CPD: biological and gender-based health inequalities

It’s important to be aware of the inequalities in healthcare provision and health outcomes for men, women, transgender, non-binary and intersex employees, which arise from biology and societal attitudes. Emma Persand looks at what this means for occupational health practitioners.

It’s an unfortunate reality that women spend a significantly greater proportion of their lives in ill health and disability compared to men, which contributes to wider socio-economic inequalities. Not enough focus is placed on women-specific issues, through fractured and hard-to-access women’s health services; lack of education for self-management of reproductive health needs; and lack of sex-specific health professional training curriculums (Royal College of Obstetricians & Gynaecologists, 2019).

All women, some trans men, some intersex individuals, and some who identify as non-binary, will have to meet their reproductive health needs in their own time and are not accounted for in the majority of workplace health and wellbeing policies. For example, they are recommended to have a total of 11 cervical screens between the ages of 25 and 64 (Cancer Research UK, 2017) and five days for breast screening, between the ages of 50 and 65 (NHS, 2021). Furthermore, 50% of working-age women who have accessed sexual health services use long-lasting reversible contraception requiring an annual review (Statista, 2022).

Leaving sexual and reproductive health needs out of the health and wellbeing agenda reinforces historic stigma and shame. This also presumes that the worker does not have reproductive health needs, and therefore the resulting gender-neutral approach to employee health is based on the premise that the standard body is male.

Pregnancy-related issues and menopause aside, health education on sexual and reproductive health conditions such as premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), polycystic ovarian syndrome (PCOS), endometriosis, adenomyosis, abortion care, fertility treatment, breast cancer and gynaecological cancers are not widely available or acknowledged at work.

Menopause guidance

In November 2022 NHS England released guidance, as part of the National Menopause Improvement Programme (NMIP), to support staff experiencing symptoms of the menopause transition (NHS England, 2022). This work is embedded in the overarching NHS ‘People Promise’ of coming together to improve the experience of those working in the NHS and to support the retention strategy. The guide provides managers with signposting support and step-by-step instructions on how to record menopause-related absence. The data gathered will inform on the extent of the impact of menopause and assist in future improvements. Included in the programme is soon-to-be-released training and education specifically for occupational health professionals.

The NMIP aligns with the Women’s Health Strategy (WHS), launched in June 2022, which details the government’s 10-year plan of action to improve the health and wellbeing of women and girls. It advocates that employers should introduce or improve their workplace provisions and policies to better support women in different situations (Department of Health and Social Care, August 2022).

The Women’s Health Strategy notes that high-quality occupational health services play an important role in helping women to thrive in work. Mental health support, line manager training and workplace adjustments are indicated as credible ways to manage and maintain good health at work. It also states that inclusive occupational health can be valuable in tackling stigmas and taboos around menstruation, menopause, and gynaecological conditions. This should enable individuals to speak up and support managers to be competent and feel confident in discharging their duty of care.

Linking in with the development of the Women’s Health Strategy, the Voluntary, Community and Social Enterprise Health and Wellbeing Fund is a joint initiative run by the Department of Health and Social Care, NHS England and the UK Health Security Agency (Department of Health and Social Care, May 2022). In December 2022 it awarded 16 organisations across England a share of £1.97m to support women experiencing reproductive health issues such as menopause, fertility problems, and pregnancy loss to remain or return to the workplace.

Surge in occupational health referrals?

Increasing population awareness and training managers in identifying when sexual and reproductive needs become a workplace health issue will inevitably lead to an increase in referrals to occupational health. Suzanne Banks CBE, clinical programme lead for the NMIP, has said that OH systems will need to be able to cope with this potential surge.

There is a need for occupational health to take account of wider social and cultural gender discrimination issues in work-related risks and their prevention through gender-sensitive assessments (European Agency for Safety and Health at Work, 2003).

Rees et al., (2021) maintain that the employer’s duty of care includes identifying and supporting groups of workers who might be particularly at risk, including any specific risks that women may experience during menopause because of their workplace environments.

In addition to the biological phase of the menopause transition, there are substantial differences in the working lives and employment situation of women and men, and therefore access to occupational safety and health.

Inequalities beyond reproductive health

Disparities in health outcomes extend beyond sexual and reproductive health. A British Heart Foundation study, ‘Bias and Biology’, found women who have heart attacks receive poorer care than men from diagnosis through treatment and aftercare; a woman is 50% more likely than a man to receive a wrong initial diagnosis. The study found that using a more sensitive troponin test has established a new threshold for women and could double the diagnosis rate (British Heart Foundation, 2022).

