The standard torso used for CPR training has long been flat-chested and androgynous, a design that experts say may inadvertently contribute to lower survival rates for women experiencing cardiac arrest in public. This anatomical oversight, prevalent in nearly 95 percent of manikins on the market as of 2022, is increasingly being recognized as a factor in why women are less likely than men to receive bystander CPR.
An analysis of over 300,000 cardiac arrests revealed that women are 14 percent less likely to receive CPR from a stranger. Researchers and advocates suggest this disparity stems from bystanders' hesitation and discomfort in performing CPR on individuals with female anatomy, particularly breasts. This discomfort can be exacerbated by fears of misinterpretation, accidental injury, or a general lack of recognition of cardiac arrest symptoms in women, who may present differently than men.
For decades, the default representation in training simulations, whether for CPR manikins, crash-test dummies, or even medical care in combat, has been male. The first CPR manikin, Resusci Anne, developed in 1960, was based on a female drowned victim but featured the anatomy of a prepubescent teen, with the creator prioritizing male trainees' comfort with mouth-to-mouth resuscitation over female trainees' needs. Today, despite advancements in manikin technology, the overwhelming majority remain androgynous.
Experts believe that increased familiarity with female anatomy during training could significantly reduce this hesitation. Studies, such as one conducted at MIT's MassCPR program, have shown that participants trained with manikins retrofitted with breasts reported greater comfort performing CPR on women. This suggests that repeated exposure during training can alleviate the awkwardness and discomfort that might otherwise cause dangerous hesitation in a real emergency.
Addressing the Design Gap
Efforts are underway to improve the representation of female anatomy in training tools. Researchers, advocates, and governing bodies like the American Heart Association and the European Resuscitation Council are pushing for more representative manikins. This includes developing new anatomically accurate female models or retrofitting existing ones. While the availability of female manikins has tripled in the past four years, with about a fifth of training organizations owning one, widespread adoption is still hindered by the commercial availability and cost of these models.
This issue extends beyond CPR training. In vehicular crash testing, the development of the THOR-05F crash-test dummy marks a significant step toward more accurate female representation, moving beyond scaled-down male models. Historically, female crash-test dummies were merely smaller versions of male dummies, failing to account for anatomical differences that can impact injury rates in accidents. New research by the National Highway Traffic Safety Administration (NHTSA) has affirmed the need for better crash-testing protocols for women, as they continue to experience higher injury rates in various types of vehicular accidents.
Initiatives like the Womanikin, a universal attachment with silicone breasts for CPR manikins, launched in 2019, aimed to spark conversation about the gender gap in training. More recently, manufacturers like Prestan have begun offering newly designed female manikins and replacement female skin, increasing their visibility and accessibility through channels like the American Red Cross Store.
The implications of this design disparity are critical. When women constitute half the world's population yet are not adequately represented in the standards and tools designed for safety and care, the consequences can be literally fatal. Whether in CPR training, crash testing, or battlefield medicine, the historical exclusion of female anatomy from mainstream design and testing means that women may not receive the same level of safety and care as men. The core principle is that increased familiarity with female bodily characteristics during training can reduce hesitation, ensuring that the ability to perform life-saving techniques like CPR is not compromised by discomfort or unfamiliarity.