Legislative Council, Tuesday 19 November 2024

Ms FORREST (Murchison) - Mr President, in noting the motion I acknowledge that the vast majority of work done that is reported in this report was done in the last parliament. The report was actually signed off by the committee of the 50th Parliament but could not be tabled before the calling of the election in March 2024, a second early election, subsequent prorogation of the parliament, and the inevitable delay in re-establshing the committee. That was a little bit disappointing but eventually we got there. Having said that, the information does not really date in this report. The matters that are relevant then are still relevant now. Despite the delay, I do not believe there would have been any major changes to the findings or recommendations contained in this important body of work.

I thank all members of the committee for their work and the support of the committee secretariat in this inquiry and report.

This report confirms the lived experiences of gendered bias of many Tasmanians who access primary and acute healthcare. Gender bias in healthcare is real and negatively impacts members of our community, particularly members of the LGBTIQA+ community and women. This bias is described by many witnesses to the committee and I suggest it is something that is not well understood throughout the community.

Gendered bias is evident across many areas of healthcare, including access and affordability, safety, inclusivity, timely and accurate diagnosis, and it increases the risk of misdiagnosis and poor health outcomes. Many people, particularly women and members of the LGBTIQA+ community, have sadly come to experience much of this bias and discrimination as the norm. Some may have not experienced any other alternative that leads them to question their care. I thank those courageous individuals who shared some of their own or their patients' lived experiences of gendered bias and/or discrimination to assist the committee in understanding the scale and ubiquity of this experience.

The committee also found that discrimination toward members of the LGBTIQA+ community can compound the negative impacts of gendered bias. The committee made 34 findings and 17 recommendations. These findings and recommendations draw attention to evidence of gendered bias in healthcare and highlight actions needed to mitigate against and address the negative impacts on the health and wellbeing of Tasmanians, particularly for women and members of the LGBTIQA+ community. The committee's recommendations include: the provision of improved training and education for healthcare trainees and professionals; consistent and contemporary clinical guidelines, particularly in areas of women's and reproductive health; dedicated services for members of the LGBTIQA+ community; improved data collection; and adequate funding for dedicated women's and reproductive healthcare. The committee also recommends the introduction of a human rights act to support and enhance the other recommendations to address gendered bias in healthcare.

Intersectionality, that is the impact of gender in addition to other factors, can amplify the gender-related bias that some members of the Tasmanian community experience when accessing healthcare, especially for those who are culturally and linguistically diverse, Aboriginal or Torres Strait Islander, living with disability, members of the LGBTIQA+ community, and/or of a particular age. The age factor can present bias in differing ways depending on the circumstance.

In addition, for members of the LGBTIQA+ community, a lack of information regarding the location of inclusive and safe care often leads to delays in seeking care and a heightened risk of an adverse experience accessing services that may not be inclusive. Evidence provided to the committee shows that dedicated LGBTIQA+ clinics and outreach services are needed. The committee recommend the government publish and regularly update on the Department of Health website a list of healthcare providers that indicate they provide safe and inclusive care, and establish regionally accessible health services or clinics that are safe and inclusive. While there is some information available, mostly provided by inclusive service providers, it is not easily accessible or inclusive, and it relies on practitioners themselves, so it may not be visible to those living in regional areas.

There are also many gaps in health data, particularly with regard to female specific health conditions and reproductive health. Data collection and record keeping within the Tasmanian Health Service at the time of the inquiry was inadequate. This has been recognised by the government and investment in digital data management and data collection is underway, although it is still not rolled out, as I heard at a recent Public Accounts Committee inquiry. The long awaited Human Resources Information System (HRIS) has a very long gestation indeed. I still do not believe it is completed, but we move ever closer.

The committee also heard that many people accessing the health system experience a level of disempowerment when navigating the system. Women regularly experience gendered bias in primary and acute healthcare settings. This is evidenced by women's experiences of being more likely to have the severity of their physical pain and symptoms dismissed by treating medical professionals. Women in this room may have experience of that themselves. This can and does delay timely treatment and provision of adequate pain relief and can contribute to misdiagnosis.

I know when I presented to the Accident and Emergency Department when I was out door knocking once and was bitten by a German shepherd -

Ms Rattray - That dog again?

