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Show Notes for Episode Seventeen of seX & whY: Impact of Gendered Masculinity in Health Engagement and Decision-making

Host: Jeannette Wolfe

Guests:
Dr Fahad Saeed, Nephrologist and Palliative Care Specialist from the University of Rochester

Dr Lauren J. Parker, PhD, Dual PhD in Gerontology and Health Promotion, scientist at the Johns Hopkins Bloomberg School of Public Health

The topic today discussed how masculinity and race can impact access to health and health related decisions.

Take home points

• Overall, men have a shorter life expectancy than women and this is likely influenced by both biologically and sociocultural based factors associated with an individual’s gender identity
• Race based stressors amplify these sociocultural mortality differences
• Men are less likely to access preventative health care services and some of this is likely related to biological sex differences and behavioral patterns that begin in early adulthood as females are more likely to interact with health systems due to pregnancy and child related issues.
• Sociocultural “masculinity norms” may discourage health engagement due to an individual’s desire to be perceived as tough and independent.
• Ways to better engage men with their health (with an emphasis on men of color)

Increase public messaging to normalize the need for men’s preventative health

Increase diversity amongst medical providers

Reach men where they are like sporting events, barber shops and churches

Acknowledge and appreciate the unique roles and challenges that many men face

Target and adjust messaging to engage men at different life points

• Men can get caught in a warrior-like mentality which may impact their end-of-life choices. In cancer patients this may make them less receptive to palliative care due to a concern that it may suggest that they are “giving up”.

Palliative care is a specialty that helps patients, and their families cope with a life shortening illness and to optimize their quality of life.  Patients in palliative care can still receive aggressive disease modifying therapy like chemotherapy with the except of patients receiving “hospice care”.   Hospice care, although still under the palliative care umbrella, has slightly different rules.  Under hospice, it is recognized that a patient is likely in their last 6 months of life and that they would no longer benefit from aggressive treatments, all care is redirected to optimize comfort.

Dr Saeed’s tips surrounding palliative care engagement in men with advanced cancer

• Normalize messaging such that palliative care is considered a natural part of cancer treatment
• Appreciate impact of non-verbal language- be authentic in conversation
• Recognize that most conversations have a logical and emotional component and appreciate that both need to be addressed
• Take time to know the patient’s story, this humanizes the interaction and increases empathy
• Remember goal is to figure out their preferences and then honor them
• Sometimes shifting focus from fighting terminal cancer to fighting for comfort and to ease families suffering can make patients more amenable to palliative care services

Links

– Dr Lauren Parker’s paper that examines ways to more effectively engage men in their health.
– List of her other publications–
TEDX Rochester talk by Dr Saeed
– Links to Dr Saeed’s publications
– His specific research that we discussed
– 2012 paper that Dr Saeed referenced by Susan Wong

Show Notes for Episode Sixteen of seX & whY: Interview with Dr Saralyn Mark

Host: Jeannette Wolfe

Dr Mark has had an incredibly interesting and eclectic career. She is trained in Endocrine, Geriatrics and Women’s Health and has worked for and/or consulted with:

The Office of Women’s Health in Department of Health and Human Services, NASA and 4 different Whitehouse Administrations

She has also written the book Stellar Medicine: A Journey through the Universe of Women’s Health

In addition, she has founded two different companies

• Solamed Solutions a boutique consulting firm that advances scientific and strategic direction for public and non-public sectors
• The non-profit iGIANT (Impact of Gender and Sex on Innovations and Novel Technologies)

Our discussion features some of the highlights of Dr Mark’s career as well as surveys a bunch of uncommonly recognized, yet important sex and gender based differences in medicine, technology and industry. We talk about sex and gender based differences in military equipment, PPE,  laparoscopic tools, automobile safety and Covid-19.

