Introduction

When a patient enters the healthcare system, we assume that the person will be treated with sound judgement and treatment will be based on objective, evidence-based practice parameters set by reliable research. We rarely, if ever, anticipate that the clinical decision making may be influenced by the patient’s attributes such as religion or socioeconomic status or any other feature that is not relevant to their treatment. The United States’ citizens pride themselves in our democratic form of government and equal opportunity for all. Some may take for granted that the healthcare system provides equally. But does it? What if there are some facets of healthcare that favor one portion of the population while hindering another? What if that hindrance was affecting virtually half of the adult population—adult women. There is evidence to support that women do not receive equal care not only in the United States, but internationally as well. To understand this topic fully, we must clarify a few related terms.

The Cambridge Dictionary defines gender bias as “unfair difference in the way women and men are treated” (“Gender Bias,” n.d.). Literature related to gender bias in healthcare primarily focuses on situations in which women are examined, diagnosed, referred, and treated differently and at a lower quality than men with comparable health concerns. As a result, women may have higher complication rates, higher morbidity, and increased mortality. Bias, whether conscious or subconscious, can come about from assuming uniformity between male and female patients where there are substantial differences in physiology and overall response to treatment or assuming differences where none occur. Either assumption can cause flawed, stereotypical assessments about women and men that may impact how healthcare providers practice and deliver care. One example is minimizing a woman patient’s complaints of symptoms of pain, attributing them to emotional causes rather than physical (Unruh, 1996, p. 129).

To clarify, this review is not equating the problematic of gender bias in healthcare with the issue of gender disparity. Several clinically substantial differences exist between women and men related to prevalence, clinical presentation, therapy management, and outcomes of CVD. An example is that women who present several cardiovascular risk factors including diabetes are less likely to be prescribed lipid-lowering agents than men (Jarvie & Foody, 2010, p. 493). Differences between women and men are quite common and deserve recognition. However, when differences in healthcare and treatment are due to gender bias, a more pressing concern calls for our attention owing to the potential to harm patients.

Not everyone agrees that gender bias exists in healthcare. Kadar (1994) said that one physician stated “It is commonly believed that American healthcare delivery and research benefit men at the expense of women, the truth appears to be exactly the opposite” and continued to cite women’s higher life expectancy as evidence that women receive better medical care. Many recent reviews continue to uphold research evidence of gender bias in healthcare internationally, which includes a wide spectrum of clinical areas ranging from pain management, surgery, and orthopedics to behavioral and mental health. This review will examine that literature, cite research targeted to critical care, and consider some implications of this information.


Evidence of Gender Bias


Behavioral Health

A study aimed to detect gender-sensitive signs of mental health in economically diverse areas that used data from the national databases in Columbia, Peru, and Canada in a multidisciplinary context proposed by the World Health Organization. The study showed that the most significant inequalities for women were depression, anxiety, suicide attempts, use of mental health services, and alcohol dependence, and female-to-male prevalence ratios for mental illness ranged from 0.1 to 2.3 (Diaz-Granados et al., 2011). The authors hope for a reduction in gender inequalities in all three nations.


Peripheral Arterial Disease

With many cardiovascular disorders, intensive risk-factor modification is imperative in peripheral arterial disease (PAD) to reduce the risk of problematic events. The American College of Cardiology and American Heart association have set forth guidelines for the use of aspirin, statins, and angiotensin-converting enzyme for peripheral arterial disease inhibitors after a patient is discharged for peripheral arterial surgery. Despite those guidelines, however, those therapies are irregularly prescribed to both women and men. Women are far less likely to receive beta blockers, antiplatelet, or lipid-lowering treatments and/or medications for either PAD or cardiovascular disease (Smith et al., 2011, p. 2458). Additionally, treatments for PAD are comparable for men and women. However, women are less often given the option of surgical revascularization. Reasons for this include women’s age at disease onset which is typically higher than men’s, worse post-surgical outcomes, as well as psychosocial factors. A recent discovery that women are offered surgery less in every age group researched for carotid endarterectomy implies that factors outside of age and risk may impact the decision to offer this surgical option to women (Poisson, Claiborne Johnston, Sidney, Klingman, & Nguyen-Huynh, 2010, p. 1892). These results are more alarming given that the female gender is a recognized and negative risk factor for cardiovascular interventions in peripheral arterial disorders.


