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Pain, No Gain: Healthcare Gender Gaps Still Remain, Especially in India

S. still dreadfully recalls the time when she would end up finishing an entire packet of painkillers every month just to get through her period.

“[The] stabbing pain, [it was] like someone was pulling my insides out, or someone was crushing my organs. My cramping was worse than childbirth, now that I’ve experienced it,” she said.

Many doctors in India told S., who has asked to be identified by the initial of her first name to protect her privacy, that her unbearable menstrual pain was normal. When she complained a bit more, they reluctantly performed a few ultrasound tests. They found some ovarian cysts like endometriomas but didn’t explicitly diagnose endometriosis. Instead, the doctors put her on birth control pills to help the pain. “That was a temporary solution. Never once did anyone tell me to get a laparoscopic surgery done to diagnose and treat endometriosis.” (Laparoscopy is a minimally invasive procedure that allows doctors to see the insides of the abdomen and pelvis with a camera, and then cut off endometriosis lesions that contribute to the symptoms.)

“Never once did anyone tell me to get a laparoscopic surgery done to diagnose and treat endometriosis.”

Women frequently face discrimination in healthcare, where their gender identity affects how they receive medical attention and treatment (This article uses “women” to describe people who menstruate while recognizing that not all people who identify as women menstruate, and not all people who menstruate identify as women.) Others see them as emotionally unstable and prone to exaggerating complaints of pain. Such preconceptions and (often) unconscious bias interfere with the management of real problems, leading to a significant gender gap in healthcare.

The roots of this gender gap can be found as far back as ancient Greece, where people believed that a ‘wandering womb,’ or a displaced uterus, was responsible for women’s pain whose cause wasn’t obviously visible. This led to the medical diagnosis of ‘hysteria’ (from the Greek word hystera for uterus) as a mental disorder up until 1980. Though this diagnosis is now widely rejected, its ghosts continue to haunt female patients even thousands of years later. In fact, during one of her visits to an Indian gynecologist, S. was told that the only way to rectify her retroverted uterus and minimize menstrual pain was to get pregnant. When she pushed back that she wasn’t ready to have a baby, the doctors “looked at me like some fool”, S. described.

“As we were analyzing the data, we discovered that we were treating women differently. I was surprised by this finding because anecdotally, I don’t feel that I treat women differently. However, the overall data from our group suggest otherwise.”

The gender gap in healthcare also means that acquiring pain medicines is a whole battle for most female patients. An American study published in 2008 found that on average, women had to wait a whopping 33% (16 minutes) more than men to receive painkillers for abdominal pain at an urban academic emergency department. Even after controlling for age, race, triage class, and pain score, women were still 13% to 25% less likely than men to receive opioid painkillers.

Professor Esther H. Chen. (Courtesy of UCSF Health)

Esther H. Chen, the lead author of this study, had recently completed a medical residency at the University of Pennsylvania. Her research group was simply looking to improve how they treated abdominal pain patients. So, they created a registry of these patients. “As we were analyzing the data, we discovered that we were treating women differently. I was surprised by this finding because anecdotally, I don’t feel that I treat women differently. However, the overall data from our group suggest otherwise.”

After seeing the results, Chen, now the associate program director for the University of California, San Francisco (UCSF)’s residency program in emergency medicine, said that they are making efforts at an institutional level. “We are trying really hard to educate our providers about unconscious bias in the way we treat patients.”

 

Studies such as Chen’s are good examples of how gender-biased contexts in developed countries affect women’s health, and the steps that are being taken to bridge this gender gap in healthcare. However, studying how socio-cultural aspects surrounding gender affect healthcare in developing countries like India remains a challenge.

India is a predominantly patriarchal society where women are less likely to be educated, receive equal pay as men, or participate in the labor force. This overall poor social development is usually associated with some gender-specific health concerns, such as poor nutrition, lack of contraception, and maternal mortality. Moreover, topics of menstruation and female reproductive health are considered taboo in India. As a culmination of these factors, the World Economic Forum ranked India dead last among 146 surveyed countries in the Health and Survival subindex in their 2022 Global Gender Gap Report, meaning that the country has the biggest disparities in sex ratio at birth and healthy life expectancy anywhere in the world. No group has felt this contrast stronger than Indian expats.

Although endometriosis remains a global challenge and patients worldwide have to wait an average of 6.7 years before receiving the correct diagnosis, S. noticed a stark contrast in the general approach towards female healthcare in the U.S. compared to India. When she moved to the States and approached doctors there for her pain, the American medical professionals first asked about her pain and discomfort levels on various levels, including any back pain, pain during intercourse, and vomiting. Then they referred her to a specialist, who finally diagnosed her with endometriosis and educated her about her treatment options while preserving her fertility.

Even acknowledging the existing health inequities stateside, not only did S. get the impression that American healthcare professionals took her pain seriously, but they were also very transparent in explaining to her the details of the disease, laying out all her options, and answering her questions. In India, in contrast, the most common medical advice she got was to get pregnant to help with the pain.

