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Population Health for Nurses

9.3 Gender Disparities

Population Health for Nurses9.3 Gender Disparities

Learning Outcomes

By the end of this section, you should be able to:

  • 9.3.1 Describe how gender affects health outcomes.
  • 9.3.2 Assess influencing factors contributing to gender disparities.
  • 9.3.3 Discuss health disparities faced by the LGBTQIA+ community.

Research shows men and women experience different health outcomes beyond what would be expected for sex-specific conditions and treatments. Women and members of the LGBTQIA+ community frequently experience poorer health outcomes and face more barriers to health care access.

Concepts Related to Sex and Gender

The terms sex and gender are sometimes used interchangeably. While they are interrelated terms, they have distinct differences. Sex refers to the physiological and biological characteristics of males and females. Gender refers to male and female characteristics that are socially constructed (World Health Organization [WHO], 2023). Gender identity refers to a person’s internal experience and belief of gender, which may or may not correspond to their physiology or designated sex at birth (WHO, 2023). LGBTQIA+ is used to refer collectively to lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual/aromantic/agender, and other related groups. The terms used to describe these groups are fluid and may change frequently, and not all people feel that they are represented by a specific term.

Physical differences can result in the development of sex-specific conditions. For example, each sex has a different reproductive system and corresponding reproductive diseases. Gender health disparities appear to encompass both sex and gender characteristics as biological, psychological, and social mechanisms intertwine to affect health outcomes in those with long-term disabling conditions (Thakral et al., 2019).

Gender Disparities in Health Care

In this video, women share their experiences of health care bias that delayed their diagnoses and treatments.

Watch the video, and then respond to the following questions.

  1. What are the trends or consistencies in the cases described in this video?
  2. What can nurses learn from these stories that they can incorporate into their practice?

Gender Differences

Gender norms are social and cultural principles that influence ideas on how different genders are supposed to behave in society. Such norms are often harmful. For example, gender stereotypes, or generalized preconceptions about what roles or traits should be performed by men and women, often limit their potential and create inequality. Society may also assign rank or status according to gender (i.e., men have a higher standing than women), which causes inequalities between genders that intersect with other social and economic inequalities. Discrimination based on gender often crosses, or intersects, with other societal factors such as ethnicity, disability, socioeconomic status, age, geographic location, gender identity, and sexual orientation (WHO, 2023). This is known as intersectionality, a concept that considers how multiple disadvantages can interact with clients individually and reflect the inequities and injustices at the systems level. Sexism, racism, classism, colonialism, heterosexism, and ableism are a few of the structures that result in systems-level oppression and privilege (Crenshaw, 1991).

Globally, gender norms negatively affect girls and women more than boys and men (Office of the High Commissioner for Human Rights [OHCHR], 2023). For example, over 575 million girls reside in countries where their basic rights related to education, health, and safety are violated as a consequence of inequitable gender norms (Save the Children, 2023). According to the OHCHR, gender stereotypes and discrimination, intersecting with other social and economic stereotypes, are particularly detrimental to women from minority or Indigenous groups, women with disabilities, women from lower caste groups or with lower economic status, and migrant women (OHCHR, 2023).

Boys and men may also be negatively affected by gender norms, particularly those that emphasize rigid notions of masculinity. For example, some gender norms may encourage young men to engage in risky practices such as smoking, unprotected sexual behavior, and alcohol use and abuse, and it may make them less likely than women to seek medical attention (WHO, 2023). Some conceptions of masculinity lead males to commit violence against women and make men subject to violence perpetrated by other men. These pressures may lead some individuals to develop mental health issues (WHO, 2023).

Individuals who identify as gender diverse or transgender also experience negative consequences related to gender. Gender-diverse individuals do not conform to conventional gender norms of being a man or a woman, or they may not “place themselves in the male/female binary” (OHCHR, 2023, para 1). Individuals who are transgender identify with a different sex than the one assigned to them at birth. Globally, both groups experience marginalization, exclusion, violence, discrimination, and other human rights violations related to their gender identities (OHCHR, 2023).

Gender affects people’s experiences with and access to health care. How health services are organized and provided may either enable a person’s access to health care services, information, and support or hinder it (WHO, 2023). Women’s health and well-being is placed at risk because of gender inequality and discrimination. Women more frequently face barriers to accessing health information and services than men. Throughout the world, women face restrictions on movement in the health care system, lack of access to decision-making power, low health literacy rates, discriminatory attitudes of communities and health care providers, and a lack of training among health care providers specific to the health care needs and challenges they face (WHO, 2023).