Critical Care

Beery (1995) noted nearly twenty-five years ago thirty different aspects of gender bias that have been acknowledged in transfers or referrals of female patients with coronary artery disease for diagnostic and therapeutic treatment such as angioplasty, coronary revascularization, implantable cardioverter defibrillators (ICDs), and heart transplants. This partially explains why women who are older and have worse symptoms suffer from more complications and comorbidities by the time they do get treatment and why their results and outcomes are worse than those of men. The results in a summary published by the European Institute of Women’s Health in collaboration with the World Health Organization also support this notion. Women with heart disease tend to be older than their male counterparts when first hospitalized, more prone to risk, and receive substandard care in China, India, and western Asia (“Gender Bias Continues in Heart Health”). Clearly, the issue of women not receiving equal and adequate medical treatment for heart disease has not progressed in more than two decades.

Abuful el al (2006) designed a 2-part study to compare medical professionals and physicians’ attitudes with their practice in preventative care for CAD in Israel. This “attitude study” assessed the attitudes of 172 physicians toward treatment and care of two hypothetical patients, a 58 year old male and a 58 year old postmenopausal female, with identical clinical and laboratory data and mild coronary atherosclerosis on angiography. In the “actual clinical practice study,” researchers examined lipoprotein levels and prescriptions for lipid-lowering medications from the medical records of 344 male and female patients with angiographic evidence of CAD. The “attitude study” discovered that “physicians in general considered the male patient to be at higher risk and prescribed aspirin (91 vs. 77%, p < 0.01) and lipid‐lowering medications (67 vs. 54%, p < 0.07) more often for the male patient.” Assessment and evaluation of the medical charts of patients with CAD revealed that patients with baseline low‐density lipoprotein cholesterol > 110 mg/dl, 77% of the males received a lipid‐lowering medication, compared with only 47% of the female patients (p < 0.001). The researchers concluded that they revealed clear evidence of gender bias in both attitude and actual clinical practice of secondary therapies for patients with CAD.


Reasons for Gender Disparities/Bias

There are a variety of reasons that have been offered to explain the inequalities among men and women in healthcare that seem to imply prejudice related to the patient’s gender. Some of the potential reasons include the following:

  • Misunderstanding a woman’s risk for health problems or complications (Jarvie & Foody, 2010)
  • Differences in the way women experience cardiac symptoms (Beery, 1995).
  • Differences in the way women perceive themselves and their illness (Beery, 1995).
  • Patients may have misperceptions of indications, risks, or benefits of surgery. Women are less likely to discuss medical concerns with physicians(Borkhoff, Hawker, & Wright, 2011).
  • Differences in communication methods that women and men use to describe their symptoms or injuries to the physician. (Birdwell, Herbers, & Kroenke, 1993).
  • Unconscious prejudices among physicians—social stereotyping (Borkhoff et al, 2008).
  • Blatant discrimination based on sex in that some physicians do not take women’s symptoms seriously (Borkhoff et al, 2008).
  • Cultural biases, especially among older male physicians (Laino, 2006).
  • Women thinking of stroke and heart disease as men’s diseases (Laino, 2006).

There is no knowing for certain which factor or combination of factors that lead to gender biased situations in healthcare. Various scenarios may be influenced by various factors. Additionally, no medical professional has suggested that this evidence or clear bias against women is intentional. It is crucial, however, to keep in mind that gender bias doesn’t need to be intentional to be harmful. In fact, gender bias can enter and influence healthcare in the most subtle and undetected ways.