Ms FORREST - That dog, yes. I was basically offered nothing in pain relief. When I was, I was offered a small dose of Panadol, which I took, but that did not touch it. Based on my medical knowledge and background, I effectively demanded some endone or a narcotic to try to take the edge off it. Then, when they wanted to do an invasive procedure on my arm, I was offered nothing, perhaps more endone. Thankfully, I knew one of the nurses in the emergency department. I looked after him and his wife when they had their babies, so I called out to him rather loudly until he came to my assistance and told him that he was to stop the doctor proceeding with what he had already started and to give me something that would at least take the pain away.

I suggested that he give me some nitrous oxide and make sure I had enough on board before we went any further. The nurse had to argue with the doctor to get it. I basically pulled my arm away so he could not access it until I got something that was half decent. After that, as I got the gas in my hands, he wanted to start again. I put the other arm back away. I used the good arm to suck on the gas furiously. I said, 'You are not starting until I have enough of this on board'. I should not have to do that.

Any other woman who may not have had the same knowledge and experience in the health system to know what options there might have been may well have had to suffer extraordinary pain with an invasive procedure that I could barely cope with. Thankfully, I had a good nurse whose name I knew and I could scream loudly enough to get his attention. He was very helpful and very good.

Going on to the issue of, not necessarily pain, but can be pain related, women presenting with atypical cardiovascular disease symptoms or abdominal pain also experienced delays to care, pain relief, and accurate diagnosis. The lack of a clear and consistent care pathway for female abdominal pain in emergency departments contributes to these adverse impacts and can delay admission.

The committee heard some very disturbing accounts of the lived experiences of some women, where it is very clear a male patient would not have had the same experience. Women were often assumed to have low pain thresholds, like we do not give birth to babies -

Ms O'Connor - Yes, like we are hypochondriacs and whingers - that is the feeling you get in front of male doctors.

Ms FORREST - Sometimes, yes. - despite our ability to birth children, often without pain relief, and are seen as hysterical or having some gynae issue, but without this gynae issue being diagnosed are not referred to a gynaecologist. These women describe as being unheard, disbelieved, ignored, and not offered adequate pain relief.

In order to address this very real issue, and the lived experience of many, the committee recommended the Tasmanian Health Service establish contemporary and consistent clinical practice guidelines for the assessment, treatment, and admission of women presenting to a Tasmanian emergency department with all presentations of abdominal pain, or women presenting with atypical cardiovascular symptoms, and birth trauma and miscarriage. There needs to be very clear clinical guidelines around the management and assessment of these conditions.

The committee also found that women's reproductive health services are inadequately funded to ensure equitable, timely, safe, effective, and accessible care can be provided both for contraceptive care and termination of pregnancy care throughout Tasmania. It is absolutely unacceptable that this is the case. Many women are unable to afford the costs or to access in a timely way to a medical termination of pregnancy. This effectively denies these women the right to safe and timely health care for a very time sensitive healthcare matter. These circumstances have led to an increase in the number of women accessing a surgical termination in the Tasmanian Health Service. This is, for the majority of women, a higher risk procedure that could have been avoided and that adds to the pressures of the acute health services more broadly.

I am sure all members would be aware that, as with medical termination of pregnancy, surgical terminations of pregnancy are equally time sensitive and cannot be delayed. As a result of these barriers, and failings of healthcare for women in some cases, women continue an unwanted and unplanned pregnancy. This is not an ideal outcome.

Members may not be aware that the Medicare rebate for many reproductive health-related care and investigation is completely inadequate to cover the cost of providing this care. This leaves GPs facing financial barriers for the provision of timely care and is another example of gender bias and the provision and funding of healthcare.

Evidence to the committee from Family Planning Tasmania's submission discusses the insufficient numbers of general practitioners available to provide women's health services. This is all included in the report, but I will reiterate some of this evidence. From their submission Family Planning Tasmania (FPT) said:

• Many patients come to FPT because they are unable to access quality women's health care in General Practice. In particular, typically only female GPs provide cervical screening tests, Implanon inserts/removals and Interuterine Device (IUD) inserts. Very few GPs (male or female) provide medication termination of pregnancy (MTOP), in part because it is time consuming and financially unsustainable to deliver and these GPs have not undertaken additional training and qualifications to understand the complexity in women's health.