Show Notes for Episode Fifteen of seX & whY: Sex Differences in Immunology and Drug Therapy

Host: Jeannette Wolfe

Guests:

Evelyne Bischof MD, Associate Professor of Medicine at Shanghai University of Medicine and Health Sciences and internist at University Hospital of Basel Switzerland

Sabra Klein, PhD, Professor of Molecular Microbiology and Immunology at Johns Hopkins Bloomberg School of Public Health

This podcast focused on sex differences in immunology and pharmacology and its relevance to the Covid-19 pandemic.

Key points

• Males are more likely to be admitted to the ICU and die from COVID-19 compared to females
• Males and females have differences in both innate and adaptive immunity (which likely are a combo of chromosomal, hormonal and epigentic differences)
• One difference in Innate immunity (the initial non-specific reaction to a foreign pathogen) is Toll-like receptor 7 (TLR7) This is a major player in the initial physiological response to a foreign pathogen and the gene for it is on the X chromosome. X-lined genes (like Ace-2 which is the receptor which SARS-Cov-2 initially binds to in the body) are interesting because they immediately bring up two considerations.  First, if someone has a specific variant of that gene, it could change their susceptibility to certain pathogens. Males, as they have an XY pair of sex chromosomes, only have one X chromosome and thus could be more adversely impacted than females (XX) who have a second copy of the gene (which may or may not express the same variant)  from their other X chromosome. The second consideration is that in the cells of most females, one of the X chromosomes is automatically turned off (X inactivation). It appears however, that some X-linked immune cells- like TLR7- don’t do this, leading to the possibility of increased expression of the gene like getting an “extra dose”.
• In adaptive immunity (which involved B and T cells), females generally have a greater immunological response to most pathogens.
• As such, females generally exhibit a more robust immune response to natural infections and vaccinations. The flip side, however, is compared to men, women are also at greater risk for autoimmune diseases and are more likely to get local and systemic reactions after a vaccination.
  • When testing the effectiveness and side effects of SARS-CoV-2 vaccines it would be ideal to consider the variables of biological sex and age.
  • In an influenza study, when women were given a ½ dose of the flu vaccine, they mounted a similar immune response to males who got full dose. If the same held true for developing SARS-Cov2 vaccinations, it could potentially increase the amount of vaccine available (though it is unclear if this is even being considered in early vaccine trials).
  • Aging can also impair the immune response and older adults may require higher doses of booster doses of some vaccines to optimize their immune response
• The use of Artificial Intelligence in drug development may revolutionize the pharmaceutical research industry by allowing more predictive drug modeling leading to more successful drug development.
• This could also be used to better identify potentially important biological sex- based pharmacodynamic and pharmacokinetic differences earlier in drug development.

Two unexpected findings associated with COVID-19

• Males appear to be more vulnerable to cytokine storm (mechanism still not entirely clear may be differences in ACE-2 receptors, or chromosomal/hormonal differences in innate/adaptive immune system)
• Elderly sick males who survived COVID-19 appear to have significant protective antibody production against SARS-Cov2

References:

Bischof E, Wolfe J, Klein S: Clinical trials for Covid-19 should include Sex as a Variable. JCI 2020

Engler R, Nelson M, Klote M, et al. Half- vs Full-Dose Trivalent Inactivated Influenza Vaccine (2004-2005) Age, Dose, and Sex Effects on Immune Responses, JAMA Internal Medicine 2008

Gender and COVID-19 Working Group website

Global Health 50/50  global deaths disaggregated by sex

Klein S, Pekosz A, Park H. et al.  Sex, age and hospitalization drive antibody responses in a Covid-19 convalescent plasma donor population. JCI 2020

Roberts M, Genway S How Artificial Intelligence is transforming drug design. DDW

Souyris M, Cenac C, Azar P, et al. TLR7 Escapes X Chromosome Inactivation in Immune Cells. Autoimmune Disease 2018

Takehiro T, Ellingson M, Wong P et al. Sex Differences in Immune Responses that underlie COVID-19 disease outcomes. Nature 2020

Zucker I, Prendergast B.  Sex differences in pharmacokinetics predict adverse drug reactions in women. Biology of Sex Differences 2020

Special thanks to Doug Deems for help with editing.

