November marked the beginning of World Diabetes Month, with the theme for 2024 being ‘Breaking Barriers, Bridging Gaps’, emphasizing the importance of addressing the inequalities that prevent people from accessing the care and support they need. Linking to this, women across the world with Type 1 diabetes (T1D) are more likely to experience life-threatening complications and have poorer quality of life compared to Type 1 diabetic men. Women with T1D face a higher risk of strokes and cardiovascular disease, as well as depression and eating disorders. This month offers a chance to reflect on these disparities, ask why they occur, and consider what can be done to address these issues. This article aims to highlight how gender and sex shape the physical, psychological and social challenges of living with Type 1 diabetes, and how we can work towards a better solution.

There are different experiences for women and men due to both biological and gendered factors in the management of T1D. Sex and gender shape our everyday interactions with the world around us, so it should be no surprise this extends to healthcare. In lab research over five times more male than female cells are used, and in clinical trials only around 20% of participants are female. This means findings in medical research may not directly link to the realities of the female body and may lead to poorer health outcomes. This issue can be found in research and management surrounding T1D, with gender/sex centric focuses marginalised in favour of a more ‘universal approach’. This gender-blind approach to diabetes care fails to address gender/sex specific needs, perpetuating inequalities and hindering women’s health. To change this, we first have to understand how this manifests in the female experience.

Biologically, women with T1D face different challenges, having the complicating factors of hormonal fluctuations during menstruation, pregnancy, and menopause. These fluctuations make insulin sensitivity variable, resulting in more hypoglycemic and hyperglycemic episodes. A general lack of knowledge on this matter makes managing T1D during these times increasingly difficult. With cases of T1D expected to reach between 13.5 and 17.4 million by 2040, it is evident that a sizable number of women will be affected by this in the coming years. At present, it has been found that women have worse glycemic. Women with T1D are at higher risk for long-term complications including permanent damage to the eyes, kidneys and heart. This impact extends to reproductive health. As insulin therapies improved, reproductive abnormalities generally decreased, however ovarian disturbances are on the rise. Poor diabetic control can create hormonal fluctuations and an increased frequency of menstrual disorders, with studies finding this affects up to 54% of T1D adolescent girls. Later in life this can lead to fertility issues, metabolic disorders and cardiovascular disease. Menstrual variability is often not properly addressed in therapeutic instructions, meaning few women are educated on this topic. With most sex specific advice directly linked to pregnancy, other important stages of female development receive minimal attention.

Additionally, women with T1D face disproportionally high mental health struggles and social challenges. Increased prevalence of anxiety, depression and perceived societal stigma compared to male Type 1 diabetics and the population as a whole underpin the urgent need for more tailored intervention and support. Studies show that women with T1D are more likely to suffer from formal mental health conditions and diabetes burnout, a psychological strain linked to the constant demands of self-management. Moreover, other findings show female patients have significantly lower qualities of life compared to their male counterparts, with gender forming a key predictor in this study. Equally, women with T1D report higher rates of body image dissatisfaction than other women. Adolescent girls with T1D are twice as likely to develop an eating disorder than their peers, ad 25% of T1D women experiencing an eating disorder in their lifetime. A subset of this is ‘Diabulimia’, a term characterising the deliberate restriction of insulin resulting in weight loss and is a life-threatening eating disorder more prevalent in women than men. Efforts to raise awareness such as the 2017 BBC documentary ‘Diabulimia: The World’s Most Dangerous Eating Disorder’ have had minimal impact, with patients still reporting stigma and a lack of understanding within medical communities. The UK government’s NICE guidelines state that sufferers should be offered education on the consequences of insulin restriction, however research suggests that psychological treatment would be more effective given that most sufferers understand the consequences of their actions.

Current gender-specific policies addressing Type 1 diabetes in the UK remain limited, however examples of good practices can be found. Targeted education on the impacts of hormonal changes on blood sugar levels can be seen in certain practices, and pregnancy specific advice is the best success of this strategy. Yet the broader healthcare system often chooses not to adopt a gender-sensitive framework. This issue is compounded by insufficient funding for gender-specific education, research and mental health support. For healthcare policymakers, integrating gender and sex-aware strategies, increasing funding, and focusing on women’s lived realities could significantly improve health outcomes and overall quality of life.

A one-size-fits-all approach has created disparities in experience and outcomes. Addressing this gendered experience is crucial for improving the quality of care and support in T1D management, and ensuring health policy can represent every gender, every sex, and everybody equally. By looking into patterns of inequalities we can bridge the gaps in healthcare, and come up with tailored educational, technological and psychological interventions. And there is reason to be hopeful. A new sex and gender policy framework was published on the 12^th of November 2024 looking to address gaps in health data, and subsequent experiences of health, illness, and care. If this new framework is adopted, it could mark a new era in how we think about gender and health in the UK. Hopefully this, and future projects can help us change how gender and sex shape the physical, psychological and social challenges of living with of Type 1 diabetes.

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