• This problem is particularly bad in rural and remote parts of Tasmania. Family Planning Tasmania is contacted frequently by medical services in rural and remote regions requesting women's health outreach. While FPT has doctors who are keen and willing to provide outreach (and have in the last 6 months carried out successful outreach to St Helen's, which was funded by the requesting organization), FPT is not funded to provide this and cannot cover the cost through the Medicare rebate. The lack of GPs providing women's health services results in women forgoing essential screening tests such as cervical screening. [OK]

The submission from Women's Health Tasmania also discussed issues with reproductive health literacy in the health workforce. Doctors, particularly general practitioners, need to be encouraged to do extra training in women's health. We are aware of a patient whose menopausal symptoms were disregarded by her long-term male general practitioner. He told her that it does not tend to last very long.

Ms O'Connor - Just five to 10 years.

Ms FORREST - She says she felt her symptoms were invalidated, minimised and brushed aside. It is important to note menopause can have serious psychosocial effects on women, including loss of income but of course, he had been through it, had he not? He would know.

They did not say that in their submission. I am just adding a little bit. To go back to their submission, when the same patient saw a female GP, she got a comprehensive assessment and was offered hormone replacement therapy, appropriate care. The submission went on:

Women in rural and remote areas may not have the benefit of choice of gender of their GP they see and their care can be even more disrupted by the use of locums.

This evidence was elaborated on in a hearing by Ms Jo Flanagan from Women's Health Tasmania and I will quote some of her evidence to the committee from the report. She said: [tbc 3.51]

We are concerned about the state of maternal health care in Tasmania and our concerns are based on anecdotal information we have received from clients over the last five years. They include: problems finding GPs who are knowledgeable about pregnancy and pregnancy care pathways; problems gaining access to specialist midwifery programs, service responses during the COVID-19 pandemic, specifically with the withdrawal of services during the pandemic; what appears to be premature discharge of new mothers and infants from the hospital to a lack of support in inappropriate housing; lack of support for women experiencing maternal exhaustion and difficulties with breastfeeding; poor access to GPs post birth for new mothers and infants who cannot get appointments and are referred to emergency departments after the birth (hardly an ideal location to send a newborn baby when they just need the support of a GP or other health provider); limited access to CHaPS, the child health and parenting services; lack of access to allied health supports, for example, pelvic floor physiotherapists and psychologists who work with women experiencing birth trauma. We are also concerned about the very high rate of birth trauma that we are seeing in our counselling services. That is trauma associated with childbirth complications, interventions and outcomes.

Evidence received from the Royal Women's Hospital in Victoria - I might just add that it was very pleased to be asked to provide evidence to this committee and, obviously, as a Women's Hospital it has a very direct and keen interest in this matter. I said the difficulties that could be faced by women seeking terminations across Australia were real and they elaborated on this:[tbc 3.53]
Early medical abortion using the medications mifapristone and mysoprostol is an established alternative for surgical abortion for early pregnancy. These routinely used medications are widely recognised as safe and effective, including by the World Health Organisation. Early medical abortion is non-invasive and should be the first option for unwanted pregnancy. However, in Australia it is usually still comparatively low to that of other countries where it is considered to be a standard option and easy to access.

The submission added that:

With various conditions, surgical abortion is legal in all Australian states and territories, providing it is done by a registered medical professional. Yet, many publicly funded hospitals in Australia that provide maternity and women's health services do not provide abortion services at all. Others provide very limited services or have complicated care and referral pathways, making access very difficult. One of the reasons is that public hospitals are not mandated through state government directives or funding agreements to provide contraception and surgical abortion care. Each state authority releases clinical capability framework directives that govern the level of service a public hospital must provide, with hospitals ranked from level 1 being basic care, through to 6, being high risk and complex care. Yet these directives and individual funding agreements do not include any mention of women's health or gynaecological care, let alone the mandated provision of abortion or contraceptive services.

