in October 2017. All health care professionals who completed the Gender-Career IAT were eligible for the first analysis. Surgeons of any age, gender, title, and country of origin at the meeting were eligible to participate in the second analysis. Data were analyzed from January 1, 2018, through March 31, 2019.

Main Outcomes and Measures   Measure of implicit bias derived from reaction times on the IATs and a measure of explicit bias asked directly to participants.

Results   Almost 1 million IAT records from Project Implicit were reviewed, and 131 surgeons (64.9% men; mean [SD] age, 42.3 [11.5] years) were recruited to complete the Gender-Specialty IAT. Healthcare professionals (n = 42 991; 82.0% women; mean [SD] age, 32.7 [11.8] years) held implicit (mean [SD] D score, 0.41 [0.36]; Cohen d  = 1.14) and explicit (mean [SD], 1.43 [1.85]; Cohen d  = 0.77) biases associating men with career and women with family. Similarly, surgeons implicitly (mean [SD] D score, 0.28 [0.37]; Cohen d  = 0.76) and explicitly (men: mean [SD], 1.27 [0.39]; Cohen d  = 0.93; women: mean [SD], 0.73 [0.35]; Cohen d  = 0.53) associated men with surgery and women with family medicine. There was broad evidence of consensus across social groups in implicit and explicit biases with one exception. Women in healthcare (mean [SD], 1.43 [1.86]; Cohen d  = 0.77) and surgery (mean [SD], 0.73 [0.35]; Cohen d  = 0.53) were less likely than men to explicitly associate men with career ( B coefficient, −0.10; 95% CI, −0.15 to −0.04; P  < .001) and surgery ( B coefficient, −0.67; 95% CI, −1.21 to −0.13; P  = .001) and women with family and family medicine.

Conclusions and Relevance   The main contribution of this work is an estimate of the extent of implicit gender bias within surgery. On both the Gender-Career IAT and the novel Gender-Specialty IAT, respondents had a tendency to associate men with career and surgery and women with family and family medicine. Awareness of the existence of implicit biases is an important first step toward minimizing their potential effect.

Enrollment of women in medical school has been nearly equivalent to that of men in the United States since 1999 1 and has recently surpassed that of men for the first time. 2 Despite this apparent equality, as of 2017 only 41% of all faculty and approximately 24% of full professors were women. 3 These gaps are even larger when looking at department chairs: only 14% are women. 4 Many factors likely contribute to women’s lack of equal representation in medical careers beyond medical school. Perhaps academic medical careers are less interesting or attractive to women than they are to men, or maybe pressures within medical training and academics favor men over women.

Implicit biases, or mental associations outside of conscious awareness or control that influence one’s interactions with others, 5 may hinder the advancement of women in medicine. Sometimes, implicit biases lead people to act in ways that are not in line with their explicit beliefs or values. 6 For example, one may explicitly believe that men and women are equally good at math. However, implicitly or unconsciously, one might be more likely to associate math with men than with women. These biases are shaped by the environment in which we live and are only weakly related to one’s conscious attitudes or beliefs. Importantly, implicit biases are associated with behaviors in socially sensitive contexts, such as interracial interactions. 7 , 8

Direct evidence of implicit biases concerning women in medicine has not yet been reported, to our knowledge, but existing evidence is suggestive of subtle or hidden biases. For example, women physicians are often addressed as Nurse instead of Doctor or are introduced by their first name rather than their title. 9 A study from 2016 showed that Medicare reimbursements to female physicians are lower than reimbursements to male physicians. 10 When Silver et al 11 tracked societal awards given out since 1945, they found that many societies had never given an award to a woman. Women are also less likely than men to be invited to give grand rounds, particularly as an outside speaker. 12 One might argue that these discrepancies are due to women being less competent than men. However, these biases persist even in experiments in which candidates are matched on qualifications but differ in gender. For example, despite identical qualifications on a curriculum vitae, evaluators perceive male applicants to be more hirable and worthy of higher salaries than female applicants. 13 Together, these data suggest that bias is an important factor that preempts women’s success in medicine.

The Implicit Association Test (IAT) was developed and validated to measure implicit biases 14 and has demonstrated high internal consistency and robust evidence for predictive validity in numerous studies. 7 , 15 , 16 To understand the degree of gender bias within the broad context of hospitals and health care systems, we examined the data of several thousand health care professionals who took the Gender-Career IAT from Project Implicit, the largest host of online IATs, with more than 26 million IATs started since 1998. Similar to how others have used IATs to assess health care professionals’ weight bias 17 or associations of race with adherence, 18 we developed a novel Gender-Specialty IAT to assess how surgeons associate men and women with surgery and family medicine. Surgery is of particular interest because of the known gender imbalance in the field, with only 25% of assistant professors being women. 19 Previous data suggest that men and women in surgery perceive a gender ability stereotype to exist within this field. 20 We chose family medicine as a comparison field because it may not be widely stereotyped as being masculine or feminine compared with other medical specialties. We hypothesized that men and women would be faster to associate men with surgery and women with family medicine than the reverse.

We followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for reporting cross-sectional studies. Use of the Gender-Career IAT data and recruitment for the Gender-Specialty IAT were approved by the institutional review board of Washington University in St Louis, St Louis, Missouri. Participants taking the Gender-Specialty IAT provided written informed consent.

In an IAT, people sort words that appear on the screen into categories as quickly as they can. Concepts that are closely associated should be easier to sort together quickly. For example, in the Gender-Career IAT, participants sort gender ( male or female ) and career ( career or family ). In 1 part of the Gender-Career IAT, participants sort words related to male or career to one side of the screen and words related to female or family to the opposite side. In the next part, they do the reverse: instead of male/career and female/family being sorted to the same side, male/family are sorted together, as are female/career . The test uses reaction times for these tasks as a measure of the strength of associations between concepts. Thus, if one is faster at pairing male with career and female with family than male with family and female with career , a stronger association for men with careers and women with families than the reverse is suggested.

