Emerging Health and 

Safety Issues Among Women 

in the Fire Service

March 2019

Emerging Health and 

Safety Issues Among Women 

in the Fire Service

March 2019

Mission Statement

We provide national leadership to foster a solid foundation for 

our fi re and emergency services stakeholders in prevention, 

preparedness and response.

This project is supported by a Contract (HSFE20-16-0-0253) between the 

U.S. Fire Administration and Women in Fire.

Acknowledgments i

Acknowledgments

Women in Fire and the U.S. Fire Administration (USFA) would like to thank the following 

individuals and their respective organizations for their contributions to this project. It has 

been through these partnerships and collective efforts that this document was created. 

Together we strive to make the fire service an inclusive atmosphere, with health and safety 

considerations at the forefront of priorities.

Steve Austin 

Cumberland Valley Volunteer Firemen’s 

Association

Jim Brinkley 

International Association of Fire Fighters 

(IAFF)

Battalion Chief Carol Brown 

Women in Fire

Kimberly Cox

Women in Fire

Deputy Chief I. David Daniels

International Association of Fire Chiefs 

(IAFC), Safety, Health and Survival Section

Jeff Dill

Firefighter Behavioral Health Alliance

Yvette Graham, LISW-S

The Ohio State University

Dr. Tom Hales

National Fallen Firefighters Foundation 

(NFFF)

Assistant Chief Amy Hanifan 

Women in Fire

Captain Angela Hughes 

Women in Fire

Kristen Matlack, MPH

Editing Consultant

Dr. Candice McDonald

Women in Fire

Dr. Beth Murphy

Integrative Mental Health and Wellness

Racquel Segall

IAFF

Lori Shirley 

National Volunteer Fire Council (NVFC)

Chief Ronald J. Siarnicki

NFFF

Division Chief Sue Tamme

IAFC, Human Relations Committee

William J. Troup 

USFA
ii Emerging Health and Safety Issues Among Women in the Fire Service
Table of Contents iii

Table of Contents

Acknowledgments............................................................................................................... i

Chapter 1: Introduction ...................................................................................................... 1

Increasing number of women in the fire service ..................................................... 1

Emerging health and safety concerns ....................................................................... 2

Chapter 2: Women Firefighter Occupational Health and Safety Issues ...................... 7

Health status of women firefighters.......................................................................... 7

Recommendations........................................................................................................ 9

Chapter 3: Recruitment and Retention Issues Related to Women Firefighter 

Health and Wellness..................................................................................................... 11

Physical challenges....................................................................................................... 11

Psychological strain...................................................................................................... 12

Culture of the fire service............................................................................................ 12

Recommendations........................................................................................................ 13

Chapter 4: Heart Health for Women in the Fire Service ................................................ 15

Core principles for healthy behaviors........................................................................ 16

Eating well...................................................................................................................... 16

Hydration ....................................................................................................................... 17

Physical activity............................................................................................................. 17

Recommendations........................................................................................................ 18

Chapter 5: Women Firefighter Injury and Death Tied to Roadway Incidents ............. 19

Recommendations........................................................................................................ 20

Chapter 6: Emergency Vehicle Operation-Related Women Firefighter Injury and 

Death .............................................................................................................................. 21

Seat belts........................................................................................................................ 21

Lack of apparatus maintenance ................................................................................. 22

Excessive speed and loss of control........................................................................... 22

Apparatus operation and distractions ...................................................................... 23

Intersections.................................................................................................................. 24

Recommendations........................................................................................................ 24
iv Emerging Health and Safety Issues Among Women in the Fire Service

Chapter 7: Mental Health and Suicide Among Women Firefighters ............................ 25

Depression..................................................................................................................... 25

Post-traumatic stress disorder ................................................................................... 26

Alcohol............................................................................................................................ 27

Suicide ............................................................................................................................ 27

Mental health effects of discrimination and harassment ...................................... 29

Summary........................................................................................................................ 30

Recommendations........................................................................................................ 30

Recognizing suicide warning signs in firefighters and emergency medical 

technicians .............................................................................................................. 33

Chapter 8: Discrimination, Harassment, Bullying and Inclusion Issues...................... 35

Culture of the fire service............................................................................................ 35

Harassment and discrimination against women firefighters ................................ 36

What to do if being harrassed..................................................................................... 37

Workplace violence, bullying and the impact to women firefighters ................... 37

Sexual harassment....................................................................................................... 38

Lack of reporting........................................................................................................... 39

Recommendations........................................................................................................ 40

Chapter 9: Firefighter Cancer and the Woman Firefighter............................................ 41

The evidence.................................................................................................................. 42

Overall cancer incidence in firefighters .............................................................. 42

Risk for specific cancers in women firefighters ................................................. 42

Factors that impact exposures............................................................................. 43

Recommendations........................................................................................................ 44

Chapter 10: Opportunities for Future Research ............................................................. 45

Injuries among women in the fire service................................................................. 45

Cancers affecting women firefighters and the exposures that cause them........ 45

The effect of serving as a firefighter on a woman’s reproductive health ............ 45

The effect of improperly fitting protective gear for women firefighters ............. 45

Recruitment, retention and promotion for women in the fire service................. 46
Table of Contents v

References............................................................................................................................ 47

Appendix A: Resources ....................................................................................................... 55

Appendix B: Acronyms........................................................................................................ 59

Appendix C: Campaign Ads ................................................................................................ 61
vi Emerging Health and Safety Issues Among Women in the Fire Service
Chapter 1: Introduction 1

Chapter 1: Introduction

Increasing number of women in the fire service

For over 200 years, women have been firefighting in the United States. Stories of individual 

women serving in the 19th and early 20th centuries eventually grew to all-female volunteer 

fire companies in the 1910s. World War II led to an influx of women filling the needs of the 

volunteer fire service as existing male firefighters left to serve in the war. After the war, 

women began getting paid for their firefighting work, but it was not until the mid-1970s 

that women entered into career fire suppression roles. It was around this time that women 

began to integrate more into local fire departments and work alongside their male peers. 

African-American women also became career firefighters in the 1970s (Floren, 2007).

In 1999, the USFA worked jointly with Women in the Fire Service (WFS) to conduct a study 

of women firefighters. With just over 25 years of experience in career-level fire suppression 

positions, the number of women in career roles climbed to over 4,500 nationwide. The 

estimate of volunteer and paid-on-call women in the fire service was 10 times higher than 

those in career roles, and that did not account for emergency medical technicians (EMTs) 

and paramedics. The study also reported hundreds of women serving in federal and state 

fire agencies. In 1999, women comprised about 2 percent of career firefighters nationally, 

although this varied widely with some major departments having no women and others 

having up to 10 to 15 percent (Berkman, Floren, & Willing, 1999b).

Figure 1. Number and percentage of career women firefighters, 1983 to 2015

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

Women

Percent of women

Data source: National Fire Protection Association (NFPA). (n.d.). Firefighting occupations by women and race. Retrieved 

from https://www.nfpa.org/News-and-Research/Data-research-and-tools/ARCHIVED/Fire-statistics/The-fire-service/

Administration/Firefighting-occupations-by-women-and-race.
2 Emerging Health and Safety Issues Among Women in the Fire Service

In 2015, women made up about 3.7 percent of career U.S. firefighters (Haynes & Stein, 

2017). The percentage of women in the fire service had nearly doubled in the 15 years 

since the USFA/WFS study. The “U.S. Fire Department Profile — 2015” offered more reliable 

data than in the past and reported that women held 12,850 career firefighting roles and 

72,250 volunteer roles nationally, averaging 7.3 percent of the U.S. fire service overall 

(Haynes & Stein, 2017). 

Today, women are found in all ranks of the fire service, from recruit firefighters to chiefs 

of departments. Women fire chiefs lead organizations ranging in size from small volunteer 

fire departments to large metropolitan fire departments, including Decatur, Georgia and 

San Francisco, California. Many of the departments that were on the cutting edge of hiring 

women in the 1970s and 1980s employed these women through a full career to retirement, 

and are now experiencing the power of mentorship as the second generation of women 

are entering the fire service and joining these pioneering departments. The women 

who volunteer or serve as career firefighters within today’s fire service share the same 

dedication to their work and commitment to their community as the women 200 years ago.

Emerging health and safety concerns

Integrating women into organizations and departments that for generations had been 

bastions of all-male “homes-away-from-home” has not been easy. Despite more women 

serving in the fire service in recent years, growth and inclusion of women in the ranks 

has been extremely slow and lags behind the growth of women in other male-dominated 

fields (Hulett, Bendick, Thomas, & Moccio, 2008). Additionally, the fundamental purpose 

and mission of the fire service has changed in the last 35 years from departments that 

primarily fought fires to fire rescue organizations that provide multiple services. These 

include fire suppression, Emergency Medical Services (EMS), rescue services, hazardous 

materials mitigation, water rescue services, community risk-reduction services and 

education, technical rescue, arson investigation, and fire code enforcement.

The USFA recognized the changes happening as more women joined the fire service 

nationwide. In 1979, the USFA convened a “Women in the Fire Service” seminar seeking 

to identify emerging issues and offer chiefs and departments the tools to face the future 

of an integrated and diverse fire service (Armstrong, Berkman, Floren, & Willing, 1993). In 

1993, the USFA published “A Handbook on Women in Firefighting: The Changing Face of the 

Fire Service” to address issues of a gender-integrated workforce (Armstrong et al., 1993).

Following the publication of the 1993 handbook, concerns arose pertaining to health 

and safety issues among women in the fire service. Subsequently, the USFA convened 

a symposium in 1994 to identify these issues and create recommendations for action 

(USFA, 1996). Almost 25 years later, the recommendations made by the task force at the 

symposium are still relevant. In fact, many are just now starting to be investigated or 

resolved, and others have yet to be initiated or instituted. The recommendations listed 

below are those from the 1994 symposium that continue to relate to health and safety 

issues among women firefighters in 2018.
Chapter 1: Introduction 3

USFA recommendation: Develop an improved data reporting system with more 

detailed incident and exposure information, including gender 

(USFA, 1996).

How it would help: Having a functional dataset would enable researchers and 

departments to validate and address or eliminate problems. It 

could help more quickly identify national and regional trends. 

More detailed data would strengthen the database.

Status check: There has been an improvement in the data reporting system, 

but it remains a voluntary system. The information relies 

on local departments to categorize and report incidents. 

Gender-specific information on health- and safety-related 

issues often go unreported.

USFA recommendation: “USFA develops a national clearinghouse to gather and 

disseminate information on successful or innovative programs” 

(USFA, 1996).

How it would help: Having a single point of contact, i.e., “clearinghouse,” would 

enable departments to research and evaluate different 

programs that have been proven effective. This resource 

would increase standardization throughout the fire service, 

make better use of limited resources to address these issues, 

and minimize the false starts and trial and error in policies 

and procedures.

Status check: The successful and innovative programs developed by 

individual departments are shared through conferences, 

trade magazines, and personal contacts. The National Fire 

Academy (NFA) is very loosely considered a “clearinghouse” 

to gather and disseminate information. There needs to be a 

validation system to assist local jurisdictions in identifying 

applicable programs in similar communities that could be 

adopted or adapted.

USFA recommendation: National and state organizations must create a mechanism 

for applicable information to reach those who need it most, 

the firefighters (USFA, 1996).

How it would help: The fire service has historically relied on the traditional 

hierarchical distribution of information. This system often 

takes months for information to trickle down to the appropriate 

end user from the desk of the chief or executive officer.

Status check: The hierarchical distribution method still prevails. Although 

the internet has made more information available to the 

end user in theory, this does not usually work as an effective 

dissemination method in practice.
4 Emerging Health and Safety Issues Among Women in the Fire Service

USFA recommendation: Develop teamwork training to better support an integrated, 

diverse workforce (USFA, 1996).

How it would help: The development of functional teamwork training would enable 

fire service members to better understand the diversity of the 

team and their strengths. The rising issue in the modern fire 

service is that of firefighter mental health. The stresses of the 

job and the fire service’s macho “do not talk about feelings” 

and “handle it like a man” mentalities are incongruent with 

the modern fire service. Functional teamwork includes an 

open, honest and safe place to talk.

Status check: Teamwork training tends to be offered by a human resources 

department or outside provider that understands very little 

about the fire service, including the challenges of living 

together, working long shifts together, and depending on 

one another to save each other’s lives.

USFA recommendation: The NFA will train administrators on women’s issues in the 

fire service (USFA, 1996).

How it would help: Leaders need to take all team members into consideration 

and to model appropriate behaviors. Putting one agency in 

charge of training would help streamline the process.

Status check: The NFA includes the female perspective in their trainings, 

whenever possible. However, less than 0.4 percent of the fire 

service attended the NFA in 2015, regardless of gender. A clear 

and consistent message must be delivered by the NFA and 

then taken back to home departments and acted upon.

USFA recommendation: Study various ways of completing tasks effectively and 

disseminate approved task attainment options in local trainings 

for all fire service members (USFA, 1996).

How it would help: A woman’s center of gravity is lower than that of a man, 

and in general, a woman has less upper body strength. By 

disregarding these facts, it forces women to use unsafe 

biomechanics and increases the chance of injury.

Status check: Most training is still based on standardized practices that do 

not allow for variation. To support Women in Fire’s mission 

to address this gap, in 2018, the Fire Instructor Development 

Conference included the hands-on course “Fireground Drills 

from the Street: Leverage, Force, and Aggression,” which had 

a focus on unconventional methods for overcoming height 

and strength issues, using the proper tools, and adjusting 

technique with recognition of body type and strength.
Chapter 1: Introduction 5

USFA recommendation: Develop a program to inform health care providers about the 

work of first responders and their health concerns (USFA, 1996).

How it would help: Health care providers must be familiar with potential exposures 

for fire service personnel in order to develop proper treatment 

plans, especially in relation to returning to work after an illness 

or injury.

Status check: Over the past 25 years, numerous studies have investigated 

firefighters’ exposures and increased risk for disease (see 

Chapters 4, 7 and 9). The National Institutes of Health is 

currently conducting a study on the safety of firefighter’s 

breast milk. Some of the health issues are addressed through 

the IAFC’s/IAFF’s Wellness Fitness Initiative. If a department 

has yet to adopt the Initiative, medical providers may know 

very little about the demands, exposure risks, and stresses 

of the fire service.

USFA recommendation: “USFA ensures that the full diversity of the fire service is 

represented in groups that develop equipment and facility 

designs” (USFA, 1996).

How it would help: This issue goes back to the feeling of being integrated and 

welcome, truly being a part of the team and not a guest that 

others are hoping will soon leave. If a woman must question 

whether she is welcome every time she enters a fire station, 

she will be less likely to stay for a career. There is an undertone 

of bullying and harassment in not providing adequate facilities 

for all employees. Once again, this adds to the overall stress 

of the career.

