Fighting Bias in Healthcare: Sexism & Gender-Related Prejudice

In 2002, the Institute of Medicine, a branch of the National Academy of Science, published a groundbreaking report detailing how some populations do not receive the same quality of care as others. Unfortunately, this disparity in quality of care has been directly linked to the gender, race, and ethnicity of a patient.

Inequality in care due to gender has a measurable impact. For example, a study published in the journal Academic Emergency Medicine noted that women are 25 percent less likely to be prescribed opioids for abdominal pain versus their male counterparts. The Journal of the American Heart Association found that women waiting to be evaluated for a heart attack wait 29 percent longer, and the Journal of Women’s Health uncovered that women who presented with chest pain and other heart disease symptoms were diagnosed with a mental illness twice as often as men.

Research on bias outcomes in healthcare is relatively recent, with more studies performed each year as the problem can no longer be dismissed. However, research suggests that the difference in the type and level of care provided has less to do with overtly sexist healthcare providers and more to do with an unconscious process. “If we think about it, we all have biases. It’s not explicit bias like a belief system, but if we really understand what implicit biases are, we all have them in some area or another,” says Dr. Janice Sabin, a research associate professor in biomedical informatics and medical education at the University of Washington

Women like Dr. Janice Sabin are leading the way in research and educating future generations of healthcare providers to recognize and mitigate bias in medical care so that all patients can receive equal treatment regardless of race, gender, or sexuality.

Dr. Janice Sabin is a leading researcher and educator on the science of implicit bias and its effect on medical care, health equity, and social determinants of health. With an MSW in health/mental health and a PhD in social welfare, she has long been at the forefront of applying this science to healthcare disparities research.

Dr. Sabin’s expertise ranges from pediatricians’ racial bias to discrimination against lesbian women and gay men, as well as designing and evaluating health disparities education for faculty members, graduate medical students, and nursing trainees. Currently, she is a research associate professor in biomedical informatics and medical education at the University of Washington.

The National Institute of Health defines implicit bias as “a form of bias that occurs automatically and unintentionally, that nevertheless affects judgments, decisions, and behaviors.” Simply put, it is a bias that affects behavior without the person realizing its happening.

This psychological theory about implicit bias is less than 30 years old. “When I started my doctoral program, I sought out Anthony Greenwald, who is an international expert on implicit social cognition,” says Dr. Sabin. “He had been developing this idea starting in 1995.” Dr. Greenwald went on to develop the Implicit Association Test, which can help test takers determine their own unconscious biases.

While implicit bias may be individual, it stems from systemic societal norms and beliefs. “The issue is bigger than the individual level—it’s our system that needs help,” says Dr. Sabin. The long-standing patriarchal society most live in continues to contribute to an implicit bias against women, even from the most aware healthcare provider.

“Bias is more likely to impact medical decision-making and communication, particularly when the provider is under a heavy cognitive load with time constraints,” shares Dr. Sabin. The less a medical decision is cut and dry, the greater the chance for bias. “For example, everybody knows what to do if someone enters the ER with a fractured arm. Get an x-ray, cast the arm, and maybe they need surgery. There isn’t a lot of ambiguity around what to do. However, ambiguity in that situation is in deciding how much pain the person is actually in and then prescribing pain medication or not. There are a lot of disparities in pain management because it’s an ambiguous situation.”

Study after study has shown that overwhelmingly women do not receive the same care as their male counterparts. As far back as 1989, before implicit bias was understood or studied in healthcare, researcher Karen Calderone found that women were half as likely to be given narcotic painkillers after coronary bypass surgery as men. More recently, in 2021, a European Society of Cardiology study uncovered that “acute coronary syndrome was more likely to be considered the cause of chest pain in men compared to women” for patients presenting to the emergency room.

And it doesn’t just apply to adult women: a study conducted at Yale found that adults take young girls’ pain less seriously than boys.

The awareness of implicit bias has brought to the forefront how much work needs to be done to help mitigate harm: “At the institutional level, the advice is to collect data to help determine whether there are disparities or not. If you don’t do that, you can just go along your merry way, and patient complaints are just complaints. If an institution finds disparities, they need to figure out why it is happening,” encourages Dr. Sabin. “Healthcare institutions need to assume responsibility and accountability.”

“Research from psychology shows us that implicit bias can only be changed for a very short period of time. There is no evidence you can change an implicit bias on a sustained basis because it comes from our culture. This is not our personal belief system. We are bathed in bias every day,” notes Dr. Sabin. “Changing it is not the focus. The focus is to identify it, recognize it’s there, and then manage it. You’re not a racist, and you’re not homophobic. Everybody has these hidden biases, so what do we do about it?”

“Beyond awareness, examples of actions that clinicians can take immediately to manage the effects of implicit bias include practicing conscious, positive formal and informal role modeling; taking active-bystander training to learn how to address or interrupt microaggressions and other harmful incidents; and undergoing training aimed at eliminating negative patient descriptions and stigmatizing words in chart notes and direct patient communications,” says Dr. Sabin in a piece published by the New England Journal of Medicine.

Effective training is at the core of helping providers do better. “It’s a matter of giving people new skills. One method we have found that works is to train people to be excellent communicators. It’s really important for providers to elicit information from and listen to their patients and then to trust what they’re hearing,” says Dr. Sabin.

Healthcare providers and the general public can educate themselves about implicit bias in many ways. Here are some resources:

• National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care
• Implicit and Unconscious Bias in Healthcare Course at the University of Michigan
• Implicit Bias Training from the March of Dimes
• Association of American Medical Colleges Unconscious Bias Resources for Health Professionals