Related:


Implicit Bias in Women’s Healthcare


Conclusion

The abundant discrepancies between the care that men and women receive deserve more than notice. Diagnostic procedures are not performed, therapeutic drugs are not prescribed, and referrals are not made and these discrepancies are hindering the life and well-being of women internationally. As healthcare professionals, we can initiate an approach to the problem of gender bias in three ways: identification, recognition, and modification. Acknowledging that not only does gender bias exist, but that it may influence several aspects of healthcare decision making and monitoring from the physician to the patient may be a starting place of eradicating gender bias and its influence. Utilizing tools that can assist in ensuring equal opportunity for healthcare are contained in various sets of evidence-based protocols and guidelines. When cases of gender bias occur, and are confirmed, they will need to be communicated to those responsible for patient care so that all investigations can be swiftly and promptly performed to reveal the causes and develop appropriate solutions to correct patient care.


References

  • Abuful, A., Gidron, Y., & Henkin, Y. (2006). Physicians’ attitudes toward preventive therapy for coronary artery disease: Is there a gender bias?

    Clinical Cardiology

    , 28, 389-393.
  • Beery, T. (1995). Gender bias in the diagnosis and treatment of coronary artery disease

    . Heart & Lung,

    24, 427-435.
  • Birdwell, B. G., Herbers, J. E., & Kroenke, K. (1993). Evaluating chest pain. the patient’s presentation style alters the physician’s diagnostic approach.

    Archives of Internal Medicine

    , 153(17), 1991-1995.
  • Borkhoff, C. M., Hawker, G. A., & Wright, J. G. (2011). Patient gender affects the referral and recommendation for total joint arthroplasty.

    Clinical Orthopaedics and Related Research

    , 469(7), 1829-1837.
  • Borkhoff, C. M., Hawker, G. A., Kreder, H.J., Glazier, R. H., Mahomed, N. N, Wright, J. G. (2008). The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty. CMAJ, 178(6), 681-687.
  • Diaz-Granados, N., McDermott, S., Wang, F., Posada-Villa, J., Saavedra, J., Rondon, M., . . . Stewart, D. (2011). Monitoring gender equity in mental health in a low-, middle-, and high-income country in the Americas.

    Psychiatric Services

    , 62(5).
  • Gender Bias Continues in Heart Health. European Institute of Women’s Health http://eurohealth.ie/2012/04/23/gender-bias-coninues-in-heart-health. Accessed July 9, 2019
  • Gender bias. (n.d.). Retrieved July 1, 2019, from Cambridge Dictionary website: https://dictionary.cambridge.org/us/dictionary/english/gender-bias
  • Gomez, D., Haas, B., de Mestral, C., Sharma, S., Hsiao, M., Zagorski, B., . . . Nathens, A. (2012). Gender-associated differences in access to trauma center care: A population-based analysis.

    Surgery

    , 152, 179-185.
  • Jarvie, J. L., & Foody, J. M. (2010). Recognizing and improving health care disparities in the prevention of cardiovascular disease in women.

    Current Cardiology Reports

    , 12(6), 488-496.
  • Kadar, A.G. (1994). The sex-bias myth in medicine.

    The Atlantic Monthly

    . 274(2), 66–70.
  • Laino, C. (2006). Gender bias in stroke care persists. Retrieved July 12, 2019, from WebMD website: https://www.webmd.com/stroke/news/20060216/gender-bias-in-stroke-care-persists#1
  • Poisson, S. N., Claiborne Johnston, S., Sidney, S., Klingman, J. G., & Nguyen-Huynh, M. N. (2010).  Gender differences in treatment of severe carotid stenosis after transient ischemic attack.

    Stroke

    , 41, 1891-1895.
  • Sex-based discrimination. (n.d.). Retrieved July 1, 2019, from U.S. Equal Employment Opportunity Commission website: https://www.eeoc.gov/laws/types/sex.cfm
  • Smith, S., Jr., Benjamin, E., Bonow, R., Braun, L., Creager, M., Franklin, B., . . . Taubert, K.  (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: A guideline from the American Heart Association and American College of Cardiology Foundation.

    Circulation

    , 124, 2458-2473.
  • Unruh, A. M. (1996). Gender variations in clinical pain experience.

    ScienceDirect

    , 65(2-3), 127-163.


