A shallow glimpse into modern psychiatry or how it systematically neglects sex and gender differences.
In biomedical research, bias is said to arise when a specific diagnosis or treatment performs better for a particular group of patients compared to others. