BY BECKY DONELON
Providing excellent care for every patient, regardless of sex, gender expression, socioeconomic status, or location, experiencing a health matter is the commitment of every paramedic. A better understanding of paramedic practice is emerging where practice can now be framed within the variabilities of practice, as relational and across the health and social continuum.1 Healthcare provided by paramedics most often occurs within the patient’s environment, and while usually within a model of clinical oversight, is dependent on the ability of the individual or pair of paramedics to interpret and apply knowledge and skill to meet the patient needs with the resources available in the moment. Paramedics must lean on many ways of knowing, incorporating evidence, expertise, experience, assumptions, intuition, and procedural knowledge into thinking and action. It is in the enacting ways of knowing that paramedics must consider the relevancy and quality of the evidence that underpins the treatment pathways they develop.
Assumptions about the clinical evidence utilized by paramedics as representative of all patients across sex and gender boundaries is possible. Where sex and gender are often thought of as having the same meaning and are often used interchangeably, the difference between the two is significant for paramedics to understand. Data bias means the available data is not representative of the population or phenomenon of study. Specific to this article, when sex and gender are relevant to the issue but remain absent from the issue. Data is the main ingredient of research where the study design, collection, and analysis of data all determine the findings and directly impact the outcomes. It is important to know that sex is defined as the biological differences (such as chromosomes, sex organs, and hormonal profiles) between men, women and persons with differences in sex development. The definition of gender is the socially constructed, culturally reinforced and enacted roles and behaviours attributed by what is thought to be feminine or masculine.2 These social constructions play a significant part in how the patient tells their story and presents it to the paramedic; and how the paramedic interprets the information and patient presentation, depending on their preconceived notions of gender. What follows is that both biology (sex) and the expression of gender3 are implicated in the provision of quality care health.
While there are varying degrees of adherence required in the regulatory frameworks intended to guide and control paramedic clinical practice, paramedics must often adapt the evidence to support complex and new cases. The evidence underpinning paramedic practice is generated from other professions such as physicians employing quantitative, qualitative, and mixed methods research approaches. Subsequently, clinical pathways or protocols developed for paramedic practice are often heavily influenced by other health research and while the number of contributing paramedic clinical researchers is growing, bringing paramedic clinical science and expertise to bear still remains mostly absent in the process. In the evidence-based health care arena inequality and bias still occurs in relation to gender and sex. This existing inequality often has negative implications for how paramedics interpret and synthesize findings to enact and balance protocol driven practice with clinical judgment. Many paramedics navigate the implications of sex and gender in clinical practice when interpreting presentations of pain differently depending on patient gender, or having to change pain management protocols to meet the female patient needs who is mid-menstrual cycle.
Sex and gender differences are significant to how individuals manifest disease signs and symptoms, access health and social care, and are interpreted and therefore treated by paramedics.4 In fact, sex and gender research is a growing focus where a better understanding of biological differences and socioeconomic and cultural factors are becoming known as directly linked to health equity and patient centered care.5 Data bias or data blindness exist in research such as random clinical trials, designed to provide a better understanding of cause and effect, is still likely to use white males as the comparator or the norm to which the findings are most likely referenced. This gap in sex and gender representation is detrimental to the outcome of care when “You can’t automatically extrapolate your results to both sexes if you don’t even test the females”.5 Medications found in the paramedic drug kit are assumed to work the same way for women as for men, except that until the early 2000s, women were not even considered for clinical drug trials. Concerning to both patient and paramedic when adverse drug events are now known to be more severe for women.6 The issue of men representing women in the research data may best be described as “Men go without saying, and women don’t get said at all”. 7
Historically women were left out of research study designs for determining drug therapeutic effects8 as researchers found it too difficult, the “variables” too great 9 and burdensome10 when other than the male sex (human or of the mouse type) were included. Leaving much of the understanding of how and why particular drugs affected women or anyone in transition an unknown. This missing evidence matters to paramedics who are left to their own devices to explore and develop clinical understanding of sex and gender implications on the medications available for practice. Paramedics must make sound clinical judgments as part of their everyday practice, though may be unaware of the basis (or evidence) behind these judgments.11 Clinical judgement underpinned by weak or lacking representative evidence is poor practice. It matters to the patient how paramedics understand biological differences of sex and gender. The value of intentionally exploring the differences in how gender or sex or intersections of marginalization influence paramedic practice is shared in a recent study.12 The study focus compared how men and women experience care for their cardiac chest pain and out of hospital cardiac arrest. The findings indicate that women receive fewer medications such as aspirin and pain management, are less likely to be transported lights and siren, and when in cardiac arrest are less likely to have resuscitation begun by paramedics.