The Gender-Career IAT is hosted on the Project Implicit site and has been taken by 953 878 people during the past 12 years. From January 1, 2006, through December 31, 2017, 42 991 people who took the Gender-Career IAT self-identified as working in health care, and approximately one-fourth of these self-identified as diagnosing and treating professionals. The remaining categories of participants in health care are listed in Table 1 . We downloaded the full data set, which is available from Project Implicit. 21 In addition to the measure of implicit bias, the Gender-Career IAT included 2 questions assessing explicit bias: “How strongly do you associate career with males and females?” and “How strongly do you associate family with males and females?” Responses ranged from “strongly female” (1) to “strongly male” (7). As in previous IAT research, the measure of explicit bias was calculated as the difference between these 2 items, ranging from −6 (career is strongly female, whereas family is strongly male) to 6 (career is strongly male, whereas family is strongly female). 22

We developed an IAT with 2 categories (male and female) and 2 attributes (surgery and family medicine) based on the work of Greenwald and Banaji 5 and the Gender-Career IAT available at Project Implicit. 23 We replaced the terms for career and family with terms for surgery and family medicine . To ensure reliability of the IAT, stimuli must be accurate, clear, and similar across categories. 24 Based on pilot data, we revised the terms for this study to make them even more evocative of surgery and family medicine. Initially chosen words, such as scalpel and operating room, could cause indecision for participants because they could be associated with ideas other than surgery. They also had no corresponding terms in family medicine. Professional organizations, on the other hand, are easy to recognize and could be matched to both specialties. Thus, we ultimately used logos from societies such as the American Board of Surgery and the American College of Surgeons. eTable 1 in the Supplement shows the terms and images used for surgery and family medicine as well as the test blocks. The names of men and women we used were the ones used in the Gender-Career IAT (Ben, John, Daniel, Paul, Jeffrey, Julia, Michelle, Anna, Emily, and Rebecca). The order of the blocks was randomly assigned so that some participants were first asked to associate male with surgery and female with family medicine, whereas others were first asked to associate male with family medicine and female with surgery . The IAT was run from the Project Implicit website 21 with support from Project Implicit.

At the completion of the IAT, participants were asked questions similar to those on the Gender-Career IAT to assess their explicit bias about gender. One read as follows: “How strongly do you associate surgery with males and females? ” with responses ranging from “strongly female” (1) to “strongly male” (7). Similar to the Gender-Career IAT, a parallel question was asked about family medicine. Explicit bias was calculated as the difference between these 2 items, ranging from −6 (surgery is strongly female, whereas family medicine is strongly male) to 6 (surgery is strongly male, whereas family medicine is strongly female). Participants were also asked demographic questions, including gender, race, title, country, and region. For ease of data collection, data were collected using tablet devices.

We collected data from the Gender-Career IAT on Project Implicit and focused most analyses on participants who work in health care fields. For the novel Gender-Specialty IAT, we recruited surgeons (in practice and in training) in attendance at the American College of Surgeons meeting in October 2017 in San Diego, California. They were recruited by volunteers throughout meeting hotels and the convention center. Participants received a $10 Amazon gift card in exchange for their participation.

Data were analyzed from January 1, 2018, through March 31, 2019. The IAT is scored using the D score, a measure of bias based on the reaction times in the experimental blocks of the test (sequences 3 and 5 in eTable 1 in the Supplement ). 15 The D score is a variation on the Cohen d and is calculated by taking the difference in the mean reaction times for those 2 sequences divided by the pooled SD. The D scores range from −2 to 2, with positive D scores indicating a stronger association of men with career (or surgery) and women with family (or family medicine) and negative scores indicating the reverse. D scores are roughly equivalent in interpretation to the Cohen d , with a D score of 0.50 meaning that a participant was 0.5-SD faster in responding to men and career (or surgery) and to women and family (or family medicine) than the reverse. The means reported for the implicit IAT measure as well as those used in regression analyses for that measure are the means of the D scores.

The D score is a within-participants effect size comparing differences between one’s reaction times in 2 IAT blocks. The Cohen d , by contrast, is an effect size comparing the within-participant effect size with an external standard (eg, the point of no preference or a group mean). Thus, although the D score is an estimate of the difference in response times between blocks on the IAT, the Cohen d is an estimate of how different that score is from the point of no preference (in a single-sample test) or how different the scores of 2 different groups are from each other (when comparing means of 2 groups). As is common, we interpret effect sizes of approximately 0.2 to be small, approximately 0.5 to be medium, and approximately 0.8 or greater to be large. 25

For the Gender-Career IAT, we examined the overall D scores for health care professionals as well as differences in the D score and the measure of explicit bias by type of worker. We also analyzed differences in implicit and explicit bias by gender, age, and region.

We performed similar analyses for our novel Gender-Specialty IAT. Participants received feedback on their performance at the end of the IAT. We analyzed the D scores to assess the overall mean as well as any differences by gender, title, or region.

For both IATs, we used 2-tailed t tests for comparisons between 2 groups and analysis of variance for comparisons among multiple groups. We used linear regression analyses while controlling for demographic variables to examine associations between those variables and implicit and explicit bias. The threshold for statistical significance was set a priori at 2-sided α = .05 for all statistical analyses. All analyses were performed in SAS, version 9.4 (SAS Institute Inc). Only complete responses were included in analyses.

A total of 42 991 health care professionals completed the Gender-Career IAT ( Table 1 ). Consistent with the health care workforce, 82.0% of respondents were women, and 18.0% were men. Mean (SD) age was 32.7 (11.8) years. Most participants (69.2%) were white. A little more than one-third (33.5%) were nursing and home health care assistants, and 24.9% were diagnosing and treating professionals. Data were also available from 910 887 participants who were not health care professionals (67.5% female and 68.3% white).

The IAT scores linking men with career and women with family were significantly different from zero among health care professionals (mean [SD] D score, 0.41 [0.36]; Cohen d  = 1.14) and non–health care professionals (mean [SD] D score, 0.37 [0.38]; Cohen d  = 0.97). Health care professionals exhibited slightly stronger implicit associations for men with career and women with family than non–health care professionals ( t 46,921  = −23.65; P  < .001; Cohen d  = 0.11). Interestingly, female (mean [SD] D score, 0.44 [0.35]; Cohen d =  1.23) and male (mean [SD] D score, 0.31 [0.39]; Cohen d  = 0.79) health care professionals exhibited implicit associations of men with career and women with family that were significantly different from zero. These associations were stronger among female health care professionals than among male health care professionals ( t 10,621  = 26.89; P  < .001; Cohen d  = 0.35). A significant difference was evident among the categories of health care professionals such that diagnosing and treating professionals whose scores were significantly different from zero (mean [SD] D score, 0.37 [0.38]; Cohen d  = 0.97) showed significantly lower scores than each of the other categories ( t  ≤ −4.76; P  < .001 for all pairwise comparisons).

