Why We Should Be More Concerned About Compression Depth, Equipment Maintenance and Saving Lives Than Covering the Nipples of a Training Manikin
By Richard Purchon FRGS AC RODP
Operating Department Practitioner | Cardiothoracic Anaesthesia | Basic Life Support Instructor
Introduction: Have We Lost Sight of What CPR Training Is For?
Having spent more than twenty years working as an Operating Department Practitioner, specialising in cardiothoracic anaesthesia, and teaching Basic Life Support (BLS), I have always regarded resuscitation training as one of the most important skills we can pass on to healthcare professionals and members of the public.
When somebody suffers a cardiac arrest, immediate and effective intervention can mean the difference between life and death.
The objectives are straightforward: recognise cardiac arrest, summon assistance, commence effective chest compressions and obtain and use an automated external defibrillator (AED) as quickly as possible.
Yet a curious discussion has emerged surrounding anatomically realistic female CPR training manikins.
These models are specifically designed with breasts to help trainees become familiar with female anatomy and the practical considerations of performing chest compressions and applying defibrillation pads.
A recent promotional photograph of a PRESTAN female CPR manikin, however, raises an interesting question.
Despite the manikin having anatomically represented breasts, circular campaign stickers have been placed directly over its nipples.
Whether these stickers are intended as promotional branding, an attempt to preserve modesty, or both is unclear.
Nevertheless, their placement presents an interesting contradiction.
If we are introducing anatomically realistic female manikins to normalise female anatomy in resuscitation training, why should the nipples of a plastic training manikin need to be covered at all?
The female breast is a perfectly normal anatomical structure.
Its presence in a medical education environment is neither sexual nor inappropriate.
As healthcare professionals and educators, we should be encouraging students to recognise anatomy without embarrassment, understand the location of the sternum and apply defibrillation pads without hesitation.
Instead, we risk allowing wider societal discomfort surrounding the female breast to intrude into what should be an entirely clinical learning environment.
But perhaps this discussion is distracting us from something far more important.
How many private training organisations are still teaching CPR on outdated, poorly maintained or mechanically inaccurate manikins that no longer adequately support current resuscitation guidance?
While attention is directed towards whether a female manikin’s nipples should be visible, are we sufficiently concerned about whether that same equipment can accurately teach the compressions that might save somebody’s life?
Female Anatomy Is Not Sexual Anatomy
One of the more frustrating aspects of this discussion is the apparent difficulty some people have separating normal human anatomy from sexualisation.
Breasts are part of human anatomy.
They are encountered routinely in healthcare, whether during physical examination, diagnostic imaging, surgery, anaesthesia or emergency treatment.
Their presence does not automatically make a clinical interaction sexual.
Similarly, a female CPR manikin with anatomically realistic breasts should not be considered inappropriate simply because those breasts include nipples.
The purpose of realistic medical simulation is to familiarise trainees with the anatomical structures they may encounter in practice.
If nipples are considered inappropriate for display, where does that reasoning end?
Would we consider covering anatomical structures on a breast examination simulator?
Should a model used to teach chest drain insertion avoid representing normal female breast anatomy?
Would anatomical accuracy suddenly become inappropriate when teaching defibrillation?
These questions illustrate the potential problem with allowing social embarrassment to influence clinical education.
There is, of course, no evidence from the photograph alone that the company involved deliberately intended to sexualise or censor the manikin. The stickers may simply have been placed there to promote the Bra Off Defib On campaign.
Nevertheless, the visual contradiction is striking.
A model created to familiarise students with female anatomy has promotional material placed directly over part of that anatomy.
Surely the educational objective should be to remove unnecessary discomfort rather than inadvertently reinforce it.
A breast is not an obscenity, and a nipple on a CPR manikin should not be controversial.
Are Conventional CPR Manikins Sexist?
Research published in Health Promotion International in 2024 examined the anatomical representation of CPR training manikins.
Of the 20 models examined, 95% lacked breasts.
The researchers suggested that limited female anatomical representation might contribute to inequalities in resuscitation education.
However, the study did not establish that conventional CPR manikins were deliberately designed to discriminate against women.
Nor did it demonstrate that flat-chested training equipment was responsible for differences in cardiac arrest outcomes.
It documented anatomical under-representation within a particular sample.
That finding is worth considering, but it should not be confused with proof of sexism.
Furthermore, the commercial market has continued to develop.
