Gender bias in medical diagnosis

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A female doctor takes the pulse of a male patient

Gender-biased diagnosing is the idea that medical and psychological diagnosis are influenced by the patient's gender. Several studies have found evidence of differential diagnosis for patients with similar ailments but of different sexes.[1] Female patients face discrimination through the denial of treatment or miss-classification of diagnosis as a result of not being taken seriously due to stereotypes and gender bias. According to traditional medical studies, most of these medical studies were done on men thus overlooking many issues that were related to women's health. This topic alone sparked controversy and questions about the medical standard of our time. Popular media has illuminated the issue of gender bias in recent years.[2][3][4][5] Research that was done on diseases that affected women more were less funded than those diseases that affected men and women equally.[6]

History

The earliest traces of gender-biased diagnosing could be found within the disproportionate diagnosis of women with hysteria as early as 4000 years ago.[7] Hysteria was earlier defined as excessive emotions; adapted from the Greek term, "Hystera", meaning "wandering uterus".[8] These terms stemmed from mind-body associations regarding the uterus affecting women's overall health, especially emotionally and mentally.[9] Within a medical setting, this hysteria translated to the over exaggeration of symptoms and ailments. Because traditional gender roles usually place women at a subordinate position compared to men, the medical industry has historically been dominated by men.[10] This has led to misdiagnoses in females, often influenced by a predominantly male workforce in healthcare holding onto gender stereotypes. These gender roles and gender biases may have also contributed to why pain associated with experiences unique to women, like childbirth and menstruation, were dismissed or mistreated.

Women's overall health has long been associated with their reproductive abilities; further compounded by traditional views of sex, female gender roles, and femininity. Emotional and mental health are intertwined with reproductive functions, encompassing menstruation, fertility, and labor. Furthermore, societal expectations, including the desire for children, motherhood, subservience, and femininity, also play significant roles. More specifically, if a woman did not meet the expectations of reproductive functions (such as inconsistent menstruation cycles, inability to conceive or carry to term, as well as display negative reactions such as nausea, pain), it was assumed that she held resentment or non-desire to bear and raise children, as well as being defiant of her feminine nature and role.[11] Conversely, if a woman were not to behave in alignment with femininity and gender role expectations (such as unable to maintain and care for family and housework, insubordinate, sick or in pain), then they were labeled as mentally ill or disturbed, often diagnosed with hysteria.[12]

In a 1979 observational study, 104 women and men provided responses regarding their health in five areas: back pain, headaches, dizziness, chest pain, and fatigue. The study found that doctors tended to conduct more extensive checkups for men compared to women with similar complaints. This observation supports the notion that female patients are often taken less seriously than their male counterparts when reporting medical issues.[13]

In 1990, the National Institutes of Health acknowledged the disparities in disease research between men and women. At this time, the Office of Research on Women's Health was created, primarily to raise awareness of how sex affects disease and treatments.[14][15] In 1991 and 1992, recognition that a "glass ceiling" existed showcased that it was preventing female clinicians from being promoted.[16][17] In 1993, the Women’s Health Equity Act gave women the chance to participate in medical studies and examine gender differences.[18] Before this, there had been no research done on infertility, breast cancer, and ovarian cancer, which are conditions prevalent to women's health.[18] In 1994, the FDA created an Office of Women's Health by congressional mandate.[19]

Clinical trials and research

The approach to women shifted from paternalistic protection to access in the early 1980s as AIDS activists like ACT UP and women's groups challenged ways that drugs were developed. The NIH responded with policy changes in 1986, but a Government Accountability Office report in 1990 found that women were still being excluded from clinical research. That report, the appointment of Bernadine Healy as the first woman to lead the NIH, and the realization that important clinical trials had excluded women led to the creation of the Women's Health Initiative at the NIH and to the federal legislation, the 1993 National Institutes of Health Revitalization Act, which mandated that women and minorities be included in NIH-funded research.[20][21][22] The initial large studies on the use of low-dose aspirin to prevent heart attacks that were published in the 1970s and 1980s are often cited as examples of clinical trials that included only men, but from which people drew general conclusions that did not hold true for women.[22][23][24] In 1993 the FDA reversed its 1977 guidance, and included in the new guidance a statement that the former restriction was "rigid and paternalistic, leaving virtually no room for the exercise of judgment by responsible research subjects, physician investigators, and investigational review boards (IRBs)".[19]

