We need to pay attention when brain injury decisions are made
In Ontario, a decade of hospital data has surfaced a quiet inequity: women suffering traumatic brain injuries are 26 per cent less likely than men to reach the specialized care designed to treat them, even when injury severity and health history are held equal. The gap points not to deliberate neglect but to something more elusive — the way clinical instinct, built on research that has long centred male bodies, may render women's injuries less visible in the urgent calculus of emergency medicine. It is a reminder that systems, like people, carry the biases of their formation, and that measuring a disparity is the first, necessary act of correcting it.
- A study of more than 55,000 Ontario patients reveals women with traumatic brain injuries are being systematically under-admitted to trauma centres at a rate that cannot be explained by medical factors alone.
- The disparity persists even after researchers account for age, injury severity, existing conditions, and socioeconomic status — pointing toward unconscious bias embedded in triage decision-making.
- Women's injuries often stem from falls and low-velocity impacts, presentations that may register as less urgent in a busy emergency department shaped by protocols built around male injury patterns.
- Ontario's triage and transfer guidelines are themselves under scrutiny, with the study noting high rates of both overtriage and undertriage despite standardized protocols — a system under strain.
- Researchers are now pushing into the next layer of the problem: whether admission disparities translate into worse outcomes and longer recovery times for female trauma patients.
- The call is for hospitals to examine the instincts and structures driving these decisions — not to assign blame, but to create the pause that allows bias to be seen and interrupted.
A new study published in the Canadian Medical Association Journal has found that women with traumatic brain injuries in Ontario are 26 per cent less likely to be admitted to specialized trauma centres than men — a gap that holds even after accounting for injury severity, age, existing health conditions, and socioeconomic status. The research, which examined more than 55,000 patients treated between 2009 and 2020, was led by Natalia Angeloni, a PhD student at the University of Toronto. "This is the first step, to recognize that there's a gap," she said. "Once we recognize that, we can start to hypothesize and test different components."
The data reveals meaningful differences between male and female patients in the study: women tended to be older, with a median age of 78 compared to 67 for men, and were more likely to have dementia and high blood pressure. Men showed higher rates of severe head trauma. But these differences do not account for the admission gap. Researchers point instead to the nature of how women typically sustain brain injuries — often through falls from standing height or low-velocity impacts — circumstances that may appear less critical in the compressed urgency of emergency triage.
Underlying the individual decisions is a structural problem: Ontario's triage protocols were largely developed from research populations that skew male, creating a quiet misalignment between the guidelines and the way brain injuries present in women. Angeloni noted that emergency-care workers must make rapid decisions with incomplete information, conditions that leave room for gendered assumptions to shape outcomes without anyone intending them to.
The finding echoes documented disparities in care for women experiencing heart attacks, kidney disease, and other serious conditions — gaps that tend to remain invisible until someone measures them carefully enough to see them. Angeloni and her colleagues are already investigating what happens after admission: whether the disparities in access translate into disparities in recovery. Their broader call is for hospitals and policymakers to examine the triage instincts and clinical protocols that allow these gaps to persist — not as an accusation, but as an invitation to build systems that see every patient clearly.
A new study from Ontario has found something troubling buried in the numbers: women with traumatic brain injuries are being admitted to specialized trauma centres at significantly lower rates than men, even when researchers account for the severity of their injuries, their age, and their overall health. The disparity is stark. Women were 26 per cent less likely to be admitted, according to research published this week in the Canadian Medical Association Journal, a finding that suggests the problem runs deeper than simple medical judgment.
The study examined more than 55,000 patients admitted to Ontario hospitals with traumatic brain injuries between 2009 and 2020. Of those, roughly 18,650 went on to receive care at a specialized trauma centre. Among that group, 26 per cent were female and 38 per cent were male—a gap that persisted even after the researchers stripped away variables like age, injury severity, existing health conditions, and socioeconomic status. Natalia Angeloni, a PhD student at the University of Toronto who led the work, described it as a foundational moment in understanding a systemic problem. "This is the first step, to recognize that there's a gap," she said. "Once we recognize that, we can start to hypothesize and test different components."
The numbers tell part of the story. Female patients in the study tended to be older—a median age of 78 compared to 67 for men—and were more likely to have dementia and high blood pressure. Men, conversely, showed higher rates of severe head trauma. But those differences don't explain the admission gap. The researchers point instead to unconscious bias and the way injury patterns themselves may shape clinical decisions. Women more often sustain traumatic brain injuries from low-velocity impacts or falls from standing height, circumstances that may seem less urgent in the moment and therefore receive lower priority in a busy emergency department.
There is also a structural problem at work. Triage and transfer guidelines used in Ontario hospitals may not fully capture how brain injuries present in female patients, the study suggests. When clinical protocols are built primarily on research populations that skew male, the result is a kind of invisible misalignment—guidelines that work well for typical male presentations but miss or delay recognition of injury in women. The authors note that triaging decisions in Ontario hospitals are "suboptimal," with both overtriage and undertriage occurring at high rates despite standardized protocols.
Angeloni acknowledged that many factors influencing these decisions remain unmeasured: family preferences, patient wishes, advance directives, and the sheer pressure of making rapid decisions with incomplete information. Emergency medicine operates in a fog of urgency and uncertainty. But that fog, she suggests, may settle differently depending on the patient. "Emergency-care decisions have to be made quickly and health care workers are often working with limited or incomplete information, which can lead to gendered assumptions," she explained. The hope is that naming the problem creates a moment of reflection—a pause in the clinical workflow where providers might question their own instincts.
This finding fits into a larger pattern. Previous research has documented similar disparities for women seeking care for heart attacks, kidney transplants, and other critical conditions. Gender-based gaps in healthcare access are not new, but they remain persistent and often invisible until someone looks closely enough to measure them. Angeloni is already part of a team digging into the next layer: what happens to male and female patients after they are admitted to a trauma centre, and whether the disparities in admission translate to disparities in outcomes and recovery.
The researchers are calling for deeper investigation into how triage decisions are actually made in Ontario hospitals, and whether conscious or unconscious bias plays a role. They want to understand the interaction between sex, gender, and clinical decision-making in ways that have been explored for other conditions but not yet fully for traumatic brain injury. Angeloni noted that this problem is not unique to Ontario—it has been recognized in emergency departments around the world. But recognition is only the beginning. The real work is what comes next: changing the systems and the instincts that allow these gaps to persist.
Notable Quotes
This is the first step, to recognize that there's a gap and that females are less likely to be admitted to a trauma centre. Once we recognize that, we can start to hypothesize and test different components.— Natalia Angeloni, lead researcher
Emergency-care decisions have to be made quickly and health care workers are often working with limited or incomplete information, which can lead to gendered assumptions.— Natalia Angeloni
The Hearth Conversation Another angle on the story
Why would a 26 per cent difference persist even after controlling for severity? That suggests something systematic, not random.
Exactly. The researchers think it's partly about how injuries present differently. Women tend to have lower-velocity injuries—falls, impacts that seem less dramatic. In a busy emergency department, that might not trigger the same alarm bells.
But you controlled for severity. So a severe injury in a woman should look the same as a severe injury in a man on paper.
It should. But the guidelines themselves may have been built on populations that skew male. If you've never seen a severe brain injury present the way it does in an older woman, you might not recognize it when it's in front of you.
That's a knowledge gap, not bias.
It's both. The knowledge gap creates the space where bias can operate. A doctor sees a 78-year-old woman with a fall. They see an older person, maybe some dementia already in her chart. They might think: this is what happens at that age. They might not think: this is a severe brain injury that needs a trauma centre.
And the men in the study had higher rates of severe trauma to begin with.
Right. So the men were already flagged as high-risk. But that doesn't explain why women with equally severe injuries weren't being admitted at the same rate. That's the gap the study is trying to illuminate.
What changes now?
Awareness, first. Angeloni hopes this makes clinicians pause and question their own instincts. But the real work is systemic—updating guidelines, making sure they capture how injury manifests across different populations, and investigating whether bias is actually playing a role in real-time decisions.