In 2026, anatomically female CPR manikins are readily available through established UK suppliers.
PRESTAN produces complete female anatomical manikins, including feedback-enabled models.
Other manufacturers and suppliers offer breast attachments or replacement chest skins that allow compatible existing manikins to represent female anatomy.
Some female and conventional models are advertised at identical prices.
It would be inaccurate to claim that female models account for exactly half the market without a comprehensive count of current products and sales.
However, it is equally inaccurate to suggest that female anatomical training equipment is unavailable.
Modern training providers have genuine purchasing choices.
But a conventional, flat-chested training torso is not necessarily an anatomically male manikin.
Many traditional models were designed as simplified mechanical simulators.
They provide a consistent platform for practising compressions, ventilation and basic airway management.
The absence of breasts is not, by itself, proof of sexism.
The more important consideration is whether the equipment prepares students to deliver effective resuscitation on real patients.
The Evidence That Women Receive Less CPR
There is genuine evidence of disparities in bystander resuscitation.
A study published in 2018, examining 19,331 out-of-hospital cardiac arrests, found that women experiencing cardiac arrest in public settings were less likely to receive bystander CPR than men.
Approximately 39% of women received CPR compared with 45% of men.
Interestingly, in private settings, the difference was much smaller, at approximately 35% compared with 36%.
These findings deserve serious attention.
Researchers have explored possible explanations, including difficulty recognising cardiac arrest, concerns about causing injury and hesitation associated with touching or exposing a woman’s chest.
However, the existence of a disparity does not establish that the design of CPR manikins is responsible.
A difference in outcomes should prompt investigation into its causes, rather than an automatic assumption of discrimination.
If unfamiliarity with female anatomy contributes to hesitation, realistic female manikins may help address that problem.
If fear of inappropriate contact contributes to hesitation, education should directly confront that concern.
But simply labelling conventional equipment sexist does not demonstrate how many additional lives will be saved.
The objective should be to identify barriers to intervention and remove them.
Breast Exposure Versus Death: Surely the Priority Is Obvious?
Imagine a woman collapsing in a public place.
She is unresponsive and not breathing normally.
She is in cardiac arrest.
Without effective circulation, oxygen delivery to the brain ceases, and the chances of survival diminish rapidly.
A bystander recognises the emergency and begins CPR.
An AED becomes available.
At that moment, the rescuer’s responsibility is to position the electrode pads correctly and follow the device’s instructions.
Yet concerns have been raised that some rescuers may hesitate because they are uncomfortable touching or exposing a woman’s breasts.
This is where we need to distinguish social embarrassment from clinical necessity.
There is nothing sexual about performing CPR.
There is nothing indecent about exposing a chest when doing so is necessary to apply defibrillation pads.
And there is a fundamental difference between inappropriate physical contact and an emergency intervention intended to preserve somebody’s life.
The Resuscitation Council UK’s 2025 Adult Basic Life Support Guidelines are clear.
AED pads must be applied to bare skin in the correct anatomical positions.
If a bra does not interfere with correct positioning, it may remain in place.
If it prevents correct pad placement, it should be removed.
The guidance explicitly prioritises life-saving intervention over concerns about chest exposure.
Importantly, breasts do not need to be exposed simply to commence chest compressions, unless clothing prevents appropriate positioning.
Patient dignity remains important, but preserving dignity and delivering emergency treatment are not mutually exclusive.
A woman’s chance of survival should never be compromised because somebody is embarrassed about exposing her breasts.
This should be one of the simplest lessons taught during Basic Life Support education.
The More Serious Concern: Outdated Compression Depth
There is, however, another aspect of CPR training equipment that I believe deserves substantially more scrutiny.
The mechanical accuracy of the manikin itself.
Current Resuscitation Council UK guidelines recommend adult chest compressions to a depth of 5–6 centimetres, delivered at a rate of 100–120 compressions per minute, allowing complete chest recoil.
But some older CPR manikins were manufactured when different compression-depth recommendations applied.
An earlier generation of Laerdal Little Anne provides a particularly interesting example.
According to the manufacturer’s instructions, its audible clicker activates when the chest is compressed approximately 1½ inches, equivalent to 38 mm.
Compare that with today’s recommended minimum adult compression depth of 50 mm.
The difference is 12 mm.
That means the clicker activates at a depth 24% below the current recommended minimum.
Now consider a student attending a first-aid course.
They position their hands on the manikin and begin compressions.
