Women's experiences of discrimination and the impact on health: research

Executive Summary

Purpose of the project

The Women's Health Plan for 2021-2024 aims to improve health outcomes and health services for all women and girls in Scotland. It is underpinned by the acknowledgement that women face particular health inequalities and disadvantages because they are women. A two-phase research project was developed to address the following medium-term action within the Plan: To build an evidence base on women's health inequalities, with specific focus on the impact of sexism, racism, ableism, and other forms of discrimination including homophobia and transphobia on women's health.

The purpose of this research was to explore and understand experiences of discrimination among women in Scotland and the impact those experiences have on women's health. Intersectionality, the idea that different aspects of a person's identity overlap to form their unique experience, was used as a theoretical and analytical framework in this study.

There are three parts to this report. The first examines the current evidence base and provides a rationale for the research approach. The second part reports on a series of focus groups with women from different backgrounds. The final part describes the methods and analysis of in-depth interviews with young women aged 16-25 years.

Aims

The overall aim of the project was to develop an initial understanding of how women in Scotland experience discrimination and how it affects their health. The present study had the following underlying research objectives:

• To explore women's experiences and perceptions of health in Scotland, involving women throughout Scotland and from marginalised groups
• To take an intersectional approach to help understand how multiple different aspects of women's identities (e.g. age, disability, race/ethnicity, social class) result in particular experiences of discrimination related to health

Methods

The evidence review involved searching of scientific databases, government reports and grey literature. The qualitative research projects involved fieldwork taking place in August 2022 and between December 2022 and March 2023. The first project comprises four online focus groups with women or people who use women's services residing in Scotland. The overall sample was 14, with each focus group recruiting women from a different population: women aged 16-25 (n=4), women aged over 25 (n=3), women from an ethnic minority background (n=3) and women with a disability or long-term condition (n=4). The second project was informed by these focus groups. It involved 28 interviews with young women aged 16-25, residing in Scotland. All discussions were transcribed and analysed thematically by two researchers. Findings are not generalisable to the wider population of women in Scotland and interpretation of the findings should be done with this in mind. Nevertheless, the themes reported here provide important insight into how women in Scotland from different backgrounds and population groups experience discrimination in relation to their health.

Key findings

Focus groups

The focus groups were designed to capture a broad range of experiences and direct researchers towards a population or health topic for more in-depth analysis through interviews.

Four themes were identified that revealed several potential ways women in Scotland experience discrimination and how those impact on their health. Theme 1: "Excuses for not investigating" describes how women across the focus groups gave many examples of not being listened to, being dismissed and ignored. What's more, participants noted that various parts of their identity, such as their age, gender identity, weight status, mental health status and relationship status were sometimes used by health professionals as reasons for symptoms they were reporting. They described how these reasons were used against women as "excuses" to not investigate or suggest treatment for a range of mental and physical health concerns.

Theme 2: Health as a concept showed how participants drew on the broader concept of "health" and described how "the system assumes you're a man", resulting in sexist and ablest experiences. This, in turn, fed into perceptions of women's health not being understood and individuals being held to standards of 'healthy' that they were unable to meet.

Theme 3: Navigating racial discrimination provided examples of discrimination from women from ethnic minority backgrounds, who spoke of the exhaustion and mental strain of navigating racism. The healthcare examples given highlighted direct interpersonal and structural racism, resulting in perceptions of unequal access to resources.

Finally, Theme 4: Self-advocacy described the ways participants attempted to improve their health and receive appropriate care. These self-advocacy approaches included: extensively researching health conditions and symptoms before seeing doctors, being assertive and articulate, being persistent, challenging healthcare professionals and seeking private or alternative avenues for treatment and support. Women recognised that not everyone has the resources to do this self-advocacy work.

The salience of the findings from the young people's focus group, coupled with the limited evidence base for this age group, prompted researchers to develop an in-depth second phase to the research, involving one-to-one interviews with young women.

