Moving beyond awareness: The evidence on sexism within paramedicine is in – it's time to transform the system

The current landscape of gender-based inequity and everyday sexism experienced by women-identifying paramedics has been under intensified scrutiny over the past decade.^1,2 Empirical research, organisational culture scans and advocacy from special interest groups have collectively pushed the profession into a stage of confrontation with its cultural shortcomings.^3–5 Yet, despite the depth and clarity of evidence, the pace of structural change continues to lag behind compared with implementing other evidence-informed priorities within the profession. Priorities reflect values. Recognition is not enough; now is the time to move from conceptual commitments to practical action, and from awareness to accountability in order to eradicate everyday sexism and gender-based violence in paramedicine.

In this commentary, we set out clear, actionable proposals to help transform the profession from within. These include gender equity auditing and transparent reporting, stronger leadership accountability, enforced anti-harassment standards and the meaningful inclusion of structurally marginalised voices. These aren’t peripheral suggestions; they are central to shifting paramedicine from performative inclusion towards genuine, systemic reform. By bringing these actions to the forefront, we aim to focus attention on what must change and who that change is for.

In this issue, McFarlane et al. present powerful evidence of the persistent, systemic and structural nature of everyday sexism and sexual harassment within the paramedic profession. Exploring Australia as a context, their qualitative study, titled ‘The culture of everyday sexism and gender inequality in the paramedicine profession: A qualitative study’ reveals a troubling cultural landscape in which women are routinely subjected to gendered microaggressions and overt harassment, both of which are not only tolerated but increasingly normalised. ⁶ More alarming still is the finding that these behaviours are frequently internalised by women themselves as something to be endured rather than addressed, a grim reflection of institutional inertia and a lack of psychologically safe reporting systems and meaningful accountability that mirrors paramedic organisations across the globe.

The profession appears to be arriving at a long-overdue stage of acceptance – not of the behaviours themselves, but of their embeddedness. A professional culture that continues to devalue half of its workforce cannot credibly claim a serious commitment to achieving best practices in health care and well-being. Organisations that cling to this outdated culture of structural marginalisation are complicit in perpetuating harm and are called to make way for the urgent progress needed towards growth phases of meaning-making, deconstructing, rebuilding and reinvention. However, where those who benefit from disproportionate power hold positions of authority, this transformative work will not happen organically. It must be proactively designed, driven, and held to account.^7,8

To this end, feminist political economy offers a critical lens. It reminds us that sexism is not merely a matter of interpersonal behavior; it is a feature of oppressive power dynamics – structurally embedded and perpetuated through policy, organisational design and patterns of professional development and recognition. Addressing gender-based inequities in paramedicine requires more than performative inclusion, diversity, equity and accessibility initiatives. McFarlane challenges that ‘the benefits of diversity are increased when womens’ skill sets are recognised and valued which can prove to be a challenge in masculinised cultures’. ⁹ It calls for critical, power-conscious frameworks that integrate intersectionality and disrupt existing hierarchies. Implementation must prioritise outcomes that redistribute power equitably across genders so that women, too, can trust they are safe and valued in their profession.

Translating these principles into action requires a set of coordinated, evidence-informed interventions at the organisational level. Institutional responses must be intentional and measurable. Given the unique nature of paramedic work (e.g., often working in pairs, in isolated environments such as stations or ambulances), there is a heightened responsibility on organisations to proactively prevent harms. McFarlane cautions that ‘simply increasing numbers of women does not suffice’. ⁶ Representation without power – and without safety, agency and authenticity risks reinforcing the very system it seeks to challenge. When women are unable to safely participate in the workplace as their authentic selves, the consequences reverberate far beyond the organisation. Inevitably, the public loses, because the quality of care is compromised when the workforce does not reflect, or relate to the diversity of the communities served. Evidence consistently shows that health systems are stronger, more equitable and more effective when those delivering care mirrors the identities, values and lived realities of those receiving it. Gender equity, therefore, is not just a workforce issue; it is a public health imperative.^10,11