 

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Introduction

When a patient enters the healthcare system, we assume that the person will be treated with sound judgement and treatment will be based on objective, evidence-based practice parameters set by reliable research. We rarely, if ever, anticipate that the clinical decision making may be influenced by the patient’s attributes such as religion or socioeconomic status or any other feature that is not relevant to their treatment. The United States’ citizens pride themselves in our democratic form of government and equal opportunity for all. Some may take for granted that the healthcare system provides equally. But does it? What if there are some facets of healthcare that favor one portion of the population while hindering another? What if that hindrance was affecting virtually half of the adult population—adult women. There is evidence to support that women do not receive equal care not only in the United States, but internationally as well. To understand this topic fully, we must clarify a few related terms.

The Cambridge Dictionary defines gender bias as “unfair difference in the way women and men are treated” (“Gender Bias,” n.d.). Literature related to gender bias in healthcare primarily focuses on situations in which women are examined, diagnosed, referred, and treated differently and at a lower quality than men with comparable health concerns. As a result, women may have higher complication rates, higher morbidity, and increased mortality. Bias, whether conscious or subconscious, can come about from assuming uniformity between male and female patients where there are substantial differences in physiology and overall response to treatment or assuming differences where none occur. Either assumption can cause flawed, stereotypical assessments about women and men that may impact how healthcare providers practice and deliver care. One example is minimizing a woman patient’s complaints of symptoms of pain, attributing them to emotional causes rather than physical (Unruh, 1996, p. 129).

To clarify, this review is not equating the problematic of gender bias in healthcare with the issue of gender disparity. Several clinically substantial differences exist between women and men related to prevalence, clinical presentation, therapy management, and outcomes of CVD. An example is that women who present several cardiovascular risk factors including diabetes are less likely to be prescribed lipid-lowering agents than men (Jarvie & Foody, 2010, p. 493). Differences between women and men are quite common and deserve recognition. However, when differences in healthcare and treatment are due to gender bias, a more pressing concern calls for our attention owing to the potential to harm patients.

Not everyone agrees that gender bias exists in healthcare. Kadar (1994) said that one physician stated “It is commonly believed that American healthcare delivery and research benefit men at the expense of women, the truth appears to be exactly the opposite” and continued to cite women’s higher life expectancy as evidence that women receive better medical care. Many recent reviews continue to uphold research evidence of gender bias in healthcare internationally, which includes a wide spectrum of clinical areas ranging from pain management, surgery, and orthopedics to behavioral and mental health. This review will examine that literature, cite research targeted to critical care, and consider some implications of this information.


Evidence of Gender Bias


Behavioral Health

A study aimed to detect gender-sensitive signs of mental health in economically diverse areas that used data from the national databases in Columbia, Peru, and Canada in a multidisciplinary context proposed by the World Health Organization. The study showed that the most significant inequalities for women were depression, anxiety, suicide attempts, use of mental health services, and alcohol dependence, and female-to-male prevalence ratios for mental illness ranged from 0.1 to 2.3 (Diaz-Granados et al., 2011). The authors hope for a reduction in gender inequalities in all three nations.


Peripheral Arterial Disease

With many cardiovascular disorders, intensive risk-factor modification is imperative in peripheral arterial disease (PAD) to reduce the risk of problematic events. The American College of Cardiology and American Heart association have set forth guidelines for the use of aspirin, statins, and angiotensin-converting enzyme for peripheral arterial disease inhibitors after a patient is discharged for peripheral arterial surgery. Despite those guidelines, however, those therapies are irregularly prescribed to both women and men. Women are far less likely to receive beta blockers, antiplatelet, or lipid-lowering treatments and/or medications for either PAD or cardiovascular disease (Smith et al., 2011, p. 2458). Additionally, treatments for PAD are comparable for men and women. However, women are less often given the option of surgical revascularization. Reasons for this include women’s age at disease onset which is typically higher than men’s, worse post-surgical outcomes, as well as psychosocial factors. A recent discovery that women are offered surgery less in every age group researched for carotid endarterectomy implies that factors outside of age and risk may impact the decision to offer this surgical option to women (Poisson, Claiborne Johnston, Sidney, Klingman, & Nguyen-Huynh, 2010, p. 1892). These results are more alarming given that the female gender is a recognized and negative risk factor for cardiovascular interventions in peripheral arterial disorders.


