Gender Disparities in the Care of Type 1 Diabetes Mellitus: Myth or Reality?

Abstract

Type 1 diabetes mellitus (T1DM) is a lifelong condition requiring intensive management; however, gender disparities persist in its care, particularly in conservative and resource-limited settings. This manuscript explores the impact of gender bias on the treatment and well-being of female patients with T1DM through three real-life case studies. The first case highlights the neglect of an eight-year-old girl with diabetic ketoacidosis (DKA), whose delayed treatment was influenced by gender-based devaluation. The second case emphasizes the emotional burden faced by a 16-year-old girl whose exemplary glycaemic control was overshadowed by concerns about marriageability. The third case illustrates the reproductive pressures imposed on a 32-year-old woman with T1DM, whose recurrent miscarriages were met with blame rather than medical support. These cases reveal systemic gender disparities in healthcare access, emotional support and societal attitudes toward women with T1DM. Addressing these challenges requires community education, integrated family counselling and multidisciplinary pre-conception care.

INTRODUCTION

Type 1 diabetes mellitus (T1DM) is a chronic condition necessitating lifelong insulin therapy and continuous monitoring of blood glucose levels. Numerous studies have highlighted the significant influence of gender on the management and outcomes of T1DM.[1,2,3,4,5] Research indicates that women with T1DM often experience a poorer quality of life and are more susceptible to complications such as diabetic ketoacidosis (DKA), eating disorders, stress, anxiety, depression and increased cardiovascular mortality compared to men.[1,2,4] Despite advancements in diabetes care, the impact of gender remains substantial, especially in rural and conservative settings where women’s health tends to receive less priority.

Baseline gender discrimination embedded in many parts of society continues to impact various aspects of a female’s life, from nutrition and education to healthcare access. Although improvements have occurred over the past few decades, a diagnosis of T1DM often worsens this disparity, with females facing neglect, reduced care-seeking and stigma, thereby deepening their vulnerability. In my practice as an endocrinologist, I have encountered several distressing cases where the intersection of gender and disease has significantly influenced the treatment and overall well-being of female patients. These cases have prompted me to reflect on the broader challenges that women face in managing T1DM. These challenges extend beyond the medical complexities of insulin therapy and glucose regulation, involving social issues such as neglect, emotional distress and stigmatization. Additionally, women often face pressure to conform to expectations surrounding marriage and motherhood, which can further complicate their diabetes management.

This manuscript delves into these issues through three real-life case studies that illustrate the gender disparities in the care of T1DM patients. The discussion concludes with practical recommendations to address these inequities and improve outcomes for women living with T1DM.

CASE 1: NEGLECT AND THE COST OF BEING A GIRL

An eight-year-old girl presented to my outpatient department with DKA, a life-threatening complication of T1DM, her random blood glucose being more than 600 mg/dL, urine ketones 4+ and venous blood gas analysis showing severe acidosis with a pH of 7.1, bicarbonate (HCO₃^-) of 4 meq/L. She was critically dehydrated and was struggling to breathe. Alarmingly, she had been experiencing the classic symptoms of T1DM for over a month—polyuria, polydipsia and significant weight loss. Despite these clear warning signs, her family did not seek medical attention until she developed respiratory distress.

Upon examining her, I immediately diagnosed DKA, explained to the family the critical nature of her condition, and emphasized the need for immediate hospital admission and aggressive treatment. I took the time to explain what DKA entailed and the potentially devastating consequences if left untreated.

Despite extensive counselling, the family expressed reluctance to admit the child to the hospital. They repeatedly asked for oral medications, seemingly unconcerned or indifferent to the gravity of the situation. When I firmly insisted on immediate inpatient care and arranged for her admission, the family vanished with the child, disregarding all medical advice and leaving me completely dismayed.

The child belonged to a socio-economically disadvantaged family, with both parents having only primary education. The family had six children: five daughters and one son, the patient being the third daughter. Unlike his sisters, the son received regular medical attention. Upon further inquiry, it was revealed that the family sought medical care for even minor ailments affecting the son, while the daughter was neglected for nearly a month and was brought to the hospital only after developing significant respiratory distress. When asked about this disparity, the parents casually stated that their resources were limited and had to be ‘reserved for the boy’. This response starkly highlighted a deeply ingrained gender bias within the household. It painfully highlighted how gender discrimination can affect healthcare access and decision-making, leading to the neglect of female children even in the face of a potentially fatal illness.