A foundational set of organisational strategies should include the recruitment and promotion of trustworthy leaders, alongside the establishment of robust mechanisms to identify and address problematic behaviours before they escalate. Policies must be trauma-informed and supported by clear executive accountability. Standard governance tools should include gender equity audits, policy review committees and mandatory public reporting on key indicators such as gender pay gaps and promotion rates. ¹² In cases of gender-based violence, the seriousness of such incidents must be acknowledged through appropriate criminal reporting where necessary.

Recognition without reform risks complicity. In the absence of strong institutional leadership, women within paramedicine services have mobilised to create grassroots advocacy and special interest groups across jurisdictions around the globe. These collectives have been instrumental in breaking the silence around gender-based harassment and in offering validation, support and solidarity to those affected. ¹³ Importantly, they have also begun to shift cultural narratives by asserting women identifying paramedics’ right to safety, respect and opportunity.

These women-led groups, however, cannot carry the burden alone. To be effective, they must be supported, sustainably resourced and granted influence within the organisational structures they aim to improve. Representation without power is merely symbolic. Organisational buy-in should include providing group representatives with decision-making authority and ensuring their recommendations are embedded into governance processes. National associations, such as the Australasian College of Paramedicine, have established equity and diversity interest groups at the national level – a model that could be replicated in other jurisdictions, including Canada, where such infrastructure is lacking.

Beyond internal reforms, responsibility for gender equity should be shared across the broader ecosystem of paramedicine, including unions, educational providers, regulatory bodies and government agencies. These actors must take up their roles in setting and enforcing professional standards, mandating gender equity benchmarks and requiring transparency around complaints and disciplinary procedures. Lessons can be drawn from other professions that have introduced sector-wide standards on discrimination, retaliation and restorative justice practices.

McFarlane et al.'s study is itself a form of resistance. In a climate where neoliberal imperatives of competition, stoicism and individual resilience dominate, qualitative scholarship that centers lived experiences and exposes structural harms is both politically and professionally significant. The authors disrupt the dangerous narrative that these incidents are isolated or anecdotal. Instead, they present them as systemic, cultural and deeply consequential. And importantly, their work aligns with global feminist movements that call for workplace transformation through both conceptual and practical means. ¹⁴

As a first step, it is time for the profession to embrace an integrated equity framework; one that places intersectionality, power dynamics and feminist analysis at the heart of workforce planning, curriculum design and organisational policy. Practically, this must be informed by implementation evidence to ensure tangible action: gender equity audits, transparent pay gap reporting, anti-sexual harassment standards enforced by regulators, leadership accountability metrics and accessible reporting systems that protect whistleblowers and survivors.

A critical emphasis must also be placed on elevating the voices of women from structurally marginalised communities, including Indigenous, Black, LGBTQIA+ and other racialised groups. Gender equity cannot be treated as a singular dimension; systems-level change must account for the ways in which multiple forms of oppression intersect and amplify harm.

While the recommendations above provide a roadmap for action, bridging the divide between evidence and meaningful change will require sustained leadership and research-driven reform. Leaders in paramedicine must treat McFarlane et al.'s findings as a mandate for said reform. Testimony must be linked to transformation. Institutions must resist the temptation to settle into performative empathy and instead invest in long-term, structural change. This should include funding and support for intervention research that explores what strategies effectively shift culture and power dynamics within paramedicine. Participatory action research, in particular, offers a promising path forward, placing those most affected by inequity at the centre of designing and evaluating solutions.

The profession is at an inflection point. The evidence is in. The experiences have been shared, and the harm is undeniable. What comes next isn’t just a question of goodwill – it's a question of governance, ethics and values. How we embed meaningful accountability, redesign reporting pathways and confront the power structures that sustain inequity will determine whether we shift the culture or simply document it.