In regression analyses of implicit bias from gender, age, ethnicity, and country, we found that women were slightly more likely than men to associate men with career and women with family ( B  coefficient, 0.13; 95% CI, 0.12-0.14; P  < .001). Other statistically significant findings are given in Table 2 , such as the findings related to age, race, and country of residence. However, the regression coefficients are so small that these findings are not practically significant.

Explicit bias responses associating men with career and women with family were significantly different from zero for both women (mean [SD], 1.43 [1.86]; Cohen d  = 0.77) and men (mean [SD], 1.44 [1.79]; Cohen d  = 0.80) in health care ( t 11,585  = −0.64; P  = .52, Cohen d  = −0.01 for the comparison by gender). Explicit bias was significantly different from zero among health care professionals (mean [SD], 1.43 [1.86]; Cohen d  = 0.77) and non–health care professionals (mean [SD], 1.36 [1.73]; Cohen d  = 0.79). Health care professionals exhibited more explicit bias than non–health care professionals ( t 46,554  = −7.23; P  < .001; Cohen d  = 0.04). All categories of health care professionals expressed explicit bias linking men with career and women with family, including diagnosing and treating professionals (mean [SD], 1.50 [1.61]; Cohen d =  0.93), nursing and home health care assistants (mean [SD], 1.41 [1.98]; Cohen d  = 0.71), and other health care support (mean [SD], 1.39 [1.87]; Cohen d  = 0.74). When we compared categories of health care professionals, those professionals who were diagnosing and treating patients were more likely to explicitly associate men with career and women with family than were nursing and home health care assistants ( t 24,717  = 4.06; P  < .001; Cohen d  = 0.05) and other health care support ( t 23,298  = 5.07; P  < .001; Cohen d  = 0.06).

In contrast with the regression analysis of implicit bias, Table 2 demonstrates that women were less likely than men to express an explicit association of men with career and women with family ( B coefficient, −0.10; 95% CI, −0.15 to −0.04; P  < .001). Hispanic participants and participants of other races/ethnicities were less likely than white participants to explicitly associate men with career and women with family (Hispanic participants: B coefficient, −0.11 [95% CI, −0.18 to −0.03]; t 32,009  = −2.72; P  = .007; participants of other races/ethnicities: B coefficient, −0.18 [95% CI, −0.26 to −0.09]; t 32,009  = −3.96; P  < .001).

We collected complete data on the Gender-Specialty IAT from 131 participants. Table 3 provides the demographic characteristics of the participants in the study. Eighty-five participants (64.9%) were men and 45 (34.4%) were women. The mean (SD) age of these participants was 42.3 (11.5) years, and 77 (58.8%) were white. Participants were distributed across all titles (assistant professor, associate professor, and full professor).

The mean IAT score indicated a significant association linking men with surgery and women with family medicine (mean [SD] D score, 0.28 [0.37]; Cohen d  = 0.76). No difference in IAT scores was found between male and female participants ( t 99.04  = −0.11; P  = .91; Cohen d  = −0.03). When we restricted data to those living in the United States, no significant difference in gender bias was found by region ( F 3,80  = 0.89; P  = .45).

None of the demographic variables we collected correlated with implicit bias. As shown in eTable 2 in the Supplement , no demographic variables were statistically significant in a regression analysis of implicit bias from gender, age, race, and title.

Explicit bias responses associating men with surgery and women with family medicine were significantly different from zero for men (mean [SD], 1.27 [0.39]; Cohen d  = 0.93) and women (mean [SD], 0.73 [0.35]; Cohen d  = 0.53). Men expressed more explicit bias than did women ( t 88.50  = −2.11; P  = .04; Cohen d  = 0.39).

As shown in eTable 2 in the Supplement , regression analysis of the explicit bias measure from gender, age, race, and title found that women were less likely than men to associate men with surgery and women with family medicine ( B coefficient, −0.67; 95% CI, −1.21 to −0.13; P  = .001). Those in private practice also were less likely to associate men with surgery and women with family medicine than those who had listed their title as “other” ( B coefficient, −1.13; 95% CI, −1.96 to −0.29; P  = .009). Those who identified as Asian were more likely than white participants to associate men with surgery and women with family medicine ( B coefficient, 0.81; 95% CI, 0.13-1.48; P  = .02). There was no difference in explicit bias in surgery by age ( B coefficient, 0.02; 95% CI, −0.01 to 0.05; P  = .26).

Figure 1 and Figure 2 show differences between men and women on levels of implicit and explicit bias. These figures illustrate the finding that women expressed lower levels of explicit gender bias than did men. Data for the implicit measures were mixed, with women expressing slightly higher levels of implicit bias than men on the Gender-Career IAT, whereas no difference by gender was noted on the Gender-Specialty IAT.

The data from Project Implicit’s Gender-Career IAT suggest that men and women in health care strongly implicitly associate men with career and women with family. With regard to explicit bias, however, men in health care were more likely than women to associate men with career and women with family. These findings are similar to what we found with the Gender-Specialty IAT assessing bias among surgeons. Surgeons tended to associate men with surgery and women with family medicine. Thus, from both data sets we found that, although men and women associated men with career and surgery (and women with family and family medicine), men were more likely than women to consciously express a bias linking men with career or surgery and women with family or family medicine. Future research should replicate these findings and assess whether these biases are linked to existing gender disparities. For example, previous studies 26 - 28 suggest that women may be more likely than men to leave surgical residency, and implicit gender biases could play a role. Girod et al 29 have also suggested that implicit bias among senior faculty may contribute to the gender disparity in leadership roles in academic medicine.

On the novel implicit measure of gender bias about surgery and family medicine, we found evidence of consensus. Across all social categories assessed (gender, race, title, region of the United States, and country of origin), participants taking our novel Gender-Specialty IAT expressed implicit and explicit bias about men and women in surgery. We found that male and female surgeons’ implicit gender-specialty biases were large and similar in magnitude to male and female health care workers’ implicit gender-career biases. With explicit biases, we found evidence of a difference between genders. Explicit gender-specialty biases for male surgeons were large and similar in magnitude to explicit gender-career biases for male health care workers. However, explicit gender-specialty biases for female surgeons were smaller than explicit gender-career biases for female health care workers. This difference could be due to variation in sample populations or topics assessed. These data, although not definitive, suggest that biases linking surgery with men and family medicine with women may be widespread across the United States among surgeons. Unlike the Gender-Career IAT, we did not identify a difference between the genders in implicit bias on the Gender-Specialty IAT. However, this finding may be due to the smaller sample size in the Gender-Specialty IAT.