Status check: For nearly 40 years, there has been active discussion on the 

need for individual bathrooms, separate sleeping facilities, 

and the replacement of the terms fireman and firemen with 

firefighter and firefighters. This is out of the control of the 

USFA but is well within the control of individual departments 

and organizations.
6 Emerging Health and Safety Issues Among Women in the Fire Service

USFA recommendation: Collaborate with national associations and manufacturers to 

develop properly fitted clothing, gear and protective equipment 

for the diverse team members of the fire service (USFA, 1996).

How it would help: Take the sizing of gloves as an example: Women’s hands are 

not smaller versions of men’s hands; women have longer 

fingers and a narrower palm. When women are forced to 

wear oversized and ill-fitting gloves, it is a clear safety concern 

and becomes impossible for them to hold items securely. The 

inappropriately sized clothing and equipment adds another 

level of stress to an already stressful career. The military 

started accepting women into the academies about the same 

time that women were entering the career fire service, and 

yet those women have equipment that fits their body sizes 

appropriately, including uniforms and body armor.

Status check: The majority of protective gear or uniforms are sized-down 

versions of men’s gear. This leaves the onus on women to adapt 

to the ill-fitting garments. Several bunker gear manufacturers 

currently offer a women’s cut, but it is still considered a “custom 

cut” and is, therefore, more expensive. The general sentiment 

is that the purchasing pool for women’s sizes is too small to 

make it profitable. The size of the purchasing pool and the 

percentage of women in the fire service present a challenge for 

women being properly fitted for personal protective equipment 

(PPE). This issue also extends into gloves. An Ohio-based glove 

manufacturer is working with Women in Fire to address the 

issue of improper glove fit, but reports a large number of women 

firefighters they size for proper fit have hands too small to fit 

on the NFPA glove sizing chart.

USFA recommendation: Work to make mental health insurance coverage equivalent 

to physical health claims (USFA, 1996).

How it would help: First responders have high-stress jobs and are often exposed 

to traumatic events. The mental health service needs of first 

responders are great. For more information on mental health 

issues among women in the fire service, see Chapter 7.

Status check: Most medical insurance providers limit the number of mental 

health visits per year to a level far below what should be 

considered adequate for first responders. There is also a 

need for mental health providers who have an expertise in 

vicarious trauma to address the needs of first responders.

Twenty-five years have passed, and yet so many of the recommendations from the 1994 

symposium remain goals today. From not feeling welcome in a male-dominated profession 

to ill-fitting equipment to reproductive concerns, there is still a lot of work to do.

This report serves as a status check on long-term and emerging issues of health and safety 

for women in the fire service. It will highlight already existing resources that address these 

issues and make recommendations for improving the fire service for women and for all.
Chapter 2: Women Firefighter Occupational Health and Safety Issues 7

Chapter 2: Women Firefighter 

Occupational Health and Safety Issues

Firefighting is an inherently dangerous job, attributing to 69 fatalities and 62,085 injuries 

among firefighters while performing job duties in 2016 alone (Haynes & Molis, 2017). Knowing 

and understanding the risks that contribute to such outcomes has long been at the heart of 

preventing such tragedies. Identifying trends can influence policy and lead to better safety 

practices, improved training and enhanced compliance. Recognizing any differences that may 

occur with occupational risks affecting subgroups of the work force (gender, ethnicity, race, 

etc.) becomes more important as the diversity of the fire services grows.

Despite growing numbers of women in the fire service, the small sample sizes of women 

firefighters often lead to their elimination from study when it comes to research regarding 

occupational hazards (Jahnke et al., 2012). It is unknown what specific risks women face 

and whether these risks differ from the general firefighter population. This chapter 

focuses on the data available at this time, creating a snapshot of the injuries and fatalities 

of women firefighters.

“A National Report Card on Women in Firefighting” refers to several factors that contribute 

to low numbers of women in the field such as physical requirements, psychological 

tension, workplace culture, harassment and discrimination (Hulett et al., 2008). Outside 

of recognized work hazards, could similar factors attribute to the injuries and causes of 

fatalities experienced by women firefighters? Do occupational hazards of the fire service 

affect women differently?

Health status of women firefighters

In an epidemiological study of women 

firefighters conducted by Jahnke and 

colleagues, women in the fire service 

tended to repor t being in good to 

excellent health (Jahnke et al., 2012). When 

compared to their male counterparts, 

women firefighters tended to be younger, 

more educated, more likely to be single, 

more likely to use tobacco products, and 

to have healthier body compositions 

(Jahnke et al., 2012). Using self-reported 

physical activity as an estimation of 

cardiopulmonary fitness, women firefighters were significantly less likely to meet NFPA 

recommended standards than their male counterparts (career females, 22.2 percent; career 

males, 38.7 percent; volunteer females, 7.7 percent; and volunteer males, 23.6 percent) 

(Jahnke et al., 2012). However, when an exercise-based evaluation of cardiopulmonary health 

(the Gerkin protocol) was used to assess fitness, no difference between men and women 

firefighters was found (Poplin, Roe, Peate, Harris, & Burgess, 2014). 

When looking at mental health, almost 1 in 4 career women firefighters and 4 in 

10 volunteer women firefighters scored in the range of concern on the Center for 

Epidemiological Studies Short Depression Scale used to assess depression (Jahnke et al., 

2012). However, over 80 percent of both career and volunteer women firefighters indicated 
8 Emerging Health and Safety Issues Among Women in the Fire Service

that they felt confident to handle problems most of the time, indicating good coping skills 

(Jahnke et al., 2012). Using a self-reported, web-based survey, Stanley, Hom, Hagen and 

Joiner evaluated the prevalence of suicidal thoughts and behaviors over the course of 

firefighters’ careers (Stanley et al., 2015). Findings indicated that gender did not contribute 

to the rates of career suicide ideation or attempts, nor to career nonsuicidal self-injury; 

however, women firefighters were found to report suicidal plans less than male firefighters 

(Stanley et al., 2015). Factors with correlations to suicidal thoughts and behavior included 

lower rank, less experience, membership in a volunteer department, experience with 

suicide-related responses, and active-duty military history (Stanley et al., 2015).

The Bureau of Labor Statistics (BLS) conducts an annual survey of private and public 

employers’ Occupational Safety and Health Administration 300 logs (a record of reportable 

injuries and illnesses and related details) and publishes the results in the Survey of 

Occupational Injuries and Illnesses (SOII). The SOII only includes “employed” firefighters, 

thus volunteers are excluded from this dataset (BLS, 2016). In 2015, the BLS reported 

13,280 firefighter nonfatal occupational injuries and illnesses for a rate of 3.98 per 100 

full-time employees (BLS, 2016). This rate was almost four times higher than the rate of 

1.04 for all workers (BLS, 2016). The BLS also reported that firefighters took a median of 11 

days away from work that year, higher than the 8-day median for all workers (BLS, 2016).

In 2013, the BLS published a special report on firefighter injuries, illnesses and fatalities, 

titled the “Firefighter Factsheet” (BLS, 2016). The “Firefighter Factsheet” reported that, 

in 2011, firefighters had injuries and illnesses resulting in time loss from work at four 

times the rate for all workers (BLS, 2013). Women represented 8 percent of those cases 

although they only made up about 4.5 percent of the firefighting workforce (BLS, 2013). 

This suggests that women firefighters have an increased risk (1.8 times) of an occupational 

injury or illness.

Figure 2. Women fireground injuries by cause of injury, 2010-2014 annual averages

0% 5% 10% 15% 20% 25% 30% 35%

Struck or assaulted

 by person, animal

or object

Other cause

Fall

Contact with object

Slip or trip

Exposure to hazard

Overexertion or strain 30%

7%

10%

6%

22%

17%

23%

12%

12%

12%

9%

8%

16%

16%

Volunteer

Career

Source: Campbell, R. (2017). Patterns of female firefighter injuries on the fireground. Quincy, MA: National Fire Protection 

Association. Retrieved from https://www.firerescuemagazine.com/content/dam/fe/downloads/FFN-FRM-Downloads-Editorial/

osfemalefireground.pdf.
Chapter 2: Women Firefighter Occupational Health and Safety Issues 9

Both injury frequency and duration differ between men and women firefighters. Using 

compensation claims from 1987 to 1998, a large Midwestern city found that gender 

correlated with injury frequency, with women firefighters reporting 33 percent more 

injuries than their male counterparts. Age, time in career, sex, marital status, and type of 

injury all significantly influenced injury duration. Women, older employees, and married 

firefighters tended to take longer to recover. Marital status interacted with gender 

affecting return-to-work rates for all firefighters; married women firefighters returned 

to work first followed by single males, single females and lastly, married male firefighters 

(Liao, Arvey, Butler, & Nutting, 2001).

Recently the NFPA released an examination of women firefighter injuries on the 

fireground using data collected through the National Fire Incident Reporting System 

(NFIRS) and the Annual Fire Experience Survey. From 2010 to 2014, women firefighters 

experienced an estimated 1,260 injuries on the fireground. Of the reported injuries, 69 

percent were minor in nature, requiring only first aid, and only 2 percent were severe or 

life threatening. The primary cause of injury among both career and volunteer women 

firefighters was overexertion or strain; findings were similar to that of all firefighters 

injured during that time. Volunteer women firefighters were more likely to suffer from 

exhaustion, fatigue, smoke inhalation and breathing difficulty when compared to their 

career counterparts. Career women firefighters, on the other hand, were more likely to 

suffer from strain, sprain, contusions, bruising and other minor traumas. Most injuries 

happened while fighting structure fires (80 percent) and the majority of those injuries 

occurred while individuals were outside of the structure (62 percent). Thirty percent of 

injuries experienced by women firefighters happened to individuals under the age of 29, 

which was 10 percent more than the general firefighting population in that age group 

during the same period (Campbell, 2017).

Just as injuries are a growing concern among the fire service, so are acts of violence 

against emergency service personnel. Women are more likely to be paramedics than they 

are to be firefighters, and patients are more likely to assault paramedics than firefighters 

in urban fire departments. Though Taylor et al. discovered that gender was not a factor 

contributing to patient-initiated violence, the finding that women in fire departments 

tended to be emergency medical responders, and therefore at greater risk of assault, is 

concerning (2016).

Recommendations

Increase the presence of women as subjects in fire service research.

Due to the small number of women in the fire service, the sample sizes of most studies 

remain small and the generalization to the larger population of current and future women 

firefighters remains in question and warrants further study.

Research gender-specific risk factors and solutions in order to prevent injuries on 

the job, focusing on adapting tasks, gear and training to the specific needs of women 

firefighters.

The contributions and attributes of physical training programs could be investigated as a 

way to reduce a majority of injuries among all firefighters, as well as decrease instances 

of exhaustion and fatigue among women firefighters. Some promising research is already 

underway. Participation in a well-designed, 16-week physical fitness program increased 

the aerobic capacity of firefighters, better enabling them to handle the physical demands 

of the occupation (Roberts, O’Dea, Boyce, & Mannix, 2002).
10 Emerging Health and Safety Issues Among Women in the Fire Service

Cultural norms could also be contributing to some of the injury distributions. Departments 

may shy away from assigning women tasks deemed more dangerous, such as offensive 

interior operations, due to a work culture that still aligns firefighting with traditional 

gender roles. However, most of the injuries on the fireground occur outside of the 

structure, where women tend to be. Culture may also play a role in the higher rates of 

younger women firefighter injuries, as their life experiences may reflect an upbringing 

more aligned with traditional gender roles and, consequently, less experience in physically 

demanding jobs. Discovering and addressing gender-specific risk factors contributing to 

injuries is the first step in their reduction and could have impacts that reach further than 

improved safety records.
Chapter 3: Recruitment and Retention Issues Related to Women Firefighter Health and Wellness 11

Chapter 3: Recruitment and Retention 

Issues Related to Women Firefighter 

Health and Wellness

Women firefighters make up a small percentage of the fire service as a whole. To become a 

gender-inclusive industry, it is important for organizational leaders to examine successful 

methods to attract and retain women. 

Gender-specific issues were identified 

as one of the six main barriers for 

retention in the fire service (McDonald, 

2016). Developing strategies to retain 

women is also key for an organization 

to maximize human capital and for 

creating the strongest pool of leadership 

candidates (Johnson & Tunheim, 2016). 

Specific recruitment and retention 

b ar r ier s women face in t he f ire 

service include physical challenges, 

psychological strains, and challenges 

tied to the long-time culture of the fire 

service being a male-dominated field.

Physical challenges

Physical challenges can be a barrier 

for some women trying to enter the 

fire service. These physical challenges 

may also extend into the duration of 

women firefighters’ careers. Many 

depar tments, both volunteer and 

career, require the passing of a physical 

agility entrance test. Prospective women 

firefighters have an 85 percent failure 

rate with the agility test compared to 

their male counterparts’ failure rate 

of 9 percent (Sinden et al., 2013). Fire 

departments can legally refuse the 

hiring of candidates not able to pass 

the physical fitness requirements if the 

physical tasks are directly related to and 

necessary for the job position. There 

have been cases where agility tests 

were created to intentionally serve as a 

barrier for women.

One method to ensure a fair and 

consistent evaluation of physical 

fitness for both women and men who 

4 Resource break

The California Joint Fire Fighter Joint 

Apprenticeship Committee (2007) has 

produced a “Candidate Preparation 

Guide: Candidate Physical Ability Test 

(CPAT).” The guide offers five training 

programs for the CPAT:

1. Flexibility & Warm-Up Exercises.

2. Weight Training Circuit Workout.

3. Calisthenics Circuit Workout.

4. CPAT Running Program.

5. Task-Specific Exercise Training.

Access this resource at: http://www.cffjac.

org/go/jac/?LinkServID=3E94B79A-1CC4-

C201-3E4BF872E67CB568.

Certified personal trainers/firefighters 

Dan Kerrigan and Jim Moss developed 

Firefighter Functional Fitness, a program 

that incorporates equipment that already 

exists in the fire department in fitness 

workouts. The program focuses on the 

Four Pillars of Firefighter Functional 

Fitness: physical fitness, recovery and 

rest, hydration, and nutrition and lifestyle.

Access this resource at: http://

firefighterfunctionalfitness.com.

The IAFF/IAFC offers a manual intended 

t o i m p r o v e t h e m e n t a l , p h y s i c a l 

and emotional capabilities and help 

firefighters withstand the stresses and 

strains of the job.

Access this resource at: http://services.

prod.iaff.org/ContentFile/Get/40146.
12 Emerging Health and Safety Issues Among Women in the Fire Service

are candidates for the fire service is for the industry to standardize the use of the CPAT. 

The CPAT evaluates an individual’s ability to perform basic firefighting functions. The CPAT 

requires a candidate to wear a weighted vest while performing a number of physical 

activities that simulate firefighting tasks. To assist candidates with passing the CPAT, 

department leadership can orientate candidates to the test, provide training resources 

to allow for physical preparation, and offer open practice sessions. 