Treatment of pain is another aspect of paramedic clinical practice that reveals some of the significance to understanding how sex and gender influence the paramedic’s evidence-based clinical judgement. The relief of pain is considered a key performance indicator within EMS systems, yet women are less likely than men with the same injury, to receive appropriate pain management.13 Gendered stereotypes held by health practitioners, including paramedics, directly influences equitable care when men and women present with pain. Women have received less pain management for severe pain in comparison, and are considered to be less tolerant, more sensitive to severe pain than men.13
Data bias and blindness about sex and gender occurs in paramedic education. A frustrating example is the difficulty in finding paramedic curriculum, textbooks and teaching tools to help to teach and learn the differences in how menstruation and lactation influence the uptake and response of the drugs provided by paramedics. Yet, the implications of drug uptake during menstrual cycle impacts are well known for medications such as antipsychotics, antibiotics, cardiac medications, and antidepressants.9,14 During menstruation typical dosing regimes can be too high or too low depending on time of cycle with extremely different outcomes for the patient. Similarly, where patients are typically accessing paramedics to care for their sudden onset cardiac chest pain, sex and gender have implications for more appropriate care. The historical evidence and subsequently the taught and thought to be typical presentation for cardiovascular disease is premised on studies conducted only on men, usually white men. This leaves other patients to become the atypical presentation where the paramedic educator or practitioner must ponder how to provide evidence-based teaching and appropriate clinical care. This atypical presentation often occurs for the other sex who are experiencing cardiac chest pain, or a psychotic episode or developing sepsis due to an ongoing and untreated UTI. It is well documented that sex affects cell physiology, metabolism, and many other biological functions, the symptoms and manifestations of disease, and responses to treatment8,9,21 therefore we need to include this knowledge in the education and practice of paramedicine. The value of disaggregated (and publicly available) sex and gender data is revealed in the treatments developed for COVID-19, where men are now understood to have a much more severe disease experience than women (similar to studies of Severe Acute Respiratory Syndrome(SARS) and Middle East Respiratory Syndrome (MERS).17 If the data were sex biased and not disaggregated, those accessing the evidence to develop and provide treatment and educational tools would find it much more difficult or impossible to utilize.
Further understanding of the implications of data bias is warranted across the profession of paramedicine. The available data that underpins the evidence for clinical practice must be representative of the population or phenomenon of study, or, and produced by persons mitigating bias against others, paramedics are able to consistently (and with ongoing improvement) provide appropriate care. Biological sex differences matter to how disease processes manifest15,16 in addition to how socially constructed genders are perceived directly relates to safe and competent health care. It remains a common concern that much of how women (and men) present with health concerns is perceived differently and actioned differently by all health practitioners, including paramedics. These gendered assumptions work much the same way as stereotypes, which are often mistakenly applied with immediate and most likely inequitable and unsafe outcomes.
In order for paramedics to fully utilize evidence for the benefit of each patient they must challenge the data as fully representative, unbiased and directly relevant. There are tools for analysis of evidence available18 that can help challenge the strength and relevancy of how sex and gender data need to be considered in developing clinical treatment pathways, operational policy and quality assurance and improvement programs. An example of paramedics challenging data bias across sex and gender boundaries involves a study design addressing intimate partner violence. The recognition of a significant data reporting failure for women experiencing intimate partner violence arose from paramedic practice. Violence against women is pervasive worldwide. Intimate partner violence has a major impact on the health and wellbeing of women where paramedics are too often called on to provide both clinical and emotional support to those perpetrating and experiencing this type of violence. Not much focus has been placed on collecting data around aspects of these events by paramedics. One of the study key findings19 is that specific sex and gender data collection and reporting directly enables analysis, accessibility for others to utilize and provides a baseline from which to develop improvements in referral and clinical care. Proving that when disaggregated data is accessible, bias is managed, evidence is more representative, better care is possible.
Changes needed to address data bias are becoming recognized where ways of knowing about women’s healthcare cannot simply be solved by extrapolating from male findings. Understanding the difference between sex and gender must translate into action in paramedic education and practice. Ongoing learning about research methods that ignore the importance of sex and gender must be considered by every paramedic. Now is the time to consider the how data bias influences the evidence guiding and misguiding the practice of paramedics. Awareness of how data bias may prevent sound evidence for practice is a significant aspect of professional knowledge.20 Good decisions, safe and competent patient care, and ongoing professional development is dependent on challenging the value of evidence that is blind to sex and gender. Paramedics must question how data is relevant to the decision under contemplation and help others to do the same.