The absence of the woman’s body from clinical trials and the subsequent impact on health outcomes has led the Canadian Institutes of Health Research to include a requirement that research proposals incorporate sex and gender, and researchers complete sex and gender training and include a person with expertise in sex and gender in their teams (Government of Canada, 2018).

Gender inequality is a health determinant

As clinicians, we need to understand and apply the knowledge that sex refers to the biological and physiological differences between men and women, and gender refers to the socially-constructed characteristics and social norms attributed to each sex. Different cultures and different times in history have dictated the socially accepted norms of how an individual should dress, behave, and present themselves, which has formed generally held opinions, beliefs and attitudes of desirable attributes (World Health Organization, 2019).

The World Health Organization defines gender as hierarchical and gender-based discrimination that produces inequalities that intersect with other factors of discrimination, such as ethnicity, socio-economic status, disability, age, geographic location, gender identity and sexual orientation. This is referred to as intersectionality (World Health Organization, 2019 (b)). A key example of this is highlighted in the MBRRACE-UK ‘Maternal Mortality Surveillance and Confidential Enquiry Report for 2022’, which considers the disparity in maternity outcomes reporting: women living in the most deprived areas are almost three-times more likely to die in childbirth than those who live in the most affluent areas. It also finds that the white population experienced 8/100,000 maternal deaths while black individuals experienced 34/100,000, mixed ethnicity experienced 25/100,000, and Asian populations experienced 15/100,000 (National Perinatal Epidemiology Unit, 2020).

Representation and stereotypes

Gender inequality, both inside and outside the workplace, can affect women’s occupational safety and health. Discrimination extends beyond the protected characteristics of sex, age, gender reassignment, pregnancy and maternity, disability, marital status, race, religion or belief, and sexual orientation. The intersection of attitudes and beliefs on the broader identities of class, where you live/were born, accent, level of education, income, and occupation contribute to generally held beliefs or stereotypes.

The gender stereotype that women are more emotional, nurturing, and natural carers has led to the disproportionate distribution of domestic responsibilities in UK society. Most unpaid carers are women, and the impact of this includes missing opportunities to progress in their careers, experiencing burnout and mental health issues, and finding it more difficult to attend appointments for their own health needs (Department of Health and Social Care, August 2022).

The European Institute for Gender Equality reports that 80% of all care provided in Europe is informal, most of which is provided by women aged 45-75 (European Institute for Gender Equality, 2019).

The institute also suggests that the gender pay gap stems from a combination of factors, including occupational and sectoral segregation, part-time or temporary work, gender stereotypes and norms, difficulties in reconciling work and private life, discrimination, hidden wage structures and the undervaluing of women’s work and skills. The fact that women are paid less compared to men overall has implications not only for their financial independence and spending, but also for their accumulation of wealth, particularly pensions (European Institute for Gender Equality, 2019).

NMIP and the WHS have established that lack of menopause transition support at work has contributed to women leaving employment, reducing working hours and stepping down from certain roles to manage their health and wellbeing. Menopause representation that emphasises the severe physical, emotional, and psychological symptoms that only 25% of women may suffer will inform general attitudes and beliefs that it is a negative phase, potentially bringing psychological distress to women who do not require any intervention or management other than health education. Stereotypical media representation of menopause as a white, middle-aged disease is also not helpful to younger women experiencing menopause prematurely after certain treatments, for example breast cancer. It can also mean that we neglect the diverse needs and experiences due to ethnicity and sexual and gender identity.

There are also some concerns about the gender sensitivity of healthcare and services. For example, women’s health services tend to focus on their sexual, reproductive, and maternal health, while other health needs are overlooked, particularly in cases of non-communicable diseases. It is also assumed that women experience non-communicable diseases in the same way as men, which can result in misdiagnosis, and ineffective and unequal treatment (Peters et al., 2016).

Conversely, men’s health needs are often presented in terms of non-communicable diseases, with little attention to their sexual, reproductive, family, and mental health needs. Gender norms around recognising and admitting emotional distress may mean that men find it more difficult than women to seek help. This has been linked to significantly higher suicide rates among men than women (World Health Organization, 2018).

In the UK, race and gender intersect with mental health needs as black men are far more likely than others to be diagnosed with severe mental health problems and are also far more likely to be sectioned under the Mental Health Act (Mind, undated).

Occupational health’s role

The Covid-19 pandemic highlighted the historic employment and social inequalities within the UK population. Occupational health professionals have a role in ensuring these inequalities are addressed.