The need for physical fitness for women firefighters extends beyond entry into the fire 

service. The injury rate among women firefighters is 33 percent higher than their male 

counterparts (Liao et al., 2001). One factor that may contribute to the higher number of 

injuries among women is a woman firefighter’s resistance to break away from a task and/

or the resistance to ask for help from male counterparts during strenuous tasks. This 

resistance may stem from the fear of being viewed as weak by their male counterparts. It 

is important for department leadership to create a culture where women firefighters feel 

comfortable speaking up about unsafe conditions and are able to ask for help from male 

counterparts without fear of judgment.

Psychological strain

The psychological strain of firefighting 

is another retention issue for women in 

the fire service (Jahnke et al., 2012). The 

risk of developing mental health issues 

is high among firefighters in general 

(Jahnke et al., 2012). Compared to their 

male counterparts, women firefighters 

face a significantly increased risk of 

mental health issues because of an 

increased level of discrimination (Jahnke 

et al., 2012). Discrimination among 

women firefighters can lower retention and negatively impact mental health (McDonald, 

2016). Women firefighters also face social exclusion, another precursor to increased 

mental health effects (Sinden et al., 2013). This social exclusion stems from being left out 

of social activities that their male colleagues participate in (Sinden et al., 2013). Conversely, 

involvement in social inclusion is a protective factor for retention (McDonald, 2016).

For more information about mental health concerns among women in the fire service, 

see Chapter 7.

Culture of the fire service

The long-time male-dominated culture of the fire service may lead to barriers for the 

success of women in the fire service. Male firefighters with negative attitudes toward 

women being in the fire service can be a barrier for women joining a department and 

create difficulty in developing a positive work culture (Sinden et al., 2013). Women 

firefighters are at risk of higher levels of anxiety, exposure to sexism, lower job association, 

and higher levels of coworker conflict (Sinden et al., 2013). Fire departments that fail to 

address negative behaviors can also develop a poor reputation (McDonald, 2016). The 

exploration of organizational culture is important for leaders seeking to improve retention. 

Organizations that invest in creating a positive culture can increase job satisfaction and 

retention in the fire service (McDonald, 2016).

4 Resource break

The NVFC’s Share the Load program is a 

free program that provides firefighters 

with access to mental health resources 

and professionals 24/7.

Access this resource at: https://www.nvfc.

org/programs/share-the-load-program/.
Chapter 3: Recruitment and Retention Issues Related to Women Firefighter Health and Wellness 13

Recommendations

Fire service leadership should implement evidence-based strategies to recruit and 

retain women firefighters.

Suggested strategies include standardizing the CPAT, promoting inclusivity through human 

resources trainings, accommodating the schedules of volunteer firefighters to address 

work-life balance challenges, offering nonwage benefits as an incentive to attract and 

retain, recognizing employee accomplishments and life moments, developing programs 

for family engagement, and employing various recruitment methods specific to gender 

inclusion (McDonald, 2016).

Conduct a study on recruitment and retention strategies specific to women 

firefighters. 

Such a study does not exist at the time of this publication. Other industries that engage 

both career and volunteer workforces have demonstrated that retention barriers vary by 

gender (Waters & Bortree, 2011). 

4 Resource break

The Fire Service Reputation Management White Paper produced by Cumberland 

Valley Volunteer Firemen’s Association (2010) identifies a series of social, cultural 

and ethical issues threatening the fire service. The document draws awareness to 

negative behaviors, outlines the implications for leadership, and strongly urges the 

incorporation of a fire service code of ethics. 

Access this resource at: https://firefighterbehavior.com/wp-content/uploads/2017/09/

Reputation-Management-White-Paper.pdf.

The National Firefighter Code of Ethics establishes criteria for fire service personnel 

to promote a culture of integrity and professionalism within the industry. 

Access this resource at: https://www.usfa.fema.gov/downloads/pdf/code_of_ethics.pdf.
14 Emerging Health and Safety Issues Among Women in the Fire Service
Chapter 4: Heart Health for Women in the Fire Service 15

Chapter 4: Heart Health for Women in 

the Fire Service

Firefighters face far higher cardiac demands than non-firefighters, making heart health a 

key aspect of physical readiness in the fire service (IAFF, 2013). The USFA (2017) indicated 

24 percent of all deaths in the U.S. were cardiac related, but 47 percent of line-of-duty 

deaths (LODDs) in the fire service were tied to a cardiac emergency. With an increase of 

women entering the fire service, additional research is needed to measure the impact 

of heart health specific to women firefighters. Currently, cardiac fatality is the number 

one killer of women in the U.S. and is responsible for one in every four deaths among 

women (Centers for Disease Control and Prevention (CDC), 2017). To address the risk, a 

proactive approach of screening, healthy diet, regular physical activity, and a supportive 

health-focused environment is essential to every career and volunteer firefighter.

Of the women in the general population who die from heart disease, 64 percent have no 

symptoms (CDC, 2017b). Even with the increase of heart disease awareness, only 54 

percent of women are aware that it is the number one killer among women (CDC, 2017b). 

Therefore, women firefighters must take control of their personal health to reduce the 

risks of cardiovascular disease. To begin, women firefighters should inform their primary 

care physicians about the unique risks of those serving in the fire service. This is especially 

true for volunteer firefighters, since they would most likely list their full-time career on a 

patient intake form and not their role as a firefighter. 

Notification to the primary care physician should occur at the 

first visit, and a reminder should be given at each subsequent 

visit. The IAFC (2016) provides a guide for health care 

providers to address the specific health needs of firefighters. 

“A Healthcare Provider’s Guide to Firefighter Physicals” is a 

quick and easy-to-read fact sheet that outlines the unique 

medical needs of patient care when treating a career or 

volunteer firefighter (IAFC, 2016). While the tool provides 

excellent information, it does not address the needs and risks 

specific to women firefighters. Additional research is needed 

to determine the gender-specific health impacts on women 

in the fire service.

YOUR PATIENT IS A FIREFIGHTER!

• Firefighters face unique occupational health risks due to the demands of their job. 

• Firefighters routinely operate in harsh work environments with: 

 o excessive heat o emotionally charged situations o toxic chemicals

 o dense smoke o extreme physical challenges 

• Firefighters wear more than 70 pounds of equipment.

• Firefighters breathe compressed air. 

• Firefighters represent a distinct subset of the general population. 

Firefighters As Tactical Athletes

Physiological Demands of Firefighting

The purpose for this document is to assist the healthcare provider in the evaluation, treatment, and ongoing 

surveillance of the health and wellness of firefighters. The recommendations in this document are supported 

by ongoing clinical research of firefighters’ health and by the extensive experience and expertise of the 

providers caring for them. These recommendations are offered as assistance for healthcare providers making 

clinical decisions regarding the medical fitness and/or treatment of firefighters. They are not to take the place 

of your medically reasonable, appropriate and necessary medical evaluation of the firefighter. As with any 

clinical references, they should be used with the understanding that ongoing research may result in new 

information and revised recommendations.

These extreme physical, mental and environmental 

stresses increase the firefighter’s risks of morbidity 

and mortality for:

 Cardiovascular events:

Cardiovascular events are the leading cause 

of on duty deaths among firefighters1 and, for 

every line of duty death, there are an estimated 

17 non-fatal cardiac events on duty among 

firefighters2

.

 Musculoskeletal injuries:

The National Fire Protection Association estimates 

firefighters get more than 71,000 injuries a year3

.

 Behavioral health issues:

Of firefighters, 46.8% have considered suicide and 

15.5% have had an attempt during the course of 

their career4

.

 Cancer:

In 32 states and in 9 Canadian provinces, several 

types of cancer are considered work-related.5

Family history and lifestyle habits obviously add 

to these risks. 

A HEALTHCARE PROVIDER’S GUIDE TO

FIREFIGHTER PHYSICALS

For more information: fstaresearch.org/GetChecked

rev:Sept2017

To provide feedback: fstar@iafc.org

4 Resource Break

The IAFC created “A Healthcare Provider’s Guide to Firefighter Physicals,” which any 

firefighter can present to a personal care provider to ensure an annual physical is 

performed with the specific demands of firefighting in mind.

Access this resource at: http://www.fstaresearch.org/resource/?FstarId=11591.
16 Emerging Health and Safety Issues Among Women in the Fire Service

Core principles for healthy behaviors

Changing the culture toward healthier choices can be challenging but may reduce the 

risk of cardiovascular disease and events among women firefighters. Fire departments 

must establish an environment that supports making healthy choices in order to decrease 

the risk of cardiac events to members. The first step in the process incorporates the 

recommendations of NFPA 1583, Standard on Health-Related Fitness Programs for Fire 

Department Members and includes obtaining annual physicals compliant with NFPA 1582, 

Standard on Comprehensive Occupational Medical Program for Fire Departments. NFPA 1583 

(2015) indicates a fire chief should appoint a health and fitness coordinator, which can be 

an internal or external individual.

The health and fitness coordinator is 

key to setting the tone and momentum 

of the health efforts. The coordinator 

can offer health programming and 

opportunities to collaborate with local 

resources. For example, the Winona Fire 

Department (Ohio) collaborated with 

the Ohio State University Extension’s 

Expanded Food and Nutrition Education 

Program (EFNEP). The EFNEP offered 

firefighters and family members food 

and nutrition education classes at no cost to the department. The group met monthly 

over a period of time to increase personal knowledge of basic nutrition, the benefits 

of physical activity, food safety, and stretching food dollars. Winona Fire Department 

members succeeded in a 92 percent behavior change in nutrition practices and a 77 

percent change in food safety practices (Expanded Food and Nutrition Education Program, 

2014). Similar services are available through local extension offices across the U.S.

Eating well

According to the U.S. Department of Health and Human Services (HHS) and the U.S. 

Department of Agriculture (USDA), the prevalence of preventable diet-related chronic 

diseases has increased at an alarming rate. Over the past century, Americans have moved 

from malnutrition and deficiencies to half the population becoming overweight and obese, 

resulting in an increase of cardiovascular disease, cancer and type 2 diabetes. Dietary 

changes are key to reducing risk.

Everything counts when thinking about making healthier choices — 

meals, snacks and drinks. Small changes, like reducing the amount 

of salt, fat and sugar in one’s diet, can make a big impact and build 

momentum in a new lifestyle. The USDA’s MyPlate outlines userfriendly strategies to make healthier food choices. The resource also 

provides strategies for special populations such as older individuals, 

high-risk groups, and children. MyPlate recommends:

ĵ Making half the plate fruits and vegetables.

ĵ Eating lean cuts of animal proteins and opting for plant-based proteins.

ĵ Drinking low or nonfat dairy.

ĵ Making half of grain consumption whole grains.

4 Resource break

Engage firefighters and family members in 

a culture of physical fitness and nutrition 

through a USDA funded EFNEP.

A complete listing of EFNEPs programs 

can be accessed at https://nifa.usda.gov/

resource/efnep-partner-websites-2017.
Chapter 4: Heart Health for Women in the Fire Service 17

Choose a variety of foods, drinks and colors from each food group. Consuming a wide 

variety of nutrients is essential to a healthy lifestyle. For example, add vegetables that are 

red, orange or dark green to meals or snacks. These colorful options are full of vitamins 

and minerals. Other great vegetable choices are acorn squash, sweet potatoes or collard 

greens. They taste good and are full of vitamins and minerals.

For more information about MyPlate go to www.chooseMyPlate.gov.

Hydration

Women firefighters also need to keep hydration a priority because dehydration increases 

cardiac strain. Hydration is also a key element of firefighter rehabilitation under NFPA 

1584, Standard on the Rehabilitation Process for Members During Emergency Operations and 

Training Exercises, so sipping water throughout the day is a key strategy to stay hydrated. 

This process, called prehydration, is vital on days with increased risk of heat stress. 

According to the CDC (2017b), dehydration can cause unclear thinking, mood changes, 

constipation, overheating and kidney stones.

Beverages are an important part of staying hydrated and establishing healthy eating 

patterns. Sugary drinks add to the overall caloric intake but offer little or no nutrients. 

Drinking water can quench thirst, hydrate the body, and control calorie intake when 

substituting for sugary drinks. Choose water first.

Physical activity

Physical activit y and healthy 

e a t i n g g o h a n d i n h a n d i n 

achieving a healthy lifestyle. In an 

average year, there are close to 

70,000 injuries and 100 fatalities 

in the fire ser vice (Haynes & 

Molis, 2017). Women firefighters 

also have 3 3 percent more 

injuries than males (Sinden et al., 

2013). Strain, sprain or muscular 

pain represents the largest injury 

category, and cardiac events are 

the leading cause of firefighter 

fatalities (Haynes & Molis, 2017). 

The more physical activity, the 

greater the benefits and overall feeling of well-being. Most Americans do not get enough 

physical activity (MyPlate, 2017). The 2008 Physical Activity Guidelines for Americans 

recommends 150 minutes of vigorous physical activity per week (HHS, 2008). While this 

sounds like a lot, research has found that there are cumulative benefits in blocks of 

physical activity time as short as 10 minutes, as long as it totals 150 minutes per week 

(CDC, 2015).

The benefits of physical activity are broad and long lasting. The benefits include reducing 

the risk of cardiovascular disease, high blood pressure, arthritis symptoms, weight gain and 

stroke. Physical activity increases mental health, fitness, sleep and cognitive functioning 

(CDC, 2017b). According to the CDC, women are at a higher risk for osteoporosis than their 

male counterparts. Maintaining a diet high in calcium along with weekly weight-bearing 

physical activity can reduce the risk of osteoporosis (2016). Activities such as weight lifting, 

running, doing pushups and jumping rope are good choices.
18 Emerging Health and Safety Issues Among Women in the Fire Service

Certified personal trainers and firefighters, Dan Kerrigan and Jim Moss, indicated a need 

to focus on “The Big 8” to improve physical fitness and reduce the occurrence of injury on 

the fireground. “The Big 8” includes functional movements and interrelated components 

during workouts that include push, pull, carry, lift, drag, core, capacity and flexibility 

(Moss & Kerrigan, 2015). The eight components encompass flexibility/core strength, 

cardiovascular capacity and strength training. Moss and Kerrigan (2015) indicated by 

adding healthy nutrition and lifestyle, optimal firefighter functional fitness can be reached.

Recommendations

Fire service leadership should review and implement NFPA 1582 and 1583 to ensure 

department compliance.

Suggested strategies include incorporating structured fitness and nutrition programs, 

annual physicals, and referrals to community supporters.

Conduct additional research on gender-specific health and wellness needs that are 

specific to both career and volunteer firefighters.

Fire service leadership should review the NVFC’s Heart Healthy Firefighter website 

for resources on implementing health and wellness programs.