The clicker activates.
The instructor hears the click and the student receives what appears to be confirmation that an adequate compression has been delivered.
But if the student compresses only until that click occurs, they may never reach the recommended depth.
It is important to recognise that a clicker activating at 38 mm does not necessarily mean the manikin cannot be compressed further.
Nor does it prove that every instructor using that model teaches inadequate compression depth.
A knowledgeable instructor may compensate for the older feedback mechanism and ensure that students perform compressions to the correct depth.
Nevertheless, the audible feedback itself may be misleading if its historical specification is not understood.
How many instructors know the compression-depth threshold at which their manikin’s clicker activates?
And how many simply assume that hearing the click means the student has delivered an adequate compression?
This is a tangible question about educational accuracy.
It deserves considerably more attention.
Do Twenty-Year-Old Manikins Still Meet Current Standards?
A training manikin does not automatically become unfit for purpose simply because it is twenty years old.
There is no universal Resuscitation Council UK requirement that every manikin must be replaced after a prescribed number of years.
However, age, mechanical wear, maintenance and compatibility with current training objectives all matter.
A manikin that has been used repeatedly over two decades may have experienced considerable wear.
Its compression springs may have deteriorated.
Its recoil mechanism may no longer function as intended.
Its feedback system may be inaccurate or unreliable.
Its chest structure may have been damaged through repeated compression.
The equipment might still look perfectly serviceable.
It may still produce an audible click.
But does it continue to deliver an accurate and appropriate training experience?
That cannot simply be assumed.
The manufacturer’s requirements for periodic maintenance provide an important reference.
For example, Laerdal recommends replacement of specified Resusci Anne QCPR components after approximately 500,000 chest compressions.
This includes components involved in the mechanical and feedback systems.
That recommendation applies to the specified model and should not be treated as a universal service interval.
Nevertheless, it demonstrates something fundamental.
CPR training manikins are mechanical devices, and mechanical devices wear.
The question is whether training organisations have effective systems for identifying that wear before it begins to compromise the quality of instruction.
What About Lung and Airway Replacement?
Compression performance is only part of the problem.
Many training manikins also incorporate replaceable lungs, airway assemblies, valves and filters.
These components are essential when teaching ventilation.
They enable students to practise opening the airway, delivering rescue breaths and recognising adequate chest rise.
But they require maintenance.
Depending on the model, manufacturers specify cleaning, component replacement and hygiene procedures.
For example, PRESTAN’s Professional Adult manikin instructions specify replacement of the face-shield and lung-bag assembly after each class, or sooner if excessive moisture accumulates.
Older Laerdal Little Anne models also use replaceable airway components.
Newer models may incorporate filters and different replacement schedules.
These are not interchangeable maintenance requirements.
The correct procedure depends on the manufacturer and the specific manikin.
Failure to follow the appropriate instructions may have hygiene implications.
It may also affect training performance.
Damaged or leaking lungs can interfere with effective ventilation and visible chest rise.
An incorrectly installed airway can alter the resistance encountered by the student.
This can make assessment of ventilation technique unreliable.
And yet I would be interested to know how many private first-aid training companies can produce comprehensive maintenance records for their manikins.
When were the lungs last replaced?
When were the valves and airway components inspected?
How frequently are the manikins cleaned?
Does the organisation follow the manufacturer’s current instructions?
Are consumables replaced according to a documented schedule?
These questions are not accusations.
They are the kinds of questions that should form part of any meaningful equipment quality-assurance process.
What Does Resuscitation Council UK Actually Require?
The 2025 Resuscitation Council UK Education Guidelines place considerable emphasis on effective teaching, objective feedback and appropriate simulation.
They recommend real-time CPR feedback devices to improve compression skills and accuracy.
They also encourage frequent assessment, appropriate simulation and training relevant to the learners’ roles and patient populations.
The community CPR and AED training quality standards recommend, where possible, objective assessment using manikins capable of providing feedback on compression depth, rate, hand position and chest recoil.
They also expect organisations to have processes to ensure that training equipment and supplies are operational.
Not every CPR course requires expensive high-fidelity simulation equipment.
And the absence of an electronic feedback device does not automatically mean that a training manikin is unsuitable.
However, training providers should be able to demonstrate that their equipment is appropriate for the skills being taught.
The guidance does not mandate equal numbers of male and female manikins.
It does not characterise conventional flat-chested training torsos as sexist.
