Closing the Gender Health Gap: A Capabilities Approach to Why Women Deserve More than a Band-Aid by Sloane Caroline Walker
MEd. Inclusion and Special Educational Needs
Introduction
Hysterical. Dramatic. Sensitive. When women seek medical attention, they can sometimes encounter words such as these, as well as dismissive attitudes from healthcare professionals who may not take their health concerns seriously (Mihaila, 2024). For decades, gender health inequality, also known as the gender health gap, has been a significant issue, creating damaging taboos and stigmas that prevent women from seeking help as they do not feel supported or taken seriously by the healthcare system (Department of Health and Social Care & Caulfield, 2021). The gender health gap relates to the inequality concerning the healthcare between women and men. The women’s healthcare gap equates to “75 million years of life lost due to poor health or early death each year” (Whiting, 2024, p.1). Moreover, while women face gender-based discrimination in health, one also needs to consider the additional inequalities women experience in healthcare based on their age, ethnicity, and economic status.
I will focus on the case study of Jodie, a woman who lived through 20 years of intense pain, had to give up a promising career as a chef, and was ignored by her doctors before she was finally diagnosed with endometriosis, as detailed by the Fawcett Society (2024). Using Jodie’s experience with the gender health gap, I will apply it to Nussbaum’s (2011) Capabilities Approach, which assesses people’s capabilities and functioning by asking the key question “what is each person able to do and to be” (p. 18). Nussbaum presents ten Central Capabilities that she argues are essential for human life to truly attain human dignity, she asks “what does a life worthy of human dignity require? Nussbaum replies, “At a bare minimum, an ample threshold level of ten Central Capabilities is required” (p. 32). While exploring Jodie’s experience, I will focus on three Central Capabilities: Life, Bodily Health and Bodily Integrity.
Context
The gender health gap describes the institutionalized and systemic sexism embedded within healthcare systems, leading to inferior services and outcomes for women (Benenden Health, 2023). Benenden Health, a not-for-profit mutual society in the UK providing private medical coverage, published a data report in 2023 focusing on the gender health gap. The results from surveying 10,000 women in the UK highlighted their experiences and barriers in the health care system. Within the results, 60% of women felt that their health issues had not been taken seriously by medical professionals, with an additional 35% believing it was because of their gender (Benenden Health, 2023). Furthermore, 57% said they had a negative experience with a healthcare professional, 36% said they had experienced a late diagnosis, 33% said they had received an incorrect diagnosis, and 24% said they were put on the wrong medication (Benenden Health, 2023). Gender bias in health care creates significant impacts on women’s daily lives, affecting both their mental and physical well-being. A press release from The Department of Health and Social Care shared that over eight in ten women in the UK felt that their concerns were not listened to by healthcare professionals (Department of Health and Social Care & Caulfield, 2021). Additionally, the UK has been found to have the most significant female health gap among the G20 countries (Winchester, 2021).
It is essential to clarify what the gender health gap is towards women and specifically how this impacts women’s social, emotional, economic, and physical well-being. The gender health gap creates massive impacts on women’s sexual reproductive well-being (Ghebreyesus et al., 2024). British feminist author Caroline Criado Perez, author of Invisible Women, exposes the adverse effects on women created by gender bias in data collection. Perez states how healthcare has been “systematically discriminating against women, leaving them chronically misunderstood, mistreated and misdiagnosed” (Perez, 2019, p. 196). Perez writes about Rachael, a woman who had suffered painful periods for years and was insistent that something was wrong but was continuously dismissed by her doctors, who told her, “there is nothing wrong with you” (Perez, 2019, p. 224). Bringing attention to the frustration women feel while being denied healthcare due to gender bias, Perez adds, “instead of believing women when they say they’re in pain, we tend to label them as mad. And who can blame us?” (Perez, 2019, p. 225). Eventually being diagnosed with endometriosis, Perez uses Rachael’s story to bring to light the dismissive attitudes towards women’s health and the time it takes in the UK to obtain a diagnosis of endometriosis, an average of eight years in the UK and up to ten in the US. It took until 2017 for England’s National Institute for Health and Care Excellence to release guidance to doctors despite one in ten women being affected by endometriosis (Perez, 2019).