Interviews

There were four themes that described the interview data. These themes outlined different aspects of the objectives, but all contribute to the identification of different ways in which young women experienced and understood discrimination and health in Scotland. These themes were:

Theme I: Ageist Sexism

Several participants spoke of assumptions about them being "fit and well" as resulting in age discrimination within healthcare. Many participants described how this discrimination intersected with being a woman, producing a specific experience for young women. Sometimes, participants found it a challenge to talk about sexism or ageism as separate things, with many participants claiming their experience of discrimination was likely elements of both. Participants described times where they were made to feel as though young women are "naïve" "overdramatic", "don't know about the world", "stupid", "hormonal" and "irrational". Some of these assumptions could be seen as sexist stereotypes experienced by women of any age, others were expressed by participants as amplified because of their young age. These experiences led some participants to pursue private healthcare and for others it discouraged them from seeking health support and treatment at all.

Theme II: Mental Health

Almost all participants in the sample explained how discrimination had affected their mental health or wellbeing. For example, being discriminated against increased their levels of stress and anxiety and negatively impacted their relationships with themselves and others. Almost half of the participants in the sample (n=13) explicitly spoke about having mental health issues and their experiences seeking support. All these participants reported struggling to get their mental health symptoms taken seriously. A common experience related to this was that mental health symptoms, namely anxiety, were at times described by health professionals as a natural female attribute, as opposed to a condition that needed treatment or support. Some women experienced gender stereotypes about mental health that also acted as a barrier for healthcare in other areas. This largely revolved around physical health symptoms being dismissed as psychological. Some of these young women were willing to entertain that a mental health diagnosis was a possibility, but described how the diagnosis often felt like an initial reaction to their gender and age. Participants described how these assumptions were sometimes made with "no tests", "no investigations" and very few "questions" asked about their health complaint.

Theme III: Hormonal contraception

The intersection of gender and age discrimination becomes especially apparent in participants' experiences related to contraception. Fourteen participants recounted their "journey" with reproductive technologies when asked to share an experience in which they felt discriminated within or outside a healthcare setting. The most common experience among these young women was that they felt uninformed about contraception options the and potential side effects of the pill. Following this, some young women in the sample went on to experience mental and physical symptoms while on a form of contraception, and then felt they were met with resistance from medical professionals when they asked to investigate the side effects or consider changing methods. Several participants reported being told to "wait and see", which left them feeling dismissed and like their "pain was undervalued". The breakdown in trust between the young women and the healthcare professionals, as well as the lack of information about access to other contraception options, led some participants to "coming off" hormonal contraception all together and being "put off" going to the GP about this and other health complaints.

Theme IV: Racism, structural sexism and socioeconomic disadvantage

Thirteen participants in the sample were from minority ethnic backgrounds. These participants talked about experiences of racism within and outside the health system, using both structural and interpersonal examples of discrimination. One structural experience of discrimination related to participants feeling as though there was little knowledge or understanding about certain health conditions and how they present in people from their ethnic background. Further, some young women described how the systemic racism within the health system and wider society allowed "micro-aggressions" or subtle types of interpersonal discrimination to occur.

Women across the sample also gave examples of structural sexism and socioeconomic disadvantage. For instance, in relation to trying to access physical activity, factors such as financial challenges, safety and general discomfort meant that some young women in the sample face unique challenges. Not only do some young women have to make economic decisions about their health in the current economic climate in Scotland, but they have the added consideration of whether the space is safe and what time they are able to visit. These barriers to health are embedded with wider structural-level discrimination such as gender-based harassment and income inequality.

Conclusion

Women in this research described being discriminated against in multiple ways and through cultural, institutional and interpersonal levels. Participants in these studies described how discrimination has the potential to impact on their health. This includes an impact which is partially linked to their experience of mental health, through the exhaustion and frustration resulting from discriminatory experiences. Discrimination was also described to have tangible impacts on physical and mental health outcomes for women through unequal access to healthcare and delays in referrals, diagnosis and treatment. The discrimination described by women in these studies was almost always intersectional, but usually underpinned by gendered inequalities. Participants in the interview study revealed the unique challenges faced by young women in terms of discrimination and their health. They felt as though stereotypes of the "anxious teenage girl" shaped their experience of healthcare for a range of physical and mental health symptoms. Such stereotypes were described as manifested in interactions with healthcare professionals to the extent where participants felt discouraged to access healthcare due to the expectation of negative treatment because of their age and their gender. The findings in this project contribute to the evidence base on women's health inequalities, discrimination and young women through in-depth exploration of women in Scotland's intersectional experiences.