The National Academy of Medicine published a report called "Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies" in 1994[20] and another report in 2001 called "Exploring the Biological Contributions to Human Health: Does Sex Matter?" which each urged including women in clinical trials and running analyses on subpopulations by sex.[19][25]

Although guidelines have been introduced, sex bias remains an issue. A 2001 meta-analysis found that of 120 trials published in the New England Journal of Medicine, on average just 24.6% of participants enrolled were women. In addition, the same 2001 meta-analysis found that 14% of the trials included sex specific data analysis.[26]

A 2005 review by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use found that regulation in the US, Europe, and Japan required that clinical trials should reflect the population to whom an intervention will be given, and found that clinical trials that had been submitted to agencies were generally complying with those regulations.[27]

A review of NIH-funded studies (not necessarily submitted to regulatory agencies) published between 1995 and 2010 found that they had an "average enrollment of 37% (±6% standard deviation [SD]) women, at an increasing rate over the years. Only 28% of the publications either made some reference to sex/gender-specific results in the text or provided detailed results including sex/gender-specific estimates of effect or tests of interaction."[28]

The FDA published a study of the 30 sets of clinical trial data submitted after 2011, and found that for all of them, information by sex was available in public documents, and that almost all of them included sub-analyses by sex.[19] In a 2019 meta-analysis it was reported that 36.4% of participants in 40 trials for anti-psychotic drugs were women.[29] Another 2019 analysis found that worldwide 43% of clinical trial participants were women, with women's participation at around 49% female participants in the United States in 40% in non-US studies.[30]

As of 2015, recruiting women to participate in clinical trials remained a challenge.[31] However, efforts have been made by the U.S. government to expand women's health research and the inclusion of women in clinical studies. In 2016, the United States Congress passed the 21st Century Cures Act which codified into law the strengthening of women's health research through government funding.[32] This act also established the policy at the National Institutes of Health known as sex as a biological variable (SABV), which requires basic research studies to examine sex in experimental design when relevant.[33] In 2018, the U.S. Food and Drug Administration released draft guidelines for inclusion of pregnant women in clinical trials.[34][35]

On March 18, 2024, U.S. President Joe Biden made an “executive order on advancing women's health research and funding.”[36] In this executive order, he called for the establishment of more stringent guidelines to women's health research, further funding for clinical studies on women's health, and reduction of barriers for female participants in trials. He also demanded funding be allocated to menopause research to promote women’s health in the United States’ aging population.

Medical diagnosis

The possibility of gender differences in experiences of pain has led to a discrepancy in treating female patients' pain over that of male patients.[37] The phenomenon may affect physical diagnosis. Women are more likely to be given a diagnosis of psychosomatic nature for a physical ailment than men, despite presenting with similar symptoms. Women sometimes have trouble being taken seriously by physicians when they have a medically unexplained illness, and report difficulty receiving appropriate medical care for their illnesses because doctors repeatedly diagnose their physical complaints as related to psychiatric problems or simply related to female's menstrual cycle.[38] Clinical offices that rely on healthcare routines become less distinct due to biased medical knowledge of gender. There is a distinct differentiation between gender and sex in the medical sense. Because gender is the societal construction of what femininity and masculinity is, whereas, sex is the biological aspect that defines the dichotomy of female and male. The way of lifestyle and the place in society are often considered when diagnosing patients.[39]

An example of a significant condition from which an extreme gender bias and differential medical attention and treatment can be noted is that of Cardiovascular disease. Of this condition, Coronary heart disease is the most prevalent; with women more often than men reported as fatalities.[40] For example, women who are experiencing a heart attack are seven times more likely to be misdiagnosed and released from the hospital during the heart attack. This difference is often because women generally experience different heart attack symptoms, like flu-like symptoms, than men.[41] Due to sex based medical prerogatives, women tend to be more concerned with their primary and secondary sex health characteristics; i.e., gynecological health and breast health especially in terms of cancer; as opposed to heart health.[42] Furthermore, mortality rates of women have increased since 1979; whereas men's conversely have displayed a decline.[40] This can be attributed to differential treatment, specifically; preventative measures, refined diagnostic techniques and advanced medical and surgical capabilities that are directly catered to men's health.[40] One proposed explanation of gender bias pertaining to cardiac concerns and treatment is that men are more likely report or assume symptoms to be cardiac related than women, i.e., stress, (in stressful situations, personal situations or as a controlled variable); however these hypothesis were found to be inconsistent.[43] When addressing women's health in relation to cardiovascular health, sexed based differences are imperative in acknowledging in order appropriately diagnose and treat symptoms. Specific diagnostic criteria for assessing women's cardiovascular health include: evaluating for high levels of triglycerides/low levels of HDL cholesterol (after menopause), diabetes, smoking, metabolic syndrome, gestational diabetes, and pre-eclampsia.[44]