Show Notes for Episode Fourteen of seX & whY: COVID-19 through a Gender Based Lens Part 2

Host: Jeannette WolfeGuests: Dr Gary Barker CEO of Promundo- an organization that promotes healthy masculinity and gender equality

Dr Stephen Burrell Assistant Professor in the Dept of Sociology at Durham University – whose area of focus in on engaging men and boys in the prevention of violence against women.

Here are some of the take-home points of our discussion.

• The need to clearly label preliminary studies as “preliminary” to avoid early adoption of inadequately proven therapies
• The importance of both including both males and females in research drug trials and in analyzing results by biological sex. (For example, from toxicology research it is known that females are at greater risk for drug-induced QTc prolongation – which can trigger a dangerous arrhythmia- than men, yet this consideration was not taken into the design and analysis of almost all the hydroxychloroquine studies even though we know that QTc prolongation is one of this drug’s most well-known side effects.
• The need to go beyond biological sex to look at social and environmental determinants that help identify “which men” or “which women” (or “which nonbinary person”) is at greatest risks so that we can better direct interventions. This approach often quickly spotlights longstanding heath inequity issues.
• If the goal is to improve health outcomes to consider subtly shifting the approach away from how can men better engage with health care systems towards how can health care systems better engage with men is quite important. Dr Barker shared an excellent example of a project he was involved with in Brazil in which men were approached during their partners prenatal clinic visits to make their own health related appointments.
• This pandemic has been associated with some significant collateral health related damage including: people being afraid to seek out medical care for true emergencies; huge shortages of reproductive health services; increasing prevalence of domestic violence; and mental health related issues triggered by loneliness and isolation.

Here is the link to the Pew Study that Dr Barker mentioned.

Here is the link for the Harvard GenderSci

Here are some links for the challenges India is having with obstetrical care including this NY Times article

Amanda Nguyen’s Rise UP 19 program that allows domestic violence victims to be helped by restaurant owners.

Special thanks to Doug Deems who helped me edit this podcast.

Show Notes for Episode Fourteen of seX & whY: COVID-19 Through a Gender Based Lens Part 1

This is a discussion on how gender-associated norms impact disease process.

Host: Jeannette Wolfe
Guests: Dr Gary Barker CEO of Promundo- an organization that promotes healthy masculinity and gender equality

Dr Stephen Burrell Assistant Professor in the Dept of Sociology at Durham University- who’s area of focus in on engaging men and boys in the prevention of violence against women.

Today’s podcast features the first part of our discussion which focuses on how “gender” roles and norms impact general health and the COVID-19 pandemic. Both of our guests are experts on how societal perceptions and stereotypes surrounding “masculinity” influence the health and well-being of both men and women. Through Promundo, Dr Barker has done significant amounts of work in Brazil where toxic masculinity has been associated with the early deaths of millions of young men and Dr Burrell recently wrote the article: Coronavirus reveals just how deep macho stereotypes run through society.

Our discussion focuses on:

• The intentionality required to engage diverse groups of people to actually talk about how gender and masculinity associated issues significantly impact health outcomes.
• Research from Promundo which suggests that of the about overall 5 year mortality difference between men and women, that about 20% of that gap is due to genetics and about 50% is associated with the following three factors:
  • diet
  • smoking
  • substance abuse
• The recognition that more men than women are dying of Covid-19 and that we need to go beyond binomial data to look at “which” men and “which” women are at highest risk for death which leads us to the intersection of biological sex and other sociocultural influences.
• How the words different countries use to describe the pandemic often appear to reflect that country’s approach in how they are addressing it.
• The importance of intentionally creating neuro and cultural diversity amongst teams tasked to solve complicated problems.

Show Notes for Episode Thirteen of seX & whY: LGTBQI Health-related Issues Part 3

How best to support students and colleagues in the LGBTQ community

This is a very special podcast and I want to deeply thank Shana Zucker, Ellie Ragone and Mike Gisondi for sharing their very personal experiences.