The NVFC website offers a collection of resource guides for establishing and funding 

wellness programs. The site can be accessed at https://healthy-firefighter.org/start-aprogram/.
Chapter 5: Women Firefighter Injury and Death Tied to Roadway Incidents 19

Chapter 5: Women Firefighter Injury 

and Death Tied to Roadway Incidents

Performing first responder operations on the roadway is a frequent 

occurrence for fire service members, and one that comes with great 

risks. According to the Emergency Responder Safety Institute (ERSI), 

from 2000 to 2017, 87 firefighters were struck by a moving vehicle 

and killed on the roadway (ERSI, 2017). Firefighters are not exempt 

from the dangers that come with roadway operations. Women 

firefighters had almost double the proportion of deaths from struck 

by incidents compared to their male counterparts (ERSI, 2017). 

Between 1994 and 2015, 12 percent of women firefighter fatalities 

and 7 percent of male firefighter fatalities were tied to struck by 

incidents on the roadway (IAFF, 2005).

To help standardize how first responders perform traffic control 

duties at incident scenes, NFPA 1091, Standard for Traffic Control 

Incident Management Professional Qualifications (2015 Edition) 

was created to establish on-the-job requirements for roadway 

operations (NFPA, 2015). NFPA 1091 promotes safer operations with minimum job 

performance requirements for Traffic Control Incident Management Personnel, to help 

authorities having jurisdiction ensure personnel are adequately prepared to carry out the 

duties of the job (NFPA, 2015).

To improve the safety of first responders operating on the roadway, the Federal Highway 

Administration developed the Traffic Incident Management (TIM) program, a framework 

for a planned and coordinated multidisciplinary process for roadway operations. This 

includes the National TIM Responder Training (National Highway Institute (NHI), 2018). 

The goal of this no-cost course is to provide first responders with a shared understanding 

of requirements for safe, quick clearance of roadway incident scenes, clear and reliable 

communication, and responder safeguards for roadway operations (NHI, 2018).

4 Resource highlight: Responder Safety Learning Network

The Responder Safety Learning Network offers free online resources for first 

responders. Resources of interest discussed in this chapter include:

ĵ Understanding the New NFPA 1091 online course.

ĵ National TIM Training Certificate online course. Upon completion of the modules 

and passing of the Skills Challenge test, credit will be given and a download of a 

certificate equivalent to completing the National TIM Responder Training Program 

will be made available.

ĵ PIO and Public Educator Engagement page. Information is designed specifically 

for PIOs and educators for educating the public. Resources include video public 

service announcements, media templates, downloadable posters, a press packet, 

and information for leadership.

Access this resource at: http://www.respondersafety.com/.
20 Emerging Health and Safety Issues Among Women in the Fire Service

The next challenge in reducing injury and LODDs 

on the roadway is public education to prevent 

distracted driving. Over 3,400 people will die and 

390,000 will be injured due to distracted driving 

(National Highway Traffic Safety Administration, 

n.d.). Each year, dozens of responders from 

fire, law enforcement, EMS, the Department 

of Transportation, safety service patrols, and 

towing and recovery are killed from being struck 

by passing vehicles while operating at roadway 

incidents, with a greater number sustaining 

injuries (ERSI, 2017). These deaths and injuries 

are preventable.

Recommendations

Make the National TIM Responder Training a department requirement for all 

team members as a proactive approach to reducing injury and LODDs of women 

firefighters on the roadway.

Knowledge gained from the course will allow first responders to use a common set 

of practices and advanced standards during roadway operations. It will equip first 

responders with a common set of core competencies and will assist in achieving the TIM 

National Unified Goal of strengthening responder safety (NHI, 2018).

Increase the number of PIOs and Public Educators to educate their communities about 

the dangers distracted drivers pose to first responders operating on the roadway.

PIOs are integral to the safety of first responders and protecting property (Emergency 

Management Institute (EMI), 2016). They are responsible for effectively communicating 

with community members (EMI, 2016). It is key for the first responder community to 

inform the public that personal behaviors matter greatly when approaching and passing 

emergency scenes on the roadway and how these behaviors can affect the work of 

emergency personnel.
Chapter 6: Emergency Vehicle Operation-Related Women Firefighter Injury and Death 21

Chapter 6: Emergency Vehicle 

Operation-Related Women Firefighter 

Injury and Death

Firefighters are more likely to die in a motor vehicle accident than during the course of 

firefighting operations (Haynes & Molis, 2017). In fact, vehicle-related deaths account for 

20 to 25 percent of all fire service fatalities, which is the second leading cause of death for 

firefighters behind cardiac-related causes (USFA, 2014). The risk of injury or death from 

emergency vehicle or apparatus accidents does not differ among genders.

In 2015, the NFPA estimated there were 16,600 collisions involving fire department 

emergency vehicles responding to or returning from incidents (Haynes & Molis, 2017). 

This is the highest number of collisions since the NFPA began collecting this information 

in 1990 (Haynes & Molis, 2017). Firetruck, or apparatus, accidents may account for only 

a small percentage of injuries, but when they do happen, the outcomes are often more 

serious injuries and more fatalities (USFA, 2014).

Many factors play into an apparatus accident, but through review of case studies and 

research, there are five common themes: lack of seat belts, lack of apparatus maintenance, 

excessive speed and loss of control, apparatus operation and distractions, and intersections.

Seat belts

Statistically more than 80 percent of firefighters killed in collisions are not wearing 

seat belts (IAFF, 2005). When firefighters do not wear their seat belts, ejection from the 

apparatus becomes frequent since nothing is counteracting the force of the accident. 

Research shows that 3 out of 4 people 

who are ejected from an apparatus 

will die, and 8 out of 10 fatalities from a 

rollover crash involve occupant ejection 

(USFA, 2014). Wearing a seat belt while 

in an apparatus could ultimately be the 

determining factor in whether or not 

a firefighter survives a crash. Despite 

these statistics, seat belts are still not 

being worn. The common complaint 

is that seat belts are restrictive or 

uncomfortable to wear over their PPE. 

This has resulted in some vehicles 

having the seat belts removed or 

tucked away beneath the seat cushions.

NFPA 1500, Standard on Fire Department Occupational Safety, Health, and Wellness ProgramTM

requires all riders on a fire apparatus to be seated and belted prior to the movement of 

the apparatus (NFPA, 2018). Nevertheless, considering many are not abiding, a “seated 

and belted” policy should be enforced to ensure the safety of all firefighters, and this 

responsibility falls on the operator. Having high visibility seat belts or monitors that send a 

signal if belts are not buckled are some ways to enforce seat belt use. Ultimately the operator 

must enforce that all firefighters have their seat belts on before the apparatus moves.

4 Resource Break

Get your depar tment on board by 

instituting a seat belt policy and signing a 

seat belt pledge. For example:

ĵ International First Responder Seat Belt 

Pledge: https://www.seatbeltpledge.

com/.

ĵ Sample seat belt policy: http://www.

vfis.com/seat-belt-safety.
22 Emerging Health and Safety Issues Among Women in the Fire Service

Lack of apparatus maintenance

Sometimes apparatus accidents are not a result of the driver but are due to neglected 

maintenance. An apparatus that is not properly maintained can negate the safest driving 

practices. Leaking fluid, brake or steering defects, inoperable wiper blades and poor tire 

conditions can all result in apparatus accidents. Additional problems that may appear to 

be small, such as broken door latches and missing or inoperable seat belts, can contribute 

to injury and/or death. Apparatus with any of these problems should be removed from 

operations until repairs are made.

When it comes to apparatus maintenance, it is important to create a program that meets 

the requirements of NFPA 1915, Standard for Fire Apparatus Preventive Maintenance Program

(NFPA, 2000). Drivers should perform operational safety inspections every day before 

their tour of duty. If there is a minor problem, they should attempt to correct it. If there 

is a major problem, then the operator must notify their supervisor. Defective apparatus 

must not remain in service, and it is important to repair small problems, like a broken 

door latch, as soon as possible. All maintenance problems, both small and large, must be 

resolved before an apparatus can return to operation.

Excessive speed and loss of control

Approximately two-thirds of fire apparatus crashes happen while en route to an 

emergency situation (Donoughe, Whitestone, & Gabler, 2012). Although many factors may 

contribute to a crash, excessive speed often results in loss of control of the apparatus. 

There is a direct correlation between excessive speed and decreased safety when 

operating any vehicle, especially during curves, passing maneuvers and inclement weather 

(USFA, 2014). The use of lights and sirens can also cause “siren syndrome” where drivers 

tend to drive faster and more aggressively because they are operating under emergency 

conditions (USFA, 2014). 

Figure 3. Causes of firetruck collision, 2000-2009

Collision with a

motor vehicle in

transport

Collision with a

parked motor

vehicle

Rollover/Overturn Collision with a pedestrian, Other

animal or moving object

Collision with a tree

Collision with a post/pole

Data source: Donoughe, K., Whitestone, J., & Gabler, H. C. (2012). Analysis of firetruck crashes and associated firefighter 

injuries in the United States. Annals of Advances in Automotive Medicine, 56, 69-76. Retrieved from https://www.ncbi.nlm.nih.

gov/pmc/articles/PMC3503424/.
Chapter 6: Emergency Vehicle Operation-Related Women Firefighter Injury and Death 23

To lower the risk around excessive speed, it is important for operators to understand that 

adding response time is better than having an accident. Apparatus should not exceed 

the speed limit, and it is acceptable to tell a driver to slow down but never acceptable to 

tell them to speed up. Since many accidents happen when apparatus wheels leave the 

paved road, it is recommended that operators stop the apparatus completely before 

creeping back onto the road. To combat siren syndrome, some fire departments have 

created policies where different calls require different responses: low risks mean no lights 

or sounds, high risks require both, and medium risks may have just lights but no sirens. 

St. Louis, Virginia Beach, Salt Lake City and Phoenix have implemented “on the quiet” 

responses where they do not use lights or sounds for certain calls (USFA, 2014). They have 

all observed drastic reductions in collisions, but no reduction in service delivery or patient 

care, nor increases in fire losses or mortality rates (USFA, 2014).

Apparatus operation and distractions

Many apparatus accidents are a result of drivers 

being distracted or not being trained on a specific 

apparatus. There are many distractions today, 

such as cellphones, computers, maps and radios, 

and they are all leading to an increase in accidents 

because they divert the driver’s focus away from the 

road (USFA, 2014). In addition to distractions, drivers 

may be undertrained on an apparatus or may not 

be qualified to drive a specific vehicle. Switching to a 

different size vehicle or having limited familiarity with a specific vehicle can result in more 

collisions when driving to and from a call or while backing up at a site or at the station.

Distractions are hard to ignore, but to lower that risk a second person should operate all 

devices so that the driver can focus solely on the road and navigating traffic. Apparatus 

operation is difficult; therefore, departments are encouraged to follow the NFPA 1002, 

Standard for Fire Apparatus Driver/Operator Professional Qualifications, which states 

all drivers must complete a formal training program on the exact types of apparatus 

they will drive (NFPA, 2017). If they are not thoroughly trained they must not operate 

the vehicle. It has also been suggested to make it a requirement that drivers obtain a 

commercial driver’s license and have formal training with ample practice time. Backing up 

an apparatus is another operational concern, but best practices are to follow NFPA 1500 

to create a backing policy, one that states if the driver cannot see the spotters then they 

must not back up the vehicle (NFPA, 2018). 

4 Resource Break

The Emergency Vehicle Safety Initiative, launched in 2002, has 

two main goals:

1. Learn more about emergency responder fatalities associated 

with the roadway.

2. Create a list of best practice safety measures, which reduce 

the likelihood of firefighter fatalities during a response or 

roadway scene.

Access this resource at: https://www.usfa.fema.gov/downloads/

pdf/publications/fa_336.pdf.

U.S. Fire Administration

Emergency Vehicle 

Safety Initiative

FA-336/February 2014
24 Emerging Health and Safety Issues Among Women in the Fire Service

Intersections

The most likely location for a fire apparatus collision is at an intersection. This is a result 

of civilian drivers failing to yield to emergency vehicles when they have a green light or 

stop sign, or firefighters not coming to a complete stop before proceeding through a red 

light or stop sign. Firefighters often do not come to a complete stop and many do not slow 

down prior to an intersection either, which has resulted in collisions. These accidents can 

also be a result of low visibility due to weather, distracted civilian drivers, or drivers who 

do not abide traffic laws and standards.

NFPA 1500 requires the apparatus come to a complete stop before proceeding (NFPA, 

2018). A complete stop could extend the response time by two or three seconds per 

intersection, but adding a few seconds to a call is better than a collision (USFA, 2014). If it 

is not possible to stop completely, the vehicle must slow down to a speed where it can be 

stopped if necessary. Drivers are encouraged to at least “cover the brake,” meaning keep 

a foot on the brake in case they need to abruptly stop. In addition, if multiple vehicles are 

travelling from the same start location to final destination, they should follow the same 

route to reduce the chance of vehicles encountering each other at an intersection. 

Recommendations

Departments should create and strictly enforce seat belt policies in alignment with 

NFPA 1500. 

Seat belts must be worn at all times when riding inside the fire apparatus. Integrate into 

the fire service culture and, more importantly, enforce seat belt pledges, policies, and 

standards of procedure. 

Follow NFPA 1915 for apparatus maintenance guidelines. Departments need to 

create and adhere to apparatus maintenance programs.

Apparatus maintenance is critical to operational functions and should be performed 

daily. Small issues can become big issues when related to safety and should be resolved 

immediately or the apparatus should be taken out of service.

Reduce speed to the legal limits and come to a complete stop at intersections when 

operating fire apparatus.

Speed is directly correlated with reduced safety, and although responding to an 

emergency, following the speed limit is better than being involved in a collision. 

Intersections are dangerous and a common place for collisions involving fire apparatus. 

Stopping or at least reducing speed at intersections is recommended for the safety of 

firefighters and civilians.

Follow NFPA 1002 guidelines to ensure apparatus operators are properly trained.

Distractions should be minimized for the apparatus operator, and personnel should be 

trained specifically for the apparatus they will be driving. 
Chapter 7: Mental Health and Suicide Among Women Firefighters 25

Chapter 7: Mental Health and Suicide 

Among Women Firefighters

It is common knowledge that firefighting is stressful. According to CareerCast (2017), 

“firefighter” ranked as the second most stressful job, just below enlisted military personnel. 

Firefighters have a plethora of varied stressors that involve family, their career, their 

gender, finances, personal health and many other stressors (Kimbrel et al., 2011; Jahnke 

et al., 2012). Exposure to occupational stress, traumatic stress, discrimination and sleep 

deprivation can contribute to cardiac issues, gastrointestinal issues, alcohol use, weight 

gain, depression, post-traumatic stress disorder (PTSD) and other stress-related reactions 

(Jahnke, Poston, Haddock, & Murphy, 2016; Sawhney, Jennings, Britt, & Sliter, 2017).