Men and women are biologically different. They differ in the mechanical workings of their hearts and in their lung capacities, resulting in women being 20-70% more likely to develop lung cancer.[45] The differences between men and women are also seen at the cellular level. For example, the ways immune cells convey pain signals are different in men and women.[46] As a result of these biological differences, men and women react to certain drugs and medical treatments differently.[45] One example is opioids. When using opioids for pain relief, women and men have different reactions. Surveys of the literature also conclude that there is a need for more clinical trials that study the gender specific response to opioids.[47]

Although there is evidence pointing to the biological difference between men and women, historically women have been excluded from clinical trials and men have been used as the standard.[48] This male standard has its roots in ancient Greece, where the female body was viewed as a mutilated version of the male body.[48] However, the male bias was furthered in the United States in the 1950s and 60s after the FDA issued guidelines excluding women of childbearing potential from trials to avoid any risk to a potential fetus.[49][20] Additionally, the thalidomide tragedy led the FDA to issue regulations in 1977 recommending that women should be excluded from participating in Phase I and Phase II studies in the US.[19] Studies also excluded women for other reasons including that women were more expensive to use as test subjects because of fluctuating hormone levels. The assumption that women would have the same reaction to the treatments as men was also used to justify excluding women from clinical trials.[45]

However, more recent studies have shown that women respond differently to a variety of common drugs than men, including sleeping pills, antihistamines, aspirin and anesthesia.[50] As a result, many drugs may actually pose health risks to women.[50] For example, a 2001 study conducted by the Government Accountability Office about drugs removed from the market between 1997 and 2000 showed that "Eight of the 10 prescription drugs posed greater health risks for women than for men."[51]

Pain bias

In recent decades, there has been increasing attention given to the disparity between the treatment of pain in females compared to males.[38][52] Chronic pain is more prevalent in women than in men, and women report more severe, frequent, and prolonged cases of pain; however, they are less likely to receive adequate health treatment.[53][38] Over 90% of women with chronic pain believe that they are treated differently by healthcare professionals because of their gender.[54][55]

Providers are also more likely to under-estimate female patientsʻ pain compared to males' pain. Studies show that physicians often perceive women's complaints as emotional responses rather than physiological pain. Women are often referred to psychiatrists for treatment, and prescribed sedatives or psychotherapy medications.[56][38][57] In addition, women are less likely to be prescribed painkillers after surgeries, according to several studies conducted in the 1980s. For example, after undergoing coronary artery bypass surgery, women received more sedatives rather than pain treatment.[38] Studies from the 2000s showed that physicians dismissed women's pain as inexplicable because they refused to believe the complaints; some physicians even blamed the female patients for their pain.[56]

There are still gendered attitudes towards reporting uncontrolled pain to a healthcare provider. An exploratory study in 2020 found that women are more likely to advocate for themselves and use more varied self-advocacy strategies. However, this finding is contradictory, as women actually receive less pain treatment and experience worse health outcomes than men.[58]

Western cultural recognition of pain bias

As the issue of pain bias becomes more popular, media coverage of the topic has also increased. In 2014, the National Pain Report conducted an online national survey of almost 2,600 women with a variety of chronic pain conditions. 65% felt that their pain was being given inadequate attention because they were female, and 91% believed that the health-care system discriminated against women.[59] Nearly half of the women were told that their pain was psychological, and 75% were told they must learn to deal with the pain.[59] In 2015, The Atlantic published an article about a woman's experience with acute abdominal pain. She had to wait almost two hours at the emergency room before receiving treatment, but she endured the pain longer than necessary due to a misdiagnosis.[2] In the United States, women wait an average of 65 minutes before receiving an analgesic for acute abdominal pain, while men only wait 49 minutes.[2] A 2019 article published by The Washington Post references a 2008 study that supports the statements made in 2015 The Atlantic article.[3]

