On 8 July 2021, the House of Lords is due to debate Baroness Jenkin of Kennington’s (Conservative) motion:
That this House takes note of the steps taken to improve women’s health outcomes.
Is there a gender health gap?
Health gaps are differences in the prevalence of disease, health outcomes, or access to healthcare across different groups. A study by Manual, a wellbeing platform for men, found that in many countries, men are more likely to face greater health risks. However, the UK does not follow this trend. It was found to have the largest female health gap in the G20 and the 12th largest globally.
A variety of studies have shown that in many areas of healthcare women experience poorer outcomes. For example, in 2016, researchers at University College London found that women with dementia receive worse medical treatment than men with the condition. They found that women make fewer visits to the GP, receive less health monitoring, and take more potentially harmful medication. Another study found that in US emergency departments, women who are in acute pain are less likely to be given opioid painkillers than men. Women also had to wait longer to receive painkillers when they were prescribed. In addition, University of Rhode Island researcher, Karen L Calderone has found that women are half as likely to receive painkillers after surgery.
In the UK independent reports and inquiries have highlighted situations where mostly women have suffered harm because of poor healthcare:
- Paterson Inquiry Report: This report presented the findings of a government commissioned independent inquiry into Ian Paterson, a surgeon who in 2017 was convicted of wounding with intent and sentenced to 20 years in prison. It found that he subjected more than 1,000 patients to unnecessary and damaging operations over 14 years. He mostly operated on women who had found a lump in their breast. He invented or exaggerated the risk of breast cancer to persuade them to have surgery and practiced a procedure he had developed that was unapproved and breached national guidelines.
- First Do No Harm Report: Also known as the Cumberlege report, this independent review into independent medicines and medical devices safety looked at the response of the healthcare system to patients’ reports of harm from drugs and medical devices. It focused on three medical interventions. Sodium valproate, an effective medication for epilepsy, but one that causes harm to unborn children when taken by their mother during pregnancy. Pelvic mesh, which is used to treat pelvic organ prolapse and urinary incontinence, and Primodos, a hormone pregnancy test taken between the 1950s and late 1970s, which is associated with birth defects and miscarriages. The report detailed the suffering of patients, many of them women, and found that the healthcare system is “disjointed, siloed, unresponsive and defensive”.
- Saving Lives, Improving Mothers’ Care Report: This report is one of several published by MBRRACE-UK as part of the maternal, newborn and infant clinical review programme. This report said that between 2016 and 2018, 217 women, or 9.7 women per 100,000, died during or up to six weeks after childbirth from causes associated with their pregnancy. It also highlighted disparities in maternal mortality rates amongst women from different ethnic groups. In the same period, 34 Black women died among every 100,000 giving birth, 15 Asian women died among every 100,000 and 8 white women died among every 100,000. Overall, the report found that systemic biases due to pregnancy, health and other issues prevent women with complex and multiple problems receiving the care they need.
Women are also more likely to experience common mental health conditions than men. While rates have remained relatively stable in men, research has found that prevalence is increasing in women. Young women in particular have been identified as a high-risk group, with over a quarter (26%) experiencing a common mental disorder—such as anxiety or depression—compared to 9.1% of young men. In addition, Office for National Statistics (ONS) data has shown that since 2012 suicides among females aged 10 to 24 have increased significantly: in 2019, it reached its highest level of 3.1 deaths per 100,000 females. However, in 2019, three-quarters of deaths registered as suicide were among men (4,303 deaths).
The Mental Health Foundation has said that social and economic factors can put women at greater risks of poor mental health than men. However, it has also highlighted that there are factors that protect women’s health, including the tendency for women to have better social networks and that many women find it easier to talk about their feelings.
In her book, ‘Invisible Women: Exposing Data Bias in a World Designed for Men’, Caroline Criado Perez has gathered various statistics that show how women are treated unevenly. She has argued that the data shows that healthcare is “systematically discriminating against women, leaving them chronically misunderstood, mistreated and misdiagnosed”.
Why is there a gender health gap?
