How pharmacists can overcome their own unconsciously dismissive bias of women’s health concerns by asking the right questions.

Despite the many good intentions of health professionals in Australia, historic gender bias in healthcare continues to be evident.¹

A systemic and sometimes oblivious bias to matters such as pain in women has pervaded our health system in which much research has historically been based largely on men, and healthcare professionals are often unaware it is there.

It is not deliberate, but given how long it takes to diagnose certain conditions in women and how many, tend to normalise their symptoms to cope – from endometriosis to mental health issues – healthcare professionals may be unaware of the systemic bias against female and non-binary people. Women may receive short-term treatments for long-term situations, like menopause. 

But pharmacists can help by spending more time listening for symptoms, developing an understanding of patient concerns, even encouraging them to be pushy with GPs or specialists to get referrals or plans for next steps. Asking that extra question can be vital.

AP asked two experienced female pharmacists for their suggestions on overcoming unconscious gender bias in Australian healthcare.

Mary Bushell MPS, Clinical Assistant Professor in Pharmacy, University of Canberra

In Australia, when compared to men, women are twice as likely to have their health concerns dismissed or ignored by a health professional.² This is a concern. 

As pharmacists, it’s important that we consciously check in and register our own unseen biases and take active steps to compensate for the biases of the system. One practical way to do this, is to stay across the growing body of literature on gender bias in healthcare.

For example, published studies show, that when compared to men, women with chronic pain are less likely to be prescribed pain medicines, despite reporting more frequent and severe pain levels.³ There are also studies that show women are more likely to be told that their pain is psychosomatic or ‘in their head’.³  

And recently it has been shown that it takes on average 6–8 years for endometriosis, a women’s only medical condition, to be diagnosed, and until that time the condition is undertreated, underdiagnosed, and misdiagnosed. ⁴ When you know the literature, and explicit examples of the gender bias in healthcare, you are more able to see your own unseen bias and take ownership of it.

For me, knowing the evidence on gender disparity is the first step. It serves as a reminder, forces me to challenge my perceived stereotypes and in doing so empowers me to provide better care for my patients. I also use substitution if I think that gender bias is creeping into my patient care. I simply ask myself, what questions, treatment, and counselling would I provide if the patient was the other sex? 

It is also important as a health professional to recognise that medical conditions, for example stroke and heart attacks, do not always present or are treated the same in both men and women.^5,6 Knowing this and taking active steps to ensure that I have the up-to-date knowledge on how medical conditions present and are treated in both men and women, is a practical step that can be taken, to support personalised patient care.   

As a pharmacist, I have supported many people, both men and women in their battle with depression and/or anxiety. As a practical tip, I found the mental health first aid course a really good tool to support my practice and gain insight into some gender differences. While depression is twice as common in women, they are also more likely to seek out help.

As a pharmacist it is important that I don’t dismiss symptoms. For example, that I don’t put the symptoms of depression down to moodiness. Actively listening to my patients is key.

Angela Xenikis, National Pharmacies, Glenelg, Adelaide

Women have different cues to men when they are talking about their health. They tend to open up more to pharmacists and will often ask questions they might have been too afraid to ask of their doctor earlier. 

I try to ask open-ended questions to understand what is really going on in their mind. I find the PSA guidelines and tools good in this regard.

With conditions like endometriosis or heavy periods, it’s important that women are not treated like it’s all in their head. With endometriosis, women are generally put on the pill. But if I see them changing pill after pill with no results I will investigate. I will ask questions like: ‘What is the reason for changing that pill in the last 3 months? What prompted the change? Do you think you should go back to the doctor?’ 

If I’m encouraging a patient to raise an issue with her doctor, I will say things like: ‘What was your impression of what the doctor said? Did you understand fully what the duration of the treatment should be and what your goal should be out of this therapy? What is the timeframe you have been given to refer back to the doctor?’ I stress that it’s important to get that reassessment and not to be afraid to answer questions. 

Of all the issues I deal with, I find mental health the hardest. Women often feel like they are not in control. I try to ensure they have the support mechanisms they need and work closely with their GP and other health professionals.

I had a young female patient who kept reverting back to suicidal thoughts and never really stabilised on any medicine. She made quite a few attempts on her life. I worked closely with her doctor but it was hard because when she was released from the Emergency Department there wasn’t the home support to stop her relapsing.

We always put her in a quiet space in the pharmacy to allow her to release any emotions and we had a table she could lie down on if she needed that. The good thing is that she was always willing to come in and always willing to stay as compliant as she could. I was happy about that. 

I had another friend who had to go through withdrawal of her mental health medications for extreme anxiety and depression only to be put back on the same medication. I don’t see the sense in putting them on highly addictive medications and expecting them to manage their mental health when they just don’t have the ability to do that.  We seem to resort to just managing the symptoms. We are not giving them the tools to be able to deal with the pressures of life.

References

1. Samulowitz A, Gremyr I, Eriksson E, et al. “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.
2. Australian Broadcasting Cooperation. Have you ever had health concerns dismissed by a doctor? 2021; At: www.abc.net.au/news/2021-06-07/australia-talks-survey-finds-gps-often-dismiss-women-issues/13377282.
3. Zhang L, Reynolds Losin EA, Ashar YK, et al. Gender biases in estimation of others’ pain. J Pain 2021. Epub 2021 Mar 5.
4. Mechsner S, [Endometriosis : an often unrecognized pain disorder]. Schmerz 2016;30(5):477–90.
5. Lichtman JH, Leifheit EC, Safdar B, et al. Sex differences in the presentation and perception of symptoms among young patients with myocardial infarction: evidence from the VIRGO study (variation in recovery: role of gender on outcomes of young AMI patients). Circulation 2018;137(8):781–90.
6. Bushnell CD, Chaturvedi S, Gage KR, et al. Sex differences in stroke: challenges and opportunities. J Cereb Blood Flow Metab 2018;38(12):2179–91.

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