Ending Gender Bias

What is it? And how can we end it?

Melanie Irwin, Primary Times Managing Editor

Source: APNA Primary Times Summer 2024-5

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^{Caption: Hon Ged Kearney, Assistant Minister for Health and Aged Care.}

According to a recent survey, two-thirds of women in Australia have experienced gender-biased health care. And these survey results are backed up by current research that shows significant healthcare disparities between men and women. So, what exactly is gender-biased health care, and how can primary health care nurses help to end it? 

Chaired by the Assistant Minister for Health and Aged Care, Hon Ged Kearney, the National Women’s Health Advisory Council published a summary of its #EndGenderBias Survey results in March 2024.¹ The survey gathered insights from more than 3,000 Australian women, caregivers, and health experts (including many nurses) about experiences of gender bias in the healthcare system. 

Two-thirds of women reported experiencing gender bias in health care, with nearly 80% of caregivers noting similar experiences for those they supported. Gender bias was experienced most in relation to sexual and reproductive health and chronic pain. Common themes included women’s sense of dismissal and not being believed, disrespectful treatment, significant financial burdens and poorer health outcomes due to delayed diagnoses and treatments. 

These descriptions of lived experience and expert observations are backed up by global research: Women and girls worldwide suffer from serious disparities in health care due to a range of complex reasons. So, what exactly is gender-biased health care, and how can primary health care nurses help to end it? 

What is bias? 

Bias is a human tendency to favour one group over another and it can be conscious or unconscious. Some bias is unavoidable, as our brains have evolved to rapidly categorise the people we meet. Our early ancestors relied on their ability to quickly recognise whether a person, animal or situation was threatening and this tendency to form judgements is still prevalent in how we think.²  

Whether conscious or unconscious, negative biases towards members of specific groups can affect our thoughts and behaviour. It’s even common for women to be biased against women.³ Seemingly harmless generalisations – such as ‘Men make good leaders’ and ‘Women are naturally caring’ – perpetuate gender norms that devalue women’s contributions to society. Unfortunately, these cultural norms are deeply entrenched and the only way to achieve gender equality will be for each of us to recognise and shift these attitudes.⁴  

Biased health care 

In a healthcare setting, bias can influence clinician–patient interactions.⁵ In some cases, it can lead to lower standards of care for patients due to aspects of their identity, such as their gender, sexuality, race, age or disability status.^2,5  

It takes guts to admit you’ve been biased. Before she went into politics, Ged Kearney was a nurse for 20 years, working at Melbourne’s Austin Hospital and in aged care. She remembers taking her cues from older nurses whose attitudes were biased. ‘The healthcare system has been developed in such as biased way. It’s what you were taught!’ Ged says. ‘Even if it was unconscious, you were taught by older health professionals to see the world through a biased lens.’   

‘I worked on a general surgical ward, and I know that I judged women differently to men when it came to pain. I’m ashamed of that now! We would always think, “Oh, she’s carrying on!” and I don’t think we did that towards men.  

‘Part of it was society. I was taught by my mother not to complain. But that societal view was compounded in the health system, which was developed for hundreds of years by men, for men. Women were seen as hysterical, attention-seeking, not capable of describing their symptoms properly.’ 

Some patients are at higher risk of bias-related healthcare disparities. LGBTQIA+ patients, including gender-nonconforming individuals, are particularly vulnerable to biased treatment that compromises their care.^6,7 Other patients may be vulnerable due to multiple intersecting identity characteristics (e.g., being a woman of colour).¹ ‘I definitely would see that on a daily basis when I worked in hospitals,’ Ged says. ‘Migrant women might express their emotions differently. They might have language difficulties. However, the system – and I think society – taught us to be quite judgemental. And that’s why I’m so excited that things are changing now!’   

Gender-related healthcare disparities 

The #EndGenderBias Survey results are backed up by recent studies from around the world describing sex- and gender-related healthcare disparities.8 For example, the age at first diagnosis for many conditions tends to be older for women than for men9 and women are less likely to receive timely preventive treatments for chronic disease.^_10,11 These discrepancies tend to result in poorer health and socioeconomic outcomes for women. 