Critical Care

Beery (1995) noted nearly twenty-five years ago thirty different aspects of gender bias that have been acknowledged in transfers or referrals of female patients with coronary artery disease for diagnostic and therapeutic treatment such as angioplasty, coronary revascularization, implantable cardioverter defibrillators (ICDs), and heart transplants. This partially explains why women who are older and have worse symptoms suffer from more complications and comorbidities by the time they do get treatment and why their results and outcomes are worse than those of men. The results in a summary published by the European Institute of Women’s Health in collaboration with the World Health Organization also support this notion. Women with heart disease tend to be older than their male counterparts when first hospitalized, more prone to risk, and receive substandard care in China, India, and western Asia (“Gender Bias Continues in Heart Health”). Clearly, the issue of women not receiving equal and adequate medical treatment for heart disease has not progressed in more than two decades.

Abuful el al (2006) designed a 2-part study to compare medical professionals and physicians’ attitudes with their practice in preventative care for CAD in Israel. This “attitude study” assessed the attitudes of 172 physicians toward treatment and care of two hypothetical patients, a 58 year old male and a 58 year old postmenopausal female, with identical clinical and laboratory data and mild coronary atherosclerosis on angiography. In the “actual clinical practice study,” researchers examined lipoprotein levels and prescriptions for lipid-lowering medications from the medical records of 344 male and female patients with angiographic evidence of CAD. The “attitude study” discovered that “physicians in general considered the male patient to be at higher risk and prescribed aspirin (91 vs. 77%, p < 0.01) and lipid‐lowering medications (67 vs. 54%, p < 0.07) more often for the male patient.” Assessment and evaluation of the medical charts of patients with CAD revealed that patients with baseline low‐density lipoprotein cholesterol > 110 mg/dl, 77% of the males received a lipid‐lowering medication, compared with only 47% of the female patients (p < 0.001). The researchers concluded that they revealed clear evidence of gender bias in both attitude and actual clinical practice of secondary therapies for patients with CAD.


Reasons for Gender Disparities/Bias

There are a variety of reasons that have been offered to explain the inequalities among men and women in healthcare that seem to imply prejudice related to the patient’s gender. Some of the potential reasons include the following:

  • Misunderstanding a woman’s risk for health problems or complications (Jarvie & Foody, 2010)
  • Differences in the way women experience cardiac symptoms (Beery, 1995).
  • Differences in the way women perceive themselves and their illness (Beery, 1995).
  • Patients may have misperceptions of indications, risks, or benefits of surgery. Women are less likely to discuss medical concerns with physicians(Borkhoff, Hawker, & Wright, 2011).
  • Differences in communication methods that women and men use to describe their symptoms or injuries to the physician. (Birdwell, Herbers, & Kroenke, 1993).
  • Unconscious prejudices among physicians—social stereotyping (Borkhoff et al, 2008).
  • Blatant discrimination based on sex in that some physicians do not take women’s symptoms seriously (Borkhoff et al, 2008).
  • Cultural biases, especially among older male physicians (Laino, 2006).
  • Women thinking of stroke and heart disease as men’s diseases (Laino, 2006).

There is no knowing for certain which factor or combination of factors that lead to gender biased situations in healthcare. Various scenarios may be influenced by various factors. Additionally, no medical professional has suggested that this evidence or clear bias against women is intentional. It is crucial, however, to keep in mind that gender bias doesn’t need to be intentional to be harmful. In fact, gender bias can enter and influence healthcare in the most subtle and undetected ways.


