CPR on Women: Why Bystanders Hesitate and What You Need to Know
If somebody collapses in cardiac arrest, the basic message is relatively simple: call 999, start CPR and use a defibrillator as soon as one is available.
In reality, people can hesitate.
One area I think deserves far more open discussion in first aid training is CPR on women. Research has repeatedly identified differences in how likely men and women are to receive bystander CPR, and research into public perceptions suggests that discomfort about touching or exposing a woman's chest may be one of several contributing factors.
For trainers, workplace first aiders and the businesses responsible for training their staff, that raises an uncomfortable question: are we preparing people for what a real emergency looks like, or simply teaching them to perform CPR on a bare training manikin?
Are women really less likely to receive CPR?
There is evidence that they are.
A widely cited study analysed 19,331 adult, non-traumatic out-of-hospital cardiac arrests recorded between 2011 and 2015 in the Resuscitation Outcomes Consortium registry. When the arrest happened in a public place, 45% of men received bystander CPR compared with 39% of women. In private settings, there was no significant difference - 36% of men compared with 35% of women.
The same study found that men had higher adjusted odds of survival to hospital discharge. However, this was observational research, so it cannot prove that the difference in bystander CPR caused the survival difference.
Those figures need context. They come from a North American registry and should not be presented as current UK rates. What they do illustrate is a disparity that has been identified across multiple settings and studies.
A 2024 scoping review examined 80 articles worldwide, 58 of which evaluated sex differences in receipt of bystander CPR. Thirty-four of those 58 studies (59%) found women were less likely to receive bystander CPR, 21 found no significant difference and three found women were more likely to receive it.
That matters because Resuscitation Council UK states that bystander CPR and use of an AED can increase the chances of survival from out-of-hospital cardiac arrest by two- to four-fold.
Why might people hesitate?
There probably isn't one simple explanation.
Research into public attitudes has identified concerns including inappropriate touching, exposing a woman's breasts, causing injury and fear of accusations or legal consequences. Other suggested factors include stereotypes about who suffers cardiac arrest and failure to recognise that a woman may genuinely be in cardiac arrest.
It would be wrong to claim that reluctance to expose the chest explains the entire disparity. But as a trainer, I think it is something that needs discussing. If somebody is unsure whether they are allowed to touch the casualty, move clothing or expose the chest to use an AED, that uncertainty can become hesitation. In cardiac arrest, those delays matter.
Is CPR different on a woman?
The technique is not different.
Resuscitation Council UK's 2025 Adult Basic Life Support guidelines tell rescuers to place the heel of one hand on the lower half of the sternum - the centre of the chest - and start compressions as soon as possible. You do not need to remove somebody's clothing simply because you are starting CPR. However, if clothing prevents you from adequately visualising the sternum, the guidance says it is reasonable to move or remove those garments so you can identify the correct anatomical landmark.
Real people come in different shapes and sizes. Breast tissue, body shape and other anatomical differences can make the situation look and feel very different from practising on a standard manikin. That is exactly why it is worth discussing during training rather than leaving people to work it out for the first time on a real casualty.
What about using a defibrillator on a woman?
This is where clothing becomes particularly relevant, because AED pads need to make contact with bare skin.
Current European Resuscitation Council 2025 guidance prioritises correct AED pad placement and bare-skin contact. If this can be achieved quickly without unfastening or cutting a bra, the bra can remain in place. If the bra interferes with correctly locating or applying the pads, it should be displaced or removed. Rescuers should not allow concern about exposing the chest to delay lifesaving treatment.
It isn't about automatically removing clothing. It is about doing what is clinically necessary.
The underwire question
One question worth addressing directly is the underwire bra.
The key issue is still correct pad placement and bare-skin contact. Current European Resuscitation Council guidance notes that there is no evidence that an underwire itself causes harm during defibrillation, and there is insufficient evidence to support routinely unfastening or cutting every bra. If the bra does not interfere with pad placement, it can stay in place; if it does interfere, move or remove it.
For pad placement, follow the diagram on the AED or the electrode pads. In the usual antero-lateral position, one pad is placed on the upper right chest and the lateral pad is positioned below the left armpit in the mid-axillary line. The aim is good contact with bare chest wall and correct placement, avoiding breast tissue where possible.