The reasons for these disparities are complex. Expert respondents to the #EndGenderBias Survey noted that women are ‘missing from the evidence base.’1 Historically, men have been regarded by the medical establishment as the ‘default standard’ and women have been treated as ‘merely smaller men.’8 This ‘gender-blindness’ disadvantages female patients, but it also fails men, who tend to be under-diagnosed with conditions such as depression.¹²  

Gender bias in the workplace 

It’s not just patients who are vulnerable to gender bias. Ninety percent of nurses worldwide are women, and – despite their numbers – female nurses tend to face significant barriers to fair pay and leadership positions due to biased perceptions of women’s roles in caregiving, social gender norms and the historical legacy of a traditionally subordinate role.¹³ 

‘It’s getting better,’ says Ged. ‘It was very hierarchical, and men were at the top of the hierarchy. Things are changing. More women are becoming doctors. Nurses are professionally developing a lot more now. 

‘And that’s one thing that I’m really proud of. The Albanese Government has recognised the gendered issue in pay, and we’ve really tried to address that with aged care workers and early childhood educators. The gender pay gap is the lowest it’s ever been. There’s still a long way to go, but a lot of that is because of feminised workforces.’  

It’s in everyone’s best interests to achieve gender equity in the health workforce. Evidence shows that greater institutional support and respect for nurses improves the quality of care they provide.¹³  

Ending gender-biased health care 

What can primary health care nurses do to end gender-biased health care? Here are some suggestions. 

Listen to women, believe them and be kind 

‘It’s just as simple as listening, and paying attention,’ says Ged. ‘Don’t discard anything a patient says about their health. That’s really important!’  

The Australian Government is currently funding 22 new endometriosis and pelvic pain clinics across Australia, providing specialised care for women and girls with these conditions. ‘Women are telling me that for the first time, they feel heard and believed,’ Ged says. ‘This is sad, in a way! But it’s also really exciting.’  

Miscarriage is another issue that is under-researched and misunderstood. ‘It can be devastating,’ says Ged. ‘This is a gendered issue that gets swept under the carpet. I’ve heard firsthand accounts from women who’ve been told by hospital staff to ‘Go home and bleed it out.’ I would ask primary health care nurses to please be kind to women who miscarry. They often need to grieve.’ 

Recognise your own biases 

Each individual’s awareness and self-reflection about bias can contribute to systemic and cultural change in the healthcare system.  

‘Be aware of your inherent biases,’ Ged says. ‘It doesn’t make you a bad person. We all have them. Reflect on your work. At the end of the day, ask yourself “How did I treat everyone today?” If possible, debrief with a supervisor who can help you reflect and identify opportunities for improvement.’ 

Consider sex and gender 

There’s still a long way to go, but we now have a better understanding of sex-specific anatomy and physiology and we know that some conditions require different diagnostic and treatment approaches for women and men.  

One important example of this is heart disease. The Heart Foundation has developed resources about sex-specific risk factors for cardiovascular disease and heart attack warning signs, encouraging healthcare professionals to know the full range of signs for women and men.¹⁴ 

Another example is neurodiversity. The diagnostic tools for autism are skewed towards males, which often results in delayed diagnosis for other genders. Healthcare providers need to understand the different ways that neurodiversity can present in different genders so they can recognise the signs before more complex conditions develop.¹⁵  

Remember, some conditions are exclusive to people whose biological sex is female (e.g., painful periods) and some are more prevalent in females. For example, females comprise: 

• 78% of all people with autoimmune disorders¹⁶  
• 72% of migraine sufferers¹⁷ 
• 75–80% of people with chronic fatigue syndrome¹⁸ 
• 67% of people with an eating disorder.¹⁹ 

‘When you’re learning about something new,’ says Ged, ‘put a gender lens on it. Do we need to think about how women experience this condition compared to men? Is this a gendered issue? Is this something that mostly women experience? Does the issue receive equal attention?’ 

Educate your patients 

To combat gender bias, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists recommends patient-focused initiatives aimed at improving health literacy and empowering patients to self-advocate. This self-advocacy is especially relevant for patients who encounter bias in their interactions with healthcare providers20 and could be a powerful tool in the progression towards health equity and better health outcomes for women and girls. 

The journey to ending bias 

The road to health equity is a long one. We’ll only reach our destination when everyone can access their full potential for health and well-being, regardless of their gender, age, race or any other defining characteristics.21 To do this, we need all healthcare professionals to understand and recognise signs of bias and to strive for an unbiased approach to care that is tailored to each individual’s needs. 