Host: Jeannette Wolfe
Guests:

Shana Zucker, MS

• Shana is a rising 4^th year medical student at Tulane in the MD/PhD program
• When she was a first-year medical student at Tulane she helped to create The Queericulum, an educational program geared at helping medical students become more culturally competent surrounding LGTBQ health related issues and patient interactions
• Since its creation, it has now become a mandatory course for all first-year Tulane medical students and she is currently working to expand the program to other medical schools
• In addition, she and Mike are creating (with another MD/PhD student at Stanford) an online educational program to help medical educators teach medical students about LGTBQ health
• Here is Shana’s talk at Feminem’s Fix conference in NYC

Ellie Ragone DO

• Is a first-year emergency medical resident at UMMS-Baystate
• Ellie is a transwoman and has graciously shared her personal experiences about transitioning as a medical student
• One of her largest concerns about transitioning was being able to successfully identify a primary care provider who was both competent and comfortable with LGTBQ patients and their health-related needs

Michael Gisondi

• Vice chair of education at the Dept of EM at Stanford
• Mike shares how his identity formation was actually quite different at different points of his own life
• He reflects on the generational differences of LGBTQ physicians

Tips offered by the group

• If you have a trans colleague and you misgender them, besides apologizing in real-time consider sending them an email or text later on to let them know you have reflected upon the mistake and appreciate the challenges they are routinely facing and that you want to support them.
• When you are looking at a program or job, be authentic and find the program who accepts you for who you are versus trying to be the image of the person you think the program wants.
• Let medical students and residents lead. They often are much more on point about what does and doesn’t work than most senior educators

Accountability buddy article

https://www.aliem.com/peer-accountability-strategy-maintaining-commitment/

Special thanks to Doug Deems who helped me edit this podcast.

Show Notes for Episode Thirteen of seX & whY: LGTBQI Health-related Issues Part 2

How to take better care of transgender patients when they seek medical care

Host: Jeannette Wolfe
Guests:

• Dr Elizabeth Samuels Assistant Professor of Emergency Medicine Warren Alpert School of Medicine at Brown University
• Dr Michelle Forcier Professor of Pediatrics at Warren Alpert School of Medicine at Brown University and Director of Gender and Sexual Health Services

Quotes used are from Dr Samuel and her team’s paper: “Sometimes You Feel Like the Freak Show”: A Qualitative Assessment of Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients Ann Emerg Med 2018

Here are 10 take-home points

1. Delivering Intentional habits to care for our transgender patients actually helps us deliver better care to our cisgender patients too.
2. Appreciate that many trans and gender non-conforming patients are incredibly reluctant to seek out medical care due to previous discriminatory treatment,
3. Don’t assume a trans patient is out to the other people in the room and offer to speak with them privately
4. Ask their name, if different than expected ask them if they have a different legal name, then confirm how they would like to be addressed and what pronouns they use.
5. Respectfully update other team members about this information so that the patient doesn’t need to unnecessarily repeat themselves. Importantly how we model this message to our staff can set the tone for how these patients will be treated, so take this responsibility seriously.
6. When asking about past medical history, surgical histories and current medication make sure that you are clear as to why you are asking and how it relates to their current medical problem.
7. In trans patients that present with abdominal pain, don’t assume because they physically look like their asserted sex that they lack organs from their biological one such as ovaries or a prostate. Remember to ask.
8. When admitting a trans patient, if a private room is unavailable they should be roomed with patients of their asserted gender.
9. If not already doing so, encourage your hospital to use software that allows an individual’s sexual orientation and gender identity to be included in a separate field of their medical record
10. If you are a medical educator, look for ways to include an issue

Show Notes for Episode Thirteen of seX & whY: LGTBQI Health-related Issues Part 1

Host: Jeannette Wolfe
Guests:

• Dr Elizabeth Samuels Assistant Professor of Emergency Medicine Warren Alpert School of Medicine at Brown University
• Dr Michelle Forcier Professor of Pediatrics at Warren Alpert School of Medicine at Brown University and Director of Gender and Sexual Health Services

This is the first of a three-part series that will cover LGTBQI health related issues. This podcast focuses on some basic definitions and general principles surrounding the care of gender non-conforming children and adolescents. It also discusses some of the gender affirming hormonal and surgical options available to patients.