- Tavares, W., Bowles, R. & Donelon, B. (2016). Informing a Canadian paramedic profile: framing concepts, roles and crosscutting themes. BMC Health Serv Res 16, 477 https://doi.org/10.1186/s12913-016-1739-1
- Hamberg,K., (2008). Gender bias in medicine. Women’s Health (2008) 4(3), 237–243
- Sex and Gender in Women’s Health. Retrieved Feb 2021 from https://orwh.od.nih.gov/sex-gender
- Lord B, Keene T, Luck C., (2019).The influence of paramedic qualification level on the administration of analgesia in the prehospital setting. Irish Journal of Paramedicine. 4(2). https://doi.org/10.32378/ ijp.v4i2.187 Received
- Schiebinger L, Leopold SS, Miller VM. (2016). Editorial policies for sex and gender analysis. Lancet. 10;388(10062):2841-2842. doi: 10.1016/S0140-6736(16)32392-3. PMID: 27979394.
- Page, D., Conference Remarks. Retrieved Jan 2021 from https://www.cedars-sinai.edu/research/news/cedars-science/2019/examining-gender-bias-in-medical-care.html
- 7. Perez, C, (2019). Invisible Women: Data Bias in a World Designed for Men. Abrams Press, New York
- Holdcroft, Anita (2007). Gender bias in research: how does it affect evidence based medicine? Journal of the Royal Society of Medicine, 100
- Iberra, M., Vazquez,M., Fagliano,P., (2017). Sex effect on Average Bioequivalence. Clinical Therapies, 39:1, 23-33
- Mergaert, L., Lombardo, E., (2014) Resistance to implementing gender mainstreaming in EU research policy. European Integration Online Papers (EIoP), special issue 1, vol 18, p1-21
- Wyatt, A. (2003). Paramedic Practice – Knowledge Invested in Action. Australasian Journal of Paramedicine, 1(3). Retrieved from http://ro.ecu.edu.au/jephc/vol1/iss3/9
- Lewis, J., Scott, L., Zeger,L., Li, x., Mann, C., Newgard, C., Haynes, S., Wood, S., Dia, M., Simon, A., McCarthy, M., (2019). Gender Differences in the Quality of EMS Care Nation wide for Chest Pain and Out-of-Hospital Cardiac Arrest. Women’s Health Issues, 29/4
- Lord B, Cui J, Kelly AM. (2009).The impact of patient sex on paramedic pain management in the prehospital setting. Am J Emerg Med.Jun;27(5):525-9. doi: 10.1016/j.ajem.2008.04.003. PMID: 19497456.
- Zopf,Y., Rabe, C., Neubert, A., Gassmann, KG., Rascher, W., Hahn, E., et al. (2008).Women encounter ADRs more often than do men. Eur J Clin Pharmacol. Oct;64(10):999-1004. doi: 10.1007/s00228-008-0494-6. Epub 2008 Jul 5. PMID: 18604529.
- Paulson, E., (2020). Recognizing, Addressing Unintended Gender Bias in Patient Care: how can you improve care for female patients? Retrieved March 1, 2021 from https://physicians.dukehealth.org/articles/recognizing-addressing-unintended-gender-bias-patient-care
- Robinson ME, Riley JL, Myers CD, et al. Gender role expectations of pain: relationship to sex differences in pain. J Pain 2001;2:251-7.
- Maleki, D., Sadoughi, F., Hallajzadeh, J., Asemi, Z., Mansournia, M., Yousefi, B., Momen-Heravi, M., (2020). An insight into the sex differences in COVID-19 patients: what are the possible causes? Prehosp Disaster Med. 35(4):438–441.
- Gender Based Analysis Plus (GBA+)-Applying Tools and Best Practices. Retrieved Jan 2021 https://csps-efpc.gc.ca/catalogue/courses-eng.aspx?code=T730
- Sawyer S, Coles J, Williams A, Williams B. (2015).Preventing and reducing the impacts of intimate partner violence: Opportunities for Australian ambulance services. Emerg Med Australas. Aug;27(4):307-11. doi: 10.1111/1742-6723.12406. Epub 2015 May 4. PMID: 25939504.
- Eraut, M., (1994). Developing Professional Knowledge and Competence. Routlege Taylor & Francis Group: London
- Cirillo, D., Catuara-Solarz, S., Morey, C. et al. (2020).Sex and gender differences and biases in artificial intelligence for biomedicine and healthcare. npj Digit. Med. 3, 81 (2020). https://doi.org/10.1038/s41746-020-0288-5