We know this. That the law might may say it is legal, but the policies of the government of the day can make it inaccessible. Further to the challenges experienced by women and access to reproductive healthcare in its submission, Family Planning Tasmania also raised the issue of cost barriers to women seeking medical terminations in Tasmania: [tbc 3.55]

There are cost barriers to Tasmanian women accessing medical termination of pregnancy. Perversely, it is now more affordable for many Tasmanian women to access surgical termination of pregnancy than medical termination of pregnancy. Access to surgical termination of pregnancy in Tasmania has greatly improved since the service was introduced in Tasmanian public hospitals in October 2021 and surgical termination of pregnancy is now free for all women, including non-Medicare cardholders. This approach is strongly supported by Family Planning Tasmania.

It seems incongruous that surgical terminations are cheaper to access than medical terminations. They go on:

Nonetheless, noninvasive medical termination of pregnancy is the preferred abortion alternative for many Tasmanian women. Family Planning Tasmania provides approximately 400 medical terminations of pregnancy per year in a primary care setting. Medical termination of pregnancy is also provided by some GPs.

Family Planning Tasmania is not specifically funded to provide medical termination of pregnancy and therefore currently needs to charge out-of-pocket expense costs for women who are not eligible for state government funding. Out-of-pocket expenses for health consumers of medical termination of pregnancy are required because the service requires significant patient preparation, monitoring and follow-up.

It is not something you can do in a quick five minute session.

I am sure members can appreciate the issue here. Family Planning Tasmania added:

While the cost of a medical termination of pregnancy in Tasmania may be reimbursed for people who can demonstrate financial hardship with government funding administered by Women's Health Tasmania and the Link, this creates a further barrier for medical termination of pregnancy compared to surgical termination of pregnancy.

These women who are accessing this service are dealing with a lot of other things. For them to then have to apply because of financial hardship for something they may not want to disclose to members of their family is extraordinary, prohibitive, discriminatory and unacceptable. The Family Planning Tasmania goes on:

Medical practices such as Family Planning Tasmania may still advertise the cost of medical termination of pregnancy and consumers have to declare that they cannot pay in order to access financial hardship support.

You have to diminish yourself to the point of saying I cannot afford to pay for this, but please give it to me.

There is evidence that some clients are unable or unwilling to make this declaration to Family Planning Tasmania, including feelings of shame and embarrassment.

How dare we do this to women in already vulnerable situations?

Some of these women unfairly incur financial hardship of medical termination of pregnancy out-of-pocket expenses.

They just pay for it and something else gives.

Others do not proceed with the medical termination of pregnancy at all and instead access a surgical termination of pregnancy.

Which I have already said is higher risk.

It also occurs in our acute healthcare settings, which are already overburdened.

This is unnecessary.

An unknown number of women may proceed with an unwanted pregnancy.

That is not an ideal outcome either.

Women who prefer to choose medical termination of pregnancy, but cannot due to out of pocket costs can instead access free surgical termination of pregnancy in public hospitals at an approximate cost to the health system of $3000 per procedure.

Would it not be cheaper to fund medical termination of pregnancy?

Conversely, every woman who chooses to access medical termination of pregnancy in a primary healthcare setting instead of a surgical termination of pregnancy in a public hospital reduces pressure on the public health system.

Medical termination of pregnancy also provides options for Telehealth delivery that are not possible with surgical termination of pregnancy, which can be particularly beneficial for women in regional and remote Tasmanian communities.

Family Planning Tasmania indicated that it could, with appropriate funding, improve the situation by providing medical termination through its clinics and outreach programs. They said:

Family Planning Tasmania proposes to provide equitable access to medical termination of pregnancy for all Tasmanian women by fully funding medical termination of pregnancy through Family Planning Tasmania clinics in Glenorchy, Launceston and Burnie and via Family Planning Tasmanian outreach to remote and regional parts of Tasmania.

 

Family Planning Tasmania is a proven high quality provider of medical termination of pregnancy services in Tasmania and Family Planning Tasmania has systems, processes, facilities and equipment in place, including nursing support and specialised GP training to expand on its current provision of 400 medical termination of pregnancy services per year. Family Planning Tasmania now provides in house ultrasound, required prior to some medical terminations of pregnancy procedures, and has a focus on providing reliable contraception and support to all medical termination of pregnancy patients to prevent future unplanned pregnancy.