Ms Criado Perez has argued that women have been considered less important in healthcare as far back as Ancient Greece. Arguing that the problem still exists due to a patriarchal world view being prevalent in our healthcare system, she said that women are routinely underrepresented in clinical trials and that medical research proposed by women, for women, is not allotted the same funding as medical research proposed by men, for men. Also considering why there are differences in the treatment women receive, Dr Janine Austin Clayton, director of the US Office of Research on Women’s Health, has argued that “we literally know less about every aspect of female biology compared to male biology”.
Explaining why this is the case, Irving Zucker, a professor emeritus of psychology and integrative biology at the University of California, Berkeley, said that for decades, women were excluded from clinical drug trials based, in part, on unfounded concerns that female hormone fluctuations make women difficult to study. He also said that until the early 1990s, women of childbearing age were kept out of trial studies due to medical and liability concerns about exposing pregnant women to drugs and risking damage to their foetuses.
Zucker also reported that even in cell and animal studies, subjects have been predominantly male. The Canadian Institutes of Health Research agreed, stating that the exclusion has meant that researchers do not have the opportunity to identify and study sex differences in diseases. This “creates assumptions that similar medical treatments will work for both sexes”. However, a study from the University of California, Berkeley and the University of Chicago, led by Professor Zucker, found that women are more likely than men to suffer adverse side effects of medications because drug dosages have historically been based on clinical trials conducted on men.
The Canadian Institutes of Health Research has reported that trends were improving: from 2015 to 2016, women made up 43% of participants in clinical trials globally. However, it also cited findings that of the ten drugs the US Food and Drug Administration removed from the market between 1997 and 2000, eight posed greater risks to women. In addition, in 2015, Women’s Health Research at Yale drew attention to a study on a drug only intended for women where 23 of the 25 participants were men.
The Canadian Institutes of Health Research has also argued that even when women are included in preclinical and clinical research, the results from studies must also be disaggregated by sex to account for significant differences in effectiveness and safety. For example, it said that researchers needed to disaggregate the data from the trial results to discover the safe and effective dose of desmopressin—a medication used to treat nocturia, or increased urge to urinate at night—for women was significantly lower than it was for men.
Ms Criado Perez has also highlighted that as research has focused on how men react to a health condition, this means that women are more likely to be misdiagnosed. For example, she explained that what are known as the classic symptoms for heart attacks are ‘classic’ for men. Women are actually more likely to experience breathlessness, fatigue nausea and what feels like indigestion than pain in the chest and down their left arm.
In its briefing, Manual agreed that women are less studied, but also argued that they are misdiagnosed more and taken less seriously by the health system. The 2001 study ‘The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain’ argued that women:
- get prescribed less pain medication than men after identical procedures;
- are less likely to be admitted to hospital and receive stress tests when they complain of chest pain; and
- are significantly more likely than men to be undertreated for pain by doctors.
Anecdotal evidence, such as the stories highlighted by journalist Ashley Fetters also provide examples of a range of cases where women do not feel like they are listened to or believed by healthcare professionals and are misdiagnosed as a result.
The Royal College of Obstetricians and Gynaecologists (RCOG) ‘Better for Women’ report, which focused on improving the health and wellbeing of girls and women, has also identified issues faced by women. Examining women’s access to healthcare through their entire life, the report said that several themes emerged that were common to each stage of women’s lives:
- women cannot always find accurate information;
- the NHS remains largely an intervention service, not a prevention service, and opportunities are often missed to empower girls and women; and
- many women’s healthcare services are fragmented and difficult to access.
Responding to these issues, and the responses of over 3,000 women to a survey that informed the report, RCOG made a number of recommendations. These included the creation of national strategies for women’s health based on a life course approach (this approach “offers a more unified and woman-centred approach to health promotion, disease prevention and management”).
In a recent press release, the Government outlined some of these issues, stating that:
- Less is known about conditions that only affect women, including common gynaecological conditions that can have severe impacts on health and wellbeing. For example, on average it takes 7 to 8 years for women to receive a diagnosis of endometriosis, with 40% of women needing 10 or more GP appointments before being referred to a specialist.
- There is evidence that the impact of female-specific health conditions such as heavy menstrual bleeding, endometriosis, pregnancy-related issues and the menopause is overlooked. This includes the effect such conditions can have on workforce participation, productivity and outcomes.
