Women's injuries often attract less attention and lower prehospital priority
A decade of hospital records in Ontario has revealed that women suffering traumatic brain injuries are significantly less likely to be directed toward specialized trauma care than men — not because their injuries are less serious, but because something in the human chain of clinical judgment appears to be failing them. Across more than 55,000 patients, the gap in trauma center admissions between female and male patients persisted even after accounting for age, injury severity, and underlying health conditions. It is a quiet inequity, embedded in the routines of emergency medicine, where assumptions about who looks like a trauma patient may be shaping who receives trauma care.
- Female TBI patients in Ontario were admitted to specialized trauma centers at a rate of 26% versus 38% for males — a 12-point gap that survived every statistical adjustment researchers applied.
- The disparity is not easily explained away: even after controlling for age, injury severity, comorbidities, and socioeconomic status, women remained 26% less likely to reach the highest level of trauma care.
- Low-energy injury mechanisms like ground-level falls — more common among older women — may not trigger the same clinical alarm as high-impact collisions, even when the neurological damage is equivalent.
- Decades of male-skewed trauma research have left clinicians with an incomplete picture of how TBI presents in women, creating a knowledge gap that may quietly compound bias at the bedside.
- Researchers are now calling for direct investigation into sex-based bias in triage protocols, arguing that without targeted intervention, the disparity will continue to cost female patients their best chance at recovery.
A large Ontario study spanning more than a decade has found that female traumatic brain injury patients are routed to specialized trauma centers far less often than their male counterparts — and the numbers hold even after accounting for the factors that should govern triage decisions. Of the 55,606 patients hospitalized for TBI between 2009 and 2020, women were admitted to trauma centers at a rate of 26 percent compared to 38 percent for men. The gap remained after researchers controlled for age, injury severity, existing conditions, and socioeconomic status.
The female patients in the study were older on average — a median age of 78 versus 67 for men — and more likely to have conditions like dementia and hypertension. Male patients sustained more severe injuries overall. These differences might seem to justify the disparity, but researchers found they were insufficient to explain it fully.
Dr. Natalia Angeloni and her colleagues at Sunnybrook Health Sciences Centre and the University of Toronto identified several converging factors. Women's TBI injuries more often result from low-energy events like standing falls, which may not register the same clinical urgency as high-impact collisions — even when the underlying neurological damage is comparable. There is also the possibility of unconscious bias in how clinicians read and respond to female patients presenting with head injuries.
Adding to the problem is a longstanding gap in trauma research itself: because women have historically been underrepresented in studies, clinicians may have a narrower understanding of how TBI actually manifests in female patients. The authors argue that targeted investigation into sex-based bias in triage protocols is now essential — because for female TBI patients, the path to specialized care is not yet an equal one.
A study of more than 55,000 traumatic brain injury patients in Ontario has uncovered a stark disparity in who gets routed to specialized trauma centers—and the gap cannot be explained by the severity of the injuries themselves. Female patients were admitted to these centers at a rate of 26 percent, compared to 38 percent for male patients. The research, published in the Canadian Medical Association Journal and based on hospital records spanning a decade, suggests that something beyond medical necessity is determining who receives the highest level of trauma care.
The dataset included 55,606 patients hospitalized for traumatic brain injury between April 2009 and March 2020. Of these, 21,719 were women—39 percent of the total. When researchers looked at who actually made it to a specialized trauma center, the numbers diverged sharply: 5,666 female patients (26 percent of all women in the study) versus 12,984 male patients (38 percent of all men). The difference held even when researchers controlled for age, injury severity, existing health conditions, and socioeconomic status—the standard variables that should determine triage decisions.
The female patients in the study tended to be older, with a median age of 78 compared to 67 for men. They were more likely to have dementia and hypertension. Male patients, by contrast, sustained more severe head injuries overall—33 percent experienced severe trauma compared to 25 percent of women. On paper, this might suggest that men's injuries warranted more intensive intervention. But the disparity in admission rates was too large to be explained by these differences alone.
Dr. Natalia Angeloni, a critical care physician at Sunnybrook Health Sciences Centre and doctoral student at the University of Toronto, and her colleagues identified several possible explanations. Women's traumatic brain injuries often result from low-energy mechanisms—ground-level falls, for instance—that may not trigger the same level of clinical alarm as the higher-impact injuries more common in men. A fall from standing height looks different on paper than a motor vehicle collision, even if the neurological damage is comparable. There is also the possibility of unconscious bias in how clinicians assess injury severity in female patients. When a woman arrives at an emergency department with a head injury, the clinical team may be less likely to recognize the urgency, or to assume that her age or other conditions explain her presentation rather than the trauma itself.
The researchers also point to a gap in the medical literature itself. Because fewer women have been studied in trauma research historically, clinicians may have a narrower understanding of how traumatic brain injury actually presents in female patients. This knowledge gap can translate into missed diagnoses or delayed recognition of severity.
Ontario's trauma system is supposed to operate under standardized triage guidelines, yet the study found high rates of both overtriage and undertriage—patients sent to trauma centers who didn't need that level of care, and patients kept in lower-acuity settings who did. This variability suggests that decision-making is inconsistent, even when protocols are in place. The authors call for investigation into whether sex-based bias, conscious or unconscious, is driving these gaps. They argue that understanding how gender intersects with triage decisions is essential, and that targeted interventions based on this understanding could help close the disparity. For now, female patients with traumatic brain injury face an unequal chance of reaching the specialized care that might determine their recovery.
Citas Notables
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.— Dr. Natalia Angeloni, critical care physician at Sunnybrook Health Sciences Centre
Understanding how this variability interacts with sex and gender is critical. The role, if any, of conscious and unconscious bias in clinical decision-making should be explored.— Study authors in Canadian Medical Association Journal
La Conversación del Hearth Otra perspectiva de la historia
Why would a woman's fall from standing height be treated differently from a man's if the brain injury is the same?
Because in the moment of triage, the clinician sees a 78-year-old woman who fell at home, and they may unconsciously weight that differently than a 67-year-old man with a high-impact injury. The mechanism of injury shapes how we perceive severity, even when the actual damage is comparable.
But the study controlled for injury severity. So the bias isn't about missing the severity—it's about something else?
Exactly. The severity was documented. Yet women still weren't being admitted to trauma centers at the same rate. That suggests the bias operates at the decision-making level, not the assessment level. A clinician might look at the same scan and make a different triage call based on the patient's sex.
Is there evidence this actually affects outcomes—that women recover worse because they don't get to trauma centers?
The study doesn't measure outcomes directly, but that's the logical concern. Trauma centers exist because specialized care saves lives and reduces disability. If women are systematically less likely to receive that care, the consequences would show up in recovery rates and long-term disability. That's what researchers want to investigate next.
Why would clinicians have this bias if they're trained on standardized guidelines?
Because guidelines tell you what to do, but they don't eliminate unconscious bias in how you interpret the information in front of you. You can follow a protocol and still weight evidence differently depending on who the patient is. The study found high rates of both overtriage and undertriage, which suggests the guidelines aren't being applied consistently.
What would a targeted intervention look like?
Probably education about how trauma presents differently in older women, audits of triage decisions to identify patterns, and explicit training on recognizing unconscious bias. The researchers are essentially saying: we've found the problem. Now we need to understand why it's happening and fix it.