Family Planning Tasmania can and does already provide women centred care and is in a position to increase available women centred health care. Family Planning Tasmania representatives informed the committee that Family Planning Tasmania already has a model that works. It provides a high quality and well received service in Tasmania.

Family Planning Tasmania is definitely not funded as well as family planning organisations in other states. They stated that they are very grateful that they get some of their funding from the Department of Health, but they do not get any funding for the doctor's time. They are required to pay the doctors' salaries through fees. Family Planning Tasmania has a mixed billing model where they bulk bill patients on low incomes and everyone else pays a fee. With additional funding, they believe the model could work and could be expanded to provide services to many more people.

Family Planning Tasmania was recently selected by the federal health department to specialise in endometriosis and pelvic pain, and they are funding existing clinics to provide specialised services for endometriosis and pelvic pain.

According to Family Planning Tasmania, a lot of the issues of gender bias and inequitable access to services could be addressed at the state level simply by providing extra funding to pay doctors for their time. There are the doctors who work within Family Planning Tasmania with the understanding that Medicare rebates do not do that. They do not cover that cost. When you consider the cost of a surgical termination, it doesn't make economic sense not to do this, if you are just going to focus on the economics of it, let alone the human side of it.

Another area of gender bias that was raised with the committee related to the gendered nature of gender specific healthcare costs. Family Planning Tasmania provides evidence of this and discussed the high cost for a number of women's healthcare services. We have already discussed medical termination. I will talk about what that procedure and cost involves as a comparator perhaps.

A high quality medical termination of pregnancy service, such as that provided by Family Planning Tasmania, takes over 180 minutes of medical practitioner time to provide. Medicare via the MBS will cover 40 minutes of this. That takes 180 minutes. Medicare covers 40 minutes. At that rate, that is not sufficient to cover a GP's salary. The nurse time spent on medical termination is 75 minutes, and that is not rebated by Medicare at all. Antenatal care is another example. The Medicare rebate for an antenatal appointment is just $42.40, despite the fact these appointments overwhelmingly require a 30 minute consultation. This rebate is less than a regular consult of over 30 minutes, which is $76.95, effectively penalising pregnant women or the doctors who treat them. An antenatal appointment gets $42.40 for 30 minutes. Other regular consultations for over 30 minutes get $76.95. This is just breathtaking that this is actually the reality. This is a federal government, the Medicare rebates, but it highlights the gender bias.

Lack of rebate for nurse services. At Family Planning Tasmania, nurses provide most cervical screening tests but are unable to claim Medicare rebates at all for their time.

I note [inaudible 4.35.47] numbers for nurses previously existed, but they were withdrawn by the medical benefits scheme. This is effectively, a financial penalty for women to undertake what is an essential preventative health screening service.

The AMA provides the example of ultrasound costings that further highlight this point. These are the full rebates, not the benefits.

The rebates that radiologists receive for performing certain procedures.

An ultrasound of a scrotum: $113.95.

An ultrasound of a penis: $102.20.

The ultrasound of a breast: $102.20.

The same.

I think it takes longer to do a breast than a penis. Arguably, a pelvic scan is more complex than a scrotal scan. You get more for doing a scrotal scan than you do a breast scan. A pelvic scan requires a vaginal probe in addition to a standard probe. That is more equipment, more consumables.

Considering organisations like the AMA consulted on the fees list, it shows that bias prevails across the medical organisations and government departments to the detriment of women and their health. The AMA also discussed in their submission the cost incurred by pregnant women for scans.

The 20 week scan is imperative in determining foetal health. The first trimester scan is another important test which can help a woman calculate the chances her child has one or three foetal chromosome disorders in addition to other abnormalities. An early assessment allows her more choices with regards to further testing. With out of pocket expenses for the first trimester scans, the 20 week morphology scans being back in 2022 23, $95 for healthcare card holders and $225 for full fee-paying patients, this may be a cost avoided by some pregnant women, limiting their options.

You cannot make the woman have the scan, but if she does not because she cannot afford it, then her options are limited as to further decisions about further testing or other decisions regarding the pregnancy.