Diversity is important to the success of organizations. 30 , 31 Specifically, organizations with more diverse leadership are more productive and profitable. Patients, who come from many different backgrounds, are more satisfied with their care when it is provided by someone who looks like them. 6 , 32 Given that women are approximately 50% of the population and that an increasing percentage in the United States is of minority race or ethnicity, we must ensure that we foster physicians of all gender and racial groups. Having diverse people in leadership positions ensures that role models and potential mentors are available for all applicants. 33 Role models and mentors, in turn, are important for recruiting trainees who are members of underrepresented groups. 34 To improve recruitment and retention of diverse trainees, we need to better understand the factors that contribute to underrepresentation of women.

For many, awareness of bias is an important first step toward minimizing its effects. 35 The data presented herein help to raise awareness of gender bias within medicine. In addition, these data allow trainees to understand the context in which they will practice, thus better preparing them for their future work environment. Finally, this study adds to the existing evidence that organizations can use to make the case for prioritizing diversity and possibly implicit bias training.

This study lacks granularity about health care fields from the Gender-Career IAT data. Thus, we are not able to isolate, for example, physicians exclusively. The category of diagnosing and treating professionals may include dentists, nurse practitioners, and physician assistants, for example. In addition, selection bias for the Gender-Career IAT may lead to a lower estimate of the degree of bias present generally. As many as 0.43% of respondents may have been repeated sessions. Data from these IATs do not allow us to assess the effect of intersectionality or other genders, since both IATs focused on male/female gender alone. We cannot determine whether those sessions were different individuals using the same computer or the same individual.

A limitation of the novel Gender-Specialty IAT is that we recruited participants attending a surgical meeting. We appear to have undersampled older surgeons. This limitation is unlikely to affect the results dramatically because results on the Gender-Career IAT and other similar IATs found only small correlations between age and implicit biases. 22 If anything, having fewer older surgeons may underestimate the degree of gender bias in this context. Our sample size for the novel Gender-Specialty IAT is modest.

The main contribution of this work is an initial estimate of the extent of implicit gender bias within health care. Future research could examine implications of implicit gender biases on gender inequality and discrimination. Other research already provides some interventions for addressing gender bias regardless of whether it comes from implicit bias or other sources. For example, increasing transparency of hiring and promotion policies, considering diversity as a performance metric for organizations, and promoting flexible leave all serve to increase the success of female physicians and trainees. 36 - 38 Further documentation of implicit associations and other potential psychological obstacles to women’s success will be important for determining the most effective interventions to reduce gender inequality. It is important to also intentionally study the effects of bias on individuals who hold more than one minority identity, such as black or Hispanic women. Such research will benefit current medical students who will become our physicians tomorrow.

Accepted for Publication: May 15, 2019.

Published: July 5, 2019. doi:10.1001/jamanetworkopen.2019.6545

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2019 Salles A et al. JAMA Network Open .

Corresponding Author: Arghavan Salles, MD, PhD, Section of Minimally Invasive Surgery, Department of Surgery, Washington University in St Louis, 4901 S Euclid Ave, Ste 920, St Louis, MO 63108 ( [email protected] ).

Author Contributions: Drs Salles and Lai had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Salles, Awad, Goldin, Lai.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Salles, Goldin, Lai.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Salles, Goldin, Lai.

Administrative, technical, or material support: Salles, Lee.

Supervision: Salles, Awad.

Conflict of Interest Disclosures: Dr Salles reported receiving honoraria from Medtronic plc for consulting and speaking. Dr Lai reported serving as the director of research for Project Implicit. No other disclosures were reported.

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Medical Myths About Gender Roles Go Back to Ancient Greece. Women Are Still Paying the Price Today

W e are taught that medicine is the art of solving our body’s mysteries. And we expect medicine, as a science, to uphold the principles of evidence and impartiality. We want our doctors to listen to us and care for us as people. But we also need their assessments of our pain and fevers, aches and exhaustion, to be free of any prejudice about who we are. We expect, and deserve, fair and ethical treatment regardless of our gender or the color of our skin.

But here things get complicated. Medicine carries the burden of its own troubling history. The history of medicine, of illness, is every bit as social and cultural as it is scientific. It is a history of people, of their bodies and their lives, not just of physicians, surgeons, clinicians and researchers. And medical progress has not marched forward just in laboratories and benches, lectures and textbooks; it has always reflected the realities of the changing world and the meanings of being human.

Gender difference is intimately stitched into the fabric of humanness. At every stage in its long history , medicine has absorbed and enforced socially constructed gender divisions. These divisions have traditionally ascribed power and dominance to men. Historically, women have been subordinated in politics, wealth and education. Modern scientific medicine, as it has evolved over the centuries as a profession, an institution and a discipline, has flourished in these exact conditions. Male dominance—and with it the superiority of the male body—was cemented into medicine’s very foundations, laid down in ancient Greece.

In the third century BCE, the philosopher Aristotle described the female body as the inverse of the male body, with its genitalia “turn’d outside in.” Women were marked by their anatomical difference from men and medically defined as faulty, defective, deficient. But women also possessed an organ of the highest biological—and social—value: the uterus. Possession of this organ defined the purpose of women: to bear and raise children. Knowledge about female biology centered on women’s capacity—and duty—to reproduce. Being biologically female defined and constrained what it meant to be a woman. Women’s illnesses and diseases consistently related back to the “secrets” and “curiosities” of her reproductive organs.

Of course, not all women have uteruses, and not all people who have uteruses, or who menstruate, are women. But medicine, historically, has insisted on conflating biological sex with gender identity. As medicine’s understanding of female biology has expanded and evolved, it has constantly reflected and validated dominant social and cultural expectations about who women are; what they should think, feel and desire; and—above all else—what they can do with their own bodies. Medical myths about gender roles and behaviors, constructed as facts before medicine became an evidence-based science, have resonated perniciously. And these myths about female bodies and illnesses have enormous cultural sticking power. Today, gender myths are ingrained as biases that negatively impact the care, treatment and diagnosis of all people who identify as women.

For example, health-care providers and the health-care system are failing women in their responses to and treatment of women’s pain, especially chronic pain. Women are more likely to be offered minor tranquilizers and antidepressants than analgesic pain medication. Women are less likely to be referred for further diagnostic investigations than men are. And women’s pain is much more likely to be seen as having an emotional or a psychological cause, rather than a bodily or biological one. Women are the predominant sufferers of chronic diseases that begin with pain. But before our pain is taken seriously as a symptom of a possible disease, it first has to be validated—and believed—by a medical professional. And this pervasive aura of distrust around women’s accounts of their pain has been enfolded into medical attitudes over centuries. The historical—and hysterical—idea that women’s excessive emotions have profound influences on their bodies, and vice versa, is impressed like a photographic negative beneath today’s image of the attention-seeking, hypochondriac female patient. Prevailing social stereotypes about the way women experience, express, and tolerate pain are not modern phenomena—they have been ingrained across medicine’s history. Our contemporary biomedical knowledge is stained with the residue of old stories, fallacies, assumptions, and myths.

