March 08, 2023
A comprehensive understanding of the public health burden imposed by antimicrobial resistance (AMR) and the development of solutions to address it are only attainable when considering all factors that impact its emergence, transmission, and control. Gender is one such factor.
Gender, linked to but distinct from biological sex, refers to the socially constructed roles and norms established for men and women. In this commentary, we will discuss how women, due to biological, social, economic, and cultural factors, are at an increased risk of contracting antimicrobial-resistant infections and spreading AMR. While gender identity reflects an individual’s personal experience of gender and may or may not correspond to their assigned sex at birth, we use the term “women” to refer to cisgender women, people whose gender identity as ‘woman’ aligns with their biological sex.*
Gender norms profoundly affect many aspects of women’s lives, including their vulnerability to infectious diseases and AMR. For example, as women occupy two-thirds of positions involving caregiving, social support, and working in frontline healthcare settings, they are at higher risk of occupational exposure to pathogens in healthcare facilities.
Antibiotic use, an important driver of AMR, also seems to differ among men and women. Antibiotic prescribing trends based on gender implicate gender norms in healthcare providers’ prescribing behaviors. For instance, Tisler-Sala and colleagues showed that women were three times more likely than men to receive an unnecessary antibiotic prescription in Estonia. Similarly, a systematic review and meta-analysis from 2016 that reviewed 576 articles and included 11 studies showed that women had a 27 percent higher lifetime prevalence of receiving an antibiotic prescription than men.
Gender inequality impacts individuals’ access to healthcare, even when policies and legislation are in place to ensure equal distribution of medical services for all. Since timely diagnosis and treatment of bacterial infections are essential to combat AMR, barriers to care increase the risk of developing AMR and facing worse health outcomes. Gender inequality and norms can hinder access to care through restricted mobility; lack of autonomous decision-making; limited financial independence; illiteracy; and bias from healthcare providers. In communities that uphold strong patriarchal values and generally favor men and boys over women and girls, women may voluntarily seek care less frequently and focus on medical expenses for their families and children instead. An observational study in urban settlements in Nepal showed that women in local communities were mainly limited to visiting free health posts. In contrast, men could access pharmacies, hospitals, and a wider range of clinics. Married women were expected to gain permission from their husbands to seek paid medical help and reportedly faced violence at home if they received medical care without first asking permission. In the face of these expectations, women were frequently unable to access essential medical services, delaying diagnosis and treatment and increasing their risk of complications, including AMR.
Stigma around sexuality is another factor that directly impacts women’s ability to access health care. When a woman’s symptoms or illness is perceived to be caused by sexual activity, particularly in societies that continue to stigmatize sexually transmitted infections (STIs), they may be too embarrassed or fearful of facing discrimination or retribution to report STI-related symptoms and seek treatment. Even though STIs disproportionately affect women’s health, primarily due to the anatomy of the female reproductive tract, many do not have access to sexual education that informs on STI symptoms and when to seek medical attention. Additionally, the current inadequate standard of care for most curable STIs in sub-Saharan Africa due to inaccessible diagnostic testing and an increased focus on symptom management exposes women to inappropriate antibiotic treatments and increases their risk of developing AMR.
Inadequate prophylactic measures to avoid contracting STIs have unintended dire health consequences. Female sex workers in the Philippines and Thailand often take non-prescription antibiotics prophylactically to avoid contracting STIs, a practice perpetuated by imbalanced gender dynamics and women sex workers’ inability to safely negotiate condom use with their male partners. Prophylactic antibiotic use has been around since as early as the 1940s, but researchers point to the growing threat of AMR as a warning against depending on antibiotics and using them when no diagnosed infection is present.
Women’s biology increases their risk of AMR infections, especially during pregnancy, abortion, and childbirth. A 2016 study in a hospital in Ethiopia revealed that nearly three-fourths of isolates from women colonized by Group B Streptococcus at the time of labor exhibited resistance to the antibiotic tetracycline. When women undergo abortions and give birth through vaginal or cesarean delivery (C-section) in unsafe healthcare settings, such as those lacking adequate water, sanitation, and hygiene (WASH) standards, they are at much greater risk of exposure to infections and AMR (WHO 2022).
Puerperal sepsis, a bacterial infection of the genital tract occurring after childbirth, affects six to seven percent of women who undergo vaginal delivery and is one of the leading causes of maternal mortality, especially in low- and middle-income countries (LMICs). Treatment is often complicated by resistance to available drugs; over three-fourths of the isolates from women with puerperal sepsis in a hospital in northwest Ethiopia in 2017 were multidrug-resistant or resistant to three or more different antimicrobials.
Community-acquired uncomplicated urinary tract infections (UTIs) disproportionately affect women at all stages of life, and they are one of the leading reasons for antibiotic prescription worldwide. Estimates show that one in two women worldwide will have had at least one UTI in her lifetime. Resistance against pathogens causing UTIs, commonly including E. coli and P. aeruginosa, has emerged globally due to years of overusing antibiotics to treat these infections without performing antibiotic sensitivity testing. Alarming findings from a study in Saudi Arabia demonstrate that over 90 percent of UTI-positive urine samples collected from an outpatient clinic were resistant to antibiotics, and approximately 80 percent were resistant to multiple antibiotics. The rise in multidrug resistance among UTI-causing pathogens complicates treatment options for women and girls experiencing UTIs around the world.
Women’s increased risks of contracting and spreading AMR infections are rooted in biological, socioeconomic, and cultural factors associated with gender inequality. Gender as a social determinant and sex as a biological determinant for the spread of AMR must be considered in AMR mitigation efforts. As women face heightened vulnerability to AMR infections, work must be done to combat gender inequality and improve the quality of and access to care for infection prevention and treatment.
* The term cisgender describes people whose gender identity aligns with their biological sex or the sex they were assigned at birth. Cisgender women are labeled female at birth and currently identify as female. To explore the female biological sex as a risk factor for higher infection and AMR rates, we focused exclusively on cisgender women and their experiences in this commentary.