Some closing words from Hon Ged Kearney: ‘As the largest health workforce in the country, I think nurses can play an incredible leading role in changing the culture in the healthcare system. I’m really excited about the role that nurses can play, including primary health care nurses, because that is the grassroots of health care. That is where it begins. If primary health care nurses come along this journey with us, I think the system will change dramatically!’ 

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References 

1. Australian Government, Department of Health and Aged Care, #EndGenderBias survey results: summary report, Department of Health and Aged Care website, 14 March 2024, accessed 14 October 2024.  

2. JR Marcelin, DS Siraj, R Victor, S Kotadia and YA Maldonado, ‘The impact of unconscious bias in healthcare: how to recognise and mitigate it’, J Infect Diseases, 2019, 220(2):S62–S73, doi:10.1093/infdis/jiz214. 

3. Human Development Reports, 2023 Gender Social Norms Index (GSNI), Human Development Reports website, 12 June 2023, accessed 14 October 2024.   

4. K Ahmed, ‘Nine out of 10 people are biased against women, says “alarming” UN report’, The Guardian, 12 June 2023, accessed 14 October 2024.   

5. C FitzGerald and S Hurst, ‘Implicit bias in healthcare professionals: a systemic review’, BMC Medical Ethics, 2017, 18(19):1–18, doi:10.1186/s12910-017-0179-8. 

6. K Berrian, MD Exsted, NM Lampe, SL Pease and E L Akré, ‘Barriers to quality healthcare among transgender and gender nonconforming adults’, Health Serv Res, 2024, 1–9, doi:10.1111/1475-6773.14362. 

7. JL Frankis, ‘Understanding the mental health of LGBTQIA+ communities in western countries: what can nurses do to help?’, Evid Based Nurs, 2024, doi:10.1136/ebnurs-2024-104159. 

8. ML Figueroa and LA Hiemstra, ‘How do we treat our male and female patients? – a primer on gender-based health care inequities,’ J Isakos, 2024, 9(40):P774–780, doi:10.1016/j.jisako.2024.04.006. 

9. D Westergaard, P Moseley, FK Hemmingsen Sørup and S Brunak, ‘Population-wide analysis of differences in disease progression patterns in men and women’, Nat Commun, 2019, 10(666), doi:10.1038/s41467-019-08475-9. 

10. KK Hyun, J Redfern, A Patel et al., ‘Gender inequalities in cardiovascular risk factor assessment and management in primary healthcare’, Heart, 2017, 103:492–489, doi:10.1136/heartjnl-2016-310216. 

11. G Ferrannini, D De Bacquer, P Vynckier et al., ‘Gender differences in screening for glucose perturbations, cardiovascular risk factor management and prognosis in patients with dysglycaemia and coronary artery disease: results from the ESC-EORP EUROASPIRE surveys’, Cardiovasc Diabetol, 2021, 20(38), doi:10.1186/s12933-021-01233-6. 

12. A Samulowitz, I Gremyr, E Eriksson, G Hensing, ‘"Brave men" and "emotional women": a theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain’, Pain Res Manag, 2018, 6358624, doi:10.1155/2018/6358624. 

13. World Health Organization (WHO), State of the world’s nursing, 2020: investing in education, jobs, leadership [technical document], WHO website, 6 April 2020, accessed 16 October 2024.    

14. Heart Foundation, For Professionals: women and heart disease, Heart Foundation website, 13 March 2024, accessed 16 October 2024. 

15. C Long and N Campanella, ‘Autistic women and girls missing out on support due to male-skewed diagnostic tools’, ABC News, 29 May 2023, accessed 16 October 2024.  

16. E Dolgin, ‘Why autoimmune disease is more common in women: X chromosome holds clues’, Nature, 1 February 2024, accessed 16 October 2024. 

17. Brain Foundation, Keeping women in the workforce with migraine, Brain Foundation website, 2024, accessed 16 October 2024. 

18. Ausmed, Living with chronic fatigue syndrome (ME/CFS), Ausmed website, 8 March 2024, accessed 16 October 2024.  

19. Deloitte Access Economics, Paying the price report 2024, Butterfly Foundation website, February 2024, accessed 16 October 2024.  

20. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Improving care for women’s pain, RANZCOG website, 9 August 2024, accessed 16 October 2024. 

21. World Health Organization (WHO), Health equity, WHO website, 2024, accessed 16 October 2024.