For the past 25 years, there have been a growing number of studies that explore the 

health and wellness of firefighters. While this is extremely beneficial for understanding 

and creating programs to address the overall health of firefighters, especially as it 

pertains to mental health and suicide, women firefighters’ experiences are often excluded 

or homogenized (Jahnke et al., 2012). What has been lacking is a concerted effort to 

understand the implications of these findings on women firefighters. They do the same 

jobs and are exposed to the same stressors as their male counterparts, but unique factors 

may compound these issues.

The fire service is a male-centric and hyper-masculine culture that requires women to 

navigate a hostile environment of varying degrees (Berkman et al., 1999a; Murphy, 2011; 

Khan, Davis, & Taylor, 2017). The most visible factors unique to women firefighters are 

gender-based discrimination and harassment, and despite being documented and studied 

in relation to recruitment and retention, how these impact women and their health is not 

readily known (Hulett et al., 2008).

There is a need for research on women firefighters to gather results that may inform 

health and wellness programs to address their needs and the unique circumstances they 

face. The following discussion will focus on the available research of mental health and 

suicide risks among women firefighters.

Depression

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 

(DSM-5), major depressive disorder is linked to a high mortality rate that is attributed 

to suicide (American Psychiatric Association (APA), 2013). Depression is a mood disorder 

that negatively affects an individual physically, psychologically and cognitively. Some of 

the most prominent experiences of depression include persistent sadness or emptiness, 

loss of interest, irritability, isolation, fatigue (sleep too much or cannot sleep), cognitive 

difficulties, and multiple aches and pains (APA, 2013).

The twelve-month prevalence of major depressive disorder among women is 1.5 to 3 times 

higher than men (APA, 2013). Women firefighters also reported higher rates of depression 

than male firefighters, although women firefighters had lower rates than women in the 

general population (Murphy, Beaton, Cain, & Pike, 1994).

Jahnke et al. (2012) assessed health outcomes and health risk behaviors in career and 

volunteer women firefighters. Researchers administered several self-report surveys that 

addressed the frequency of feelings and behaviors of depression, and how stressful 
26 Emerging Health and Safety Issues Among Women in the Fire Service

they perceive their lives. The participants’ responses suggested that nearly a quarter of 

career women firefighters are at risk for depression, and more than a quarter of career 

participants noted feelings of anger, nervousness and stress in the range of fairly often 

to often (Jahnke et al., 2012). For volunteer women firefighters, the frequency was lower 

with a third scoring at a high risk for depression (Jahnke et al., 2012). Despite their noted 

struggles, both groups of women felt confident in their ability to cope (Jahnke et al., 2012).

Post-traumatic stress disorder

PTSD or post-traumatic stress syndrome (PTSS) is a disorder that arises from exposure 

to traumatic stressors. The resultant symptoms involve four main categories: reliving the 

experience or trauma-associated experience, avoiding reminders of the event, having 

negative beliefs and feelings, and feeling keyed up (APA, 2013). According to the DSM-5, 

the projected lifetime prevalence of PTSD is 8.7 percent by age 75 (APA, 2013).

PTSD development depends on the type of trauma, frequency of exposure, and appraisal 

of trauma (if the trauma is not perceived as traumatic, then few reaction symptoms 

will develop). The expectation is that groups such as veterans and first responders will 

exhibit a higher rate of PTSD. However, when men and women are compared across their 

lifespans, PTSD is more prevalent in women than men (APA, 2013). The speculation is that 

women are more likely to experience traumatic events (APA, 2013).

A plethora of research has investigated the prevalence of PTSS and PTSD in first 

responders. The study findings varied in results for the rate of PTSS or PTSD found 

among first responders, which included study participants that were predominately male 

firefighters (Boffa et al., 2017).

St anle y, Hom , Sp encer-T homas 

and Joiner (2017a) investigated the 

association of PTSD and suicide 

with anxiet y sensitivit y (“ fear of 

fear”) among women firefighters. 

The most prominent finding of this 

study supports that cognitive anxiety 

sensitivity concerns are statistically 

linked to P T SD and suicide risk 

(Stanley et al., 2017a). The study 

also investigated symptom clusters 

of PTSD and the anxiety sensitivity 

concerns (global, cognitive and social). 

The results demonstrated a couple 

of important associations: First, the 

global and cognitive anxiety sensitivity 

concerns support a link between PTSD 

symptoms of re-experiencing and 

suicide risk, and second, cognitive 

anxiety sensitivity concerns statistically 

l i n k b e t w e e n P T S D , n u m b i n g 

symptoms, and suicide risk.

Overall, the results of this study are promising. The finding of anxiety sensitivity, 

specifically cognitive concerns as a link between PTSD and suicide risk, provides several 

4 Resource Break

Chaplains are of ten thought of as a 

resource for the community, but they are 

an invaluable resource to firefighters as 

well. Sometimes firefighters find it easier 

to approach a chaplain than a peer or 

mental health professional. Chaplains may 

or may not be church affiliated. If they are 

associated with a church, it is preferred 

that their activity with the fire department 

be nondenominational so they are 

approachable to all fire department and 

community members, regardless of beliefs. 

Information to start a chaplain program 

and training can be found at: https://ffc.

wildapricot.org/institute.
Chapter 7: Mental Health and Suicide Among Women Firefighters 27

intervention points (Stanley et al., 2017a). Also, the results of this study are consistent 

with previous research conducted with predominantly male firefighters. These results 

demonstrate a link between the PTSD symptom clusters of re-experiencing, numbing 

symptoms and suicide risk (Boffa et al., 2017).

Alcohol

Alcohol is culturally accepted in the U.S., and alcohol use disorder is a common problem. 

Alcohol use disorder is characterized by several factors that include drinking more than 

intended, being unable to stop drinking, continuing to drink even if it makes you feel 

worse, and drinking or being sick from drinking that impacts the home, family and/or job 

(APA, 2013). Alcohol use and associated disorders affect men more than women. Alcohol 

intoxication is a significant contributor to suicidal behavior (APA, 2013).

In the fire service, alcohol is a socially accepted vehicle for comradery and coping. A large 

study of alcohol use in firefighters (predominately male) found that alcohol consumption 

was used to cope with the effects of occupational stress and repeated exposure to 

trauma (Jahnke, Poston, & Haddock, 2014). The prevalence of alcohol use within the fire 

service is significantly higher than the general population, with more episodes of binge 

drinking (approximately 50 percent of firefighters) contributing to poor health outcomes 

(Haddock et al., 2012). In one study, 61 percent of women firefighters reported having had 

a drink within the past three days versus 46 percent of women in the general population 

(Haddock, Poston, Jahnke, & Jitnarin, 2017).

As stated in the DSM-5, alcohol is rarely the only problem. For firefighters, excessive 

drinking is most often associated with a number of mental health issues, such as 

depression, anxiety and post-traumatic stress symptoms (Carey, Al-Zaiti, Dean, Sessanna, 

& Finnell, 2012; Jahnke et al., 2014; Jahnke et al., 2016). This study on women firefighters 

supports the notion that women firefighters use alcohol to cope with occupational stress 

and trauma, just as their male counterparts do, but at a lower rate (Jahnke et al., 2014). 

Endorsement of problem drinking is also associated with reports of occupational injury 

(Haddock et al., 2017). Treating the abusive alcohol use and identifying the co-occurring 

mental health issues provides several opportunities for earlier interventions.

Suicide

Suicide is not a diagnosis but an act that is often the result of distress that overwhelms 

the individual’s ability to cope. It most often co-occurs with mental health issues, such 

as depression, anxiety, PTSD, bipolar disorder, eating disorders, certain personality 

disorders, and alcohol and substance use and abuse (American Foundation for Suicide 

Prevention, 2018).

Women in all protective services die by suicide at a higher rate than women in any other 

occupation (McIntosh et al., 2016). The high rate is likely due to several factors that may 

increase the risk for suicide which are consistent with gender-related discrimination, 

including job-related isolation and demands, stressful work environments, and work-home 

imbalance (Chetkovich, 1997; Berkman et al., 1999a; LaTour, 2008; McIntosh et al., 2016).
28 Emerging Health and Safety Issues Among Women in the Fire Service

4 Resource Break

From experts on traumatic and occupational stress of 

military, police and fire, the NFFF has developed health and 

safety initiatives, trainings and resources to aid departments 

in caring for the overall health of their members (National 

Fallen Firefighters Foundation, 2017). The culmination of the 

work sponsored by the NFFF is the Fire Service Behavioral 

Health Management Guide (NFFF, 2017).

Access this resource at: http://www.everyonegoeshome.

com/wp-content/uploads/sites/2/2017/12/behavioral-healthmgmt-guide-122017.pdf.

Clinical Support

Peer Support

Firefighters

Leadership

Fire Service 

Behavioral Health 

Management Guide

® ®

In an effort to understand women — an at-risk group — and to develop suicide screenings, 

prevention and intervention tools, Stanley et al. (2017b) investigated suicidal thoughts 

and behaviors among pre- and post-career women firefighters, along with personal 

and occupational correlates. Overall, the study found high rates of pre- and post-career 

suicidality. However, a decrease of rates of attempts and nonsuicidal self-injury was 

shown for post-career suicidality (Stanley et al., 2017b). Marital status and having children 

correlated with a decrease in the rate of career suicidality. While age had an inverse 

relationship to career suicidality, women who were younger and less experienced in the 

fire service reported higher career suicidality (Stanley et al., 2017b). Comparisons of preand post-career women firefighters’ career suicidality occurrences for all factors was less 

than a previous nationwide study comprised primarily of male firefighters (Stanley et 

al., 2017b). The results of this study are useful for developing pre-career screenings and 

prevention and intervention strategies.

Findings for the Stanley et al. (2017b) study suggested that marital status and having 

children decreased rates of career suicidality. The results are consistent with research 

on prevalence and risk factors for suicidal ideation in which gender, young age, lower 

education, and unmarried status confer risk (Nock et al., 2008). As a result, Stanley et al. 

(2017b) proposed that marital status and having children appear to be protective factors 

that decrease career suicidality.

The contrast between marriage as a protective factor and the high rate of divorce of 

women firefighters brings into question how protective marriage is for women in the 

fire service (Haddock, Jahnke, Poston, Jitnarin, & Day, 2015). While marriage of women 

firefighters, in this study, was found to decrease the rate of heavy alcohol use and 

depression, being a firefighter seems to negatively impact women’s marital status 

(Haddock et al., 2015).

Firefighters are exposed to suicide attempts and deaths at a higher rate than the general 

population, and they also have a higher rate of suicidal thoughts and behaviors, which 

suggests a correlation between the two (Stanley et al., 2015). Gulliver et al. (2016) explored 

the possible correlation directly and found evidence to support it. In conjunction with 

and in response to the positive correlation between suicide exposures and the suicidal 

thoughts and behaviors in firefighters, they proposed a standard of practice for suicide 

postvention to increase behavioral wellness of firefighters. This would consist of programs 

and interventions for survivors following a death by suicide (Gulliver et al., 2016).
Chapter 7: Mental Health and Suicide Among Women Firefighters 29

4 Resource Break

If a firefighter is struggling, reach out. The NFFF (2017) suggests the use of ACT, an 

acronym based on the U.S. Army’s Ask, Care, Escort program.

A Ask. Ask how they feel.

C Care. Demonstrate that you care with words or body language.

T Take. The best way to know that someone is getting the help they need is to 

accompany them.

Mental health effects of discrimination and harassment

Since women first entered the career fire service, unique factors have posed challenges 

for fire departments. Two handbooks were written in response to the recognized and 

expected challenges of integrating women into a male-dominated environment: “The 

Changing Face of the Fire Service: A Handbook for Women in Firefighting” (Armstrong et 

al., 1993), and “Many Women Strong: A Handbook for Women Firefighters” (Berkman et 

al., 1999b). The earlier handbook highlighted issues such as recruitment, station facilities, 

reproductive issues, childcare, hair standards, firefighter marriages, sexual harassment 

and diversity (Armstrong et al., 1993). The latter handbook included topics addressed in 

the earlier handbook in addition to training, physical fitness, equipment and protective 

gear (Berkman et al., 1999b).

Despite the two decades that have passed since these books were written, far too many of 

these issues persist even today and have been the subject of discrimination suits brought by 

women firefighters against their departments. Most often discrimination and harassment is 

presented in terms of legal impact and financial costs, but it has a significant psychological 

cost on the target and observers. It may not occur immediately but often develops slowly 

over time. Women in the fire service have identified a number of discriminatory and 

harassing incidents, ranging from overt physical and verbal attacks to denigrating jokes 

and pranks (Murphy, 2011). With the exception of the more overt attacks, the participants 

stated that the constant little jabs wore them down over time (Murphy, 2011).

Symptoms of discrimination and harassment are physical, cognitive and psychological. 

Women firefighters claimed to experience the following psychological symptoms as 

a result of discrimination or harassment: anxiety, fear, paranoia, agitation, crying, 

depression, self-doubt, irritability and nightmares (Murphy, 2011). Cognitive symptoms 

included difficulty with concentration and decisions, forgetfulness, and increased mistakes 

(Murphy, 2011). The physical symptoms shared by women firefighters included increased 

heart rate and blood pressure, physical agitation, tremors, sweats, chest tightness, 

insomnia, headaches and stomachaches (Murphy, 2011).

Participants shared that they used several coping strategies, but concerningly most of the 

participants stated that they drank alcohol to relax or decompress (Murphy, 2011). These 

symptoms are consistent with traumatic stress response, depression, anxiety, PTSD and 

alcohol use. While no participant in the Murphy (2011) study expressed suicidal ideations, 

the resultant mental health issues increase the risk of suicide. Stanley et al. (2017b) found 

similar results in their study investigating the association between harassment, suicidality 

and psychiatric symptoms among women firefighters.
30 Emerging Health and Safety Issues Among Women in the Fire Service

For more on the discrimination and harassment of women in the fire service, see “Chapter 

8: Discrimination, Harassment, Bullying and Inclusion Issues.”

Summary

Firefighters are at increased risk for PTSD, alcohol abuse and suicide, regardless of sex, 

although women in protective services were identified to have the highest rate of death by 

suicide. There are a number of risk factors that contribute to mental health problems and 

suicide, and some risk factors are more salient for women, including job-related isolation, 

job demands, stressful work environments and work-home imbalance (McIntosh et al., 2016).

