The Nature of Implicit Bias

My husband, who is also a physician, told me something recently that perfectly encapsulated how women’s unique symptoms are often regarded (or rather, disregarded) in the medical field.

Apparently, a well-known (white, male) neurologist was speaking to one of my husband’s colleagues in the break room of the hospital.
“You know we have an algorithm for paresthesia,” he began.
Paresthesia is the medical term for “pins and needles.” It can signify the onset of multiple sclerosis or Bell’s palsy from Lyme disease. It’s not painful, but it’s pronounced enough that it would make you sit up and take notice.
Paresthesia would also make those of us in the ED rush you up to the radiology suite for testing, because it’s the feeling you might get at the onset of a stroke.
“What’s the algorithm?” my husband’s friend asked.
“Well,” the neurologist said, smirking. “When they come in, the first thing I ask is, ‘Are they male or female?’ If they’re male, I say, ‘Let’s do a CT scan.’ And if they’re female, I say, ‘Stop! It’s anxiety. It’s all in her head.’”
As my husband shared this story, I gaped at him, aghast. “You have got to be kidding me.”
My husband shrugged uncomfortably. “It was just locker room talk. He wouldn’t actually do that.”
Locker room talk. Sure. We’ve all heard that one before.
When a prominent neurologist, well respected in his field and with what looks on paper to be a solid track record, makes statements like this—even supposedly in jest—it reveals the true depth of our medical community’s prejudice against women. Rather than considering that a woman might be having an actual stroke, he would default immediately to a psychogenic diagnosis.
Healthcare professionals bring a lifetime of internalized beliefs, social constructs, and cognitive biases to work with them every day in addition to their wealth of actual clinical experience. These filters create expectations, preconceptions, and recognition tools; for example, we can often identify conditions without extensive testing because we’ve seen them before. However, these filters, when not examined, can also create biases that color providers’ views of everything in their worlds—including the women they treat.
It isn’t just male providers who carry these biases; depending on their social conditioning, women can be even less empathetic than men toward other women.
And yet, if you asked most healthcare providers, they would say that they aren’t biased at all—that they are thoroughly objective and make their evaluations on a situation-by-situation basis. This is the nature of unconscious bias, and its immeasurability makes it even harder to eradicate.
In our society, women are often regarded as weaker than men, more prone to emotional outbursts, less able to tolerate discomfort and pain, and more likely to exaggerate their feelings in the hope of “getting attention.” Despite the massive strides that women have made toward equality in the last sixty years, this perception persists.
What this means in real-time medical practice is that women’s complaints are not believed. Like Lydia, they tell their providers over and over what they feel and sense in their bodies—only to be told that they’re making it up.
It’s true that it’s more socially acceptable for women to show emotion than it is for men. But the act of showing emotion does not mean that a woman is “hysterical.” It does not mean that she is exaggerating or making a play for sympathy or attention. It simply means that she is communicating how she feels. However, because men are more likely to be “stoic” (i.e., to repress or conceal their emotions), women in our society who show how they feel are deemed “weak” or unreliable, while men are seen as “strong and steady.” When this perception is in play, providers and medical staff are statistically more likely to disregard what a woman says—whether or not they realize they are doing it.
One prominent manifestation of unconscious bias is the assumption that female symptoms are more likely to have an emotional cause. For example, in one study of patients with similar symptoms of irritable bowel syndrome (IBS), researchers found that men were more likely to be referred for X-rays, while women were offered antianxiety medication and lifestyle advice.1 A retrospective study discovered that emergency providers were less likely to comply with Centers for Disease Control and Prevention guidelines for documentation and treatment of sexually transmitted infections when their patients were women, specifically with regard to complete documentation of symptoms and discharge instructions.2 A 2012 study found that severely injured women were less likely to be brought to an ED or other trauma center by emergency medical service/paramedic personnel (49 percent of women versus 62 percent of men). Once other variants had been accounted for, study authors concluded that gender does play a role in victims’ access to trauma care and that “the reasons for this differential in access might be related to perceived difference in injury severity, likelihood of benefiting from trauma center care, or subconscious gender bias.”3 And, as we learned in Chapter 3, women are less likely to be referred for appropriate cardiac testing and are often given inappropriate or ineffective diagnostic tests;4 when these tests don’t reveal classic male-pattern symptoms, a default diagnosis of anxiety is often applied.
It all comes back to the mistaken belief that women inherently exaggerate and amplify their symptoms. Yes, women are more likely to have an observable emotional response to whatever is happening in their bodies—but that does not negate what is happening physically.
In fact, as we’ll explore in the next section, the female response to stress correlates in many ways to the symptoms of anxiety. But anxiety as a symptom and anxiety as a root cause are two drastically different things—and confusing the two can have life-threatening consequences for women.

References:

  • Gunilla Risberg, Eva E. Johansson, and Katarina Hamberg, “A Theoretical Model for Analysing Gender Bias in Medicine,” International Journal for Equity in Health 8, no. 28 (2009). doi:10.1186/1475-9276-8-28.
  • B. G. Kane et al., “Gender Differences in CDC Guideline Compliance for STIs in Emergency Departments,” Western Journal of Emergency Medicine 18, no. 3 (2017): 390–397. doi: 10.5811/westjem.2016.12.32440.
  • David Gomez, MD, PhD, et al., “Gender-Associated Differences in Access to Trauma Center Care: A Population-Based Analysis,” Surgery 152, no. 2 (2012): 179–185. doi: https://doi.org/10.1016/j.surg.2012.04.006.
  • A. Gupta et al., “Gender Disparity and the Appropriateness of Myocardial Perfusion Imaging,” Journal of Nuclear Cardiology 18, no. 4 (2011): 588–594. doi: 10.1007/s12350-011-9368-x; A. M. Chang et al., “Gender Bias in Cardiovascular Testing Persists After Adjustment for Presenting Characteristics and Cardiac Risk,” Academic Emergency Medicine 14, no. 7 (2007): 599–605. doi: 10.1197/j.aem.2007.03.1355.

 

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