- Lindsay Ruggles, DNP, FNP-C
Gender Disparities in Health Care
I have admired Justice Ruth Bader Ginsburg for years and have long considered her an incredible role model to people everywhere. With her recent passing, I have looked back at her stunning career and her many accomplishments that have helped to advance women’s rights and promote equality of the sexes. Her passing has prompted me to reexamine gender equality in my realm of study and work: Healthcare. Even with how far we as a society have come the last several decades in promoting gender equality, we still have a long way to go when it comes to gender disparities in healthcare, particularly women and their health.
First off, let’s address who does what in healthcare. There are long-standing preconceived notions that many healthcare providers still deal with today in regards to gender. A female physician goes into a patient’s room and the patient mistakes her for the nurse. A male nurse goes into a patient’s room and the patient mistakes him for a physician. This happens frequently. Chaunie Brusie (2020) states, “According to the U.S. Bureau of Labor Statistics (BLS), as of 2019 more than 12% of registered nurses in the U.S. are men. And while nursing has been a historically female-dominated industry, the tide is certainly changing for gender equality in all professions” (para.1). According to the Kaiser Family Foundation (2020), Idaho has the highest percentage of male nurse practitioners out of all the states (18%). While the number of male nurses in the U.S. seems low, it is rising. In contrast, the percentage of female physicians in the U.S. is 36% (Kaiser Family Foundation, 2020). The majority of medical school students in the U.S. are now female (50.5%) (Searing, 2019). The “traditional” roles of who does what in healthcare are changing in both professions and slowly but surely becoming more gender- inclusive. As one can see by the numbers, there is still progress to be made, particularly in the nursing profession. My husband is a registered nurse and is still mistaken for a physician by many patients. At 6’4’’ with the build of a football player, patients are often shocked to find out that he is their nurse. He simply smiles and is genuinely proud to be a registered nurse. He loves what he does and is incredibly intelligent. Even still, that does not mean that it doesn’t sting many healthcare providers when patients automatically assume their roles based on gender. It hurts even more when patients make comments such as they don’t want the female physician because a male is more competent to do the job, or asking a male nurse why they weren’t smart enough to get into medical school. Comments that like are both ignorant and insulting. Unfortunately, we hear them more often than you would think.
That is just the tip of the iceberg. Let’s delve into the patient side of things. There is a lot to unpack regarding gender disparities in healthcare, especially in women’s health…here we go.
There has been a negative bias toward women’s health for centuries, simply because we have a uterus. For example, Aristotle said, “…that a female is an incomplete male or 'as it were, a deformity'” (Witt & Shapiro, 2018, section 1.1). The word hysteria, which means “frenzied, frantic, or out of control” originally meant a “…sex-selective disorder, affecting only those of us with a uterus. These uteri were often thought to be the basis of a variety of health problems” (McVean, 2017, para.1-2).
Galen, a physician and philosopher, believed that psychiatric, mood, and sleeping disorders were the result of retained blood in the uterus and sexual intercourse was the recommended treatment. The famous Sigmund Freud believed that hysteria was a female problem and he promoted getting married and having sex as a solution. Any medical condition considered a mystery or difficult to treat in women was labeled as hysteria by the men who dominated the medical profession. It was not until the 1980’s that hysteria was finally removed from the DSM (Diagnostic and Statistical Manual of Mental Disorders) (McVean, 2017).
It’s no wonder that women are often brushed off or not taken seriously when they present with medical problems, given what history shows us the attitude has been towards women’s health for centuries. Consider this: Up until 1993, women were routinely excluded from clinical drug trials in the early stages, resulting in a data shortage and knowledge gap regarding the effects of drugs on women. It was a woman who pushed for women to be included in these drug trials, Dr. Bernadine Healy, the first woman to become an NIH director (NIH, n.d.). So not only was women’s health misunderstood, researchers couldn’t even study how drugs directly affected women. In general, research for years excluded or underrepresented women, leading to a gap in knowledge of how many health conditions affect women (Seegert, 2018). Let’s take a look at how all of this translates to disparities in women’s health today.
Historically, women were viewed as objects rather than agents with their own voice, so health care did not often include women’s health in their central focus. As a result, significant barriers for accessing and utilizing health care services persist for women today, including inadequate awareness and acknowledgment of problems that arise in women’s health (Women and Gender Equity Knowledge Network, 2007). Women tend to have a different experience with healthcare than men, as their symptoms may differ from men and what is considered “typical.” One of the first examples that come to mind is women who have heart disease. What we think as typical symptoms of heart disease include chest pain, shortness of breath, jaw or shoulder pain, chest tightness, and weakness. However, women often present differently with symptoms including nausea, abdominal pain, dizziness, indigestion, fatigue, difficulty sleeping, and sometimes when they present with chest tightness and shortness of breath it is written off as anxiety. What is very troubling is that women are less likely to receive the same standard of care as men, including treatment from recommended guidelines and aggressive interventions. For respiratory diseases like asthma and COPD (chronic obstructive pulmonary disease), women more often experience a delay in diagnosis or a misdiagnosis than men. Female hormones also influence the severity of asthma, so women experience the disease differently than men (Inserro, 2018).