- Studies suggest that gender biases in clinical trials are contributing to worse health outcomes for women. A University of Leeds study found that women with a total blockage of coronary artery were 59% more likely to be misdiagnosed than men, and that UK women had more than double the rate of death in the 30 days following a heart attack.
Commenting on these findings, the Government said that there was strong evidence about the need for greater focus on women’s health. It also highlighted that although in the UK female life expectancy is higher than for men, women on average spend less of their life in good health compared to men. In addition, it noted that female life expectancy has been improving more slowly than male life expectancy since the 1980s.
The government’s women’s mental health taskforce has reported that “discussions about mental health, alongside service delivery and design, frequently fails to take gender into account”. This can lead to situations where services are “inadvertently discriminatory towards women” as they have been designed around the needs of men. For example, the taskforce said that despite the clear relationship between gender-based violence and trauma and poor mental health, it had heard that this link is “rarely reflected in the support available to women” and that at times women’s contact with services could be re-traumatising due to restraint or observations, often by male staff members.
What is the Government doing to improve health outcomes?
A new women’s health strategy
On 8 March 2021, in a statement to the House of Commons, Nadine Dorries, the Minister for Patient Safety, Suicide Prevention and Mental Health, said that “for generations women have lived with a healthcare system that is designed by men, for men”. She argued that despite making up 50 percent of the population, women have been underrepresented in research, with little known about some female-specific issues. She also highlighted that despite living longer than men, women spend a greater proportion of their lives in ill health and disability, with growing geographic inequalities in women’s life expectancy.
Ms Dorries said that to mark International Women’s Day and respond to the issues, the Government would be creating the first government-led national women’s health strategy for England. To support this, she announced a call for evidence stating that the Government wants to hear “from as many women as possible, from all ages and backgrounds”.
In its call for evidence press release, the Government said it wanted to hear women’s experiences of the whole health and care system. This included hearing about: mental health; addiction services; neurological conditions; gynaecological conditions; menopause; pregnancy; and post-natal support. In addition, it explained that six core themes would be included:
- placing women’s voices at the centre of their health and care;
- improving the quality and accessibility of information and education on women’s health;
- ensuring the health and care system understands and is responsive to women’s health and care needs across the life course;
- maximising women’s health in the workplace;
- ensuring that research, evidence and data support improvements in women’s health; and
- understanding and responding to the impacts of Covid-19 on women’s health.
The call for evidence ran from 8 March to 13 June 2021. The Government is currently analysing the feedback received, however, press reports have speculated that it will publish the new strategy later this year.
During her statement, Ms Dorries highlighted work that she said would help the Government meet its goal of extending healthy life expectancy by five years by 2035:
- A new strategy for tackling violence against women and girls: The Government’s current ‘Ending Violence Against Women and Girls Strategy’ covered the period 2016–20. In December 2020, it launched a call for evidence to inform a new strategy, asking those with lived experiences of the issues as well as relevant professionals and academics to provide their views. Although the consultation initially closed in February 2021, the Government reopened it for two weeks in March “to reflect the recent public discussion” about the issue.
- A new sexual and reproductive health strategy: In June 2019, the House of Commons Health and Social Care Committee’s report, ‘Sexual Health’, recommended that a new sexual health strategy should be developed. In its response, the Government agreed with the recommendation and described existing work that it said would help support the production of a new strategy. It also highlighted the aims and objectives of ‘A Framework for Sexual Health Improvement’ (March 2013), stating that these remain valid. More recently, in answer to a written question in February 2021, Lord Bethell, Minister for Innovation, said that the Government is committed to developing a sexual and reproductive health strategy, which it plans to publish in 2021.
In addition, in 2017 the Government set up a Women’s Mental Health Taskforce in response to evidence of the deteriorating mental health amongst women and poor outcomes experienced by some women in mental health services. It aimed to define and address priorities for the next phase of improving the mental health of women, and their experiences of mental health services. The taskforce published its final report in December 2018. It drew upon women’s lived experiences and made a series of recommendations, including that women’s needs should be explicitly considered in all future mental health policy development.
Image by Hush Naidoo from Unsplash.