Evidence provided to the committee by the AMA highlighted:

Understandably, these costs may serve as a barrier to pregnant women getting equitable health opportunities that may have long term ramifications. With the poorest families in Australia scraping by on $150 a week after housing costs, it was just not possible to pay the initial outlay required for these tests, even as healthcare card holders.

The AMA also provided evidence about discrepancies in funding for women specific medications.

There are several medications specifically used by females, such as those for contraception and menopausal hormone replacement. Some are funded. Many of the new and widely recommended options are not. It is routine in general practice to have discussions about the best medications to manage contraception, menstrual bleeding difficulties and, in particular, mental health. But one must also must consider the affordability of and therefore access to prescribed medication.

The reason I have referred to significant amounts of evidence received by the committee was to highlight just how entrenched gender bias against women in health care extends. In addition, I spoke about another area of inequity following the work of this committee that reinforced the findings of these committees. I reiterate some of what I spoke previously in mid 2023.

The data I was provided with by Family Planning Tasmania related to the appalling gender disparity in contraceptive procedures …

These are figures from 2022, so they may have changed slightly, but the principle still applies, specifically focused on the intrauterine device and vasectomy. The unfairness in the rebate discrepancy and the gender bias relating to women bearing the financial burden and potential side effects of contraception is unacceptable. I am sure most, if not all, members know what an intrauterine device is and how it works, but to reiterate, the IUD is a female contraceptive procedure that involves the insertion of a small device into the uterus to prevent pregnancy. The IUD provides 99 per cent efficacy against pregnancy for five years, requiring replacement at the end of that time. Despite its effectiveness and convenience, the current system perpetuates an unfair burden on women.

The key points that emphasise this inequality are outlined and I will outline these.

• The time required: The minimum time required for a procedure is 30 minutes with an additional recovery period which can be several days. Most GPs allocate 45 minutes for the entire procedure. There is often pain associated with this procedure with varying options for pain relief, with many providers only offering mild analgesics. If you give something stronger, the patient's got to stay longer.

• Staff involved: The IUD procedure typically involves a GP or specialist gynaecologist along with a procedural assistant or nurse.

• Medicare rebate: Shockingly, the Medicare rebate for an IUD procedure is only $72.05 and is essential to note that the sterilising equipment alone costs $40. This disparity places disproportionate impact on women seeking reliable contraception.

Now let us consider vasectomy. To remind anyone who may not have a full understanding, vasectomy is a male contraceptive procedure that involves the surgical cutting or blocking of the vas deferens to prevent sperm from reaching the ovum.

The vas deferens is cut. Unfortunately, the current rebate system further exacerbates the gender bias. I will go to time required.

• A procedure typically takes approximately 15 minutes as opposed to the 30 to 45 minutes for an IUD, with some providers using a no snip technique, local anaesthetic is inserted as part of the procedure.
• Staff involved: Vasectomy procedures are typically performed by GP or specialist urologist along with a procedural assistant or nurse which is fairly similar in terms of the skills required or the skill of the practitioners.
• Training Required: Additional training is required for healthcare professionals to perform vasectomy procedures effectively and that is a good thing because we want it done properly.
• Medical rebate: Astonishingly, the Medicare rebate for a vasectomy is a significantly higher amount of $200. Remember it was much less - $72.05 for IUD. Vasectomies get $200, take 15 minutes to do. IUDs take a lot longer.

This substantial difference in rebates only reinforces the gender disparity in contraceptive choices, unfairly placing a smaller financial burden on men. Family Planning Tasmania provides and supports these services and provides a much-needed service to Tasmanians. They need to be adequately remunerated to support equity of cost to the individual, equity of access to care and timely reproductive health care.

The cost and available Medicare rebates expose unacceptable and inexplicable gender bias demonstrated by rebates for male related procedures and investigations being significantly higher than comparative female-related procedures and investigations as evidenced by the examples I have just used.

In response to some of these matters, the committee recommend the state government actively seeks the support of the Federal government to remove gender bias in Medicare rebates. Gender bias in relation to cost and pay and equity for female medical practices was also raised by the committee. Family Planning Tasmania noted the Australian Medicare Benefit Scheme incentivises short consultations, effectively penalising doctors for spending more time with patients.