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Over the past few years, gender bias in medical knowledge, research, and practice has hit the mainstream. Headlines like “Why Won’t Doctors Believe Women?,” “Doctors Are Failing Women with Chronic Illness,” and “Doctors Are More Likely to Misdiagnose Women Than Men” crop up regularly in the U.K. and U.S. press. Public awareness is growing around the way that women are all too frequently being dismissed and misdiagnosed. We’re learning that medical sexism is rife, systemic and making women sicker. But women are not a monolithic category. The discrimination women encounter as medical patients is magnified when they are Black, Asian, Indigenous, Latinx, or ethnically diverse; when their access to health services is restricted; and when they don’t identify with the gender norms medicine ascribes to biological womanhood.

It seems ridiculous now to imagine physicians once believed that women’s nerves were too highly strung for them to receive an education and that their ovaries would become inflamed if they read too much. But these outrageous myths are alive and well in a world where menstruation and menopause are still seen by many people as credible reasons why women shouldn’t hold positions of political power. When clinical research exempts women from studies and trials on the grounds that female hormones fluctuate too much and upset the consistency of results, medical culture is reinforcing the centuries-old myth that women are too biologically erratic to be useful or valuable.

Since the 1960s, feminist health campaigners have fought tirelessly against the suppression of drugs’ side effects and systemic gender and racial bias in clinical research, from both inside and outside the medical establishment. Women forced changes in law and practice by campaigning from the ground up. Their efforts, ultimately, have made medications, including the contraceptive pill and hormone replacement therapy, safer for all women. And medical feminism has a long, fascinating, and inspiring history of women raising their heads above the parapet to ensure that women are represented, cared for and listened to. Feminist social reformers denounced medicine’s perpetuation of women’s “natural” inferiority in the 18th century. Grassroots activists in the 1970s empowered women to reclaim the ownership and enjoyment of their bodies from man-made medical mystification, and created knowledge for women, by women. In the decades and centuries in between, feminist physicians, socialists, researchers and reformers have defended women’s body rights and freedoms—from normalizing menstruation and celebrating sexual pleasure to legalizing contraception and defending reproductive autonomy.

Medicine is working to revolutionize its practice and protocols, but there is a long legacy to quash when it comes to women’s bodies and minds. I know from experience that this legacy continues to stymie effective and timely care, diagnosis, and treatment. It is well past time for medicine’s checkered past to give way to a future where the fabric of women’s experience is recognized and respected in its entirety.

I believe that the only way to move forward, to change the culture of myth and misdiagnosis that obscures medicine’s understanding of unwell women, is to learn from our history. In the man-made world, women’s bodies and minds have been the primary battleground of gender oppression. To dismantle this painful legacy in medical knowledge and practice, we must first understand where we are and how we got here. No unwell woman should be reduced to a file of notes, a set of clinical observations, a case study lurking in an archive. Medicine must listen to and believe our testimonies about our own bodies and ultimately turn its energies, time, and money toward finally solving our medical mysteries. The answers reside in our bodies, and in the histories our bodies have always been writing.

Adapted from Unwell Women by Elinor Cleghorn. Copyright 2021 by Elinor Cleghorn. Published by arrangement with Dutton, an imprint of Penguin Publishing Group/Random House/The Knopf Doubleday Group, a division of Penguin Random House LLC.

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Research: How Bias Against Women Persists in Female-Dominated Workplaces

• Amber L. Stephenson,
• Leanne M. Dzubinski

A look inside the ongoing barriers women face in law, health care, faith-based nonprofits, and higher education.

New research examines gender bias within four industries with more female than male workers — law, higher education, faith-based nonprofits, and health care. Having balanced or even greater numbers of women in an organization is not, by itself, changing women’s experiences of bias. Bias is built into the system and continues to operate even when more women than men are present. Leaders can use these findings to create gender-equitable practices and environments which reduce bias. First, replace competition with cooperation. Second, measure success by goals, not by time spent in the office or online. Third, implement equitable reward structures, and provide remote and flexible work with autonomy. Finally, increase transparency in decision making.

It’s been thought that once industries achieve gender balance, bias will decrease and gender gaps will close. Sometimes called the “ add women and stir ” approach, people tend to think that having more women present is all that’s needed to promote change. But simply adding women into a workplace does not change the organizational structures and systems that benefit men more than women . Our new research (to be published in a forthcoming issue of Personnel Review ) shows gender bias is still prevalent in gender-balanced and female-dominated industries.

• Amy Diehl , PhD is chief information officer at Wilson College and a gender equity researcher and speaker. She is coauthor of Glass Walls: Shattering the Six Gender Bias Barriers Still Holding Women Back at Work (Rowman & Littlefield). Find her on LinkedIn at Amy-Diehl , Twitter @amydiehl , and visit her website at amy-diehl.com
• AS Amber L. Stephenson , PhD is an associate professor of management and director of healthcare management programs in the David D. Reh School of Business at Clarkson University. Her research focuses on the healthcare workforce, how professional identity influences attitudes and behaviors, and how women leaders experience gender bias.
• LD Leanne M. Dzubinski , PhD is acting dean of the Cook School of Intercultural Studies and associate professor of intercultural education at Biola University, and a prominent researcher on women in leadership. She is coauthor of Glass Walls: Shattering the Six Gender Bias Barriers Still Holding Women Back at Work (Rowman & Littlefield).

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Gender Inequalities in the Healthcare Sector

Inequalities in various aspects of social and economic life, and the question of overcoming them, are increasingly the subject of political decisions and the subject of academic research and papers. In addition to social justice and human rights values, they emphasize the importance of equal opportunity as a condition for social cohesion and social inclusion. This also applies to health inequalities, which have received considerable attention from the World Health Organization over the last decade.

In this essay, I would like to discuss gender inequalities in health care, as it is an issue of personal interest to me. I do not like hearing how girls are not advised to go into medicine because it is a “serious men’s job” or people do not take nursing jobs seriously and think they are too easy. Various gender inequalities in healthcare area occur in all countries. Inequalities are caused not only by living conditions but also by socio-cultural factors (values, norms, stereotypes) that shape the position of both sexes in society and people’s thinking and behavior about health.