Endometriosis, according to the World Health Organization (WHO), is “a disease in which tissue similar to the lining of the uterus grows outside the uterus. It can cause severe pain in the pelvis and make it harder to get pregnant” (World Health Organization, 2023), Listed as a chronic disease that is highly complex and affects roughly 10% (190 million) of reproductive-age women and girls globally (World Health Organization, 2023), getting a diagnosis is complicated and lengthy. So, what happens when women report their symptoms and try to receive a diagnosis? In the UK, it takes an average of eight years and ten months to get a diagnosis based on findings from Endometriosis UK (2024), and the length of time has increased from eight years in 2020. In the findings by Endometriosis UK (2024), of the 5,500 women surveyed in the UK, 47% had visited their GP ten or more times with symptoms prior to diagnosis, and 74% had visited five or more times. More worryingly, 78% of the women had experienced doctors telling them that they were “making a fuss about nothing” (Endometriosis UK, 2024, p. 3) and the severity of their symptoms had been questioned by healthcare professionals. Not only are women with endometriosis symptoms being dismissed. Healthcare professionals ignore their pain. However, due to the severity of endometriosis, those who suffer in silence face a “significant, sometimes devastating impact on all aspects of life: education, career, relationships, sexual relationships, fertility and quality of life” (Endometriosis UK, 2024, p. 2).
Case Study
Benenden Health, whose research into the Gender Health Gap highlights the urgent need to address deep-rooted inequalities in the UK healthcare system, as powerfully illustrated by the six real-life stories shared by women navigating misdiagnoses, medical dismissal, and the impact of racism in healthcare. One of those stories is Jodie’s. Starting at age 11, UK native Jodie was already experiencing the gender health gap after seeing her family doctor about her fear, pain, and excessive bleeding from her periods. Instead of being listened to, the doctor’s response was to say it was “just what all the women in your family go through” (Azad & Barnes, 2024, p. 7) and prescribe Jodie the birth control pill. Jodie continued to suppress her pain and intense periods with many types of contraception until her mid-twenties, at which point there was nothing else for her to do except just deal with the pain. Unexpectedly, Jodie became pregnant despite being told by healthcare professionals that she would probably never have children: “When I was pregnant, I often felt like my body was being torn apart. People tried to tell me it was normal” (Azad & Barnes, 2024, p. 7). After the birth of her son, Jodie’s health problems got considerably worse to the point that she bled for eight weeks straight before once again seeking medical attention. The pain affected all aspects of her life, including her career as a chef. At one stage, she collapsed in the middle of the kitchen, “but there was never any medical investigation into the cause of my problems” (Azad & Barnes, 2024, p. 7).
Finally, after 19 years of suffering through pain and dealing with the gender bias of the health care professionals, Jodie sought help from another specialist and was confirmed to have endometriosis. While there is no cure for endometriosis, Jodie was given a series of treatments, including chemically induced menopause and a hysterectomy at the age of 32. However, she is still left with pain, and there is nothing else doctors can do, “I’ve been told I’ve just got to live with it now” (Azad & Barnes, 2024, p. 7). Jodie strongly advocates that attitudes in health care need to change, and that starts with health care professionals needing to believe women and believe their pain, “our pain isn’t believed …. when a doctor can’t help, they need to point us to someone that can” (Azad & Barnes, 2024, p. 7).
I will now take Jodie’s story with the gender health gap and assess it next to the Capabilities Approach to evaluate whether Jodie was allowed to experience her capabilities and opportunities to achieve full human dignity and expose the areas where social injustices were present.
The Capabilities Approach
The Capabilities Approach, proposed by Martha Nussbaum (2011), is a normative framework which refers to central understandings and evaluating human well-being and justice, it emphasises the social injustices and inequalities individuals and groups face. This approach is grounded in the belief that human flourishing and dignity should be understood not merely in terms of resources or utility but through what individuals are actually “able to do and to be” (p. 18). Nussbaum centralises the concept of functioning’s and capabilities, defining capabilities as the real opportunities and freedoms available to all human and nonhuman animals and functioning’s as the “active realization of one or more capability …. Functioning’s are the beings and doings that are the outgrowths or realizations of capabilities” (pp. 24-25), functioning’s are the real-life results of how someone uses their opportunities. Nussbaum emphasises that capabilities are not merely about what people can do but also the genuine opportunities available based on their circumstances.