Resources that we discussed

The link to USCF’s Center of Excellence for Transgender Health

The link to the American Academy of Pediatrics statement on transgender and gender diverse children.

The link to the Gender Unicorn

Basic definitions

Biological Sex

• This is related to our innate sex chromosomes and hormones

Gender

• Influenced by biological sex and sociocultural constructs

Gender Identity

• How an individual internally perceives themselves within the norms and expectations of society in which they live

Gender Expression

• How an individual presents their gender publicly via mannerisms, appearance and clothing, etc

Gender Asserting

• How an individual perceives themselves and desires to be viewed by the world

Gender Affirming

• Hormones, procedures or clothing that align with asserted gender

Gender Dysphoria

• The distress a person may experience when their gender identity is not aligned with their assigned sex

Hormones commonly used

• To stall puberty
  • Gonadotropin-releasing hormone (GnRH) analogues

• Transmen
  • Testosterone

• Transwomen
  • Estradiol (and possible spironolactone or finasteride)

Gender affirming surgeries

Transwomen

• breast augmentation
• orchiectomy
• feminizing vaginoplasty
• reduction thyrochondroplasty
• voice surgery

Transmen

• hysterectomy
• oophorectomy
• vaginectomy
• metoidioplasty (clitoral release and enlargement)
• phalloplasty/scrotoplasty
• masculinizing chest surgery (“top surgery”)

Gender non-conforming health related issues that can occur in transgender and gender non-conforming patients

• Tucking of scrotum and penis that can lead to trauma/inflammation, infection, reflux
• Estradiol related thrombosis
• Testosterone related uterine bleeding
• Infection or emboli from body sculpting injections

Take home points

• When someone identifies themselves as transgender that simple means that their gender identity does not align with their assigned sex. It doesn’t mean that they have necessarily had specific surgeries or that they are taking certain hormones.
• Gender identity is distinct from an individual’s sexual preference.
• Some younger kids can experience their gender identity in a more fluid manner. This can often make it more difficult to predict what their gender identities will be later on as adults. Supporting and respecting these kids for where they are, and understanding that their gender identity may or may not later change, is important for their social and psychological development.
• As kids reach puberty their gender identity is generally less fluid and more permanent, for kids and their families who our struggling with gender identity, puberty blockers are an option to give people more time to process information and make decisions
• Currently there are multiple gender affirming treatments available to trans-individuals, including hormonal treatments and different types of surgeries some of which may become important when a transgender individual becomes a patient in our emergency department

Next month we will focus on how we can deliver better care to transgender and gender non-conforming patients in our emergency departments.

Show Notes for Episode Twelve of seX & whY: Sex and Gender Differences in CPR Part 3

Host: Jeannette Wolfe
Guest: Dr Justin Morgenstern

Here is a link to Justin Morgenstern’s awesome First10EM blog site where you can find an excellent review of the two papers that we discussed today: Perman’s DNR paper and Huded’s Cleveland Clinic Study on gender gaps in 30 day survival after ST elevation myocardial infarctions.

Here are some take home points for this podcast:

• We don’t know what we don’t study and when we don’t consider sex and gender as legitimate variables, we can inadvertently miss opportunities to improve the health of all of our patients.
• There appears to be lots of sex-based differences in cardiac electrophysiology
  • females are more prone to AV nodal re-entrant arrhythmias, sick sinus syndrome, prolonged QTc and postural orthostatic tachycardia syndrome
  • males are more prone to AV block, early repolarization, Brugada’s syndrome, accessory pathway-mediated arrythmias, idiopathy ventricular arrhythmias and dangerous arrythmias associated with arrhythmogenic right ventricular cardiomyopathies