Short consultations are incompatible with often complex needs of women's health care, particularly related to contraception, pregnancy and termination. Complex consultations are one reason why female doctors are more likely to spend more time with patients than male doctors, resulting in women in health care earning less than men. A 20 per cent gender pay gap exists as well as what amounts to attacks on women's health as either doctors or patients cover the additional cost of providing long consultations. In Tasmania, out-of-pocket fees for appointments with GPs specialising in women's health outside of Family Planning Tasmania are between 50 to 100 per cent higher than a standard GP appointment. This additional cost is on top of the Australian gender pay gap of 13.4 per cent. This means women are less able than men to afford their medical and healthcare costs to begin with.

The issue of female doctors spending more time with their patients was also raised by the AMA. Female GPs are usually part-time contracts in small businesses which do not offer maternity leave, job security, long service leave, employee assistance programs, employer contributed superannuation, or work cover in the long run. Those who may suffer from vicarious trauma through their chronic mental health work have to fund their own care and sick leave. This may lead to a loss of health professionals through burnout.

Female health professionals earn less than their male counterparts for a multitude of reasons. It is a common experience in general practice for patients to present to male doctors for straightforward issues and then electing to see a female GP for complex, challenging and time-consuming presentations. As well as impacting income, a heavy case load of medically complex patients can be exhausting for female GPs, especially if all you see is really complicated patients. It is very wearing.

It is important to note that underlying the lived experience of gender bias and healthcare for women is a historical legacy of research and research funding that is focused on the male body. Adding to this is the fact the body of research has been predominantly undertaken by men. In medical literature and textbooks, men's bodies are seen as the norm and women's bodies are a variation of the norm. This is compounded by the fact that the committee also heard evidence of significant gaps in education and training of health professionals in both undergraduate and postgraduate programs, particularly in the areas of LGBTQIA+ patient care, women's specific conditions such as endometriosis, menopause and miscarriage, gender and unconscious bias empathy, and bystander intervention. As a result, the committee recommended improvements to training and education to address key areas of gendered bias.

As I noted earlier, the provision of healthcare is highly feminised, which contributes to the gender pay gap when delivery of care is predominantly provided by women. The highly feminised workforce, particularly in lower paid roles, can also mean men presenting for care are less likely to be cared for by other men. This reality can also impact on stereotypes and masculinity with the nature of healthcare settings and sometimes the lack of availability of male healthcare professional can create barriers to men seeking healthcare.

The committee recognised that increased diversity in the healthcare workforce and policies to address stereotypes of masculinity can assist to address these matters, but it takes concerted efforts and pay equity.

One area where the committee found gendered bias experienced by some men was in relation to delivery of maternity services. The committee heard from an expectant father who described the need to recognise non-birthing parents throughout the childbirthing experience. The committee acknowledged the need to ensure maternity care does provide inclusive care for the childbearing family. Maternity and early parenting services require appropriate policies, education and training to ensure inclusive care.

The committee further noted parental leave in Australia does not fully consider the needs of the non-birthing parent, although there have been advances in more recent times in some places of employment to support this. It is not a consistent framework, but there are some who have done an amazing job in supporting the non-birthing parent in that area. The committee recommended the state government encourage the federal government to consider further changes to the structure of parental leave, responding to the economic and sociocultural needs of non-birthing parents.

To reiterate some of the findings of the committee. Gendered bias in healthcare is particularly prevalent for the LGBTIQA+ community and many have experienced discrimination in healthcare settings. The impact of this can result in delayed diagnosis which could have a negative impact on health outcomes for members of this community. The lack of information available and communication to members of the LGBTQIA+ community regarding providers from whom they can be guaranteed safe and inclusive care can further exacerbate these negative impacts, which have been exacerbated by deficiency and knowledge in the wider medical community about LGBTQA+ specific health-related matters. It is evident that dedicated LGBTIQA+ clinics would provide great benefit in Tasmania by enabling patients to access safe and inclusive spaces to access healthcare.

