Introduction
Hepatitis C is a viral infection that primarily affects the liver and is caused by the hepatitis C virus (HCV). It is a major global health concern, affecting an estimated 58 million people worldwide, with approximately 1.5 million new infections annually, according to the World Health Organization (WHO). While the virus can infect anyone, there are unique aspects of how it manifests, is transmitted, and affects women. Understanding why hepatitis C happens in women requires a multifaceted exploration of biological differences, behavioral and social factors, historical medical practices, and healthcare disparities.
The Biology of Hepatitis C and Gender Differences
At a purely biological level, Hepatitis C is transmitted through blood-to-blood contact. This includes sharing needles, unscreened blood transfusions, and, in rare cases, sexual transmission or from mother to child during birth (vertical transmission). While the mechanisms of transmission are the same for men and women, research has shown that biological sex can influence how the virus behaves in the body and how the immune system responds.
Hormonal Influence
One major factor is the role of estrogen. Estrogen has been shown to have a protective effect against liver fibrosis, the scarring of the liver that results from chronic hepatitis C infection. As a result, premenopausal women often experience slower disease progression compared to men or postmenopausal women. This may create a false sense of security both in the medical community and in the patients themselves, potentially delaying diagnosis and treatment.
After menopause, when estrogen levels decline, the rate of fibrosis in women can increase significantly, bringing them closer in line with men in terms of disease progression. This hormonal transition can influence treatment timing and response, especially before the era of highly effective direct-acting antiviral drugs (DAAs).
Immune Response Differences
Women generally have more robust innate and adaptive immune responses than men, which might explain why some women spontaneously clear HCV infection without treatment more often than men. However, this heightened immune response can also lead to autoimmune disorders, which can complicate the disease and its treatment.
Social and Behavioral Risk Factors for Women
While biological factors do play a role, social and behavioral dynamics are key drivers of HCV infection among women.
Injection Drug Use and Gendered Vulnerability
One of the most common risk factors for HCV infection is injection drug use (IDU). While men statistically make up a larger portion of people who inject drugs (PWID), women face different and often more dangerous dynamics when using drugs.
- Dependency on male partners: Women are often introduced to injecting drugs by male partners, who may control when, where, and how drugs are used. Women may be the second to use a shared needle, heightening their risk of infection.
- Power dynamics: Power imbalances in relationships can limit a woman’s ability to insist on clean needles or safe practices.
- Sex work and drug use: Women who use drugs are more likely to engage in sex work as a means of survival, which can expose them to both sexual and injection-related HCV risks.
These gender-specific dynamics increase women’s vulnerability not only to infection but also to reinfection after treatment.
Incarceration and the Criminalization of Women
Incarcerated women have higher rates of HCV than the general population, often due to previous histories of drug use, poverty, and survival sex. With the growing criminalization of women—especially women of color and those from impoverished backgrounds—the carceral system becomes a site where HCV is both contracted and underdiagnosed.
Women in prison are less likely to be tested or treated for HCV due to stigma, lack of healthcare infrastructure, and sometimes punitive policies that deprioritize women’s health.
Historical Medical Practices and Hepatitis C in Women
Before the widespread screening of blood products began in 1992, blood transfusions and organ transplants were a significant mode of HCV transmission. Women who underwent childbirth-related surgeries, C-sections, or gynecological procedures in the 1970s and 1980s may have unknowingly received infected blood.
This group of women—now in their 50s, 60s, and beyond—may still be living with undiagnosed HCV, especially because the virus can be asymptomatic for decades. The link between medical exposure and silent infection is a crucial historical reason why hepatitis C “happened” in women, especially those who do not fit the modern-day stereotype of a person at risk.
Vertical Transmission: Mother-to-Child Infection
While relatively rare, HCV can be transmitted from an infected mother to her child during childbirth. Studies estimate the risk of vertical transmission is about 5-6% if the mother is HCV-positive. That risk increases if the mother is co-infected with HIV.
Pregnant women may not always be screened for HCV, especially in regions or healthcare systems where universal testing isn’t standard. Infected mothers may therefore go undiagnosed, potentially passing the virus to their children unknowingly.
This contributes to a cycle of intergenerational transmission, especially in communities with limited access to prenatal care or consistent healthcare follow-up.
Gendered Healthcare Disparities
Another important lens for understanding HCV in women is the disparity in healthcare access and quality that many women experience, particularly marginalized groups such as:
- Women of color
- Indigenous women
- Rural women
- Trans women
- Low-income women
These groups often face discrimination in healthcare settings, which can lead to underdiagnosis, delayed treatment, and poorer outcomes.
Misdiagnosis and Delayed Diagnosis
Because HCV is often asymptomatic in its early stages and progresses slowly, women—especially those without a history of drug use—may not be tested even when presenting with signs of liver damage or fatigue. Many women report being dismissed or misdiagnosed with depression, menopause symptoms, or stress when they are, in fact, experiencing liver-related symptoms.
Barriers to Treatment
Even when diagnosed, women may encounter multiple barriers to accessing treatment:
- Insurance coverage gaps
- Family or childcare responsibilities
- Stigma around drug use or sexual history
- Lack of transportation or time off work
All these factors create a complex web that discourages or prevents women from completing the care continuum—from diagnosis to treatment and cure.
Intersectionality: How Multiple Identities Increase Risk
It is crucial to understand that women’s experiences with Hepatitis C are shaped not just by gender but by intersectionality—the overlapping systems of oppression that affect people differently depending on their race, class, sexuality, and other factors.
- Black women face both racial bias and gender discrimination in healthcare.
- Trans women face extremely high rates of Hepatitis C, particularly if they have a history of incarceration, drug use, or sex work, and often encounter hostility or ignorance in medical settings.
- Indigenous women in countries like Canada and Australia are disproportionately affected by Hepatitis C due to colonial legacies, poverty, and systemic healthcare barriers.
Intersectionality helps explain not just why Hepatitis C happens in women, but why it hits some women much harder than others.
The Stigma Factor
Stigma plays a profound role in shaping women’s experiences with Hepatitis C. The association of the virus with drug use, sex work, or “poor choices” can result in shame, secrecy, and delayed medical care.
Unlike men, who may more easily discuss substance use or seek treatment, women face the added stigma of violating gender norms around cleanliness, motherhood, and sexuality. As a result, many women hide their diagnosis, skip appointments, or avoid testing altogether.
Progress and Hope: Where We Stand Today
Fortunately, the landscape for HCV treatment has dramatically improved with the advent of direct-acting antivirals (DAAs), which can cure over 95% of patients within 8–12 weeks. These drugs are safe for use in women, including many who are pregnant or breastfeeding.
Additionally, public health campaigns are beginning to address the unique risks and barriers faced by women. Some countries now include universal HCV screening in pregnancy, while others are investing in women-centered harm reduction programs.
However, to truly eliminate HCV as a public health threat, interventions must explicitly address gender disparities, including:
- Women-focused addiction treatment programs
- Trauma-informed care
- Accessible HCV testing in reproductive health settings
- Education for healthcare providers about gender and HCV
Conclusion
Hepatitis C “happens” in women for many interrelated reasons—some biological, many social. Women are not just passive victims of a virus; they are shaped by systems of gendered healthcare, social inequality, historical medical practices, and stigma. Understanding these complex dynamics is crucial for prevention, early diagnosis, and effective treatment.
To combat Hepatitis C among women, we must look beyond the virus itself and address the larger structures of inequality that increase risk and reduce access to care. Only by acknowledging and dismantling these structures can we move toward a future where no woman suffers in silence from a preventable and curable disease.