Massive discrimination against women in the healthcare sector worsens the quality of care for people because of the deteriorating working conditions for this group of employees. This is because nurses and doctors who experience discrimination and unfair treatment are unable to provide appropriate care. This factor nullifies attempts to ensure the highest possible level of health for all people. I believe that society must stop discriminating against women in doctors’ posts and that the problem is severe enough to warrant a lot of media attention. In this way, society will ensure decent working conditions for women doctors and, hence, proper treatment for the population.

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IvyPanda. (2023, November 23). Gender Inequalities in the Healthcare Sector. https://ivypanda.com/essays/gender-inequalities-in-the-healthcare-sector/

"Gender Inequalities in the Healthcare Sector." IvyPanda , 23 Nov. 2023, ivypanda.com/essays/gender-inequalities-in-the-healthcare-sector/.

IvyPanda . (2023) 'Gender Inequalities in the Healthcare Sector'. 23 November.

IvyPanda . 2023. "Gender Inequalities in the Healthcare Sector." November 23, 2023. https://ivypanda.com/essays/gender-inequalities-in-the-healthcare-sector/.

1. IvyPanda . "Gender Inequalities in the Healthcare Sector." November 23, 2023. https://ivypanda.com/essays/gender-inequalities-in-the-healthcare-sector/.

Bibliography

IvyPanda . "Gender Inequalities in the Healthcare Sector." November 23, 2023. https://ivypanda.com/essays/gender-inequalities-in-the-healthcare-sector/.

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The deadly inequalities of gender bias in healthcare

If gender equality saves lives, then the opposite is also true.

Sep 16, 2022

Lakshmi Puri, who has served as both the UN Assistant Secretary-General and Deputy Executive Director of UN Women, put it best in a 2013 speech : “Gender inequalities affect health outcomes and must be addressed accordingly.”

If gender equality saves lives, then the opposite is also true: Gender inequality costs lives. This is especially true in healthcare, where gender bias is both endemic and potentially fatal. Here are nine ways gender bias in healthcare shows up — and how Concern is working to create a healthier world for all.

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A diagnosis with a long — and inaccurate — history

Some historians trace “hysteria” back to the days of the Ancient Greeks. However, as Sabine Arnaud writes in On Hysteria: The Invention of a Medical Category between 1670 and 1820, doctors from the 17th to 19th Centuries had a habit of retrofitting this term to give it more credibility as a diagnosis. While it applied to both men and women in the beginning, hysteria soon became a catchall term for many health complaints largely made by women—including premenstrual syndrome, premenstrual dysphoric disorder, anxiety, depression, and post-traumatic stress disorder.

By the end of the 1800s, treatment of hysterics in Paris’s Salpêtrière Hospital (methods included hypnosis and piercing) were sold as entertainment for the public. A generation later, Sigmund Freud refined the diagnosis—albeit through faulty and biased research. It was only in 1980 that “hysterical neurosis” was removed from the Diagnostic and Statistical Manual of Mental Disorders. Its legacy, meanwhile, lives on.

Handling physical pain “like a man”

The idea that pain is “all in your head” still disproportionately plagues women today, and applies to physical distress as well as mental. Some studies have shown that women use healthcare more often than men. This has led to a stereotype summarized in a 2017 Guardian article as: “Men are silent stoics; women hysterical hypochondriacs.”

This, as Diane E. Hoffmann and Anita J. Tarzian showed in their 2001 study, “The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain,” has implications on how women are treated. “In general, women report more severe levels of pain, more frequent incidences of pain, and pain of longer duration than men, but are nonetheless treated for pain less aggressively,” write Hoffmann and Tarzian. They attribute this in part to gender bias, specifically “a long history within our culture of regarding women’s reasoning capacity as limited.” The repercussions of this can be dire, Hoffmann and Tarzian add, as women are statistically more likely to receive inaccurate or inadequate treatment if their pain is not taken seriously.

“Men are silent stoics; women hysterical hypochondriacs.”

The waiting game for a diagnosis or care

In tandem with inadequate pain management is a lag time in getting an accurate diagnosis for women compared to men. The World Health Organization estimates that 10% of women around the world suffer from endometriosis, a chronic illness affecting women during their menstrual cycles. Yet the UK’s National Institute for Health and Care Excellence reveals that this diagnosis takes an average 7.5 years to reach — meaning that people seeking care for a monthly, chronic pain could spend as much as three-quarters of a decade finding the right course of treatment.

This is part of a pattern in how long it takes women to get answers versus men. One UK study examining over 18,600 people with 15 different types of cancer found that women consistently waited longer for a diagnosis after first noticing their symptoms. Women are also less likely to get adequate treatment for heart disease — or even CPR. One study of this, presented in 2017 and funded by the Heart Association and the National Institutes of Health, examined nearly 20,000 public cardiac arrest cases. Of these, 45% of the male cases were given CPR. Only 39% of women received the same treatment; something the study authors believed was a gender bias: “It can be kind of daunting thinking about pushing hard and fast on the center of a woman’s chest,” study lead Audrey Blewer told The Guardian.

A similar study , published in 2019, saw similar disparities along gender lines: Only 68% of women received bystander CPR, compared to 73% of men. The study, led by University of Amsterdam cardiologist Dr. Hanno Tan, also revealed that survival time between cardiac arrest and hospital admission was three percentage points higher for men (34% vs. 37%), and that the chances of survival from admission to discharge was nearly 50% higher for men (37% of women and 55% for men).

The gender bias of reproductive rights

Women’s legal rights in many countries — including those where Concern works — conflict with their human rights and requirements for quality reproductive healthcare. Often to fatal consequences. The United Nations Population Fund (UNFPA) estimates that 6.5% of women around the world want to avoid pregnancy, but are unable to do so due to a lack of access, social stigma, and harmful gender norms (among other reasons). Among them, 172 million women are using no birth control method at all. Where data is available, the UNFPA also reports nearly 25% of all women feel unable to say no to sex with their partner. “These [circumstances] all reflect the pressure that societies place on women and girls to become mothers,” concludes the UNFPA.