CASE 2: BEYOND THE PERFECT GLYCAEMIC CONTROL: THE EMOTIONAL TOLL OF LIVING WITH TYPE 1 DIABETES MELLITUS IN A MARRIAGE-OBSESSED CULTURE

In another case, a 16-year-old girl with T1DM had consistently managed her glucose levels quite impeccably. Her glycated hemoglobin (HbA1c) levels were consistently below 6.5%, a feat quite exemplary and praiseworthy. Despite her remarkable achievement, her mother was not supportive, often expressing despair about her daughter’s future in front of her. The mother frequently voiced concerns about the girl’s marriage prospects, saying, ‘Her life is ruined. Who will marry her with this disease?’ Hearing these words, the girl broke down in tears during one of the visits. Witnessing this, I took the mother aside and tried to counsel her, emphasizing the importance of being supportive and recognizing her daughter’s remarkable efforts. I explained that her negative remarks were deeply affecting her daughter’s emotional well-being and urged her to shift towards encouragement and positivity. Unfortunately, the mother persisted in expressing her despair and continued her distressing rants, seemingly unable to move beyond her fixation on societal expectations.

This incident reveals the emotional toll of living with T1DM for women, particularly adolescents who are already navigating the pressures of societal and cultural perspectives, in addition to the complexities of the management of T1DM. Rather than being praised for her diligence in managing her condition, this young girl was constantly reminded of how T1DM could ‘ruin’ her future and marriage prospects. The psychological burden of managing a chronic illness is immense, and negative reinforcement from family members can lead to lasting emotional damage.

CASE 3: TYPE 1 DIABETES MELLITUS AND THE BURDEN OF REPRODUCTIVE EXPECTATIONS

A 32-year-old woman with a ten-year history of T1DM had been married for the past seven years and was under intense pressure from her family to conceive. Tragically, she had suffered four miscarriages, each linked to poor glycaemic control during pregnancy. Her most recent HbA1c was 10%, far from the ideal range for a healthy pregnancy. Despite her ongoing health challenges, she was not offered the necessary support or guidance to manage her diabetes for a safer pregnancy. She had never received any pre-pregnancy counselling during her earlier pregnancies, nor did she ever consult an endocrinologist for managing diabetes during pregnancy. On the other hand, a few of the family members blamed her for the miscarriages and pressured her to conceive again, regardless of the risks involved.

When she came to see me, I could sense her overwhelming anxiety as she was still under immense pressure to become pregnant as soon as possible. I sat her down and advised her that it was crucial to achieve better glycaemic control before considering another pregnancy. I explained the serious repercussions of poorly controlled diabetes during pregnancy, as evidenced by her previous miscarriages, which had already taken a significant emotional and physical toll on her.

This case highlights the gender-specific pressures faced by women with T1DM, especially around fertility and motherhood. In certain societies, a woman’s value is often intrinsically tied to her ability to bear children. When a chronic condition like T1DM complicates this situation, the emotional toll can be devastating. Despite the well-documented risks of pregnancy with uncontrolled diabetes, this woman was not given the medical or emotional support she needed. Instead, the burden of reproductive expectations added to the physical and psychological struggles of her illness.

DISCUSSION

These cases provide insight into the pervasive gender bias or disparity existing in healthcare, especially in the management of chronic diseases like T1DM. Previous studies have shown that women living with chronic conditions, including diabetes, face more challenges than their male counterparts due to gender roles and expectations, and women are less likely to receive optimal treatment, which can be attributed to a mix of societal barriers, limited access to care and lack of adequate family support.[1] Furthermore, there exists a significant rural-urban divide in the care of T1DM in India, with rural patients, including females, often facing delayed diagnosis, limited access to insulin and glucometers and minimal diabetes education, leading to poorer outcomes compared to their urban counterparts.[6,7,8] Urban areas benefit from better health infrastructure, specialist availability and psychosocial support, while rural families cite affordability and unawareness as major barriers.

There is also a notable government-private sector divide in the care of T1DM. Patients managed in private sector facilities, typically in urban areas, benefit from access to specialist endocrinologists, timely diagnosis, access to analogue insulins, pen devices, advanced diabetes technology tools like continuous glucose monitoring devices and insulin pumps, diabetes education and multidisciplinary care. In contrast, those receiving care in the public sector, without dedicated endocrinology services, may face challenges like long queues of patients, delayed diagnosis, recurrent DKA, limited or erratic insulin supply, limited access to pen devices, delivery of insulin through painful syringes, inadequate self-monitoring tools and limited access to diabetes educators.[8] The West Bengal initiative represents a robust, integrated framework for T1DM in a low-resource setting.[9] By combining free medical supplies, education, monitoring, psychosocial support and community outreach, it aims to significantly enhance clinical outcomes and quality of life for individuals with T1DM.[9]

Recommendations for improving care for women with type 1 diabetes mellitus

Community education and awareness

The first case illustrates the dire consequences of gender bias in health-seeking behaviour. Community-based awareness programmes targeted at schools, village councils (panchayats) and through mass media should emphasize the early recognition of T1DM symptoms and the urgency of timely treatment for all children, regardless of gender.