When we look at mental health in women, twice as many women experience depression than men. Hormonal, genetic, and reproductive differences in women may contribute to how women experience depression, including PMS/PMDD, post-partum, and post-menopausal depression. What is truly horrifying is that 30-50% of the time, depression is misdiagnosed in women and less than half of women with clinical depression seek out care. Attitudes surrounding depression in women likely contribute to this including the normalization of depression and shame or embarrassment surrounding seeking care (Mental Health America, n.d.).
Women with autoimmune conditions that cause chronic pain often experience a long delay in diagnosis or their symptoms dismissed, yet around 75% of people with autoimmune diseases are female. Due to how women were treated historically by health providers and the traditionally paternalistic approach in medicine that persists, coupled with society’s stereotypes about women, there is an implicit, unconscious bias towards women. Pain and symptoms are sometimes dismissed or a woman is told that it’s “all in your head.” This lack of trust in a woman’s self-report of symptoms is part of why many women are under-diagnosed or misdiagnosed, even though certain medical conditions disproportionally affect women, such as autoimmune diseases (Seegert, 2018).
There are many, many more examples that I could go through, but you get the idea. Obviously, there is a problem, and we need to do something to address it.
There needs to be more education for medical professionals regarding atypical symptoms that present in women for many conditions and research going forward should include more women participants, both of which will help to reduce gender disparities in healthcare. For health care providers, there needs to be a change in attitude toward female patients by learning to recognize and acknowledge the biases that we hold. For patients, don’t be so quick to assume the role of the health care professional who walks into your room based on their gender, or make assumptions about why they are in that particular role. Healthcare is changing and hopefully, there will be more equal representation of gender in the various healthcare professions in the future. For women, if your healthcare provider is dismissing your symptoms, or you feel that you are not being taken seriously, keep fighting. Get a second, third, fourth opinion if you have to. Trust yourself and listen to your body. Please know that there are healthcare providers out there that will listen and that do genuinely want to help you.
I will leave you all with a few quotes from Justice Ruth Bader Ginsburg:
“Real change, enduring change, happens one step at a time.”
“Women belong in all places where decisions are being made. It shouldn’t be that women are the exception.”
Here are a few video links to check out if you want to learn more about gender disparities in health care.
Bowerman, H. (2019, April 23). Gender Inequality in Health. YouTube. https://www.youtube.com/watch?v=rhiFLP4Gh-E
Arnold, C. (2019, November 6). Gender Bias Creates A Culture Of Disbelief For Female Patients. YouTube. https://www.youtube.com/watch?v=U1XvFSoUhWI
McGregor, A. (2015, November 5). Why Medicine Often Has Dangerous Side Effects for Women. YouTube. https://www.youtube.com/watch?v=sJCBM9ajA5s
Cedars-Sinai. (2020, March 6). Gender Disparities in Healthcare. YouTube. https://www.youtube.com/watch?v=FwJrXlpuaJU
mymedchoices (2019, March 1). Gender Bias in Healthcare- Why Women Don’t Trust Their Doctors. YouTube. https://www.youtube.com/watch?v=lH_t76oLcXQ
Lindsay Ruggles, DNP, FNP-C
Inserro, A. (2018, May 18). 5 Thing About Gender Disparities in Care to Remember as National Women’s Health Week Ends. American Journal of Managed Care. https://www.ajmc.com/view/5-things-about-gender-disparities-in-care-to-remember-as-national-womens-health-week-ends
Brusie, C. (2020, June 16). Why Nursing is a Great Career Choice for Men. Nurse.org. https://nurse.org/articles/Male-Nurses-And-The-Profession/
Kaiser Family Foundation. (2020, March). Professionally Active Physicians by Gender. KFF. https://www.kff.org/other/state-indicator/physicians-by-gender/?dataView=1¤tTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
Kaiser Family Foundation. (2020, March). Total Number of Nurse Practitioner, by Gender. KFF. https://www.kff.org/other/state-indicator/total-number-of-nurse-practitioners-by-gender/?dataView=1¤tTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
McVean, A. (2017, July 31). The History of Hysteria. McGill University, Office for Science and Society. https://www.mcgill.ca/oss/article/history-quackery/history-hysteria
Mental Health America (n.d.). Depression in Women. MHA. https://www.mhanational.org/depression-women#13
NIH Office of Research on Women’s Health. (n.d.). NIH Inclusion Outreach Toolkit: How to Engage, Recruit, and Retain Women in Clinical Research. NIH. https://orwh.od.nih.gov/toolkit/recruitment/history
Searing, L. (2019, December 23). The Big Number: Women now outnumber men in medical schools. The Washington Post. https://www.washingtonpost.com/health/the-big-number-women-now-outnumber-men-in-medical-schools/2019/12/20/8b9eddea-2277-11ea-bed5-880264cc91a9_story.html
Seegert, L. (2018, November 16). Women more often misdiagnosed because of gaps in trust and knowledge. Association of Healthcare Journalists.
Witt, C. & Shapiro, L. (Fall 2018 Edition). Feminist History of Philosophy, The Stanford Encyclopedia of Philosophy. Edward N. Zalta (ed.), https://plato.stanford.edu/archives/fall2018/entries/feminism-femhist/.
Women and Gender Equity Knowledge Network. (2007, September). Unequal, Unfair, Ineffective and Inefficient Gender Inequity in Health: Why it exists and how we can change it. Final Report to the WHO Commission on Social Determinants of Health. World Health Organization. https://www.who.int/social_determinants/resources/csdh_media/wgekn_final_report_07.pdf?ua=1