Dignity still matters
Prioritising lifesaving treatment does not mean forgetting the casualty's dignity. Where circumstances allow, ask unnecessary bystanders to move away, create privacy with a coat or blanket, remove only the clothing that genuinely needs removing and cover the casualty again when it is practical to do so.
Where somebody is conscious and able to make decisions, explain what you need to do and seek consent wherever possible.
This is something I reinforce on my own courses. First aid is hands-on. There will be situations where it is clinically necessary to be close to somebody, touch them or move their clothing. That should always be done professionally and respectfully, but people should not be frightened out of an intervention simply because the situation feels awkward.
Just as importantly, don't let the search for privacy delay CPR or defibrillation.
What about getting into legal trouble?
This is an understandable concern.
People sometimes worry they could be sued for injuring somebody during CPR, or get into trouble over necessary physical contact. Resuscitation Council UK states that it is very unlikely that somebody in the UK who acts in good faith while trying to help another person would be held legally liable for an adverse outcome, and notes that no such action has ever been brought against someone who performed CPR.
In England and Wales, the Social Action, Responsibility and Heroism Act 2015 also requires a court considering negligence or breach of statutory duty to take into account relevant circumstances, including whether somebody was acting for the benefit of society or intervening in an emergency to assist a person in danger. The Act does not give rescuers blanket immunity, but it does require those circumstances to be taken into account.
None of that removes the responsibility to behave appropriately. But fear of getting into trouble should not stop somebody trying to save a life.
One thing that has changed - and it catches people out
This is worth flagging because it affects everything above.
Under Resuscitation Council UK's 2025 Adult Basic Life Support guidelines, you should call 999 for any unresponsive person. Rescuers no longer need to confirm abnormal breathing before making the call. Start the 999 call first, then assess breathing while waiting for the call to be answered; the ambulance service call handler can help identify abnormal breathing if needed.
Anyone trained to the previous 2021 sequence may remember assessing breathing before making the emergency call, so this is an important update to reinforce during refresher training.
Why realistic first aid training matters
My frontline emergency-service experience has reinforced something that is easy to forget in a classroom: real casualties don't look like CPR manikins.
People have different body shapes, different anatomy, different clothing and different circumstances. Someone can be perfectly capable of performing CPR on a manikin and still hesitate when faced with the reality of moving clothing or applying pads to somebody's chest.
Good training has to prepare learners for those moments too. That means talking openly about anatomy, dignity, consent and clinically necessary physical contact - and giving people the chance to ask questions they'd otherwise feel too embarrassed to raise.
What should businesses take from this?
If you are responsible for first aid provision in your workplace, having trained staff is the baseline. Confidence is what determines whether that training is put into practice when it matters.
Four questions worth asking about your own first aiders:
• Would they recognise cardiac arrest?
• Would they start CPR without unnecessary delay?
• Would they confidently use the AED, including moving or removing clothing if needed?
• Would they know what to do if the casualty in front of them looked nothing like the manikin they trained on?
It is also worth checking that any public-access AED at your workplace is registered on The Circuit, the UK's national defibrillator network. Registered AED locations can also be viewed on Defib Finder. In an emergency, however, calling 999 remains the priority; the ambulance service call handler can direct rescuers to a nearby registered AED.
Good training should prepare people for the realities of an emergency, not just teach them enough to pass an assessment.
The message to remember
If somebody is unresponsive, call 999. If they are not breathing normally, start CPR. Use an AED as soon as one is available. Protect the casualty's dignity wherever reasonably possible, but do not let embarrassment or uncertainty about necessary physical contact delay lifesaving treatment.
If you deliver first aid training yourself, I'd genuinely be interested to hear how you approach this subject with your learners.
Practical first aid training across the North West
Imperium Safety Solutions delivers hands-on CPR, AED and workplace first aid training for businesses across Warrington, Cheshire, Merseyside, Greater Manchester and the wider North West.
Our training is built on frontline emergency experience and focuses not just on knowing what to do, but on having the confidence to actually do it - including the real-world situations that can make people hesitate.
Not sure whether your team has been trained to the latest guidance? Get in touch to discuss refresher training or first aid training for your workplace.
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