Related:


Implicit Bias in Women’s Healthcare


Conclusion

The abundant discrepancies between the care that men and women receive deserve more than notice. Diagnostic procedures are not performed, therapeutic drugs are not prescribed, and referrals are not made and these discrepancies are hindering the life and well-being of women internationally. As healthcare professionals, we can initiate an approach to the problem of gender bias in three ways: identification, recognition, and modification. Acknowledging that not only does gender bias exist, but that it may influence several aspects of healthcare decision making and monitoring from the physician to the patient may be a starting place of eradicating gender bias and its influence. Utilizing tools that can assist in ensuring equal opportunity for healthcare are contained in various sets of evidence-based protocols and guidelines. When cases of gender bias occur, and are confirmed, they will need to be communicated to those responsible for patient care so that all investigations can be swiftly and promptly performed to reveal the causes and develop appropriate solutions to correct patient care.


References

  • Abuful, A., Gidron, Y., & Henkin, Y. (2006). Physicians’ attitudes toward preventive therapy for coronary artery disease: Is there a gender bias?

    Clinical Cardiology

    , 28, 389-393.
  • Beery, T. (1995). Gender bias in the diagnosis and treatment of coronary artery disease

    . Heart & Lung,

    24, 427-435.
  • Birdwell, B. G., Herbers, J. E., & Kroenke, K. (1993). Evaluating chest pain. the patient’s presentation style alters the physician’s diagnostic approach.

    Archives of Internal Medicine

    , 153(17), 1991-1995.
  • Borkhoff, C. M., Hawker, G. A., & Wright, J. G. (2011). Patient gender affects the referral and recommendation for total joint arthroplasty.

    Clinical Orthopaedics and Related Research

    , 469(7), 1829-1837.
  • Borkhoff, C. M., Hawker, G. A., Kreder, H.J., Glazier, R. H., Mahomed, N. N, Wright, J. G. (2008). The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty. CMAJ, 178(6), 681-687.
  • Diaz-Granados, N., McDermott, S., Wang, F., Posada-Villa, J., Saavedra, J., Rondon, M., . . . Stewart, D. (2011). Monitoring gender equity in mental health in a low-, middle-, and high-income country in the Americas.

    Psychiatric Services

    , 62(5).
  • Gender Bias Continues in Heart Health. European Institute of Women’s Health http://eurohealth.ie/2012/04/23/gender-bias-coninues-in-heart-health. Accessed July 9, 2019
  • Gender bias. (n.d.). Retrieved July 1, 2019, from Cambridge Dictionary website: https://dictionary.cambridge.org/us/dictionary/english/gender-bias
  • Gomez, D., Haas, B., de Mestral, C., Sharma, S., Hsiao, M., Zagorski, B., . . . Nathens, A. (2012). Gender-associated differences in access to trauma center care: A population-based analysis.

    Surgery

    , 152, 179-185.
  • Jarvie, J. L., & Foody, J. M. (2010). Recognizing and improving health care disparities in the prevention of cardiovascular disease in women.

    Current Cardiology Reports

    , 12(6), 488-496.
  • Kadar, A.G. (1994). The sex-bias myth in medicine.

    The Atlantic Monthly

    . 274(2), 66–70.
  • Laino, C. (2006). Gender bias in stroke care persists. Retrieved July 12, 2019, from WebMD website: https://www.webmd.com/stroke/news/20060216/gender-bias-in-stroke-care-persists#1
  • Poisson, S. N., Claiborne Johnston, S., Sidney, S., Klingman, J. G., & Nguyen-Huynh, M. N. (2010).  Gender differences in treatment of severe carotid stenosis after transient ischemic attack.

    Stroke

    , 41, 1891-1895.
  • Sex-based discrimination. (n.d.). Retrieved July 1, 2019, from U.S. Equal Employment Opportunity Commission website: https://www.eeoc.gov/laws/types/sex.cfm
  • Smith, S., Jr., Benjamin, E., Bonow, R., Braun, L., Creager, M., Franklin, B., . . . Taubert, K.  (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: A guideline from the American Heart Association and American College of Cardiology Foundation.

    Circulation

    , 124, 2458-2473.
  • Unruh, A. M. (1996). Gender variations in clinical pain experience.

    ScienceDirect

    , 65(2-3), 127-163.


 

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