Most of the listed risk factors can be attributed to three main factors: personal, 

occupational and fire service culture. The personal factors include increased prevalence 

of depression and anxiety, particularly for women (APA, 2013); a higher divorce rate for 

women firefighters (Jahnke et al., 2012); stigma against mental illness; and barriers to 

seeking help (Mardikar et al., 2013; Hom, Stanley, Ringer, & Joiner, 2016). The occupational 

factors include exposure to another’s physical and mental pain, knowing a victim of suicide 

(Harvey et al., 2016; Kimbrel et al., 2011), and exposure to hazardous environments. The 

fire service culture factors include issues that are particularly salient for women, such 

as isolation, exclusion or loss of comradery (no room in the brotherhood) and varying 

degrees of harassment (Hulett et al., 2008; Mardikar et al., 2013; Murphy, 2011).

Therefore, it is in the best interest for fire service organizations to implement programs 

that address all contributing factors, including discrimination and harassment.

Recommendations

Create a comprehensive behavioral health policy that addresses mental health and 

alcohol issues within the fire service.

Define who the program will serve, and identify leaders within the ranks to champion the 

behavioral health program within the department. The behavioral health program should 

include several components:

ĵ Membership support at all levels, especially the leadership.

ĵ Ongoing education on behavioral health issues.

ĵ Self-care practice.

ĵ Peer support team.

ĵ Chaplain program.

ĵ Clinical support.

Ensure that all members of the fire department understand the expectations and goals 

of the program, especially confidentiality. Firefighters cite several reasons for not seeking 

mental health care, including embarrassment, harm to one’s reputation, fear of special 

treatment by peers, concerns for appearing weak, and loss of reputation (Hom et al., 

2016). Despite the cited reasons, firefighters with severe mental health issues did seek 

help but still held those beliefs (Hom et al., 2016).

In developing a peer support program, it is necessary to engage a mental health 

professional to oversee and provide support for the peers. Members should be chosen 

carefully and should be approachable by most members of the department. They 

need to be properly trained and have ongoing training. They need to be healthy, both 

mentally and physically, because they need to be able to help in traumatic and high-stress 
Chapter 7: Mental Health and Suicide Among Women Firefighters 31

situations. They also need to be available for other stressors that department members 

may encounter. Have the peers be visible and easy to access. Peers also need to clearly 

understand confidentiality and when it may be broken (NFFF, 2017). Also ensure that peer 

support team members know where to refer affected individuals.

Research supports the use of certain work recovery strategies to mitigate development 

of mental health symptoms after stress exposure (Sawhney et al., 2017). These strategies 

should be included in a comprehensive behavioral health management program. A few 

strategies that help mediate occupational and traumatic stressors and mental health 

symptoms are: work-related talks, time with coworkers/supervisors, exercise, recreational 

activities, relaxation, and mastery experiences (Sawhney et al., 2017).

4 Resource break

Firefighters benefit from mindfulness meditation and yoga. Firefighters who 

practiced mindfulness reported fewer symptoms of PTSD, depression, physical aches 

and pains and alcohol problems (Smith et al., 2011). Kaplan, Bergman, Christopher, 

Bowen, & Hunsinger (2017) found support for the efficacy of Mindfulness-Based 

Resilience Training for increased stress resilience and reduced burnout. The results 

suggest that mindful meditation helps build resilience and contributes to better 

stress management (Kaplan et al., 2017). Yoga has also proven effective in helping 

firefighters; perceived PTSD symptoms decreased after just four yoga classes, and a 

measurable improvement on functional movement was shown (Cowen, 2010).

If the resources are available, it is strongly urged to include family members in the 

behavioral health program (Gulliver et al., 2016; NFPA, 2018).

A final component of a behavioral health program is having clinical support. When seeking 

clinical support, a decision needs to be made regarding how the clinician will be integrated 

into the fire department. Larger departments with a comprehensive behavioral health 

program may want to employ a clinician full time, while other departments may contract 

with a clinician and use them as needed (for training, consulting and/or therapy). Ensure 

that any individual or group that works with your department understands the fire 

service culture and the unique factors facing women firefighters, namely the impact of 

discrimination and harassment (Murphy, 2011). 

Conduct psychological testing at the time of hiring to establish a baseline and 

identify possible mental health risks. Follow up with annual psychological 

screenings along with fitness screenings, and consider conducting full psychological 

evaluations at periodic intervals to track changes to allow earlier interventions for 

alcohol use, mental health issues, and suicidality. Ensure resources are available 

for team members.

A study on pre-career and career prevalence rates of suicidal thoughts and behaviors of 

women firefighters noted that women who endorsed suicidal thoughts and behaviors 

pre-career were at increased risk for suicidal thoughts and behaviors later in their career 

(Stanley et al., 2017b). The information from these evaluations or screenings should not 

be grounds to reject a potential employee or dismiss a current one, but instead should be 

used proactively to promote health, prevention and interventions (Stanley et al., 2017b). 
32 Emerging Health and Safety Issues Among Women in the Fire Service

4 Resource Break

Post mental health awareness resources around the firehouse and remind 

firefighters monthly of the resources available.

The NVFC’s Share the Load program is a free program to career and volunteer 

departments that provides access to critical resources to help first responders and 

their families. The program includes the Fire/EMS Helpline, which is a no-cost 24-hour 

service to provide assistance with issues such as stress, PTSD, addiction, etc.

ĵ Fire/EMS Helpline — 1-888-731-FIRE (3473).

ĵ Share the LoadTM videos and print resources addressing warning signs and how 

to seek assistance are also available at no cost.

Access this resource at https://www.nvfc.org/programs/share-the-load-program/.

The IAFF has created an Online Behavioral Health Awareness Course. Designed 

specifically for fire service members, this online self-paced course provides an 

overview of a range of mental and behavioral health topics, including strategies for 

maintaining emotional wellness. It is open to all firefighters, whether a member or not. 

Access this resource at: http://client.prod.iaff.org/#page=behavioralhealth.

Reduce the stigma associated with mental health in the fire service through 

education and open dialogue.

Reducing stigma in the fire service means talking about mental health and education 

and normalizing stress reactions (Moffitt, Bostock, & Cave, 2014). Educate all members 

throughout their careers to recognize mental health signs, symptoms and risk factors. Apply 

the same concept for firefighter mental health as for apparatus and equipment checks.

When mental health issues are suspected, a direct nonjudgmental conversation in a 

nonthreatening and private location should occur. Offer objective evidence as to what 

behaviors have been observed. Provide prevention and intervention strategies, suited 

to short-term modifiable risks, specific to the individual and the department (Franklin et 

al., 2017).

Identify local resources, and become involved in local and state government, to gain 

support for policies that benefit firefighters who are impacted by mental health issues. 

The research has provided a number of needed interventions to mitigate the impact of 

the cumulative effects of traumatic and occupational stressors. In the general population, 

there are a number of treatments for disorders related to stress reactions — such as 

PTSD, depression and alcohol use — but only a few studies have examined interventions 

specific for the fire service. 
Chapter 7: Mental Health and Suicide Among Women Firefighters 33

Recognizing suicide warning signs in firefighters and emergency 

medical technicians

Behavioral health is a key component of an overall firefighter health and wellness 

program. Unfortunately, it is a difficult subject to discuss — many factors affect a 

firefighter’s ability to understand when a fellow brother or sister is suffering, but 

that does not make it any less critical an issue.

By far, the number one comment by fire and EMS chiefs associated with 

departments that have suffered a loss is that they did not realize or recognize the 

warning signs that their member was displaying until after the loss had occurred.

The Firefighter Behavioral Health Alliance (FBHA) tracks and validates firefighter 

and EMT suicides in the United States. FBHA has traveled across North America 

presenting behavioral health workshops with an emphasis on suicide awareness.

Top five suicide warning signs — Think RAILS

R Recklessness/ 

Impulsiveness

These might be subtle signs such as purchasing guns 

when a person has always been against them, riding a 

motorcycle recklessly, or charging into burning buildings 

against policy or procedure.

A Anger Suppressed anger or explosive anger from seemingly 

minor issues can be a dangerous sign. Displacement 

(directing one’s anger at someone else instead of the 

intended person) is often observed. Displacement is 

most often directed at a firefighter or EMT’s family.

I Isolation Becoming distant from their career company around the 

station or volunteer firefighters who do not participate 

in drills or calls as much. Members might even display 

isolation around their family. They lose interest in family 

activities.

L Loss of confidence 

in skills/abilities

Several firefighters and EMTs have advised FBHA they 

lost confidence in their ability to get the job done due 

to concentrating on emotional or personal issues they 

were battling. A seasoned team member who cannot 

remember how to put an engine in gear to pump is an 

example.

S Sleep deprivation Loss of sleep can indicate stress, anxiety, post-traumatic 

stress or several other emotional issues a member 

might be struggling with and not realize.

For more information, visit: http://www.ffbha.org/.
34 Emerging Health and Safety Issues Among Women in the Fire Service
Chapter 8: Discrimination, Harassment, Bullying and Inclusion Issues 35

Chapter 8: Discrimination, Harassment, 

Bullying and Inclusion Issues

Harassment and discrimination are challenges in organizations throughout the U.S., and 

the fire service is no exception. Women face discrimination and harassment in the fire 

service, and it impacts not only recruitment and retention of women firefighters but also 

their physical and mental health (Murphy, 2011; Hulett et al. 2008).

Harassment and discrimination have no place in the fire service. From unwanted sexual 

attention, sexist comments, bullying, hazing, exclusionary practices based on gender, to 

rape, harassment is not only illegal; it has financial impacts as well. Employers may be 

held liable for actions, even if they were not aware of an incident. These behaviors may 

cause a negative financial impact, stress, decreased productivity, and high turnover rates 

(McDonald, 2017).

In a study of gender differences of occupational stressors experienced by firefighters, male 

and female participants identified the same top-five stressors: wage/benefit concerns, job 

skill concerns, sleep disturbance, substandard equipment, and safety concerns (Murphy 

et al., 1994). The biggest difference was that discrimination was ranked sixth by women 

firefighters and was not relevant for the men (Murphy et al., 1994). Murphy et al. (1994) 

suggested that the prominence of discrimination for women may actually be an important 

mediating factor for some of the stressors that the women identified.

Culture of the fire service

In 2016, the Equal Employment Opportunity Commission (EEOC) released a report of 

workplace harassment, that noted women in male-dominated occupations are at a greater 

risk of harassment (Feldblum & Lipnic, 2016).

The culture and traditions of the fire service create institutional barriers that 

disproportionately affect women, including:

ĵ Bunkroom and bathroom configurations (not having appropriate facilities, not allowing 

privacy, controlling access time) (Yoder & Aniakudo, 1997).

ĵ Recruiting and testing (lowering the physical standard, not training at all, or over-training).

ĵ Equipment and personal protective gear (not made available, poor quality, or too big) 

(LaTour, 2008).

ĵ Outdated policies.

The old adages, “that’s how it has always been done” or “it’s always been that way” are 

often used as excuses for failing to update policies and practices.
36 Emerging Health and Safety Issues Among Women in the Fire Service

Harassment and discrimination against women firefighters

Women firefighters have repeatedly described discrimination and harassment as key 

barriers to having more women in the fire service and as the most impactful stressors they 

deal with on the job (Hulett et al, 2008; Murphy, 2011). Women in the fire service share: 

“I have experienced different treatment because of my gender”; “I have encountered 

ill-fitting equipment”; and “My gender has created barriers to my career development” 

(Hulett et al., 2008). Additional discriminatory practices experienced by women in the fire 

service include:

ĵ Being shunned or isolated (Hulett et al., 2008).

ĵ Lacking privacy while changing, showering, and using the bathroom (Hulett et al., 2008).

ĵ Training denials or differences (Hulett et al., 2008).

ĵ Exclusion from firehouse relationships (both inside and outside of work) (Yoder & 

Aniakudo, 1997) and isolation at work (Murphy, 2011).

ĵ Lack of social support (Murphy, 2011).

ĵ More severe discipline than male counterparts (Murphy, 2011).

ĵ Lack of promotional opportunities (Murphy, 2011).

ĵ Disregard for competencies (Yoder & Aniakudo, 1997).

ĵ Highlighting mistakes made by women and enforcing a double standard (Yoder & 

Aniakudo, 1997).

ĵ Unwillingness to accommodate special physical needs (e.g., allowing different 

biomechanical techniques to raise a ladder) (Yoder & Aniakudo, 1997).

Such acts of discrimination toward women firefighters can negatively impact mental 

health, which in turn can result in lower retention rates of women firefighters. Women 

firefighters experiencing negative attitudes from male counterparts may experience lower 

job satisfaction due to a poor work environment. Compared to their male counterparts, 

women firefighters are at risk for higher anxiety, exposure to sexism, and higher levels of 

conflict in the workplace (McDonald, 2016).
Chapter 8: Discrimination, Harassment, Bullying and Inclusion Issues 37

What to do if being harassed

Fire department employees or volunteers who are the victims of harassment should:

ĵ Confront their harasser ONLY if they are comfortable doing so.

ĵ Know the department’s policies and procedures for filing a complaint.

ĵ Immediately notify their supervisor or their supervisor’s superior if their supervisor 

is the harasser.

ĵ Document the incident to include time, place, actions and witnesses.

ĵ Immediately notify police if the behavior involves criminal behavior such as 

attempted rape, rape, battery or sexual assault.

ĵ Contact their employee assistance program.

ĵ File a formal complaint with the Federal EEOC or with their state or local fair 

employment practices agency.

ĵ Consult an attorney if harassment continues or they are not confident in the 

internal remedies, or if they are retaliated against for filing a complaint (Berkman 

et al., 1999a).

Sexual harassment and the decision to take action can be very stressful. If the 

department offers an employee assistance program, consider using it. Victims 

should try not to place blame on themselves. No one has to tolerate, on or off duty, 

sexual harassment, assault, hazing or bullying.

Workplace violence, bullying and the impact to women firefighters

Workplace bullying has been described as a counterproductive workplace behavior that 

includes mistreatment and abuse. The U.S. Department of Labor (DOL) indicates almost two 

million Americans report being a victim of workplace violence annually. The DOL defines 

bullying as any act or threat in the workplace that may include physical violence, harassment, 

intimidation, or disruptive behavior that is threatening. Bullying behaviors may range from 

subtle behaviors that include excessive work assignments, jokes and gossiping to extreme 

behaviors such as violence, aggression, 

threats and insults (Samnani, 2013). 

Unfortunately, public service workers, 

and thus first responders, are at a 

higher risk for workplace violence as 

compared to those in other professions 

(McDonald, 2017).

Women firefighters are not exempt 

from workplace bullying, and the 

impact on women can differ from 

their male counterparts. Workplace 

violence directed toward women 

is usually subtle. Female victims of 

bullying often experience a greater 

amount of health issues and long-term 

sicknesses (Mundbjerg Eriksen, Hogh, 

& Hansen, 2016).

4 Resource break

The IAFC Safety, Health and Survival 

Section partnered with a number of 

organizations, such as Women in Fire and 

Cumberland Valley Volunteer Firemen’s 

Association, to create a bullying and 

workplace violence prevention toolkit. 