It places the emphasis on effective education and resuscitation competence.
That distinction matters.
A beautifully detailed female manikin is not necessarily a better training device if its compression mechanism is defective.
Equally, a simplified conventional torso may provide excellent training if it delivers appropriate resistance and accurate feedback.
The educational value of the manikin should be determined by its ability to teach and assess resuscitation, not simply its anatomical appearance.
Who Checks the Equipment Used by Private Training Providers?
This leads to a wider concern about the quality assurance of private first-aid training.
Since October 2013, the Health and Safety Executive has no longer operated its former system of directly approving individual first-aid training providers.
Instead, employers have a responsibility to select competent training organisations.
The HSE provides guidance on choosing an appropriate provider, including matters such as instructor competence, syllabus content, assessment and quality assurance.
Many private training companies work under established awarding organisations or recognised quality-assurance arrangements.
It would therefore be inaccurate to suggest that the entire sector operates without oversight.
But this does not answer an important question.
How consistently is the physical condition and mechanical accuracy of training equipment independently verified?
There is currently no reliable nationwide audit demonstrating how many private CPR training providers are using manikins with incorrect compression feedback, damaged mechanical components or inadequately maintained lung systems.
Consequently, we cannot claim that these problems are widespread.
But neither should we assume that they do not exist.
A meaningful sector-wide review could examine the age, model and condition of manikins used by independent training providers.
It could assess their compression-depth capability, feedback accuracy, mechanical recoil and maintenance records.
It could also establish whether instructors understand the limitations of older manikin models.
That would provide evidence capable of informing future quality standards.
And it might uncover problems considerably more relevant to patient survival than the presence or absence of nipples on a training torso.
The Financial Cost of Updating Equipment
Cost is an inevitable consideration for private training providers.
Modern CPR manikins represent an investment.
A training company delivering courses to relatively small groups may be reluctant to replace equipment that appears to remain functional.
However, replacement is not always the only option.
Some manufacturers supply service kits and replacement components that extend the life of compatible equipment.
Newer feedback-capable adult manikins are available commercially at prices within reach of many training organisations.
PRESTAN supplies female and conventional manikins with integrated feedback options.
Laerdal supplies modern Little Anne QCPR models with objective feedback systems.
Other manufacturers offer different levels of functionality.
The important point is not that every organisation must immediately purchase the most expensive equipment available.
It is that training companies should understand the limitations of the equipment they own.
Where appropriate, maintenance may restore performance.
Where a model cannot adequately support current training requirements, upgrading or replacement may be justified.
And where a training organisation wishes to introduce anatomical diversity, it should consider whether female anatomical models can also provide the necessary mechanical accuracy and feedback.
There should be no conflict between anatomical realism and technically effective CPR training.
Both can be achieved.
The Responsibility of the BLS Instructor
As a BLS instructor, I believe much of the responsibility ultimately rests with the person delivering the training.
Students must understand why they are performing particular actions, not simply learn to reproduce a sequence of movements.
They should know where the sternum is located.
They should understand why chest compression depth and recoil are important.
They should know how to identify correct AED pad positions.
They should understand how anatomical variation may affect the practical delivery of resuscitation.
And they should be confident that temporary exposure of the chest for necessary emergency treatment is not inappropriate.
But instructors must also understand their own equipment.
They should know whether the manikin’s feedback mechanism reflects current recommendations.
They should recognise when mechanical wear might affect training.
And they should ensure that lung systems and other consumables are appropriately maintained.
If somebody teaches students that an audible click represents an adequate compression, they should know what depth activates that click.
If a student is being assessed on their ability to ventilate a manikin, the instructor should be confident that the airway and lung system are functioning correctly.
These are basic educational responsibilities.
A CPR instructor should not rely on a manikin simply because it was supplied with the training course twenty years ago.
Nor should they assume that the presence of modern anatomical features guarantees that the equipment is technically suitable.
A competent instructor must understand both the physiology being taught and the limitations of the simulator being used.
Are We Concentrating on the Wrong Problem?
The debate surrounding female CPR manikins has identified legitimate concerns.
Women may receive less bystander CPR in some situations.
Anatomical unfamiliarity may affect confidence.
Some people may hesitate because they are uncomfortable touching or exposing female breast tissue.
Realistic training models can help address these issues.
But the discussion should remain firmly grounded in clinical education.
The sight of an anatomically accurate female manikin with promotional stickers covering its nipples highlights how uncomfortable society can remain with normal female anatomy.