Capabilities can be categorised in two ways, internal capabilities and combined capabilities. Firstly, when looking at internal capabilities, Nussbaum refers to the internal abilities of individuals, things that can be trained or developed. In other words, things based on our own accord, such as “personality traits, intellectual and emotional capacities, state bodily fitness and health” (p. 21). Secondly, combined capabilities refer to the freedoms and opportunities created by an individual’s internal capabilities in combination with their political, social, and economic environment (p. 20), which allow the conditions necessary for individuals to have access to a threshold level of these capabilities, which is essential for leading a dignified life. In Nussbaum’s Capability Approach, the term threshold refers to a minimum level of capability that must be secured for individuals to lead a life worthy of human dignity, as mentioned above in my introduction, “what does a life worthy of human dignity require? At a bare minimum, an ample threshold level of ten Central Capabilities is required” (p. 32). Threshold is not merely about survival or basic needs. Instead, it is about encompassing essential capabilities which allow individuals to pursue dignified lives and participate fully in society.
There are ten Central Capabilities developed by Nussbaum (2011) that are crucial to living a life worthy of human dignity: Life; Bodily health; Bodily integrity; Senses, imagination, and thought, Emotions; Practical reason; Affiliation; Other species; Play; and Control over one’s environment. (pp. 33-34)
Nussbaum presents several reasons why the ten Central Capabilities are central to the Capabilities Approach. Furthermore, Nussbaum integrates a sensitivity to cultural pluralism which refers to a societal framework where multiple distinct cultures coexist harmoniously, each maintaining its unique identity while participating equally in the broader society (Oxford Review, 2024). Furthermore, the approach is an open-ended argument that can be applied to anything, “the list is open- ended and subject to ongoing revision and rethinking” (p. 108), which means that the approach can change based on how it is applied to the issue at hand. Secondly, the approach “deliberately specifies the items on the list in a somewhat abstract and general way” (p. 108). The approach is abstract and general and can be applied to any context. Finally, major liberties that protect pluralism specifically, freedoms that all individuals should be entitled to, such as freedom of speech and political access, which are critical to a society that protects religious and cultural pluralism, these protections are “central items on the capabilities list …. By placing them on the list we give them a central and non-negotiable place” (p. 110).
Application of the Capabilities Approach to Case Study
There are ten Central Capabilities that Nussbaum presents that all individuals should attain to achieve true human dignity. As stated in my introduction, I will focus on three of these Central Capabilities and how they are affected in Jodie’s case. These three are Life, Bodily Health and Bodily Integrity. The three Central Capabilities I am focusing on, as defined by Nussbaum (2011), are as follows:
Life. Being able to live to the end of a human life of normal length … or before one’s life is so reduced as to be not worth living.
Bodily Health. Being able to have good health including reproductive health …
Bodily Integrity. Being able to move freely from place to place … and for choice in matters of reproduction (p. 33).
However, most of the ten Central Capabilities are being affected negatively when applied to Jodie as the Central Capabilities are intertwined and reliant on one another.
Firstly, due to Jodie’s significant pain, she was unable to fulfil her capability of living a quality life. Jodie’s Life was impacted substantially by her doctors constantly dismissing her chronic condition as just something she was dramatising, and something that all women deal with. She was also being rejected for adequate access to healthcare or medical professionals who would take her concerns seriously, which contributed to the decades-long poor quality of life due to her undiagnosed endometriosis. Jodie was unable to access adequate healthcare services, which would have allowed her to live a life free from pain. Furthermore, the effects on her life also impacted her livelihood. Due to her undiagnosed condition, Jodie was forced to give up her career as a chef. In an already male-dominated field, Jodie was forced to turn down opportunities presented to her as a working chef due to gender bias. Her pain was labelled as “women’s issues” (Azad & Barnes, 2024, p.7), and she could not handle it because she was a girl. Because it took nearly two decades for Jodie to be diagnosed with endometriosis, during that time Jodie’s quality of life was affected physically and economically, and her emotional well-being was reduced.
Intense pain for prolonged periods and attitudes from healthcare professionals affects the mental well-being of individuals who have endometriosis. A BBC study from 2019 involving 13,500 women living with endometriosis showed that half of the women had considered suicide and relied heavily on painkillers, leading many to develop addiction (Bevan, 2019). Impacts such as these leave a person more vulnerable to a reduced life expectancy or a life not worthy of living due to physical and mental torment. Jodie falls below the minimum level of functioning for this capability. She faced increased mortality and impacts on her daily life, hindering her ability to do work and be an individual who fully participates in society.