Findings from a recent survey on women’s experiences with the U.S. health care system are consistent with the WHO’s conclusions. For example, 29 percent of U.S. women aged 18–64 who were surveyed reported their doctor dismissed their concerns, and another 15 percent reported their provider did not believe they were telling the truth (Long et al., 2023). Among survey participants aged 40–64, only 35 percent reported their health care provider discussed what to expect with menopause (Long et al., 2023). In another study, researchers used data from the CDC Behavioral Risk Factor Surveillance System (BRFSS) to study differences between males' and females’ ability to access medical care for atherosclerotic cardiovascular disease (ASCVD). They found that women were more likely to report a delay in accessing health care and an inability to see a health care provider or take prescribed medications due to cost than men (Daher et al., 2021).

Global health-related challenges females face include (WHO, 2023):

  • Higher rates of unintended pregnancies for women and girls.
  • Greater risk of developing diseases and conditions such as malnutrition, lower vision, and respiratory infections.
  • Greater risk of experiencing elder abuse than older males.
  • Higher rates of violence directed toward them when compared to males, which includes sexual and physical violence. Approximately one in three women worldwide have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime.
  • In some developing countries, women experience female genital mutilation and early and forced marriage.

How the Gender Gap in Clinical Drug Trials Is Affecting Women

Decades ago, the United States took an important step toward addressing gender disparities in medicine. In 1986, the National Institutes of Health (NIH) established a policy requiring that women be included as subjects of clinical research. The following year, the Food and Drug Administration (FDA) began requiring pharmaceutical companies to demonstrate medication safety and effectiveness by sex, age, and race (Office on Women's Health, 2020). Despite these policy gains, more work is needed; this video offers a glimpse of the impact of the persistent gender gap in today’s clinical drug trials.

Watch the video, and then respond to the following questions.

  1. Beyond the immediate physical effects the women in the video experienced, what other consequences could these women face?
  2. Knowledge gaps in medical research are a form of gender bias in health care. What other forms of gender bias against women exist in health care?

Special Considerations for the LGBTQIA+ Population

Research shows that the LGBTQIA+ population experiences poorer health outcomes compared to the cis-heterosexual population. In a systematic review of the literature, Medina-Martinez et al. (2021) found that as compared to the cis-heterosexual population, this community experiences higher rates of mental health problems, substance misuse, and suicide. They also found that certain cancers, including colon, liver, breast, ovarian, and cervical, are more prevalent among lesbian and bisexual women. Gay and bisexual men have higher rates of sexually transmitted infections, including HIV, as well as increased rates of anal, prostate, testicular, and colon cancers (Medina-Martinez et al., 2021). Compared with the general population, individuals who are transgender experience a higher prevalence and earlier onset of disabilities, more chronic health conditions, and higher rates of health problems related to AIDS, substance use, mental illness, and sexual and physical violence (Medina et al., 2021). For children and adolescents who identify as lesbian, gay, bisexual, transgender, questioning, or queer (LGBTQ), the risks of suicidal thoughts and behaviors is higher (AHRQ, 2022).

Along with the disease risks for members of the LGBTQIA+ population, there are the issues of homophobia, stigma, and discrimination regarding their identity (CDC, 2022c). Limited access to culturally appropriate and orientation-appropriate services can hinder treatment. Finally, members of this group may be fearful about talking about their gender identity and sexual orientation. LGBTQIA+ people face barriers when trying to access health care, including negative and discriminatory experiences with health care workers (Medina-Martinez et al., 2021). Transgender people often experience verbal and physical abuse, hostility, and refusal of care during their interactions with the health care system or with individual health care providers (Medina et al., 2021). See Caring for Vulnerable Populations and Communities for more information on health care challenges related to the LGBTQIA+ population.

Unfolding Case Study

Part A: Addressing Disparities

Read the scenario, and then answer the questions that follow.

As part of her role as a registered nurse case manager for Medicaid clients, Marinelle works with pregnant clients to coordinate their prenatal care. These clients are part of a group that has been identified as high risk for pregnancy-related complications. For the past few months, Marinelle has tracked her clients’ prenatal appointments and detects a trend in missed appointments. Most clients who miss appointments live in the same area of the county. It is a small rural neighborhood located in the vicinity of an abandoned factory. All the clients are Black women.

1.
Which of the following factors should the nurse consider as most likely contributing to the clients’ poor pregnancy-related outcomes?
  1. Genetics
  2. Biological factors
  3. Cultural environment
  4. Physical environment
2.
One aspect of health care access is clients’ ability to attend scheduled appointments. Which of the following factors is most likely to facilitate clients’ ability to access health care?
  1. Having a chronic disease
  2. Having adequate insurance coverage
  3. Having strong social support
  4. Having the ability to take time off work for appointments
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