• In many ways, biological sex represents a much “cleaner” variable to study in that most of us have a sex specific chromosomal pairing and hormonal cocktail that allows us to be more easily placed into a binary male or female category.
• Biological sex differences are often detected and treated by tweaking technology- adjusting the results of a blood test or using a different type of imaging modality to account for sex based physiologically differences.
  • Biological sex is akin to the variable of age- its importance is related to context. Although a 15 year and 50-year-old may get the same evaluation for an ankle sprain they should not get the same evaluation for chest pain. Similarly, how females and males react to any particular treatment may or may not be associated with a clinically important difference.
  • As the science of earnestly studying males and females side by side is still so new, we are just beginning to understand where differences actually exist and in what contexts they are clinically relevant.

• As the influence of gender can be quite subtle and often involves many touchpoints, recognizing and fixing gender-based differences can be challenging. For example, here is how an individual’s gender might influence what happens to them if they have a heart attack.
  • Whether they live alone
  • If and when they call an ambulance
  • If they come in by car, how quickly they are triaged
  • Where they are geographically placed in the department
  • How they describe their symptoms
  • How their symptoms are perceived by providers (which in turn may be confounded by provider gender)
  • How quickly an EKG is done
  • How comfortable they are with procedural consent
  • How quickly they go to the cath lab
  • When and what type of medications they are prescribed
  • Who they are referred to for follow up
  • Whether they are compliant with their new meds or appointments
  • Whether they are referred to and participate in cardiac rehab

• Currently, I suspect that most of us in medicine would likely acknowledge that there are some legitimate examples out there of gender and race- based health inequities. The next step, however, requires an acknowledgement that those inequities are not just happening somewhere else, but that they have also likely creeped into our own practices. This can be difficult because it directly threatens our explicit belief that we deliver “the same” excellent care to all of our patients.
• Recognizing and mitigating gender disparities, especially those related to implicit bias, requires deep self-reflection along with an individual and organizational commitment to actually want things to change.
• Solutions include wide-spread “no-blame” educational forums and the development of technical safeguards to help reduce unintentional bias. For example, the creation of default “opt in” disease specific order sets and operational checklists.

Here is a table that shows outcome data from Bosson’s JAHA paper from LA County data base that we briefly mentioned on the podcast.

Other studies discussed.

European study that examined sex-differences in atrial fibrillation study

Danish study on cardiac arrests in people less than 35 with 2 to one ratio of men to women

Korean eunuch study suggesting that a historical lineage of castrated males outlived several socioeconomically matched peers, supporting the concept of a disposable soma theory.

Cleveland Clinic informational sheet on arrhythmias in women

Study that suggests more women than men die or go to hospice after an intracranial hemorrhage and brings up idea of gender-based differences in “social capital” contributing to this difference

EOL choices in advanced cancer patients showing gender differences in palliative care and DNR preferences

Show Notes for Episode Twelve of seX & whY: Sex and Gender Differences in CPR Part 1 & 2

Host: Jeannette Wolfe
Guest: Dr Justin Morgenstern

Two big databases surrounding cardiac arrest

• Cares- Cardiac Arrest Registry to Enhance Survival which is based on information from national EMS data input via the NEMSIS national EMS information system
• ROC- Resuscitation Outcomes Consortium (ROC) 2011-2015. The ROC is a network of National Institutes of Health -funded clinical trial network evaluating out of hospital cardiac arrests that collects data from 11 different sites around the United States

Here are two great articles that cover this material in depth

• AHA 2019 stats
• When the Female Heart Stops: Sex and Gender Differences in Out-of-Hospital Cardiac Arrest Epidemiology and Resuscitation

What we know

• Over 350,000 people will have a cardiac arrest this year
• Men account for about 2/3 of OHCA
  • average age for men 66
  • average age for women 72
• About 20-25% will occur in public place
  • Men are proportionately more likely to collapse in public place than women (19% versus 8.4% in one study)
• About half of cardiac arrests are witnessed (about 37% by layperson and 12% by EMS)
  • compared to men, women have higher rate of unwitnessed arrest.