“I kind of decided not to follow up [with Indian doctors] assuming if I pop a few pills every month that gets me through that horrible period, then why bother going to the doctors as they’re not helpful other than telling me to have a baby?”

“I kind of decided not to follow up [with Indian doctors] assuming if I pop a few pills every month that gets me through that horrible period, then why bother going to the doctors as they’re not helpful other than telling me to have a baby?” she asked. The millions of Indian women bearing pain instead of seeking medical help for fear of being judged or dismissed might agree.

 

Endometriosis is just a small slice of the healthcare gap in India. A study that analyzed data from over 2.3 million outpatients of the All India Institute of Medical Sciences (AIIMS) in New Delhi, India, found extensive gender inequalities in accessing healthcare, which could not be explained by the population ratios of females to males. Researchers found that fewer women than men visit outpatient departments. This outcome is worse when women live farther away from the hospital, particularly among younger and older women.

The reason for this could be that women are traditionally burdened with domestic work, with little time to spare for their health. In order to encourage more women to utilize healthcare, Anita Raj, then a faculty member at the Boston University School of Medicine writing for The Lancet India Group for Universal Healthcare, argued in 2011 that healthcare must be made more accessible. According to her, one of the steps to achieving this is creating a universal health fund, and reducing the cost of healthcare.

However, this may not solve the problem of gender bias in resource allocation. Researchers of The George Institute for Global Health based in India, the U.K., and Australia analyzed a health insurance program sponsored by the southern coastal state of Andhra Pradesh, which guaranteed economically marginalized residents free access to medical services. What they found out from data spanning five years and across nearly a million patients were extensive gender disparities in terms of hospitalizations, bed days, and costs. A similar health insurance program in the northern state of Rajasthan was analyzed in a non-peer-reviewed National Bureau of Economic Research (NBER) working paper. After conducting a spatial analysis of each insurance claim resulting from 4.2 million hospital visits from late 2015 through late 2019, researchers also found that far fewer females utilize this scheme than can simply be explained by sex differences in disease prevalence. Indians simply spend less on female healthcare than they do on male healthcare, and unfortunately, reducing the cost of healthcare through health insurance did not narrow this gender gap.

“While we expected some gender differences, we were struck by the magnitude of the disparities.”

“The expansion of health insurance programs for low-income households in recent years has been a major policy to address health inequality. We wanted to study how much women are benefitting from them,” said Radhika Jain, an Assistant Professor of Health Economics at University College London, who co-authored the NBER working paper. “While we expected some gender differences, we were struck by the magnitude of the disparities,” she added.

Professor Radhika Jain. (Rod Searcey/Courtesy of UCL Centre for Global Health Economics)
Professor Pascaline Dupas. (Rod Searcey/Courtesy of NBER))

Additional efforts from healthcare providers may improve outcomes. But how will healthcare providers help, if women can’t even get into contact with them? Pascaline Dupas is the Kleinheinz Family Professor of International Studies and Professor of Economics at Stanford University and the lead author of the NBER working paper. Building upon her research on understanding challenges facing poor households in lower-income countries, she has an insight. “Village nurses or ASHAs (Accredited Social Health Activists) may be able to have an impact, because they can visit women at their home to encourage care seeking,” she said. “We hope to address this in future work.”

Moreover, it appears that traditional social customs in deep-rooted patriarchy compound the problem of gender inequity in healthcare. For instance, dowry is a social practice where the groom’s family demands expensive gifts (like refrigerators) or cash from the bride’s family during the wedding. Though illegal since 1961, this practice is still prevalent, especially in rural India. The prevalence of dowry practices is associated with poor health quality for women. To this effect, Sanjay Zodpey, now the President of the Public Health Foundation of India, and his colleague Preeti Negandhi, an Additional Professor, argued in a 2020 editorial that women may subconsciously internalize patriarchy, believing that male members deserve more nutrition, healthcare access, and education which could aggravate women’s poor health conditions.

“The fear of getting misdiagnosed causes many women to back out of accessing healthcare, especially around menstruation or reproductive issues.”

According to experts, public health infrastructure policies such as health insurance, more women’s health clinics, and better transport facilities can help expand women’s access to healthcare. However, while such policies are important for making healthcare more accessible to women, the root of gender inequity in healthcare ultimately circles back to systems that simultaneously refuse to treat women with the same dignity as men while failing to provide targeted solutions to women’s health conditions.

And India still has a long way to go to catch up with its neighbors and aspiring rivals. “The fear of getting misdiagnosed causes many women to back out of accessing healthcare, especially around menstruation or reproductive issues,” S. concludes from her ordeal.

 

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Sneha Khedkar

From Mumbai, India, Sneha obtained a B.S. in Microbiology and Biochemistry from St. Xavier’s College (Autonomous) in Mumbai, and an M.S. in Biochemistry from the Maharaja Sayajirao University of Baroda, in Vadodara. She was a Research Fellow at the Institute for Stem Cell Science and Regenerative Medicine (DBT-inStem) in Bengaluru and has written for Slate, Undark, and The Hindu.

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