By incorporating culture and gender into the biological/psychological/social risk assessment process, the diverse needs of employees will be identified, risk reduction strategies can be implemented, and signposting can be used.

Stigma and lack of education have been identified as influencers of poor health outcomes. Occupational health should promote the greater recognition of not only sexual and reproductive health conditions, but the increased risks of other health conditions posed by the absence of female bodies in clinical trials, to ensure parity alongside other workplace health issues.

Occupational health professionals should lead the way to create a thriving environment for women. Given the powerful impact that biological sex and gender have on physical and mental health outcomes, working lives and financial security, OH professionals must be equipped with the skills to address gender-based health inequities in their work. For example, cultural competency learning for clinicians has been instigated by the NHS, and a similar programme of education could be investigated for OH.

Understanding that the menopause transition is not reduced to a biological phase and that social and cultural factors influence how it is experienced will allow occupational health professionals to deliver a holistic approach, from self-management risk-reduction strategies and clinical intervention advice through to employment recommendations to manage the workplace risks to health.

References

British Heart Foundation, (2022). Bias and biology: The heart attack gender gap. [online] British Heart Foundation. https://www.bhf.org.uk/what-we-do/in-your-area/wales/campaigning-and-influencing/bias-and-biology-the-heart-attack-gender-gap-wales

Cancer Research UK (2017). About cervical screening. https://www.cancerresearchuk.org/about-cancer/cervical-cancer/getting-diagnosed/screening/about

Department of Health and Social Care (August 2022) Women’s Health Strategy for England. https://www.gov.uk/government/publications/womens-health-strategy-for-england

Department of Health and Social care (May 2022) VCSE Health and Wellbeing Fund 2022 to 2025: women’s reproductive wellbeing in the workplace. https://www.gov.uk/government/publications/vcse-health-and-wellbeing-fund-2022-to-2025-womens-reproductive-wellbeing-in-the-workplace

European Agency for Safety and Health at Work (2003) Gender issues in safety and health at work. https://osha.europa.eu/en/publications/report-gender-issues-safety-and-health-work

European Institute for Gender Equality (2019). Informal care of older people, people with disabilities and long-term care services. https://eige.europa.eu/publications/gender-equality-index-2019-report/informal-care-older-people-people-disabilities-and-long-term-care-services

European Institute for Gender Equality. (undated). Gender pay gap in ICT and platform work. https://eige.europa.eu/publications/gender-equality-index-2020-report/gender-pay-gap-ict-and-platform-work

Government of Canada (2018). Sex and Gender in Health Research. https://cihr-irsc.gc.ca/e/50833.html 

Mind (undated) Working with young Black men. https://www.mind.org.uk/about-us/our-policy-work/equality-and-human-rights/young-black-men/

National Perinatal Epidemiology Unit (2020). MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK, https://www.npeu.ox.ac.uk/mbrrace-uk

NHS (2021). Breast screening (mammogram). https://www.nhs.uk/conditions/breast-screening-mammogram/

NHS England (2022) Supporting our NHS people through menopause: guidance for line managers and colleagues  https://www.england.nhs.uk/wp-content/uploads/2022/11/B1329-guidance-Supporting-NHS-people-through-menopause-November-2022.pdf

Peters, S.A.E., Woodward, M., Jha, V., Kennedy, S. and Norton, R. (2016). Women’s health: a new global agenda. BMJ Global Health, 1(3), p.e000080. doi:10.1136/bmjgh-2016-000080

Rees, M., Bitzer, J., Cano, A., Ceausu, I., Chedraui, P., Durmusoglu, F., Erkkola, R., Geukes, M., Godfrey, A., Goulis, D.G., Griffiths, A., Hardy, C., Hickey, M., Hirschberg, A.L., Hunter, M., Kiesel, L., Jack, G., Lopes, P., Mishra, G. and Oosterhof, H. (2021). Global consensus recommendations on menopause in the workplace: A European Menopause and Andropause Society (EMAS) position statement. Maturitas, 151, pp.55-62. doi:10.1016/j.maturitas.2021.06.006.

Royal College of Obstetricians & Gynaecologists. (2019). Better for women report. https://www.rcog.org.uk/better-for-women

Statista. (2022). Contraceptive use among women in England by type and age 2018/19.  https://www.statista.com/statistics/573210/contraceptive-use-among-women-by-type-and-age-in-england/

World Health Organization (2018). The health and well-being of men in the WHO European Region: better health through a gender approach. https://apps.who.int/iris/handle/10665/329686

World Health Organization (2019)  Gender and health. https://www.who.int/health-topics/gender