In many countries, pregnancy can be a death sentence for women and girls. Often this is due to gender biases. Pre-pandemic, an estimated 810 women died every day due to preventable causes related to their pregnancy or childbirth. Complete data have yet to indicate whether this number has gone up due to the pandemic. Almost all of these deaths occur in low-to-lower-middle–income countries. Part of this is due to a lack of infrastructure in many countries when it comes to healthcare, especially in remote and rural regions. Beyond this, however, pregnant and lactating mothers face a multitude of barriers when seeking care. Many cannot afford to access healthcare, receive poor quality service, or lack the information necessary to have a health pregnancy and childbirth. In some cases, harmful gender norms — such as women not being allowed to leave the house without a man’s permission or accompaniment — keep pregnant women at home and without the care they need and deserve. This is especially true for girls under 18.

The 10 Worst Countries to Be a Mother

Using the most recent data from the WHO, these are the ten “worst” countries to be a mother — at least in terms of how fatal the act of pregnancy and giving birth can be.

One way this can be prevented is by meeting the needs for reproductive healthcare and education—for girls/women and boys/men—from adolescent development through to maternal health and newborn care. A study from the Guttmacher Institute estimates this could reduce maternal mortality rates by nearly three-quarters in low-income countries.

Gender-based violence is a public health issue

As we’ve written before on gender-based violence, the issue is both a human rights violation and a public health crisis. Gender-based violence can affect survivors’ physical and mental health long after the attack itself. Many forms of GBV specifically affect the health of the targets of such violence, including FGM and sexual assault. Survivors need to have access to the resources they need in the wake of these events, such as emergency contraceptives and STD screenings.

However, the stigmas surviving survivors of sexual assault and other forms of GBV leave women reluctant to seek healthcare after an attack — even if there are specific laws against such behavior in the country where they live. Statistics vary by country, but in Bangladesh , only 30% of cases were reported as of 2015, and less than 3% of survivors pursued legal action.  A 2013 survey of 24 low-income countries showed that only 7% of cases went reported. Again, these gendered inequalities can have fatal consequences.

The research gap between men and women

One of the issues underpinning many of the above gender biases in healthcare is a lack of equity in research. Men’s and women’s bodies function differently from one another. Symptoms for the same condition or disease present differently depending on gender. Medications may have differing side effects. Yet often the research that fuels diagnoses and treatments is limited to male subjects and testing. Dr. Janine Clayton , Director of the Office of Research on Women’s Health at the National Institute of Health in the United States, explains that “much of medical science is based on the belief that male and female physiology differ only in terms of sex and reproductive organs, she says. Because of this, most research has been conducted on male animals and male cells.”

“Because we have studied women less, we know less about them. The result is that women may not have always received the most optimal care.” — Dr. Janine Clayton

Barriers for women working in healthcare

One way we could solve some of these gender inequalities is by establishing greater gender equity among those working in healthcare. Women are already highly represented in the frontlines of health. In the United States , they represent 66% of all entry-level healthcare employees. However, only 30% make it to the top of the ladder.

Headquartered in France and comprising 37 member countries, the OECD reports a similar statistic: Around three-quarters of people working in health and social care are women. However, the organization adds, “women working in the health and social care sector are often in lower-paid jobs.” Women represent less than half of all doctors in OECD member countries, and they often earn less than their male colleagues even after accounting for factors like age and experience.

This becomes a problem when female health workers are able to understand a fellow woman’s symptoms, but lack the credentials or respect to help influence adequate diagnosis and treatment. In addition to being underpaid, many women also complain of gender discrimination within their own workplace. An independent investigation of the British Medical Association (the trade union for doctors and medical students in the UK) found limited cases of sexual harassment, but stressed that even more harmful, were “the genuine complaints of the persistent undermining and undervaluing of some women doctors and staff, together with a corrosive and combative culture of ‘I’m right, and you’re wrong, and I know best, and you don’t know what you’re talking about.’”

Even if these incidents happen behind the proverbial closed doors, their impacts can be felt by patients.

Gender bias in healthcare is an intersectional issue

While women are statistically more likely to be discriminated against on the basis of their gender — in healthcare and in many other aspects of life — not all inequalities are experienced equally. Weight bias in healthcare has become a topic of greater study in recent years, and further study has shown that this, too, is more likely to affect women than men. This can lead to misdiagnosis as well as mental stress (and even eating disorders) for patients.

Race/ethnicity and income are also major compounding factors for receiving adequate healthcare — all the more for women. In some countries, marital status, caste, tribal affiliation, religion, sexuality, and immigration status (especially for refugees) are also additional issues that may make an already-discriminatory atmosphere even moreso.

Gender bias beyond the binary

Likewise, gender bias in healthcare becomes even more discriminatory when we look at gender beyond the binary of male and female. Even in high-income countries, transgender and nonbinary people often have fewer legal protections than women, and are more likely to face discrimination. A r ecent study of patients in the United States revealed that almost half of all trans adults in the country experienced discrimination from a healthcare professional based, or have been denied coverage for gender-affirming healthcare by their insurance. Two-thirds worry that their diagnoses and treatment will be affected by this discrimination.

“Rather than devising new ways to cope with changing social norms, transgender people are often shoehorned into inappropriate boxes instead,” writes BBC journalist Zaria Gorvett . There are similar issues at play around the world: A 2019 study revealed the lack of resources for reproductive healthcare for transgender people in South Africa. In Kenya, where homosexuality is against the law, there is also a lack of adequate resources and little support for the country’s transgender community.

Gender equality in healthcare: Your concern in action

Based on decades of experience, Concern has adopted an integrated approach to healthcare, especially for maternal and child health . We believe that many factors influence the health of mothers and children, such as nutrition, hygiene and sanitation, environment, gender attitudes, access to healthcare, and culture.

Much of our work involves designing solutions with mothers (and their partners) to the challenges faced every day in the world's poorest countries . At the community level, implement those solutions daily. At the national and international levels, we take every opportunity to advocate on behalf of women and children for better health outcomes.

In Malawi , our innovative Health Center by Phone project (funded as part of Innovations for Maternal, Newborn, and Child Health ) was integrated into the national health system, providing free access to health advice and telemedicine services in hundreds of remote communities.

Project Profile

Innovations for Maternal, Newborn & Child Health

Funded by the Bill and Melinda Gates Foundation, this program applied design thinking to improve the lives of the world’s most vulnerable women and children.

In Bangladesh , Burundi , Niger , Kenya , Rwanda , Haiti , and Sierra Leone , our Child Survival programs (funded by USAID) impacted millions of mothers and young children over the past 20 years. Our research in these programs contributed to life-saving advancements in community health.

Child Survival

For over 20 years, Concern fostered a simple, yet innovative, community-based revolution in maternal and child health.