It is imperative to integrate structured T1DM awareness programmes in all girls’ schools and colleges. Early recognition of symptoms, prompt referral and breaking myths surrounding insulin use can significantly improve outcomes, especially in adolescent girls who often face stigma and neglect. As Kalra et al.[10] highlight, ‘patient empowerment is the cornerstone of T1DM care’, encompassing not just medical knowledge, but the confidence, skills and support needed to self-manage the condition effectively. Empowering girls through education and peer support within an institutional framework can foster life-long self-care behaviours and challenge societal biases that limit access to T1DM care.

In addition, menstrual hygiene and the management of pre-menstrual syndrome (PMS) are often overlooked in adolescent girls and women with T1DM, despite their significant impact on glycaemic control and quality of life. Fluctuating hormone levels during the pre-menstrual phase and menstrual cycle can affect blood glucose levels and insulin sensitivity, with risks of hypo- and hyperglycaemia, as well as emotional lability.[11] Lack of awareness, stigma surrounding menstruation and poor access to menstrual hygiene products further compound the challenges, particularly among underprivileged girls. Empowering female patients with T1DM to track their menstrual cycles, recognize hormonal patterns affecting glucose levels and proactively adjust insulin under guidance is crucial. Comprehensive menstrual health education, access to sanitary products and school-based initiatives are crucial for empowering young girls with T1DM.[11]

Integrated family counselling

In the second case, it is seen that the pressures related to future marriage took a severe emotional toll on a 16-year-old girl who had otherwise achieved commendable glycaemic control. Adolescence is a vulnerable period, and the added burden of a chronic illness like T1DM can significantly impact mental health. Previous studies have shown that adolescents with T1DM are more susceptible to psychological distress, eating disorders, depression and anxiety.[12,13,14] Kalra et al.[15] extensively reviewed the emotional and psychological needs of people living with diabetes and concluded that unmet psychological and emotional needs could impact glycaemic control, self-care behaviour and quality of life, leading to an increased risk of diabetes-related complications.

Many women may conceal their diagnosis of T1DM due to stigma and the fear of rejection by their potential or current husbands and in-laws. They may even skip insulin doses to avoid disclosing their condition, putting themselves at risk of serious complications like DKA. This highlights the urgent need to integrate family counselling into diabetes care, especially for adolescent girls, to create a supportive environment where health is prioritized over societal expectations. A diagnosis of T1DM should never be a source of shame or something to hide, especially in the context of marriage. Incorporating psychological counselling as part of comprehensive diabetes management can help adolescent and young girls and their families cope with the emotional burden of living with a chronic illness and encourage open, stigma-free communication.

Pre-conception counselling and multidisciplinary care

The third case illustrates the gender-specific challenges faced by women with T1DM concerning reproductive health. It highlights a critical gap in the healthcare system where women with chronic conditions are not adequately counselled or supported in managing their health during pregnancy. Previous studies have consistently shown that women with T1DM are at increased risk of complications during pregnancy, including miscarriage, pre-term birth and congenital anomalies in the foetus, especially if glycaemic control is suboptimal.[16,17] However, pressures around fertility and motherhood, without a proper supportive environment, can lead to poor consequences, as was evident in the case. Pre-conception counselling and better integration of endocrinology and obstetrics care are essential to improve pregnancy outcomes for women with T1DM. It is necessary to involve not just the woman but also the husband and in-laws during pre-conception counselling. Clarifying the potential for healthy pregnancies with adequate glycaemic control and educating them about the relatively low risk of genetic transmission can help reduce stigma and foster a supportive environment.

CONCLUSION

These real-life incidents highlight the complex interplay among gender, cultural and societal factors and chronic illnesses like T1DM. Addressing these disparities would require a multifaceted approach that includes medical, psychological and societal interventions to ensure equitable care for women with T1DM. Future research should focus on evaluating and developing targeted interventions to improve the quality of life and health outcomes for women with T1DM.

Author contributions

HB conceived, drafted, edited and approved the manuscript.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence

Artificial intelligence was not used in any form for analysis or writing of this research article.

Funding Statement

Nil.