Is ‘Toxic Femininity’ at Least Partly to Blame for Sleep Apnea’s Underdiagnosis in Women?

Eight years ago, just a few months after a soul-crushing layoff, I suddenly started snoring.

Not adorable little snorts, but an un-feminine, raucous wall of noise that started driving my poor husband to the couch nightly.

On top of my job loss, this new development made me feel even more humiliated, unattractive, and helpless. Women weren't supposed to snore their spouses out of the room—wasn’t it supposed to be the other way around?

At the same time, I also started struggling to stay awake when driving for a half hour or more and just generally feeling lousy—though I’d chalked this up to situational depression.

Still, it never once occurred to me to see a doctor until months later, at a family camp, when a tall, willowy woman in her mid-40s (my age at the time) entered our cabin carting a CPAP machine—a wearable device that helps treat sleep apnea. This woman absolutely did not square with my idea of sleep apnea's human profile.

I’d always thought apnea—wherein a sleeping person’s airway regularly collapses, and their breathing stops, so they’re briefly jolted awake by their panicked, oxygen-hungry brain (rendering crucial REM sleep nearly impossible)—was only a problem for overweight older men like my septuagenarian dad.

Yet as I grilled this woman—a family friend—about her diagnosis, I became convinced that I should probably get tested, too.

The apnea gender gap

The American Medical Association estimates about 30 million Americans live with sleep apnea, but only 6 million have been diagnosed, and women are, as a group, woefully under- or misdiagnosed, often with fatigue, insomnia, and/or depression.

“I’ve had [female] patients tell me, after they got diagnosed and treated and felt so much better, how many years a doctor was just saying to them, ‘Oh, you’re not getting enough sleep.’ ‘You’re working too hard.’ ‘You’re eating too much.’ ‘You’re too fat,’” says Susan Redline, MD, a Harvard professor of epidemiology and sleep medicine at Brigham and Women’s Hospital. “And lo and behold, they had something very treatable.”

This diagnosis gap isn’t just frustrating—it’s downright concerning when you consider the long, sobering list of health risks linked to untreated sleep apnea: type 2 diabetes, stroke, heart disease, high blood pressure, and more.

And while it’s still true that more men than women have apnea¹—“men have a longer upper airway…that tends to be more collapsible,” Dr. Redline explains—the estimated gender disparity has shrunk in recent years from 8:1 to 3:1² (if not even less).

Dr. Redline believes this narrowing gap is not because more women are developing apnea, but because more are being accurately diagnosed. “Early (apnea) reports were based on patients who were referred to sub-specialists for sleep studies,” Dr. Redline says. “And, like many conditions, women with sleep apnea were under-recognized. They were not referred. There’s good data on that. So I think those very early reports that said 8:1 or 10:1 were due to strong referral biases.”

How apnea shows up differently in women

To add yet another complicating factor, apnea often shows up differently in men and women¹. Though snoring is apnea’s most well-known symptom, it’s just one of many (including headaches, anxiety, daytime sleepiness, insomnia, depression); and some folks with apnea (more often women) snore quietly or not at all—which is to say, not all snorers have apnea, nor do all people with apnea snore.

Plus, if someone sleeps alone, she may not even realize she’s begun snoring; and a woman’s risk of developing apnea increases in times of hormonal change (pregnancy, perimenopause, menopause) and, more generally, as she ages.

“Each pause in breathing (while sleeping) tends to be, on average, shorter in a female than in a male,” Dr. Redline says. She chalks this up to a difference in physiology—specifically, that women have a lower “arousal threshold,” meaning they’re roused more easily from sleep. “So women are more likely to experience short pauses in breathing, and those pauses may not manifest with drops in oxygen saturation but may more manifest with sleep disruption. That may actually result in women appearing to have insomnia.”

If a woman with the condition undergoes a sleep study, then, the sleep apnea might be missed, because she may not be “desaturating” as much as a male, Dr. Redline says. “Males tend to have…longer pauses in breathing, so they’re more likely to have deeper drops in oxygen, which are easier to recognize in a sleep study.”

Another problem women face regarding apnea diagnosis involves oximeters (sensors used to measure oxygen desaturation), which have demonstrated a bias related to skin color.

“Black females have the shortest apneas and hypopneas [shallow or restricted breathing] of any group,” Dr. Redline says. “They also, because of their skin pigmentation, are less likely to desaturate. So I think there’s a real possibility of underestimating sleep apnea that becomes particularly concerning in Black women.”

Despite these obstacles, Dr. Redline notes that sleep studies are worthwhile: “The bottom line is, if you get a good representative sleep study in the lab…you’re probably still going to get a fair bit of very useful data.”

