Even with guidelines in place, clinicians are making different calls.
In Ontario, a decade of hospital data reveals that women with traumatic brain injuries are 26 percent less likely than men to reach specialized trauma centers — a disparity that persists even after accounting for age, injury severity, and health history. The pattern suggests that the mechanisms of injury common to women, such as ground-level falls, may be systematically underestimated, and that unconscious bias may quietly shape clinical decisions even where standardized guidelines exist. It is a reminder that the architecture of care is never fully neutral, and that what medicine has not learned to see, it will continue to miss.
- A measurable 26% gap in trauma center admissions separates women from men with similar brain injuries — not by chance, but by pattern.
- Women's injuries, often from low-energy falls, may be coded as lower priority before they ever reach a specialist's hands.
- Unconscious bias in severity assessment may be quietly overriding the standardized triage protocols designed to protect against exactly this kind of disparity.
- The evidence base itself is skewed — fewer women in trauma research means clinicians may simply not recognize how brain injury presents differently in female patients.
- Researchers are now calling for targeted investigation into sex-based decision-making in trauma triage, with the goal of designing interventions that can close the gap.
A woman arrives at an Ontario hospital after a fall. A man with a comparable injury, admitted the same day, is sent to a specialized trauma centre. She is not. This scene, repeated across more than a decade of admissions data, is the subject of a new study published in the Canadian Medical Association Journal.
Analyzing 55,606 patients hospitalized for traumatic brain injury between 2009 and 2020, researchers found that women were 26 percent less likely than men to be admitted to a trauma centre — even after controlling for age, injury severity, existing conditions, and socioeconomic status. Of the 21,719 women in the study, only 26 percent reached a trauma centre, compared to 38 percent of men.
Dr. Natalia Angeloni of Sunnybrook Health Sciences Centre and the University of Toronto points to two likely explanations. Women's injuries more often result from ground-level falls — mechanisms that may be coded as lower priority in prehospital assessments compared to vehicle collisions or falls from height. More troublingly, the researchers also raise the possibility of unconscious bias: clinicians may perceive the same injury differently depending on the patient's sex, even when following standardized protocols.
The problem is deepened by a research gap. Women are underrepresented in trauma studies, leaving clinicians with an evidence base that may not reflect how brain injury actually presents in female patients. Ontario's triage system already shows high rates of both overtriage and undertriage, suggesting that guidelines alone are not enough to ensure consistent decisions.
The researchers call for focused investigation into how sex and gender interact with triage variability — and for interventions built on those findings. The disparity is documented. The work of understanding and closing it is just beginning.
A woman falls at home. She hits her head. Hours later, she arrives at a hospital in Ontario. A man, admitted the same day with a similar injury, is sent to a specialized trauma centre. She is not. This disparity is not random. It is systematic, and it is measurable.
Researchers analyzing more than a decade of hospital admissions data from Ontario have found that women with traumatic brain injuries are 26 percent less likely than men to be admitted to a specialized trauma centre, even when researchers account for age, injury severity, existing health conditions, and socioeconomic status. The study, published in the Canadian Medical Association Journal, examined 55,606 patients hospitalized for traumatic brain injury between April 2009 and March 2020. Of those, 21,719 were women. Only 5,666 women—26 percent of the female patients—were admitted to trauma centres, compared to 12,984 men, or 38 percent of male patients.
The numbers tell a story about who gets routed toward specialized care and who does not. Women in the study were older on average (median age 78 versus 67 for men) and more likely to have dementia and hypertension. Men, by contrast, sustained more severe head injuries—33 percent of male patients had severe trauma compared to 25 percent of women. Yet even accounting for these differences, the gap in admission rates persisted. Something else was at work.
Dr. Natalia Angeloni, a critical care physician at Sunnybrook Health Sciences Centre and PhD student at the University of Toronto, and her colleagues identified two plausible explanations. First, the injuries women sustained often resulted from lower-energy mechanisms—ground-level falls, primarily—that may receive less urgent attention in the prehospital setting. A fall from standing height looks different on a paramedic's assessment form than a motor vehicle collision or a fall from height. It may be coded as lower priority. Second, and more troubling, the researchers point to the possibility of unconscious bias in how severity is recognized and assessed. A clinician may perceive the same injury differently depending on the patient's sex, even when following standardized triage guidelines.
The problem is compounded by a gap in the research itself. Fewer women appear in trauma studies, which means clinicians have a narrower understanding of how traumatic brain injury actually presents in female patients. When the evidence base skews male, the clinical eye trained on that evidence may miss what it has not been taught to see.
Ontario's trauma system operates under standardized triage protocols designed to ensure consistent decision-making. Yet the authors note that triage performance remains suboptimal, with high rates of both overtriage and undertriage. This variability suggests that even with guidelines in place, clinicians are making different calls. The question now is whether sex and gender are factors in those decisions—and if so, how.
The researchers call for deeper investigation into the role of conscious and unconscious bias in trauma care decision-making, similar to work already underway in other clinical domains. They argue that understanding how sex interacts with triage variability is critical, and that targeted interventions based on those findings could reduce the disparities they have documented. For now, women with traumatic brain injuries in Ontario are reaching specialized trauma centres at a measurably lower rate than men. The gap exists. The next step is understanding why, and closing it.
Notable Quotes
Injuries in female patients are more often associated with lower-energy mechanisms, such as ground-level falls, that may attract less attention and may lead to lower prehospital priority. Unconscious sex-related bias may contribute to differential recognition of severity of injury.— Dr. Natalia Angeloni, critical care physician at Sunnybrook Health Sciences Centre
Understanding how sex and gender interact with triage variability is critical. The role of conscious and unconscious bias in clinical decision-making should be explored, and results should guide targeted interventions to reduce these disparities.— Study authors in Canadian Medical Association Journal
The Hearth Conversation Another angle on the story
Why would a woman's fall from standing height be treated differently than a man's?
Because it looks less dramatic on paper. A paramedic sees an elderly woman who fell in her kitchen. They see a man thrown from a motorcycle. One gets flagged as high-priority, the other as routine—even if the head injury is equally serious.
But the study controlled for injury severity. So the difference isn't just about how bad the injury looks.
Right. That's where the bias question comes in. Two patients with the same scan results, the same neurological signs—but one is a 78-year-old woman and one is a 50-year-old man. The clinician may unconsciously weight the information differently.
Is that a conscious choice or something happening below awareness?
The researchers call it unconscious bias. It's not malice. It's pattern-matching gone wrong. If your training data—the studies you learned from—mostly showed traumatic brain injury in younger, male patients, you may not recognize the same injury in someone who doesn't fit that profile.
So the solution is more research on women?
Partly. But also auditing the decision-making itself. Looking at cases where women were not admitted to trauma centres and asking: would a man with those same vital signs have been sent there? That's how you find the bias.
What happens to a woman who doesn't get to a trauma centre?
She may not get the specialized monitoring and intervention she needs in the critical hours after injury. Traumatic brain injury can deteriorate quickly. The difference between early specialized care and delayed care can be the difference between recovery and permanent disability.