Secondly, Bodily Health was affected negatively in many ways, which connects to the first central capability I assessed. The two go hand-in-hand as they are non-fungible, and if one is affected, all will be affected negatively. Jodie’s Bodily Health was diminished not only physically but also mentally. Due to her decades-long struggle with painful periods and no answers from doctors, Jodie was also dealing with mental health issues due to her pain and not being believed by doctors. Her concerns about her body were being dismissed as women’s issues which she just had to deal with, and this can be seen as medical gaslighting, “an act that invalidates a patient’s genuine clinical concern without proper medical evaluation, because of physician ignorance, implicit bias, or medical paternalism” (KS Ng et al., 2024, p.1). Additionally, her reproductive health was limited as she was placed on multiple different contraceptives and told she would probably never have children but did indeed get pregnant. Furthermore, Jodie’s Bodily Health was continuously affected for decades due to her not being diagnosed with endometriosis until later in life, “no diagnosis means no access to treatment or management of the condition, meaning that the disease may progress, risking permanent damage to internal organs and worsening physical symptoms and mental health impacts” (Endometriosis UK, 2024, p. 4). Jodie was unable to reach a minimum threshold level of functioning in Bodily Health, her access to basic healthcare services that would help her pain was not met. She was not able to be heard as a woman with medical concerns, leaving her unable to do anything to maintain her physical and mental health.
Finally, the third capability I will assess is Bodily Integrity. Jodie had no choice in her reproductive health. Jodie unexpectedly got pregnant after being told she would never have children and was put on the pill at age eleven by a doctor who would not listen to Jodie’s concerns. Jodie was unable to move freely due to pain, and she bled for eight weeks straight after the birth of her son. Despite the trauma her body and mind were dealing with post-birth, a doctor told her that having another baby would cure her endometriosis, which is untrue (Azad & Barnes, 2024). Instead of looking at Jodie’s symptoms and listening to her, healthcare professionals took away Jodie’s choice and freedom to control her reproduction by pushing contraception while at the same time suggesting that pregnancy would be a cure-all to her symptoms. While the case study provides a compelling account of Jodie’s experience with the Gender Health Gap, it does not address the potential impact her stress may have had on her unborn baby—an important gap, as research shows that high levels of maternal stress during pregnancy can affect fetal development, increasing the risk of emotional, behavioural, and health challenges later in the child’s life (Coussons-Read, 2013).
Additionally, the surprise pregnancy prevented Jodie from moving freely, as she is now responsible for a child. She may have not been spoken to about the risks of contraception or have even ever wanted to have a child, Jodie also had to have a hysterectomy due to poor health care. Because of the lack of knowledge of endometriosis by doctors in Jodie’s case, her Bodily Integrity has been severely impacted. The threshold level of functioning’s was far below the minimum level of functioning. Jodie’s Bodily Integrity was violated through inadequate medical care and lack of informed consent. Leaving Jodie unable to do what she is best for her body, and unable to be informed on choices about her body without coercion or misinformation from doctors.
Conclusion
Is there a solution to prevent widening the gender gap in healthcare? There is potential if a multi-faceted approach is implemented. This would involve educating and advocating across various levels of the healthcare system. In contrast, there are starts in advocating for policy change to address gender bias in healthcare and within workers of the healthcare profession. Moreover, women have historically been underrepresented in clinical trials, which added to the gender gap in health care as most studies focus only on men. Advocating for the inclusion of all genders in medical research must take place so that all needs are reflected. There needs to be education on unconscious bias, which can help healthcare professionals recognise their own biases and the impact these have on patient care. Furthermore, there needs to be more education for healthcare professionals about women-specific issues and recognition of them, such as endometriosis, which I explored in this essay. Finally, women should simply be listened to and believed when accessing healthcare. While there is not a one-answer solution at this current time, with more attention being brought to the gender gap in healthcare, there is hope that women like Jodie will start being believed and their capabilities will be within a threshold where they can truly live a life worthy of human dignity.
The gender gap in healthcare affects many women in the UK and worldwide. The social injustice stems from healthcare’s discrimination against women since its beginning and women traditionally being labelled as hysterical and dramatic. Specifically, when focusing on Jodie’s story and her experience dealing with doctors. Nussbaum states, “the approach espouses a principle of each person as an end. It stipulates that the goal is to produce capabilities for each and every person, and not to use some people as a means to the capabilities of others or of the whole” (Nussbaum, 2011, p. 35). Jodie has experienced capability failure. Her capabilities and functioning’s were unable to reach beyond a minimal threshold level of functioning achieved, which created an environment where Jodie experienced disadvantages and could not truly attain human dignity.
Reference List
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