When the Australian government launched its $24m Covid-19 vaccine information campaign this week, key among the primary targets were women aged 30-39, who were found to be the most vaccine-hesitant group in the Australian population by health department research.
Similar patterns of vaccine hesitancy among women have been found globally. So the question on everybody’s lips is: what’s driving it? The answer is we don’t know, because we haven’t asked.
Many reports have worried that vaccine hesitancy is being fuelled by the burgeoning wellness culture, but Dr Kate Young, a research fellow at the Queensland University of Technology’s Institute of Health and Biomedical Innovation, told the Guardian that’s not the whole story.
Young said we won’t have any luck convincing this vaccine-hesitant group to get the jab unless we know exactly what their concerns are.
“We’ve all just decided to prescribe these reasons to women as to why they are not getting vaccinated – people say it’s the wellness community, it’s because they do yoga and like to look at Instagram,” she said. “But we don’t actually know because no one has done the research.”
Young hits upon a refrain that we hear far too often in women’s health: “We just don’t know.” Or perhaps more accurately, we just don’t care to know.
But experts working in the area have their own theories, and wellness influencers aren’t on the top of the list.
Pregnant women and the vaccine unknown
First, the vaccine-hesitant population overlaps with another social group we don’t care to know very much about. There is one reason that all the experts interviewed for this story said is being overlooked in this conversation: women aged 30-39 in Australia are the group most likely to be pregnant, breastfeeding or raising a young family.
“What are most women in that age group in Australia doing? They are having babies,” Young said.
The Australian Bureau of Statistics currently puts the average childbearing age in Australia at 30.7 years, and the Australian Institute of Family Studies found that in 2020, a woman’s late 20s and early 30s are the most common age for her to become a new mother.
Dr Naomi Smith, a lecturer in sociology at the Federation University Australia who has published research on anti-vaccination beliefs in Australia, said this notion chimes with her research suggesting that vaccine hesitancy is highly feminised because the responsibility for healthcare is highly feminised.
The vaccine-hesitant movement is “connected to mothering and the responsibility women carry for the health of their children, particularly in the early years,” she said.
And when it comes to why women who are thinking about parenting are cautious about getting the vaccine, Young said the reasons are pretty clear.
“The World Health Organization has recommended that pregnant women do not get the [Pfizer] vaccine because it hasn’t been tested on pregnant women,” she said. On Tuesday, the Royal Australia and New Zealand College for Obstetricians and Gynaecologists issued similar advice, saying it did not recommend the Covid-19 vaccine for pregnant women due to a lack of safety data.
A history of exclusion
A recent study in the medical journal Lancet found that three-quarters of trials for any of the Covid-19 treatments or vaccines have explicitly excluded pregnant women. This is despite the fact we know that pregnant women who contract Covid-19 are more likely to end up in intensive care than other patients.
A review of the trials found the scientists did not provide reasons for the exclusion of pregnant women.
Concerns about the dangers of including pregnant women in clinical trials are understandable. As one study noted, “Many substances, including medications, can cross the placenta and potentially irreversibly affect foetal growth, structure, or function, there might be significant risk of harm to the unborn baby.”
The physiological changes that take place during pregnancy can also mean researchers cannot be sure how different drugs will interact with women’s bodies.
But according to Dr Loulou Kobeissi, a scientist at the World Health Organization, these reasons do not apply to the majority of Covid-19 vaccine and treatment trials. “The systematic exclusion of pregnant women cannot be justified on the basis of safety as many of the medications being evaluated are either not harmful in pregnancy, or their risks are minimal,” she said.
Because pregnant women were banned from participating in trials following the thalidomide scandal of the 1960s – a decision only overturned in 2019 – we just don’t know what the effects of the vaccine might be for mothers or foetuses. Without any evidence, mothers or would-be mothers are unsure about whether to get the jab.
Another reason for women being more vaccine hesitant is the lack of knowledge about their bodies – because the exclusion from scientific testing historically does not stop at pregnant women. It extends to all women. The majority of all scientific and medical testing is conducted on male bodies, animals and cells.
Researchers at the Brigham and Women’s Hospital in Boston said in a 2014 report that medical science “routinely fails” to include women in clinical trials and at all stages of medical research. A 2016 report in Pharmacy Practice cited evidence that historically medicine has failed to adequately enrol women in scientific studies and these deficiencies “have hindered the progress of understanding women’s response to medications”.
Until just 25 years ago, all women of reproductive age were routinely excluded from medical studies, with scientists assuming the results of testing on men’s bodies would apply equally to women.
And so this story comes back to one that we have heard more and more about recently, but not in the context of vaccine hesitancy: we simply don’t know enough about how women’s bodies work.
A matter of trust
This knowledge gap in medicine when it comes to women’s bodies is also part of a larger story. There’s a trust gap, too.
The fact doctors have always known little about women’s biology has meant women are much more likely than men to have had negative experiences with the healthcare system. That means they are more likely to feel distrustful of doctors, Dr Naomi Smith said.
“We know from previous research that women are less likely to be believed by doctors about pain and chronic conditions,” Smith said. “Women are under-diagnosed or treated for psychological problems instead of their physical symptoms.
“In a system that can often be hostile to women and their health needs, women do often have lower levels of trust in the medical establishment, because they are not taken seriously.”
Smith’s point is borne out again and again in research literature. Endometriosis, a disease in which cells that are similar to those that line the uterus, called endometrial cells, start to grow all over the body, is an oft-cited example. The errant tissue and cells can cause pain, internal adhesions, bleeding, gastrointestinal problems, fatigue, and a litany of other symptoms depending on where in the body the disease takes hold.
But the condition is poorly understood and, as a result, poorly treated. It has long been dismissed as “bad period pain”, and doctors are only now discovering that it is a whole-of-system disease with far-reaching consequences.
Studies show that women’s distrust in medicine also increases when they have other gynaecology-specific health problems such as polycystic ovary syndrome.
Many other chronic pain conditions that primarily affect women, including lupus, migraines, fibromyalgia and fibroids, are similarly under-diagnosed and under-treated. Lupus is a serious autoimmune disease whose sufferers are 90% women, and which most often occurs in women of childbearing age. But we know very little about it, and as a result 66% of people diagnosed with the condition said they had previously been misdiagnosed.
In fact, 40% of all women diagnosed with any serious autoimmune disease had previously been told by doctors there was nothing wrong or were accused of being hypochondriacs.
Young said the knowledge that medical science does not necessarily know what is best for women and their bodies is something women metabolise early on and could be a major factor contributing to vaccine hesitancy among this population.
“Women know they are not being included,” she said. “If you take an average woman on the street, she might not know about the number of women in research studies but it’s something that you grow up with, when you go to your GP again and again and they just don’t get it, and you are dismissed again and again.
“There is a lot of distrust in the system among women. Historically, we have earned that distrust.”
By failing to include women in scientific research, the medical establishment also continues to mistreat and misdiagnose disorders in women’s bodies that they know too little about, which further engenders distrust in the system, which may make these people susceptible to messaging that places doubt on medical authorities. It’s cyclical and self-reinforcing.
Acknowledging the complex reasons for vaccine hesitancy is critical to fighting coronavirus. That means we need to ask women what their concerns are, and be willing to listen if the answer is that it’s difficult to trust a system that has excluded and damaged them – over and over again.