While interest in the impact of gender disparities on healthcare has skyrocketed over the past 5 years (see Figure 1), the biases that prevent appropriate and timely eyecare persist.
Shockingly, females are 8% more likely to suffer from blindness and 15% more likely to incur moderate to severe vision impairment than their male counterparts.1
This article will discuss the reasons for this inequity and strategies that we can adopt to bridge the gap.
The state of ophthalmology in global health
According to the Royal National Institute of Blind People, despite making up 49.6% of the world’s population,2 women constitute 64.5% of the world’s visually impaired.3 This gender skew is not reserved to specific regions, but spans across the globe.
In the United States, where access to care is relatively advanced, approximately 12 million people age 40 years and older are visually impaired or blind, with women making up over half of this number.4
Nevertheless, the majority of visually impaired or blind women reside in low- and middle-income nations, with 90% of them living in poverty.3 According to an article by Elam et al., a health disparity is defined as “a difference in health outcomes that arises from health inequities that affect medically underserved populations.”5
Advocating for gender equity enables a more just system for the distribution of resources, which benefits the entire population. In the context of visual impairment, prioritizing gender equity can lead to improved access to rehabilitation centers, assistive technologies, and educational opportunities for women.6
Figure 1 demonstrates the increasing interest in gender disparity in healthcare. A PubMed search of Gender Disparity in Healthcare yields only a few hundred articles between 1980 and 2000; however, after 2020, there are over 1,000 articles written yearly. This shows a drastic increase from 1994, in which a mere nine articles on the topic were published to 1,098 articles related to the topic in 2023. At the time of publication, 516 articles have been written in 2024.
Factors leading to gender disparity in eyecare
There are multiple factors that contribute to worse eyecare outcomes for women compared to men. These encompass biological, structural, economical, and social aspects that often operate together to create gender disparities in eyecare.
Of note, the United Nations Women (UN Women) implements a “gender lens” to its Social Ecological Model that addresses gender inequalities in eye health.7 It includes factors such as behavior, traditional gender roles, institutional factors, community norms, and policy that influence women’s eye health on multiple levels.
1. Age
At present, women have longer life expectancy than men. Hence, women are more likely to suffer from eye diseases that come with older age, such as age-related macular degeneration (AMD), cataracts, and glaucoma.
Interestingly, even when these diseases are adjusted for age, women continue to be overrepresented.
2. Hormones
The majority of ocular tissue contains receptors for sex steroid hormones (SSH) and is responsive to the direct regulatory influence of these hormones.8 Ocular conditions affected by these hormones include dry eye syndrome, cataract, glaucoma, diabetic retinopathy, and AMD.
Dry eye syndrome is related to an imbalance of SSHs and can be associated with advanced age, and can affect women due to menopause. Studies have found that women are diagnosed with the condition almost 6 years earlier than men, leading to significantly worsened quality of life from ocular surface damage.8
Interestingly, some studies have found that women are more likely to seek an eye exam compared to men.9-11 However, we must note that most of these studies have been conducted in high-income countries where females are able to have financial autonomy and safety for accessing healthcare.
The prevalence of cataract also increases with age but is higher in women compared to men. While access to care is one reason to explain this disparity, the withdrawal effect of estrogen during menopause may be a bigger factor in being predisposed to the disease earlier.8,12
Estrogen serves as a protective factor due to its antioxidative effects against developing cataracts. This means that early menarche or late menopause can be beneficial. Puberty and pregnancy are associated with hormonal changes that can lead to refractive errors that may go unnoticed for those who lack agency to seek curable treatment.13,14
With respect to glaucoma, angle closure glaucoma is more prevalent in women and in Asians. This is most likely due to aging and anatomical factors where women may have shorter eyes, earlier cataract formation, and a shallowing anterior chamber that may lead to angle closure.
Estrogen also plays a role in that longer reproductive years favor a decreased risk of developing open-angle glaucoma. Hence early menopause may be associated with a higher risk of developing glaucoma.15
3. Literacy and discriminatory gender roles
Women have lower rates of literacy in developing countries.16 Consequently, lack of education and self-perceptions of being a “burden” to their families can push women to neglect their own health.
Moreover, cultural norms and certain traditions can constrain women from acquiring knowledge. In many rural areas, men are financially responsible, which often leads to increased mobility and access to information, while women are left to manage housework, which affords limited mobility.
For example, a man in rural South Asia is 46% more likely to receive cataract surgery than a female, despite the woman being visually impaired from her cataract sooner than her male counterpart.17
Trachoma, a blinding but preventable illness, is more common in women compared to men because they have greater contact with children who have the highest rate of the infection. Gender norms also reinforce financial dependency on their spouse for care, making it more difficult for women to prioritize self-care.
4. Cultural norms
Limitations posed on women, especially in rural areas of low- and middle-income countries, can stigmatize seeking eyecare for women.7 Often, vision impairment is not a favorable physical feature in these communities. This could shame women from seeking care for preventable and curable causes of vision impairment.3,7
Traveling alone to obtain care can be further discouraged depending on how safe or acceptable it is for women to travel unaccompanied. Often in patriarchal communities, women have to ask for permission from a male head of the household to attend health clinics or information sessions. Even when granted permission, women find it difficult to identify substitutes who will take care of their children while they are away.
5. Limited representation in eye health leadership
Although a majority of visually impaired individuals are women, only 25% of ophthalmologists worldwide are female.18 Moreover, there is an even smaller percentage of these women in leadership positions.
Many women in patriarchal communities are discouraged from seeing an ophthalmologist because clinics may lack accessible washrooms, privacy screens, and safe areas to breastfeed or care for their children during the long waiting periods.7 These inconveniences can further erode trust among the women of these communities from seeking timely care.
Without strong leadership of women in eyecare, these perspectives will continue to be neglected when constructing effective policies to address gender-based needless blindness.
Hence, it is believed that although biological factors may affect women’s risk of developing eye diseases, it is the structural barriers and societal demands that play a crucial role in increasing women’s risk of developing preventable, blinding diseases such as cataracts and trachoma.7
Negative effects of gender disparity on public health
Vision impairment can significantly reduce the quality of life. In rural communities, vision is critical, where women are expected to support an entire family. Not only does blindness lead to increased morbidity and even mortality, but it also decreases work productivity.
Vision impairment can also hinder educational opportunities for women, perpetuating the cycle of male dependency. As the backbone of a family, a woman’s visual impairment can have a generational impact on her children. It is not uncommon to have children discontinue their education to support the growing needs of a visually impaired parent.
Steps to eliminate gender disparities in eyecare
In order to address gender-based disparities in eye care, reforms at the institutional, community, and individual levels are imperative. Eye health policies must aim at improving structural inequalities that dissuade women from seeking eyecare.
Moreover, policies must be inclusive of the needs of women in rural communities where support may be lacking. Hence, community-based delivery of eyecare would be the most sensitive means for providing equitable care.
Furthermore, increasing the number of women in eye health leadership will improve policies and enable female patients to voice their concerns to a relatable, trusted, and socially acceptable medium. This is particularly important in rural areas where literacy regarding visual impairment must be delivered through gender-cognizant methods.
Lastly, non-government organizations (NGOs) can play a critical role in delivering assistive technologies, such as screen readers and braille that may not be otherwise affordable to patients from low-income backgrounds.7
Key takeaways
There are multiple factors outside of biological factors that contribute to eyecare inequity for women. Structural barriers and literacy must be improved for women to be able to take ownership of their eye health needs.
While low- and middle-income countries have the largest proportion of women suffering from needless blindness, there is a universal unmet need to address gender disparity in visual impairment.
