Why Clothing and CPR Outcomes Matter: Understanding Disparities in Resuscitation for Women

Cardiac arrest can happen to anyone at any time. When it does, the chance of survival depends on two critical actions: immediate cardiopulmonary resuscitation (CPR) and early defibrillation using an automated external defibrillator (AED). Every minute without these interventions sharply decreases the person’s chance of survival. Yet decades of research, surveys, and emergency care analyses show women are less likely than men to receive these life-saving measures and clothing, including bras, plays an underrecognized role in that disparity.

For thirty years emergency care guidelines have been clear: if a person collapses, call for help, begin CPR immediately, and attach an AED as soon as one is available. CPR involves deep chest compressions to maintain circulation, while an AED analyzes heart rhythm and may deliver a shock through pads placed on the chest. For both interventions to be effective, rescuers must rapidly expose the victim’s chest to ensure accurate hand placement and direct pad contact with bare skin.

What the Data Shows: Gender Gaps in Resuscitation

Multiple studies and regional registries have consistently found that women are less likely than men to receive bystander CPR or defibrillation when they have a cardiac arrest outside a hospital:

• A large out of hospital cardiac arrest registry from Victoria, Australia found women were about half as likely as men to receive defibrillation from a bystander. In interviews, bystanders reported reluctance to expose a woman’s chest or fears of injury or inappropriate touching.
• In other cohorts, women were significantly less likely to receive bystander CPR than men, particularly in public settings. Some research attributes this to social and cultural anxieties about physical contact with female anatomy.
• Surveys in the U.K. have shown that a notable percentage of people would feel uncomfortable using an AED on a woman because its pads must be placed on her bare chest. Nearly half of men reported they would be less comfortable performing defibrillation on a woman if they had to remove her clothing.

These disparities persist even though scientific consensus affirms resuscitation techniques are the same regardless of gender: hands-on chest compressions and early defibrillation save lives for everyone.

Clothing, Bras, and AED Pad Placement

CPR itself, pushing hard and fast in the center of the chest can be performed over clothing if necessary. The immediate priority is initiating compressions without delay. But when an AED arrives, the situation changesas AED pads must be placed directly on bare skin to work properly. Fabric, including shirts, bras, sports tops, or other undergarments, creates a barrier preventing reliable electrode contact with the chest muscles. As a result, electrical energy does not follow the optimal path through the heart, potentially reducing the effectiveness of the shock.

Because of this requirement, rescuers often need to move, pull aside, or remove clothing that is in the way including bras. Many AED kits include trauma shears precisely so rescuers can cut through obstructive garments quickly. If a bra or other clothing piece covers either pad placement site, the upper right chest and the lower left side must be repositioned or removed. This allows the AED’s adhesive pads to contact the skin as the manufacturer intended.

The question of forcing removal of a bra or undergarment is clinically framed, not moral. Nothing about a bra should stand between an AED pad and the skin it must touch. For chest compressions alone, clothing may not always prevent rescuers from performing effective compressions, but for defibrillation, barriers must be cleared. This is not optional,  it is fundamental to how the device operates.

Also contributing to confusion is the fact that most CPR training manikins used in courses have flat, gender-neutral chests. Historically there has been little opportunity during training to practice on realistic female torsos, which means many lay rescuers have never seen how to effectively place pads around breasts or move clothing aside. This gap in training reinforces uncertainty and hesitancy in real emergencies.

Why People Hesitate: Social, Cultural, and Psychological Barriers

Research into bystander behavior reveals that reluctance to resuscitate women extends beyond clothing. Some common factors include:

• Fear of touching breasts or exposing a woman’s chest in public. Surveys report people are uneasy with this prospect, worrying they could be seen as inappropriate even though the person is unconscious and life-threatened.
• Misinterpretation of cardiac arrest symptoms in women. Women often present with less “classic” symptoms, leading bystanders to delay recognition and action. This contributes to later starts for CPR and AED use.
• Training gaps, as mentioned, mean many lay people have no prior practice placing AED pads around breasts or shifting clothing effectively.

These factors combine to create what experts sometimes describe as a “taboo” around providing full resuscitation care to women, a taboo that costs lives because every second without CPR or defibrillation lowers the survivability of cardiac arrest.

Balancing Respect and Urgency

Some jurisdictions and training programs are updating their recommendations to explicitly address this issue. For example, recent revisions in South Korea’s CPR guidelines emphasize that undergarments do not need to be removed completely when using an AED, and rescuers should adjust them to place pads directly on bare skin while avoiding breast tissue. This approach is designed to reduce hesitancy and increase the rate of AED use in women.

However, international consensus documents like those reviewed by the International Liaison Committee on Resuscitation (ILCOR) stress that AED pads must be placed correctly on bare skin, and if clothing interferes with that, it should be moved or removed. The focus is on minimizing delays in delivering shocks and compressions. There is insufficient evidence to prescribe a one-size-fits-all rule about routine bra removal. What matters most is not leaving improper pad placement to avoid the issue.

Putting Knowledge into Action

What does this mean for training, public policy, and individual responders?

1. CPR and AED training must explicitly cover how to handle clothing in emergencies. Programs should include practice on realistic torsos of all body types so learners gain confidence in exposing chests and placing AED pads correctly.
2. Public awareness campaigns should normalize and destigmatize chest exposure for life-saving care. Hesitation to touch or expose chest anatomy must never outweigh someone’s chance of survival.
3. Bystander CPR encouragement must directly address these gender disparities. A person in arrest needs effective compressions and defibrillation — period. The checklist is simple: call for help, start compressions, open clothing as needed, and use an AED properly.
4. Dignity can be preserved even while acting quickly — towels, jackets, or bystanders can shield the scene after the pads and care are underway. This does not delay care and respects the victim.

The evidence is clear that women are statistically less likely than men to receive bystander CPR and AED use when they go into cardiac arrest. Clothing, including bras, plays a documented role in that disparity because it directly affects how quickly and accurately an AED can be applied. Social fears about touching breasts or removing clothing add barriers that do not exist for men and that lead many bystanders to hesitate or delay critical interventions.

This issue is not about modesty, it is about equal access to life-saving care. CPR and AED use are emergency medical interventions that must be executed correctly and without unnecessary delay. When every second counts, bystanders should feel equipped, confident, and legally supported to expose a chest, cut obstructive clothing, and place AED pads as needed. Effective resuscitation does not discriminate,  neither should we.