Psychological diagnosis

There was an example of gender bias in the psychiatric field as well, Hamberg notes that, "psychiatrists would diagnose women with depression and then, eventually psychiatrists would begin to assume that women were more depressed than men due to the fact that the patients that were examined by the psychiatrists were women and they had similar symptoms. As for the men, they were diagnosed with drug or alcohol problems and they were thrown out of the study."[39] There is a suggestion that assumptions regarding gender specific behavioral characteristics can lead to a diagnostic system which is biased.[60] The issue of gender bias with regard to Diagnostic and Statistical Manual of Mental Disorders (DSM) personality disorder criteria has been controversial and widely debated. The fourth DSM (4th ed., text revision; DSM–IV–TR; American Psychiatric Association, 2000) makes no explicit statement regarding gender bias among the ten personality disorders (PDs), but it does state that six PDs (antisocial, narcissistic, obsessive-compulsive, paranoid, schizotypal, schizoid) are more frequently found in men. Three others (borderline, histrionic, dependent) are more frequent in women. Avoidant is equally common in men and women.[61]

There are many ways to interpret differential prevalence rates as a function of gender. Some critics have argued that they are an artifact of gender bias. In other words, the PD criteria assume unfairly that stereotypical female characteristics are pathological. The results of this study conclude with no indication of gender-biased criteria in the borderline, histrionic, and dependent PDs. This is in contrast with what is predicted by critics of these disorders, who suggest they are biased against women. It is possible, however, that other sources of bias, including assessment and clinical bias, are still at work in relation to these disorders. The results do show that the group means are higher in women than in men, an expected result considering the higher prevalence rate of these disorders for women.[61]

The original purpose of the DSM–IV was to provide an accurate classification of psychopathology, not to develop a diagnostic system that will, democratically, diagnose as many men with a personality disorder as women. However, if the criteria are to serve equally as indicators of disorder for both men and women, it will be important to establish that the implications of these criteria for functional impairment are comparable for both sexes. Whereas it is plausible that there are gender-specific expressions of these disorders, DSM–IV criteria that function differently for men and women can systematically over-pathologize or under-represent mental illness in a particular gender. The present study is limited by the investigation of only four personality disorders and the lack of inclusion of additional diagnoses that have also been controversial in the gender bias debate (such as dependent and histrionic personality disorders), although it offers a clearly articulated methodology for studying this possibility. In addition, it provides an examination of a clinical sample of substantial size and uses functional assessments that cut across multiple functional domains and multiple assessment methods. Our results indicate that BPD criteria showed some evidence of differential functioning between genders on global functioning, although there is little evidence of sex bias within the diagnostic criteria for avoidant, schizotypal, or obsessive–compulsive personality disorders. Further investigation and validation across sexes for those disorders would be an important direction of future research.[62]

The signs and symptoms of PTSD

Considerable evidence indicates a prominent role for trauma-related cognitions in the development and maintenance of posttraumatic stress disorder (PTSD) symptoms. The present study utilized regression analysis to examine the unique relationships between various trauma-related cognitions and PTSD symptoms after controlling for gender and measures of general affective distress in a large sample of trauma-exposed college students. In terms of trauma-related cognitions, only negative cognitions about the self were related to PTSD symptom severity. Gender and anxiety symptoms were also related to PTSD symptom severity. Theoretical implications of the results are consistent with previous studies on the relationship between PTSD and negative cognitions, the self, world, and blame subscales of the PTCI were significantly related to PTSD symptoms. The study correlations indicated that increased negative trauma-related cognitions were related to more severe PTSD symptoms. Also consistent with previous reports, correlations also indicated that gender was related to PTSD symptom severity, such that women had more severe PTSD symptoms. PTSD symptom severity was also positively related to depression, anxiety, and stress reactivity.[63]

