Working toward gender equity in women’s health care

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.

–By Summer V. Allen, M.D.