"It wasn’t the medical world preventing me from diagnosis at first, but rather (what I’ve come to call) 'toxic femininity:' my innate sense that apnea wasn’t a thing women had to deal with or consider."

Research is slowly changing how we see sleep apnea

For many years, obesity or weight gain was assumed to be the primary cause of sleep apnea, hence doctors’ longtime patient directive to simply “lose weight.” And while there is still some correlation, recent studies involving young kids and people without obesity have complicated that picture, suggesting that things like air quality and genetics may also play a role.

“A large tongue, a recessed jaw, big tonsils, where [in your body] you put on weight—there are a lot of individual factors that make the airway more likely to collapse,” says W. Christopher Winter, MD, neurologist, sleep medicine specialist, and author of the bestseller The Sleep Solution.

Dr. Redline, for her part, recently published a study³ involving young people with apnea, specifically children living in largely low-income neighborhoods in the greater Boston area. “In children, obesity was not associated with sleep apnea, but poor air quality in their homes was,” she says. “The other risk factors include things like secondhand smoke, air pollution, [and] allergies.”

So the list of potential causes for apnea has greatly expanded, but our sense of who is most likely to develop it has lagged far behind.

“For a long time, it seemed like an okay stereotype,” Dr. Winter says. “You’d see a 300-pound truck driver and think, ‘I bet that person has sleep apnea.’ But when a lean 36-year-old woman snores, that just wasn’t the immediate thought. Like most stereotypes, it was initially helpful, then it just became the definition.”

Still, social stigma around the condition persists

In my case, it wasn’t the medical world preventing me from diagnosis at first, but rather (what I’ve come to call) “toxic femininity:” my innate sense that apnea wasn’t a thing women had to deal with or consider. I’d been a regular runner and practiced yoga, so I considered myself pretty fit. And while I’m not a super girly girl, the idea that I was snoring my husband away from our bed each night felt like a weird, bodily betrayal of what I considered my identity.

Even when I finally got my diagnosis and my BiPAP machine (a device similar to a CPAP machine that helps with consistent breathing during sleep), my physical relief was countered by some shame and emotional jet lag.

The embarrassment wasn’t helped by my primary care doctor referring me to a dietitian and urging me to lose weight (though I wasn’t particularly heavy), while also making me feel bad for being “dependent on a machine” indefinitely at age 46.

Neither admonishment was actually backed by data. “I don’t believe any patient should ever be made to feel bad, especially about their health, including their weight. Weight does not explain sleep apnea in a sizable proportion of people,” Dr. Redline says. “The current data does not include that PAP machines, when used correctly, contribute to adverse clinical outcomes, although they may make certain problems like sinus disease worse. Nonetheless, researchers are continuing to examine this question.”

That was all relevant to how I felt in my doctor’s office, but at home, there was an entirely different set of difficult feelings to weather.

“There’s hesitation, in terms of getting past the idea that it’s just not sexy wearing a ‘Darth Vader’ mask,” Dr. Winter says of PAP machines. “And beyond feeling unattractive, there can also be a feeling of, my God, there’s this breathing device I’m wearing every night. It feels like I’m closing in on the end here.”

Dr. Winter is quick to add, though, that once a person with apnea gets used to a PAP machine, “it’s like having a pair of reading glasses. I hate glasses, but my God, they’re life-changing.”

It’s helped, in recent years, that a number of female celebrities (Amy Poehler, Wanda Sykes, Shonda Rhimes, and Arianna Huffington among them) have openly discussed their own apnea diagnoses. (Poehler even portrayed a character who wore a CPAP in the Netflix movie Wine Country.) My hope is that their message will reach more and more women who are struggling and don’t have the slightest clue why.

But be warned: Suspecting you may actually have apnea is only half the battle. Getting the necessary appointments and sleep tests for a diagnosis can be challenging in a system that’s overwhelmed by ever-increasing demand. I had to be persistent, regularly calling my insurance provider, the sleep lab, and my doctor’s office to get the BiPAP machine I so desperately needed—and it still took weeks longer than I’d anticipated.

“There clearly are not sufficient numbers of sleep specialists and sleep facilities to care for the very large numbers of people with sleep disorders,” Dr. Redline says. “However, technology continues to improve to enable simpler tools to be used for both initial screening and sleep apnea monitoring. In parallel, there is work being done to address how primary care providers can play a more active role in sleep disorders management.”

Here’s hoping. And by way of a conclusion, I’m happy to report that my hard-won BiPAP machine has quietly and successfully treated my apnea for years now. I get the deep sleep that’s so crucial for good health every night, and my husband’s back beside me, snoozing away.

—reviewed by Angela Holliday-Bell, MD