Distinguishing between borderline personality disorder (BPD) and post traumatic stress disorder (PTSD) is often challenging, especially when the client has experienced a trauma such as childhood sexual abuse (CSA), which is strongly linked to both disorders. Although the individual diagnostic criteria for these two disorders do not overlap substantially, patients with either of these disorders can display similar clinical pictures. Both patients with BPD and PTSD may present as aggressive towards self or others, irritable, unable to tolerate emotional extremes, dysphoric, feeling empty or dead, and highly reactive to mild stressors. Despite having similar clinical pictures, PTSD and BPD are regarded differently by many clinicians. Results from a 2009 study concluded that patient gender does not affect diagnosis. This finding is consistent with research suggesting that women are not more likely to be given the BPD diagnosis, all else being equal, though it contradicts other findings from studies that have used similar case vignettes. Nor did the data support an effect of clinician gender or age on diagnosis.[64]

A 2012 study examined gender-specific associations between trauma cognition, alcohol cravings and alcohol-related consequences in individuals with dually diagnosed PTSD and alcohol dependence (AD). Participants had entered a treatment study for concurrent PTSD and AD; baseline information was collected from participants about PTSD-related cognition in three areas: (a) Negative Cognition About Self, (b) Negative Cognition About the World, and (c) Self-Blame. Information was also collected on two aspects of AD: alcohol cravings and consequences of AD. Gender differences were examined while controlling for PTSD severity. The results indicate that Negative Cognition About Self are significantly related to alcohol cravings in men but not women, and that interpersonal consequences of AD are significantly related to Self-Blame in women but not in men. These findings suggest that for individuals with co-morbid PTSD and AD, psycho-therapeutic interventions that focus on reducing trauma-related cognition are likely to reduce alcohol cravings in men and relational problems in women.[65]

Female patients

Women have been described in studies and in narratives as hysterical and neurotic, and many feel that physicians take their pain less seriously.[66] Historically, women's health was only associated with reproductive health, and thus has often been called "bikini medicine" because the field largely focused on the anatomy covered by a bathing suit.[67] Until recently, clinical research mainly used male subjects, male cells, and male mice. Many women were excluded from research because they were considered too weak, too variable, and in need of protection from the harms associated with medical research studies.[67][68] Studies important in understanding drug behavior in the male-body were extrapolated to female patients as well. This practice occurred despite biological differences in disease presentation between females and males, and the fact that women are more prone to experiencing adverse reactions to medication.[67][69][68] Modern research on human subjects are made up of approximately an equal distribution of female and male subjects, but female subjects in research are largely still underrepresented in specific areas of medical research, like cardiovascular research and drug studies.[68] Physicians' narratives often suggest that women's complaints are seen as exaggerated or invalid. Historically, women have been viewed as less stable than men, leading physicians to attribute their physical ailments to emotions. [70] In general, women's symptoms are frequently dismissed, leading to high rates of misdiagnosis, unacknowledged symptoms, or assumptions of a psychosomatic origin.[68]

A significant disparity exists in the treatment of physically attractive versus physically unattractive patients, a bias that is more pronounced in females.[71] Female patients who are considered conventionally attractive are thought to be experiencing less pain than unattractive female patients.[71] Female patients have also been considered more demanding patients, and are considered to be a greater burden than male patients.[70] One observer has stated that, "different forms of female suffering are minimized, mocked, coaxed into silence."[2] In the medical community, women are perceived as having to "prove they are as sick as male patients," what the medical community has deemed "Yentyl Syndrome."[2]

Intersection of gender and racial bias

Specifically, Black women and women of color are at an even greater disadvantage. Black women are twice as likely to have strokes, and their chances for survival are even lower than white women.[68] Black women are also more likely to have adverse maternal health outcomes compared to white women.[72] They also face greater challenges when it comes to breast cancer, and are more likely to be misdiagnosed and more likely to die.[68] In her book, The Cancer Journals, Audre Lorde speaks about her unpleasant experiences as a Black female breast cancer patient, her troubling experiences with physicians and caretakers, and her struggle to find strength after undergoing a mastectomy.[73] In recent years, new outlets have published numerous first and second-hand accounts about Black women and women of color experiencing adverse maternal health care and outcomes throughout the US. Pro-Publica and NPR published a story about racial disparities in maternal mortality and the birth experience of Dr. Shalon Irving, a CDC epidemiologist studying how structural inequality influences health.