In South Sudan , we have established a network of mobile health clinics providing health services to pregnant women, lactating mothers, and children under the age of 5, who otherwise would go without vital checkups or treatment, directly in their own villages.

“When mothers understand the risks and benefits and are well supported by their community, they are more likely to seek care,” explains Concern Health Advisor Megan Christensen. “It’s up to us to give them the knowledge and mechanisms they need to make healthier decisions for themselves and their families.”

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Opinion: Gender bias in healthcare

The systemic issues ingrained within the healthcare system perpetuate medical misogyny

By Devabala Smitha, Dr Moitrayee Das

Like several other developing countries, the Indian healthcare setting is plagued with gendered disparities. Women face layered disadvantages owing to their positionality as part of a vulnerable category, societal structure, patriarchal upbringing and institutions such as marriage that place them in a secondary status to men. Within domestic settings, more often than not, women experience differential treatment, like unequal division of labour and resource allocation, in terms of nutrition, education and healthcare. They are also increasingly susceptible to domestic abuse and intimate partner violence, regardless of urban-rural differences.

The National Family and Health Survey (2019-21) reported that 32% of ever-married Indian women have been subjected to physical, sexual, or emotional violence by their husbands. While women facing domestic abuse is a normalised part of our culture, their experience in medical settings too becomes analogous to that of their experiences within domestic settings.

Within healthcare settings, women often encounter situations where their reports of bodily discomfort are disregarded or minimised by healthcare providers, resulting in delays in diagnosis and treatment (Loughnan et al, 2020). Studies have shown that women are 2.8 times more likely to die from heart attacks than men (Maas & Appelman, 2010) due to delayed or denied health services. Meanwhile, men remain overdiagnosed for the same.

Culture-Pain Correlation

Culture greatly influences how pain is expressed and experienced by communities. In many Southeast Asian countries, the increased ability for pain tolerance is glorified and has much cultural significance attached to it. Societal roles and expectations guide the health-seeking behaviours of those communities (Campbell & Edwards, 2012). Although this forbearance is expected of both sexes, the quality of endurance to physiological suffering earns them respectability in their community.

The indulgence to live in excruciating pain then becomes a performative narrative in their lives, leading to its internalisation. This category of women may find seeking help from formal medical settings unnecessary, thereby imposing constraints or inhibitions that deter them from seeking professional medical assistance promptly (Wong & Thwaites, 2015). The result? The prevalence of menstrual disorders is about 22.7% in Southeast Asian populations (Dhar et al, 2023). Thus, women’s upbringing is rooted in societal norms, which causes a great deal of conditioning that influences their health-seeking behaviours.

Social conditioning, which suggests that women ought to bear pain, stems from gender (female) socialisation, which leads to internalised prejudice towards women’s pain and discomfort. This then becomes responsible for the formation of unconscious bias in healthcare providers since they, too, are a part of the society that propagates such attitudes. Women who do seek help for their health concerns may often encounter unconscious bias, thus experiencing a loss of autonomy/control over their health outcomes due to the lack of supportive care. Such exposures may lead to motivational deficits, characterised by delayed initiation of voluntary responses and reduced motivation to control their health outcomes (Holenstein, 2015). As a result, they may perceive that their efforts to seek help are in vain.

Women often encounter situations where their reports of bodily discomfort are disregarded or minimised by healthcare providers

When women are repeatedly made to endure aversive stimuli, such as dismissive attitudes from healthcare providers, they may internalise a sense of helplessness. This propagates an attitude that diminishes their motivation to seek help and control their health outcomes (Loughnan et al, 2020). This contributes to a cycle of disempowerment and dis/continued reliance on a healthcare system that fails to adequately address their needs, worsening/ accentuating their sense of powerlessness and submitting to the phenomenon of “learned helplessness”. (Fisher, 2015; Holenstein, 2015)

Medical Misogyny

Like many other societal institutions, the medical system, too, is inherently patriarchal. Aristotle, the father of biology, designated the female body as a distorted or mutilated form of the male body. This notion has persisted in Western medical culture, which has led to women and their bodies being historically excluded from knowledge-production activities, including trials, experiments and other forms of research (Jackson, 2019).

Even today, in contemporary healthcare settings, the patriarchal instinct to control female bodies, as per the idea of Foucauldian biopolitics, takes a front seat/is very prevalent. The persistence of outdated attitudes and practices continues to undermine patient care and satisfaction levels. From body shaming remarks that could amplify body dysphoria to a judgmental stance towards patients’ reproductive choices, the healthcare system often fails to provide compassionate and respectful treatment to the patients. Furthermore, misusing their authority, medical practitioners also often offer women unsolicited advice, particularly regarding marriage and childbearing, while overlooking health issues like dysmenorrhea, endometriosis and PCOS.

Over time, when women are repeatedly made to endure bias, dismissive attitudes and traumatic instances of violence from healthcare providers, they internalise a sense of helplessness (Loughnan et al). Research has shown that such feelings contribute to depressive symptoms, which indicates why there is a female predominance in such psychological distress in India (Gururaj et al, 2016; Santos et al, 2012).

It’s All in Your Head!

In 2019, a Guardian article observed that “medicine expected women to take control (with their minds) of their disease (in their body) by accepting their illness, making ‘lifestyle’ changes and conforming to their gendered social roles”. The higher prevalence of chronic pain coupled with higher susceptibility to mental health issues suggests how women live in constant pain. And what do doctors consistently tell female patients approaching with pain or any discomfort? That it is all in their head! Its invisibility and unverifiability are used to gaslight women into believing they are overthinking.

Pushed into self-doubt, they trivialise their own lived experience (Merone et al, 2022; Paul-Savoie et al, 2018). Of course, pain can be triggered by mental health conditions like anxiety and depression. Recently, a study published in Nature states that approximately 80% of autoimmune disease cases are reported in women due to rogue antibodies being attracted to x chromosomes (Dolgin, 2024). But, to think that it might be the only sane explanation for a woman’s pain has become the norm.

As Elaine Scarry noted in her The Body in Pain , “[t]o have great pain is to have certainty; to hear that another person has pain is to have doubt”. The systemic issues ingrained within the healthcare system perpetuate medical misogyny, resulting in the dismissal and gaslighting of women. Hence, it is crucial to establish a safe and trusting environment for all patients, regardless of gender. And healthcare should never be an act of generosity. It is well beyond time for providers to recognise that it is a fundamental human right and ensure they receive the care, support and respect they deserve.

(Devabala Smitha is UG 3rd year student and Dr Moitrayee Das is Assistant Professor of Psychology at FLAME University, Pune)

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