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Something was bothering healthcare assistant Jess Noulton as she stood in the airless conference room with 25 other medical professionals, watching an instructor demonstrate CPR on a dummy during compulsory Basic Life Support training.

“You place the heel of your hand here, on the centre of Annie’s breastbone. Your other hand goes here, on top – interlock your fingers, ”the instructor was saying. “Then kneel up high above her and using all your body weight, press straight down. You need to compress her chest by around 5 cm”.

Noulton remembers thinking, “Where are her breasts? If we’re calling her a she, why doesn’t she present as female?” Annie had a chest resembling that of a slim, white, adult man. Noulton raised her hand and asked.

She didn’t get a straightforward answer. The nurse told her that Annie’s face was based on the death mask of “l’Inconnue de la Seine”, a young woman thought to have drowned in Paris in the late 1880s. When Norwegian toymaker Åsmund Laerdal built the first CPR dummy in 1960, he modelled the face on the woman’s death mask, and named it Resusci Anne. This is why the dolls are commonly called “Annie” – despite their male physique.

It wasn’t until much later that Noulton found out about the plentiful research demonstrating that women who go into cardiac arrest outside hospitals are significantly less likely than men to receive CPR from bystanders, and have lower survival rates.

This is when she put two and two together. She’d never had to deliver CPR, and had only witnessed it twice. But when it came to electrocardiograms – a common procedure which measures the electrical activity of the heart, for which people are usually trained on similar dolls –  she’d regularly been around people, usually young men, who’d hesitated in treating female patients.

That afternoon of CPR training came back to her. “If they don’t get exposed to a boob in training, how are they going to react to it in real life?” Noulton asked.

Here’s The Evidence

Noulton’s story is far from unique. Vanishingly few people are exposed to female anatomy during training on CPR. A new study – the first to survey all manikins on the global market – has found that 95% of CPR training dummies available for purchase are flat-chested.

Surveys suggest that some people hesitate to deliver CPR to women because they believe they are frail and therefore prone to injury. Others worry they will risk being accused of sexual assault, or feel embarrassed by the prospect of removing clothing. The results are life-threatening. Women are twice as likely as men to die of a heart attack.

“We think there is a link between how we’re training people and why women aren’t getting CPR,” study co-author Jessica Stokes-Parish, an intensive care nurse and Assistant Professor of Medicine at Bond University in Australia, told me.

It was while considering how to prepare staff for birthing emergencies that Stokes-Parish and her co-author Rebecca Szabo realised they hadn’t come across CPR manikins with breasts before, let alone one that resembled a pregnant woman.

“As health professionals working in [intensive care], CPR is our bread and butter. We just know how to do it. Being female, the question of breasts was never something that occurred to us,” Stokes-Parish said. “But then we thought, what about first aid training and young people who’ve never seen another naked person before? In those cases, being exposed to breasts is a pretty big deal! So we decided to look into it.”

They set about cataloguing suppliers of adult CPR manikins, identifying 72 suppliers who sourced from nine different manufacturers, offering a total of 20 manikins. Five of these were supposedly female, but only one had breasts. Only one other offered a breast overlay as an option.

Profits vs public health

As well as cataloguing CPR manikins, the researchers also looked into whether manufacturers had publicly available diversity, equity and inclusion (DEI), human rights or sustainability policies, and whether these covered their products.

“We noticed that a lot of the focus of these policies was on their workforce, rather than on their products,” says Stokes-Parish. But many companies did not make their policies available, and only one manufacturer referenced diversity in relation to their product, pointing out that they offered a variety of skin tones.

Stokes-Parish and her colleagues were interested in the bigger picture, influenced by a growing academic field called the “commercial determinants of health”, which considers how certain industries and companies – such as big tobacco – have negatively affected people’s health. Simone McCarthy is one such researcher in this field. She studies how the commercial determinants of health contribute to gender inequity at Deakin University, Australia.

“The commercial sector often clashes with the values of public health,” McCarthy says. “Corporations have a primary objective to maximise profits and to often act in the interests of the company and its shareholders, not the consumer.” 

This means that health and social policies need to tackle the deep-rooted inequalities in our social and economic systems to prevent them from being repeated in the products and services we develop.

McCarthy says this can be done by building fairness into policy design, setting rules for industries to prioritise equity, and creating policies that challenge corporate profit goals when they conflict with public health, as in the case of the flat-chested CPR dummies.

It’s OK to Save My Life

But it takes a lot to get the cogs of social and economic change turning. “The frustrating thing is, there is market demand!” says Stokes-Parish. “I spoke to one of the company’s sales reps and they told me they get requests all the time for a manikin with breasts, that they feed that back to head office, but nothing seems to change.”

Stokes-Parish says her colleague experienced a six-month wait for a manikin with breasts from the one company that makes them. “They ended up cancelling the order and making an overlay themselves,” she says. 

Now that the problem is better understood, people are increasingly taking things into their own hands by making overlays themselves or finding other creative solutions. St John Ambulance in the UK, for example, has created what they call the “world’s first educational bra”. The bra, which can be worn by CPR manikins like Annie, features the message “It’s OK to Save My Life” on the front.

Retrofitting existing manikins in this way can create an opportunity for any worries, questions or concerns about different body parts to be aired in training.

And it’s not just gender diversity that matters – training tools should also reflect the diversity of skin colour, body shape, and size. Progress on skin-tone awareness in CPR training seems slightly ahead of gender: Stokes-Parish and her colleagues found that most suppliers they looked into offered at least two options, and half provided three. But representation of body shape and size lags far behind, with only one supplier offering a manikin with a larger body size.