Many women experience gendered bias when presenting for healthcare, particularly related to cardiovascular disease, abdominal pain and/or reproductive healthcare. This can and does result in delays to diagnosis, misdiagnosis and poor health outcomes. Women are more likely to have the severity of their physical pain and symptoms dismissed by treating medical professionals, delaying timely treatment and pain relief. There is no clear or consistent care pathway for female abdominal pain in emergency departments.

Organisations providing medical termination and pregnancy services are inadequately funded to provide equitable, accessible, and affordable care across regions. The lack of access and affordability of medical terminations often result in women seeking surgical terminations, which adds to the burden on acute health services. There is a lack of clinical guidelines or formal trauma informed briefings to support women following traumatic birth experiences and miscarriages.

There is also a historical legacy of research and funding for research focused on the male body, which has had negative implications for women and women centred healthcare. There is an inherent gendered bias in Medicare rebates resulting in cost inequity and disadvantage for women specific investigations and care. There is a significant gap in training for medical, nursing, and allied health professionals in the areas of LGBTIQA+ patient care; women with specific conditions such as endometriosis, menopause, and miscarriage; gender bias; unconscious bias; empathy; and bystander intervention.

The anatomy books currently used in Australian medical schools and training of medical professionals utilise the male body as standard and the female body as other, which influences diagnosis and treatment of women's health issues. Menopause was excluded from Australian undergraduate and postgraduate medical and allied health training. It is pleasing to note that the Australian College of Rural and Remote Medicine (ACRAM), have provided educational resources to improve ACRAM's doctors' understanding of key gender issues in practice. I commend them for that work.

Non birthing parents can also experience antenatal and postnatal anxiety and depression. Parental leave in Australia does not fully consider the needs of non birthing parents, including their economic and sociocultural needs.

Stereotypes of masculinity and the nature of healthcare settings, and sometimes the lack of availability of a male healthcare professional, can create barriers to men seeking healthcare and there is a need for increased diversity in the healthcare workforce.

To address some of these matters, the committee identified a need for greater utilisation of interpreter services where those who are culturally and linguistically diverse, or are Aboriginal and Torres Strait Islander, are not well catered for, and also the inclusion of cultural awareness and inclusion training to assist medical professionals in treating all those from diverse backgrounds.

The committee also found that gendered bias can impact on the timely diagnosis for conditions such as attention deficit hyperactivity disorder (ADHD) and autism.

There are many other findings in the report that I will not go into specifically. I want to mention that the committee found that a human rights act in Tasmania may improve the experience of Tasmanians seeking healthcare, particularly those from marginalised groups, and thus we recommended the introduction of a human rights act.

I have referred to a number of committee recommendations during the presentation. I note that I did not specifically mention all of those, and some require additional emphasis but they are all in the report.

In addition to the LGBTIQA+ community, the committee recommended the government update the Tasmanian Health Service medical records and data collection for patients who change their prefix, pronoun, or gender markers, so changes are made in a timely manner. I am sure this will become much easier to do and more prompt once the new and fancy HRIS is in place.

Also of key importance, is the need to establish regionally accessible health services and clinics that are safe and inclusive, particularly for members of the LGBTIQA+ community.

Due to the inequities I referred to in my contribution, the committee recommend the government increase funding to Family Planning Tasmania - it seems like a no brainer to me - to ensure equitable and accessible reproductive healthcare across the state, and provide additional funding to relevant organisations to provide specialist services for endometriosis and pelvic pain.

To make real change in gender bias and healthcare, the committee also recommend that the government actively seek the support of the federal government to remove the gender bias in Medicare rebates. This gender bias is simply unacceptable.

As noted in the report, I want to sincerely thank all those who took the time to make submissions or to provide evidence to the inquiry, and for sharing their invaluable experience and knowledge. It is not easy to talk about a traumatising experience you have had in our healthcare settings, whether it is in the community, in general practice areas, or in our acute health services. In particular, I thank those women who shared their own lived experiences of gendered bias when receiving healthcare. Members of the committee also noted it is often challenging and difficult to relive these experiences, and that the evidence those with lived experience provide is so valuable to the committee's work. I sincerely thank them.

Mr President, I note the report and look forward to the contributions of other members.

 

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