The toolkit is a collection of policies, 

articles and resources to prevent bullying 

in the workplace. 

Access this resource at https://www.iafc.

org/topics-and-tools/resources/resource/

bullying-and-workplace-violenceprevention-toolkit.
38 Emerging Health and Safety Issues Among Women in the Fire Service

Workplace bullying goes beyond an individual; it may also lead to negative consequences 

for a fire department’s reputation (McDonald, 2017). Organizations that have a bullying 

presence often experience high rates of turnover and legal involvement. Community 

support can also be greatly reduced from the negative attention bullying can bring. There is 

a high impact from bullying to both human and financial resources within a fire department. 

To reduce the impact bullying has on an individual and an organization, it is critical for 

department leadership to be proactive. Bullying can be reduced by implementing clear 

workplace rules and policies, offering formal training to all employees on workplace 

violence and department policies, establishing a formal process for management and 

resolution of bullying, and implementing a mentoring program (McDonald, 2017).

Sexual harassment

Federal law defines sexual harassment as “unwelcome sexual advances, requests for 

sexual favors, and other verbal or physical conduct of a sexual nature” when

ĵ Submission to such conduct is made either explicitly or implicitly a term or condition 

of an individual’s employment.

ĵ Submission to or rejection of such conduct by an individual is used as the basis for 

employment decisions affecting such individual.

ĵ Such conduct has the purpose or effect of unreasonably interfering with an individual’s 

work performance or creating an intimidating, hostile or offensive working environment 

(Equal Employment Opportunity Commission, n.d.).

Harassing behavior takes various forms: verbal, nonverbal and physical. Examples 

of verbal harassment include whistling, sexual comments, requests for sexual favors, 

repeatedly asking someone on a date, and repeatedly asking about one’s sex life (Berkman 

et al., 1999). Nonverbal forms of harassment include touching oneself sexually, staring, 

blocking one’s path, and giving unwanted gifts (Berkman et al., 1999). Physical harassment 

can range from touching, patting, squeezing, pinching, brushing against, or cornering, to 

physical aggression (Berkman et al., 1999a).

Sexual harassment is a power play 

that is degrading, humiliating and 

intimidating to its victims (Berkman et 

al., 1999). It is based on aggression and 

hostility, not sexual desire (Berkman 

et al., 1999). Often its victims feel 

powerless against it. There are two 

forms of sexual harassment found in 

the fire service. Quid pro quo involves 

demands for sexual favors in return 

for employment benefits; the conduct 

is a condition of employment or can 

be used as a decision for employment 

(Berkman et al., 1999). The other form is hostile-environment harassment which targets 

gender and makes the workplace hostile and threatening; the purpose is to interfere with 

one’s work performance (Berkman et al., 1999a). 
Chapter 8: Discrimination, Harassment, Bullying and Inclusion Issues 39

According to a 1995 WFS survey, 88 percent of career women firefighters and 83 percent 

of volunteer women firefighters had been subjected to one or more of the following types 

of harassment at some point during their work in the fire service:

ĵ Unwelcome requests or demands for sexual favors from coworkers or supervisors.

ĵ Unwelcome physical contact.

ĵ Sexually explicit or derogatory posters, photographs, or cartoons present or posted 

in the workplace that were offensive.

ĵ Sexually explicit or derogatory movies or videotapes shown in the workplace that 

were offensive.

ĵ Sexual or sexist jokes or comments that were offensive (Berkman et al., 1999a).

Most of the harassment was ongoing, with 71 percent of career women firefighters and 

59 percent of volunteer women firefighters experiencing the behavior at the time of the 

survey. Quid pro quo harassment was previously thought to be relatively uncommon 

in the fire service. However, 25 percent of career women firefighters and 30 percent of 

volunteer women firefighters reported experiencing unwelcome requests or demands for 

sexual favors in connection with their work or volunteer service (Berkman et al., 1999a).

4 Resource break

In 2014, Women in Fire and the IAFC delivered a public service announcement 

against sexual harassment and sexual assault in the fire service. The message 

states that sexual assault is “inconsistent with the values of the fire service and will 

not be tolerated” (Women in Fire, n.d.). The organizations challenged all leaders to 

foster a true climate of trust and respect. This video can be found at https://www.

womeninfire.org/sexual-harassment/.

Lack of reporting

Women firefighters may be particularly vulnerable to occupational stress and are more 

likely to encounter barriers to receiving help (Mardikar et al., 2013). The EEOC estimates 

that up to 75 percent of workplace harassment goes unreported (Feldblum & Lipnic, 

2016). The most commonly cited reasons for not reporting are: fear of losing one’s job or 

credibility, retaliation, getting a colleague in trouble, being embarrassed, and/or not being 

believed (Feldblum & Lipnic, 2016). Due to these fears, and the belief that reporting would 

do no good and make things worse, victims often suffer in silence (Feldblum & Lipnic, 

2016). There is a lack of faith that management will do anything to stop the problem. 

Additionally, the more the victim depends on their income, the more likely they are to put 

up with harassment.

Chief officers often overlook discriminatory practices. Therefore, women firefighters who 

experience harassment and/or discrimination also must endure a lack of management 

support, fear of social consequences, and fear of a confidentiality breach (Mardikar et al., 

2013). This is particularly concerning due to the significant impact of discrimination and 

harassment on mental and physical health.
40 Emerging Health and Safety Issues Among Women in the Fire Service

Recommendations

The culture of the fire service must change to be more inclusive of women.

A proposed strategy for cultural change includes these five elements (Hulett et al., 2008; 

Mardikar et al., 2013; Murphy, 2011):

1. The commitment of top leadership such as the fire chief, mayor and commissioners.

2. Accountability and monitoring that includes rewards and consequences to ensure 

mid-level leaders maintain equity in their departments.

3. Knowledgeable human resource management to provide objective, transparent, and 

performance-based procedures to minimize the impact of biases that affect hiring, 

promotions and assignments.

4. Establishment of a zero-tolerance policy for discriminatory and harassing behaviors, 

including bullying, applied equally to everyone. Provide relevant, ongoing training.

5. Sustained and consistent effort to change the culture.

Cultural change needs to come from the top down. Company officers must support the 

policies and exhibit fair treatment to all members under their command (Berkman et al., 

1999a).

Every department should adopt a clearly written zero-tolerance policy against 

discrimination, harassment and bullying for all. Provide ongoing education on the 

policy, and be proactive and accessible to all.

Fire service leaders should take a proactive approach to stopping harassment in their 

departments through the following actions (Berkman et al., 1999a):

ĵ Adopt written policies with clearly defined expectations and discipline that prohibit 

discrimination and harassment.

ĵ Provide a confidential step-by-step process to file complaints within the department.

ĵ Provide resources for filing complaints outside of the department.

ĵ Educate all members on sexual harassment, bullying and hazing.

ĵ Support people who file complaints of harassment.

ĵ Handle complaints promptly and confidentially.

ĵ Prevent retaliation against people who file complaints.

Education should be ongoing, not incident driven. Education on what constitutes 

discrimination and harassment, and the physical and mental health impacts, should be 

conducted on a regular and consistent schedule.
Chapter 9: Firefighter Cancer and the Woman Firefighter 41

Chapter 9: Firefighter Cancer and the 

Woman Firefighter

Cancer incidences among firefighters have shown to be higher than that of the general 

population. There is concern about cancer among women firefighters; however, the small 

proportion of women in the fire service has confounded researchers and resulted in a lack 

of knowledge regarding cancer and women firefighters. Also, due to small sample sizes, 

many studies do not include women, or they are unable to report on cancer statistics 

among women firefighters. The resulting knowledge gaps may have lasting health impacts 

on the community of women firefighters.

Studies that have evaluated cancer risk among women firefighters suggest that women 

firefighters, like their male coworkers, may be at an elevated risk for overall cancer 

incidence (Daniels et al., 2014). These studies also suggest that women firefighters may be 

at an elevated incidence risk for breast (Daniels et al., 2014), cervical, thyroid (Ma, Fleming, 

Lee, Trapido, & Gerace, 2006) and bladder cancers (Daniels et al., 2014).

Given the knowledge gaps regarding women firefighters’ risk for these cancers, the 

data from male firefighters indicate areas for future research to assess risks for 

women firefighters. Despite these knowledge gaps, there remains enough evidence 

regarding cancer incidence and mortality in the firefighter population to advocate for a 

precautionary approach and, therefore, for action to protect women firefighters’ health.

In addition to studies on cancer risk among firefighters, a small but growing body of 

research examines firefighters’ exposures to toxic chemicals, including carcinogens and 

hormone disruptors, on the fire ground, in stations, and from their gear. Exposure to 

carcinogenic chemicals and hormone-disrupting chemicals do not discriminate on the 

basis of sex or gender. Exposure to these chemicals may be mitigated through protective 

equipment, firehouse design and structural changes. Recommendations must be tailored 

to specific fire department needs and culture to be effective.

This chapter examines the published, peer-reviewed data regarding cancer incidence 

and mortality among firefighters. Specific attention was given to women firefighters 

and cancer, reproductive cancers in 

male firefighters, suggestive data 

for male firefighters, and specific 

cancers. The exposure risks faced by 

firefighters are detailed to suggest 

causation and association while also 

providing a framework for necessary 

improvements. Lastly, the suggested 

i n t e r v e n t i o n t a c t i c s p r o v i d e a 

framework for both exposure and 

cancer risk reduc tion as well as 

workforce empowerment in the face 

of health concerns.

4 Resource break

The Firefighter Cancer Support Network 

(FCSN) provides one-on-one mentoring 

and assistance to firefighters diagnosed 

w i t h c a n c e r. F C S N a l s o p r o v i d e s 

awareness and prevention training. 

Access this resource at: https://

firefightercancersupport.org/.
42 Emerging Health and Safety Issues Among Women in the Fire Service

The evidence

Overall cancer incidence in firefighters

Several studies have investigated overall cancer incidence and mortality in the firefighter 

population; however, very few studies include women firefighters in their sample or report 

statistics on this population. The two studies that did report on overall cancer incidence 

among women firefighters indicated a significant increased incidence of 24 to 63 percent; 

however, only one study was statistically significant (Ma et al., 2005; Daniels et al., 2014).

Three out of five studies that looked at overall cancer incidence in male firefighters found 

statistically significant elevations, ranging from 6 to 85 percent higher risk. Of those five 

studies, only two of them report statistics for cancer incidence for women firefighters. 

These data suggest elevated incidence for women firefighters (Ma et al., 2005; Daniels et 

al., 2014); however, their confidence intervals are wide because the number of women in 

each study is small. For this reason, it cannot be concluded whether nonspecific cancer 

incidence is significantly elevated in the women firefighter community.

Half of the studies that measure overall cancer mortality in the firefighter population 

indicate elevated mortality from 10 to 73 percent for male firefighters. Only one published, 

peer-reviewed study that addresses similar concerns among women firefighters was 

found, but the Daniels et al. (2014) study does not indicate elevated cancer mortality for 

women firefighters. This conclusion is not definitive because a wide confidence interval 

accompanies this finding.

Risk for specific cancers in women firefighters

Data assessing specific cancer incidence and mortality provide evidence for elevated 

incidence of cervical, thyroid (Ma et al., 2005), breast and bladder cancer (Daniels et al., 2014). 

Statistics concerning cervical and thyroid 

cancer report elevated incidence for 

both cancers (Ma et al., 2005). Cervical 

cancer incidence is more than four times 

higher in women firefighters; likewise, 

thyroid cancer incidence is nearly three 

times higher in women firefighters (Ma 

et al., 2005). Despite these significantly 

elevated incidence statistics, the ability 

to draw meaningful conclusions about 

the degree of significance of such 

incidence is thwar ted due to wide 

confidence intervals.

Furthermore, breast and bladder cancer data may suggest increased incidence and 

mortality for both cancers, while wide confidence intervals also raise questions about 

the degree of significance of these findings (Daniels et al., 2014).

While Daniels et al. found that over half of cancer cases diagnosed in women firefighters 

are breast cancers, with left-sided disease being more common, potential confounding 

variables in the research create a significant degree of doubt which may suggest that 

incidence is not elevated in this population (2014). Evidence also more firmly suggests 

elevated bladder cancer incidence and mortality, but wide confidence intervals inhibit the 

ability to perform sound assessments of the degree of significance (Daniels at al., 2014).
Chapter 9: Firefighter Cancer and the Woman Firefighter 43

Reproductive cancers are also of interest because elevated incidence and mortality 

may be associated with exposures to endocrine-disrupting chemicals in the firefighter 

population. Endocrine-disrupting chemicals could result in elevated incidence and 

mortality for reproductive cancers among women firefighters as well. This hypothesis is 

supported by the Ma et al. and Daniels et al. studies which indicate elevated breast and 

cervical cancer in women firefighters. Data should be employed to design more thorough 

studies of specific cancers in women firefighters to address concerns about reproductive 

cancers across the firefighter population.

Factors that impact exposures

There are several difficulties when attempting to assess exposure in the firefighting 

community. One such difficulty is that firefighters face several types of chemical exposures 

due to different kinds of fires, varying roles in the workplace, and duration of service.

Exposure impacts are also complicated by several factors, such as interactions between 

different chemicals and interactions between harmful chemicals and biological factors in 

different bodies both due to behaviors and biological history.

Certain aspects of firefighters’ work culture may compound chemical exposure risk factors, 

including shift work, stress and trauma exposure. Individual behaviors such as smoking 

cigarettes, drinking alcohol and chewing tobacco may also compound risk factors presented 

by occupational chemical exposure. As a group, it was found that rates of binge drinking 

(Haddock et al., 2017), cigarette smoking and tobacco chewing (Jitnarin, Poston, Haddock, 

Jahnke, & Day, 2015) were high for firefighters and impact this population’s health.

Several studies have attempted to assuage confounding factor concerns by assessing 

methods to stratify the firefighter population by fire time or by work role. Austin, Dussault 

and Ecobichon (2001) assert that failure to sort firefighters into groups based on exposure 

times may have resulted in underestimates of firefighter cancer incidence among groups 

of particularly high risk (Austin et al., 2001). 

4 Resource break

Preventing exposure to carcinogens is key on the fireground and in the workplace. 

A few practical measures firefighters can take to limit exposures are:

ĵ Gross decontamination.

ĵ Wiping down skin post fire.

ĵ Doffing and containing gear.

ĵ Showering post incident.

The Kent Fire Department and the Washington State Council of Fire Fighters created 

a best practices guide for reducing firefighter risk of exposure to carcinogens. 

“Healthy In, Healthy Out” is a well-rounded resource that provides education in 

regards to taking these preventative measures.

Access this resource at: http://www.wscff.org/2016%20Postings/Health%20In-Out.pdf.
44 Emerging Health and Safety Issues Among Women in the Fire Service

Recommendations

Develop and study firefighter cancer prevention programs that reduce risk factors 

for cancer and limit exposure to known carcinogens.