(46% vs 52%  in one study)

• Bystander CPR doubles to triples rates of survival
• Rates of bystander CPR are highly variable and depend heavily upon where you live and its demographics with CPR being less likely to be started in predominately minority and lower socioeconomic communities. Overall, it appears that about 35-40% or cardiac arrests will get bystander CPR
• Where you live is also dramatically associated with your rates of leaving the hospital neurologically intact.
  • One study that examined 132 different counties showed, depending upon the county,  functional recovery rates ranging from 0.8%-20% (which again, is likely heavily influenced by  variations in CPR and AED use.)
• CARES data bank stats suggest that out of hospital cardiac arrest (OHCA)
  • 28% live to hospital
  • 8% leave neurologically intact
• Usually less than 20% of initial rhythms of OHCA are shockable
  • though sex difference here also

(one study 29% men vs women 16% with initial shockable rhythm)

• Per one survey  about 2/3 of people has some type of CPR training with 20% being currently trained
  • CPR training noted to be lower amongst Hispanics, elderly, lower income, less formally educated
• Of those trained in CPR only about 1/3 of people will actually step up and do it when indicated

First study

Gender disparities among adult recipients of bystander cardiopulmonary resuscitations in the Public from Audrey Blewer in Cir Cardiovasc Qual Outcomes 2018

Primary study question- is there an association between an individual’s biological sex and the likelihood they will receive bystander CPR

Resuscitation Outcomes Consortium (ROC) 2011-2015

This was a retrospective analysis of data collected in a prospectively for several clinical trials in out of hospital cardiac arrests from 7 of these sites.

Exclusion:

Traumatic arrest

Occurs in a residential institution or hospital

Less than 18

CPR initiated by someone who was not a layperson (police EMS doc)

The variable they used in logistic regression modeling included whether event was witnessed, location, layperson CPR, time of event, and basic demographics including age, race, gender

Nontraumatic out of hospital cardiac arrests

19331 events

Mean age 64

63% male

17% public location (3297)

82% private (15788)

Overall 37% received CPR (38% of men and 35% of women)

If collapse occurred in public place

• 45% of men and 39% of women

If collapse occurred in private place

• 36% of men and 35% of women received CPR

Overall: Males had 29% increased odds of survival

Bottom line: If you have a OHCA in public you are about 6% more likely to receive CPR if you are a man than a woman

This is not the only study showing gender differences in CPR here is a   Netherland study and an avatar study which also highlight these differences.

There are also studies suggesting subtle gender differences in EMS treatment of chest pain/cardiac arrest:

• time to CPR, time to first rhythm strip, IV placement, medication administration
• likelihood of getting lights and sirens or aspirin

Ok so why is that happening?

So first let’s talk about some general barriers to stepping up and doing CPR in public-

A 2008 study by Swor in Annals of EM interviewed almost 700 bystanders to an OHCA. Although about ½ of the bystanders had previous CPR training only about 20% actually started doing CPR.

Cited barriers to doing CPR included:

– feeling of panic (reported by about 38% )

– concern of doing it incorrectly (9%)

– concern they could cause harm (1%)

– reluctance to do mouth to mouth (1%)

In another study which surveyed community members from areas in which there were low rates of bystander CPR to understand why the rates were so low, answers included:

– fear of getting sued

– emotional overtones of the situation

– lack of knowledge

– situational concerns

A different study suggested that disagreeable physical characteristics– read dentures and vomit-  might hamper CPR initiation.

Overall you are more likely to step up and do CPR if

• CPR training within last 5 years (OR 6.6)
• in public (OR 3.1)
• see them collapse (OR 2.3);
• bystander has greater than a high school education (OR 2.0)

So the next question is, are these the reasons why there is a gender difference in who gets bystander CPR or are there additional factors to consider.

Second study

Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation than Men in Out of Hospital Cardiac Arrest

Perman Circulation 2019

Primary Question- what are the public perceptions as to why women are less likely to get bystander CPR?

