Cardiac arrest is a leading cause of death across the world, particularly in out-of-hospital settings, where timely recognition and response are critical to survival.
First aid courses, such as DAN’s Diving First Aid, emphasize the importance of high-quality CPR and the early use of an automated external defibrillator (AED). Both interventions significantly improve outcomes. The more laypeople are trained in CPR and AED usage worldwide, the more likely it is that people will survive as a result of bystander intervention.
Despite the clear benefits of bystander intervention, research highlights a troubling disparity: Women are significantly less likely to receive CPR and defibrillation and are less likely to survive out-of-hospital cardiac arrest. Some studies indicate that this inequity in bystander intervention can be as large as 14%.
With this knowledge, researchers set out to understand the disparity. Three recurring themes appeared in their surveys and analysis: sexualization of breasts, worry about injuring a “weak” or “fragile” individual, and a lack of recognition of the more subtle cardiac arrest symptoms.
The sexualization of breasts creates hesitation among bystanders, especially since CPR requires hand placement in the center of the chest, and AED pads must be applied to the bare skin of the torso and chest. This discomfort, rooted in societal norms and fear of being accused of inappropriate behavior, is enough to prevent bystanders from taking lifesaving actions.
The perception that women, or those perceived as having female anatomy, are weak or fragile also leads to a reluctance to provide chest compressions, as bystanders report being worried about harming the individual.
While sudden collapse and chest pain are recognized as classic signs of cardiac arrest, this presentation is more typical for men. Women often experience more subtle symptoms such as shortness of breath, fatigue, or nausea. These subtle symptoms can delay recognition of a cardiac emergency, resulting in lower rates of intervention and survival.
Understanding the rationale behind these differences in bystander response rates for individuals with and without breasts is only the first step towards a solution. Empowering bystanders to act without hesitation starts in the classroom. By incorporating manikins with breasts, addressing the impacts of CPR, and including the training needed for early recognition of subtle symptoms, we can normalize responding to people with breasts and reduce this disparity.
Instructors should emphasize the following key information in first aid courses:
- Good Samaritan laws exist in many areas to protect individuals who assist in good faith and equally, regardless of the victim’s anatomy.
- Bras and binders may obstruct proper AED pad placement. It is acceptable and often necessary to move or remove clothing that prevents complete skin contact with the AED pad in the correct location.
- Trauma shears can cut through wetsuits, clothing, and underwire bras to gain access to the chest.
- It may be medically necessary to gently adjust breast tissue to correctly place AED pads.
- High-quality compressions may break ribs in any individual regardless of their anatomy. Compressions are necessary to circulate blood during a cardiac arrest.
- Symptoms can differ between men and women. While men often experience well-known signs such as collapse and chest pain, women may exhibit more subtle indicators such as shortness of breath, nausea, and unusual fatigue.
Hands-on practice is also a critical part of first aid training, as it builds muscle memory, reduces hesitation, and prepares responders for real-life situations. Most first aid courses, however, use only flat-chested manikins, which creates an unrealistic and incomplete learning experience.
Responders may need to perform CPR or apply AEDs on individuals with a wide range of body types, and not teaching these differences during training is a disservice to providers. If students never train on manikins with breasts, then encountering breast tissue in a a real emergency can feel unfamiliar and increase the likelihood of hesitation and discomfort.
Manikins with breasts are now widely available on the market, and incorporating them in training helps to normalize providing care to all bodies and reduce the social and psychological barriers that contribute to bystander inaction.
Improving survival rates from cardiac arrest requires more than just increasing the number of providers; it also requires improving training to be more realistic and inclusive. We must recognize that hesitation rooted in anatomy, perception, and discomfort can cost lives.
By embracing diverse training tools and addressing outdated assumptions in training, we can ensure that bystanders assist all individuals in cardiac arrest, not just those without breasts.
© Alert Diver – Q4 2025