To reduce cancer risks, implement programs that also reduce other risk factors and 

improve overall firehouse health. These programs would address nutrition, exercise, 

tobacco use, alcohol use and mental health. 

For example, Frattaroli et al. (2013) studied a health program adopted by 98 volunteer 

firefighters to combat cardiovascular disease, another condition of concern within the 

firefighter population. This program invested in individual, workplace and community 

measures to curb health concerns. The study highlighted the ways in which some 

intervention tactics require community outreach and cultural shifts, whereas some simply 

require the availability of physical resources. Scales, microwaveable bowls, books and 

an electric grill were purchased for this study and yielded meaningful change for the 

firehouse (Frattaroli et al., 2013).

Invest in additional, high-performing protective gear and firehouse supplies in order 

to reduce exposures.

Physical and fiscal resources play into other prevention tactics. The importance of 

providing adequate protective gear for all body types and fostering a work culture that 

supports their usage cannot be stressed enough. During fires, well-fitting masks and 

other PPE are a must, as is their accessibility. Properly fitting gear for female firefighters 

is essential. This could potentially impact the ability to work safely, for instance, ill-fitting 

bunker gear may have gaps that could act as bellows during movement, drawing in toxic 

materials. In a 2011 qualitative study of the experiences of women firefighters, multiple 

women firefighters indicated that gear, such as boots, bunker pants, and breathing 

apparatuses, was maladapted to their body shapes (Sinden et al., 2013). One woman 

firefighter asserted, “They have female gear out there, but we don’t have it” (Sinden et 

al., 2013).

Many concerns have also been raised about firefighters’ exposure when they are at their 

most vulnerable — after a fire while wearing or handling heavily contaminated gear, 

and at the firehouse while wearing no gear at all. After fires, simple supplies, such as 

an extra set of turnouts, cleaning wipes, a change of clothes on the rig and storage for 

contaminated gear, can reduce the amount of time a firefighter spends in the presence 

of contaminated clothing. In the firehouse, diesel extractors and washing extractors can 

inhibit contamination. Allocating space away from the apparatus floor for living quarters 

would also decrease exposure in the firehouse while not wearing protective equipment.
Chapter 10: Opportunities for Future Research 45

Chapter 10: Opportunities for Future 

Research

Evidence on health and safety issues among women firefighters has only recently been a 

focus of study, and the results are trickling in. Further research involving larger samples of 

women in the fire service are needed in order to generalize results to women firefighters. 

The following are areas of interest to the health and safety of women firefighters.

Injuries among women in the fire service

The NFPA annual report of firefighter injuries is based on information collected from its 

National Fire Experience Survey, which does not collect information on gender (Haynes 

& Molis, 2017). In 2016, the NFPA published a study of firefighter fireground injuries 

based on NFIRS data collected from 2010 to 2014 (Campbell, 2017). This dataset included 

gender information, but because of the relatively low proportion of women firefighters 

represented (3 percent of career, 7 percent of volunteer), further characterization of 

injuries among women was not conducted. Other variables of interest, such as cause 

of injury, nature of injury, etc., were not stratified by gender. This represents a missed 

opportunity to better understand fireground injuries among women in the fire service 

and to adapt gear and PPE to better meet the needs of women in the fire service.

Cancers affecting women firefighters and the exposures that cause them

While there has been increased attention given to research of cancers affecting 

firefighters, the data is limited in regards to women firefighters. Evidence would suggest an 

increased rate of incidence and mortality from reproductive cancers in male firefighters. 

Specifically, there has been documentation shown that testicular and prostate cancer are 

of higher incidence (Bates, 2007). Findings show increased cervical cancer in the women 

firefighter population, with incidence of more than four times higher than the general 

population (Ma et al., 2005). Elevated incidence and mortality of reproductive cancers may 

be associated with exposure to endocrine-disrupting chemicals. With the potential that 

these chemicals could affect women firefighters, further research needs to be done to 

find out more about the health concerns. Ultimately, overall nonspecific cancer incidence 

and mortality must be more thoroughly examined to make meaningful assessments of 

cancer trends in the women firefighter community. To better distill meaningful data, larger 

sample sizes stratified by workplace role and/or duration of service are necessary.

The effect of serving as a firefighter on a woman’s reproductive health

With a better understanding of how the fire service may affect fertility and pregnancy among 

women firefighters, resources for this population can be improved to better support women.

The effect of improperly fitting protective gear for women firefighters

Studies show that ill-fitting gear is a barrier for women to be successful. The lack of 

proper PPE may also lead to injuries and an increased exposure to harmful chemicals. To 

better understand the PPE requirements of women firefighters, there is a need for future 

research of sizing needs for career and volunteer women firefighters. There is also a need 

for comparison of proper sizing needs to the NFPA sizing standards, an understanding 

of the best method for measuring women for properly fitting gear, and availability of 

properly fitting gloves and turnout gear.
46 Emerging Health and Safety Issues Among Women in the Fire Service

Recruitment, retention and promotion for women in the fire service

Another area to examine is promotional opportunities for women firefighters compared 

to their male counterparts. Improved tracking of career and volunteer firefighters in 

regards to rank and gender would greatly assist in deepening the understanding of 

women’s needs for leadership development, recruitment and retention resources across 

the board. This would also give an opportunity to review standards of practice that affect 

healthy work environments.
References 47

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54 Emerging Health and Safety Issues Among Women in the Fire Service
Appendix A: Resources 55

Appendix A: Resources

Candidate Preparation Guide for the Candidate Physical Ability Test

The California Fire Fighter Joint Apprenticeship Committee has produced a Candidate 

Preparation Guide for the Candidate Physical Ability Test (CPAT). The guide offers five 

training programs for the CPAT:

1. Flexibility & Warm-Up Exercises.

2. Weight Training Circuit Workout.

3. Calisthenics Circuit Workout.

4. CPAT Running Program.

5. Task-Specific Exercise Training.

Dan Kerrigan and Jim Moss developed Firefighter Functional Fitness, a program that 

incorporates equipment that already exists in the fire department into fitness workouts. 

The program focuses on the Four Pillars of Firefighter Functional Fitness: Physical Fitness, 

Recovery and Rest, Hydration, and Nutrition and Lifestyle.

Fire Service Reputation Management White Paper

https://firefighterbehavior.com/wp-content/uploads/2017/09/Reputation-ManagementWhite-Paper.pdf

The Fire Service Reputation Management White Paper produced by Cumberland Valley 

Volunteer Firemen’s Association identifies a series of social, cultural and ethical issues 

threatening the fire service. The document draws awareness to negative behaviors, 

outlines the implications for leadership, and strongly urges the incorporation of a 

fire service code of ethics. It is important for fire service leaders to be able to identify 

and understand the impact of a toxic culture (Cumberland Valley Volunteer Firemen’s 

Association, 2010).

Firefighter Cancer Support Network

https://firefightercancersupport.org/

The Firefighter Cancer Support Network (FCSN) provides one-on-one mentoring and 

assistance to firefighters diagnosed with cancer. The FCSN also provides awareness and 

prevention training. 

Firefighter/First responder behavioral health hotlines and websites

ĵ Fire/EMS Helpline — 888-731-FIRE (3473).

ĵ Firestrong — https://firestrong.org/ or 844-525-3473.

ĵ Safe Call Now (international support) — https://www.safecallnow.org/ or 206-459-3020.

ĵ Code 4 Northwest — http://www.code4nw.org/ or 425-243-5092.

International Association of Fire Chiefs

https://www.iafc.org/

Programs, education, training, tools and resources for departments, chief officers, officers, 

families and clinicians; relevant trainings and resources under Safety and Health.
56 Emerging Health and Safety Issues Among Women in the Fire Service

International Association of Fire Fighters

http://www.iaff.org/

On-line training programs including cancer awareness and prevention, behavioral health, 

emergency incident rehabilitation, and emergency vehicle safety. Additional resources 

include CPAT, the Wellness Fitness Initiative, and materials related to health and safety.

International Association of Fire Fighters Center of Excellence for 

Behavioral Health Treatment and Recovery

https://www.iaffrecoverycenter.com/

Firefighter-specific treatment for substance use and mental health issues.

National Fallen Firefighters Foundation

https://www.everyonegoeshome.com/

Life safety initiatives, trainings and resources for departments, peers, firefighters, families 

and clinicians. 

https://www.firehero.org/

Resources for survivors, departments, firefighters, families, etc.

National Fire Protection Association

https://www.nfpa.org/

Codes and regulations, statistics, and trainings.

National Firefighter Code of Ethics

https://www.usfa.fema.gov/downloads/pdf/code_of_ethics.pdf

The National Firefighter Code of Ethics establishes a criteria for fire service personnel to 

promote a culture of integrity and professionalism within the industry.

National Volunteer Fire Council

https://www.nvfc.org/

Resources, trainings and programs to benefit departments, firefighters and families, 

including:

ĵ Serve Strong — https://www.nvfc.org/ServeStrong/.

ĵ Share the Load — https://www.nvfc.org/programs/share-the-load-program/.

Responder Safety Learning Network

https://learning.respondersafety.com/

The Responder Safety Learning Network offers a no-cost, self-paced online program using 

plain language so that first responders can gain an understanding of NFPA 1091 and how 
Appendix A: Resources 57

it can be used as a training objectives blueprint. Resources of interest discussed in this 

chapter include:

ĵ Understanding the New NFPA 1091 online course.

ĵ National TIM Training Certificate online course. Upon completion of the modules and 

passing of the Skills Challenge test, credit will be given and a download of a certificate 

equivalent to completing the National Traffic Incident Management Responder Training 

Program will be made available.

ĵ PIO and Public Educator Engagement Page. Information is designed specifically for 

PIOs and educators for educating the public. Resources include video public service 

announcements, media templates, downloadable posters, a press packet, and 

information for leadership.

https://learning.respondersafety.com/Training_Programs/Understanding_the_New_

NFPA_1091.aspx

Share the Load

https://www.nvfc.org/programs/share-the-load-program/

The National Volunteer Fire Council Share the Load program is a free program that 

provides firefighters with access to mental health resources and professionals 24/7. It 

is important for department leadership to educate members on the available resources 

for assistance.

The Cancer Alliance Report

http://www.everyonegoeshome.com/wp-content/uploads/sites/2/2016/06/

CancerAllianceReport.pdf

Prepared by the Fire Service Occupational Cancer Alliance. This addresses research needs 

and recommendations, and helps to set a plan for how the fire service approaches cancer.

Women in Fire

https://www.womeninfire.org/

Resources, training and mentorship for women in the fire service.
58 Emerging Health and Safety Issues Among Women in the Fire Service
Appendix B: Acronyms 59

Appendix B: Acronyms

BLS Bureau of Labor Statistics

CDC Centers for Disease Control and Prevention

CPAT Candidate Physical Ability Test

DOL Department of Labor

DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 

EEOC Equal Employment Opportunity Commission

EFNEP Expanded Food and Nutrition Education Program 

EMS Emergency Medical Services

EMTs emergency medical technicians

FBHA Firefighter Behavioral Health Alliance

FCSN Firefighter Cancer Support Network

HHS U.S. Department of Health and Human Services

IAFC International Association of Fire Chiefs

IAFF International Association of Fire Fighters

LODDs line-of-duty deaths

NFA National Fire Academy

NFFF National Fallen Firefighter Foundation

NFIRS National Fire Incident Reporting System

NFPA National Fire Protection Association

NVFC National Volunteer Fire Council

PIO Public Information Officers

PPE personal protective equipment

PTSD post-traumatic stress disorder

PTSS post-traumatic stress syndrome

SOII Survey of Occupational Injuries and Illnesses

TIM Traffic Incident Management

USDA U.S. Department of Agriculture

USFA U.S. Fire Administration 

WFS Women in the Fire Service
60 Emerging Health and Safety Issues Among Women in the Fire Service
Appendix C: Campaign Ads 61

Appendix C: Campaign Ads
62 Emerging Health and Safety Issues Among Women in the Fire Service
Appendix C: Campaign Ads 63
64 Emerging Health and Safety Issues Among Women in the Fire Service
Appendix C: Campaign Ads 65

RESPONDERSAFETY.com

Learning Network

2/3

4,461,000

ResponderSafety.com is funded by the Federal Emergency Management Agency (U.S. Department of Homeland Security), the U.S. Department of Justice, and public/private partnerships. October 2018.

2017

DATA SOURCES— FD roadway responses: Ahrens, Marty, and Ben Evarts. Fire Department Roadway and Vehicle Incidents. National Fire Protection Association, 2017. MV fatalities: “Safety on the Road.” National Safety Council Motor Vehicle Fatality 

Estimates, 2017. https://www.nsc.org/road-safety/safety-topics/fatality-estimates and Safety On the Road. National Safety Council. 2018. https://www.nsc.org/road-safety. FF fatalities: Fahy, Rita. U.S. Firefighters Struck and Killed by Vehicles, 2000-

2013. National Fire Protection Association, 2014; Fahy, Rita F, et al. Firefighter Fatalities in the United States, 2015. National Fire Protection Association, 2016; Fahy, Rita F, et al. Firefighter Fatalities in the United States — 2016. National Fire Protection 

Association, 2017; Firefighter Fatalities in the United States in 2014. United States Fire Administration. Federal Emergency Management Agency, 2015; United States Fire Administration Firefighter Fatalities Database 

(https://apps.usfa.fema.gov/firefighter-fatalities/); ResponderSafety.com LODD news reports; and EMS1.com news reports.

TODAY

91

RUNNING THE ROADS

FIRE DEPARTMENT RESPONSES TO ROADWAY INCIDENTS

PROTECT YOUR RESPONDERS

AT ROADWAY SCENES. 

Number of FIREFIGHTERS 

& EMTs STRUCK & KILLED

in 2017 & 2018

Number of FIREFIGHTERS

STRUCK & KILLED on 

roadways since 2000

LOCAL FIRE DEPARTMENTS RESPONDED TO

INCIDENTS ON ROADWAY PROPERTIES IN 2014

12,200

roadway responses

occur every day

of roadway 

responses were

EMS CALLS 

OR RESCUES 19

PUT DOWN YOUR PHONE.

SLOW DOWN AND MOVE OVER

GIVE THEM ROOM TO SAVE LIVES!

About 40,100 people died in motor vehicle crashes 

TOP 3 CAUSES 

ALCOHOL, SPEEDING, and DISTRACTED DRIVING

as of 11/8/18

A service of the Cumberland Valley Volunteer Firemen’s Association
66 Emerging Health and Safety Issues Among Women in the Fire Service
Appendix C: Campaign Ads 67
16825 South Seton Ave.

Emmitsburg, MD 21727

www.usfa.fema.gov

January 2019