Methods- Electric survey via Amazon’s crowdsourcing platform- Mechanical Turk. Participants were English, >18 and familiar with CPR principles

Mechanical Turk- have “master users” people achieve this rate by apparently having a history of completing other surveys out appropriately in the past (essentially successfully answering planted “attention” surveys which suggests that they are actually reading the surveys)

Participants were asked 11 multiple choice questions and one free text- “ Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?” Free text responses were coded and major themes were identified by using an inductive qualitative method.

548 subjects

542 completed surveys

average age 38

equal number of males and females about 1% of participants were transgender

81% White 7% Black 6% Asian 3% Hispanic

45% college diploma

½ were trained at some time in CPR (top reasons for training were cited a work or volunteer related requirement)

24 had actually done CPR on a collapsed person-

Three major themes evolving:

1) Sexualization of woman’s bodies (40% of men mentioned versus 29% of women)

– fear of making incidental contact with a woman’s breast

“I think that people are afraid to touch the breast region, so hesitate to administer CPR”

– fear of being wrongfully accused of sexual abuse

“Bystanders, especially male bystanders, may be afraid to touch women especially in the chest area… anxious that their help my be unnecessary and therefore touching may be misconstrued”

“Men are afraid of seeming like perverts”

2) Perception that women are weaker and frailer and thus at greater risk for injury if CPR was not really needed

“People might be afraid of hurting them since women tend to be smaller and more fragile looking than men”

3)  Misperception of what actual distress looks like in females

”They are not known to have as many heart attacks in public, they are known to be healthier”

 “ Maybe people assume they are being dramatic and overreacting so CPR isn’t needed”

Interestingly in the open- ended responses it was frequently implied by use of pronouns that the bystander initiating CPR would be a man. Along these lines, this European paper hints that gender related issues may also influence who steps up to start CPR.

My (liberal) summary of paper:

“Look I’m not super thrilled about the idea of touching a woman’s breast and quite frankly I’m a little scared about being accused of sexual assault.  And also, if I’m honest, I’m a little suspicious that the woman might be collapsing from something less serious, because most cardiac arrests seem to happen in guys. Finally, if I do start CPR on a woman and they really didn’t need it, I’m afraid I might accidentally physically hurt her.

Five take home points

• As more than 60% of cardiac arrests do not get bystander CPR, please consider sending out these CPR videos from the American Heart Association and The British Heart Foundation to friends or family members to teach and/or reinforce basic CPR principles as good CPR doubles to triples survival rates.
• There are innate biological sex differences associated with out of hospital cardiac arrests including: 2/3 of cardiac arrest occur in men who collapse on average collapse about 7-10 years earlier than women. Men are also more likely to have an initial shockable rhythm.
• Gender related issues, which can notoriously sneak under the radar if we don’t intentionally look for them, can also impact cardiac arrests. The study we talked about today suggested about a 5-6% absolute differences in public bystander CPR rates with men receiving more CPR. Concerningly there is similar research suggesting gender based inequities of both the EMS and hospital management level of cardiac arrest and we will continue this discussion in part 2 of our series. Although more deductive research is needed, there are hints that some of these gender related CPR differences are rooted in concerns surrounding sexuality, perceptions about fragility and misconceptions that collapsing women are unlikely to be having a cardiac arrest.
• The first step to gender- based gaps in cardiac arrest is to simply validate they exist. If you teach CPR, recognize and normalize that for some learners, invading someone’s personal space can feel totally awkward and then encourage them to mentally rehearse different scenarios in which they visualize themselves successfully starting CPR.  Using tools like the womanikin can help.
• As it appears that only about 30% of people who already know CPR, will actually step up to do it, we must work on ways to close this gap. Considering the introduction of stress inoculation and introducing things like Mike Lauria’s breath, talk, see and focus technique holds promise.

Other references

High Sensitivity Troponin and Gender Differences in treatment after ACS

North Carolina’s Heart Rescue Intervention

Article about CPR and Good Samaritan laws