Whether that was the intention of the promotional image is unknown.
However, it provides a useful starting point for questioning our educational priorities.
Why should a plastic breast require such attention while the accuracy of the manikin’s compression mechanism attracts comparatively little public discussion?
Why are we debating anatomical representation without also asking whether ageing equipment continues to support modern CPR standards?
Why are we not demanding clearer evidence of routine servicing, replacement of disposable components and verification of compression feedback?
And why are we not placing greater emphasis on developing rescuers who can recognise cardiac arrest and intervene without hesitation, regardless of the patient’s sex?
These are questions with genuine patient-safety implications.
Conclusion: The Priority Must Always Be Saving Lives
Anatomically realistic female CPR manikins have a legitimate place in modern resuscitation education.
There is nothing inappropriate about breasts or nipples being represented on a medical training device.
Indeed, realistic anatomy may help students become familiar with the practical requirements of CPR and defibrillation.
But the anatomical appearance of a manikin should never become more important than its ability to teach the skills required to save a life.
A twenty-year-old manikin with an outdated compression-depth clicker may provide misleading feedback if its limitations are not understood.
A poorly maintained airway system may compromise ventilation training.
Worn mechanical components may undermine objective assessment.
These are matters that deserve investigation and appropriate quality assurance.
We should not assume that every private training company uses unsuitable equipment, because the evidence to support such a claim is not currently available.
But there is a strong argument for examining equipment condition and maintenance more closely.
We must also ensure that students understand a fundamental distinction.
Touching or exposing somebody’s chest for inappropriate reasons is unacceptable.
Touching or exposing the chest when necessary to deliver life-saving CPR or defibrillation is a legitimate emergency intervention.
A woman’s breasts should never become a reason to delay resuscitation.
And the nipples of a CPR training manikin should not become more important than the quality of the training it provides.
Perhaps, before we engage in another debate about sexism in CPR education, we should ask training organisations some straightforward questions.
Does your manikin support the current 50–60 mm adult compression-depth recommendation?
Does its feedback system accurately assess compression performance?
When were its mechanical components last inspected?
When were its lungs and airways last replaced?
And can you demonstrate that the equipment used to train and assess your students remains fit for purpose?
These are the questions I believe matter most.
Because a manikin may have anatomically realistic breasts, covered or uncovered nipples, a sophisticated electronic feedback system or a relatively simple thoracic structure.
But none of that changes the fundamental objective of resuscitation education.
We are not teaching people to save a manikin. We are teaching them to save a human life.
And when that moment arrives, the patient will not care whether the training manikin had breasts.
They will depend upon the rescuer’s ability to recognise cardiac arrest, deliver effective compressions and use a defibrillator without unnecessary delay.
CPR is not sexual. Defibrillation is not indecent. Anatomical realism is not sexism.
And the quality of the training we provide should always matter more than the appearance of the equipment we use.
References and Further Reading
- Resuscitation Council UK (2025). Adult Basic Life Support Guidelines.
https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/adult-basic-life-support-guidelines - Resuscitation Council UK (2025). Education Guidelines.
https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/education-guidelines - Resuscitation Council UK (2026). Quality Standards: CPR and AED Training in the Community.
https://www.resus.org.uk/library/quality-standards-cpr/quality-standards-cpr-and-aed-training-community - Laerdal Medical. Little Anne / AED Little Anne — Instructions for Use. Historical compression clicker specification of 38 mm.
https://cdn.laerdal.com/downloads/f311/AED-Little-Anne-DFU-311.PDF - Laerdal Medical. Little Anne QCPR — Product Specifications and Feedback Systems.
https://www.laerdal.com/ - PRESTAN Products. Professional Adult CPR Manikin — Instructions for Use and Maintenance.
https://www.prestanproducts.com/ - Health and Safety Executive. Selecting a First-Aid Training Provider — GEIS3.
https://www.hse.gov.uk/pubns/geis3.htm - Szabo et al. (2024). CPR Training as a Gender and Rights-Based Healthcare Issue. Health Promotion International.
- Blewer et al. (2018). Gender Disparities Among Adult Recipients of Bystander Cardiopulmonary Resuscitation in the Public. Circulation: Cardiovascular Quality and Outcomes.
- AED Training (15 October 2026). Promotional photograph featuring a PRESTAN female CPR manikin and Bra Off Defib On campaign branding.
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