Although many women still face gender bias in their experiences with the healthcare system, progress has been made towards a fairer system. The Laura W. Bush Institute for Women's Health at Texas Tech University was founded in 2007, and has supported integration of "sex-specific instruction in medical education."[68] The team at Texas Tech created a curriculum for medical schools to include sex-differences in medical education, and ten schools are using the curriculum.[68]

Aging women

See main article: Menopause

Contemporary healthcare approaches face a significant gap in understanding and addressing age-related diseases specifically in females. Age bias in healthcare often overlooks the unique challenges faced by aging women, who tend to outlive men but experience more pronounced physical and cognitive declines. This is particularly evident in the context of menopause. Menopause is a gradual hormonal change, typically onset between the ages of 48-52 wherein menstrual periods cease, and women are no longer able to conceive and bear children.[74] Menopausal symptoms include hot flashes, mood swings, vaginal dryness, fatigue, weight gain, among others.[75]

The Women’s Health Initiative (WHI) hormone therapy (HT) trials, conducted between 1993 and 2004, demonstrated efforts to address gender bias in medical diagnosis by providing insights into managing menopausal symptoms.[76] These trials aimed to evaluate the benefits and risks of HT in preventing chronic diseases such as coronary heart disease (CHD) and invasive breast cancer in mostly healthy postmenopausal women. Despite finding that HT can effectively manage moderate-to-severe menopausal symptoms in healthy women in early menopause, the study does not recommend HT for preventing chronic diseases. It also advises caution in older age groups considering HT due to the increased risk of vasomotor symptoms and CHD.

A 2001 research interview study examined personal experiences, where age of patients within patient-doctor interactions correlated with negative experiences relating to validity and treatment of health concerns, for menopause specifically.[74] This study, involving 61 women from various backgrounds, discovered that patients reported experiencing symptoms of menopause in their early thirties and late forties. However, they were often dismissed because their age did not align with the estimated average age for experiencing these symptoms.[74]

Another significant impact of menopause is osteoarthritis. Women aged 50 to 60 years are 3.5 times more likely to develop osteoarthritis than men in the same age group.[77] This decline in bone density is attributed to the hormonal changes that occur during menopause, differences in musculoskeletal system, and varying biomechanics. For example, a 2020 cross-sectional study demonstrated that women with knee osteoarthritis had a decline in functional performance and quality of life.[78]

Women also exhibit a higher susceptibility to dementia compared to men, experiencing more frequent and rapid declines in cognitive function with aging.[79] Dementia encompasses various conditions, including Alzheimer's disease and vascular dementia. Women, including those with dementia, are more frequently prescribed specific classes of psychotropic medications, such as sleep aids, which may heighten the risk of cognitive impairment.[80]

Age bias presents significant challenges for aging women in the diagnosis and treatment of medical conditions. For example, a 2000 study found that emergency department nurses had varying views on the importance and likelihood of myocardial infarction among male and female patients seeking evaluation and treatment. Healthcare providers' failure to recognize the symptoms of myocardial infarction in middle-aged women may contribute to higher morbidity and mortality rates among this group.[81] To mitigate age bias in women's healthcare, healthcare providers are recommended to receive training on gender sensitivity and age-related issues, ensuring they understand the diverse healthcare needs of women of all ages.[82]

Avoiding gender bias

Researchers should conduct all studies with both male and female subjects in their samples.[83] From a research based perspective, we also need to increase women’s participation in conducting research to directly and indirectly address women's health concerns. A 2023 study of publications in “Clinical Pharmacology and Therapeutics" and "Clinical and Translational Science" found that women make up less than 40% of all study authors. A similar study in 2024 found that women make up 40% of first authors and 20.4% of last authors in clinical studies, with some disciplines having as low as 9% female first authorship and 7.8% female last authorship.[84]

Healthcare workers should not assume all men and women are the same, even if they display similar symptoms. In a study done to analyze gender bias, a physician in the research sample stated, '"I am solely a professional, neutral and genderless"'. While a seemingly positive statement, this kind of thought process can ultimately lead to gender biasing because it does not note the differences between men and women that must be taken into account when diagnosing a patient.[85] To avoid gender bias, we must also expand our inclusion of sex and gender in medicine to be more nuanced, providing more opportunities for sex and gender to be accounted for in research and implementing healthcare practices and policies that are more gender inclusive and affirming.[86] Other ways to avoid gender bias includes diagnostic checklists which help to increase accuracy, evidenced-based assessments and facilitation of informed choices.[87]

See also

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Further reading

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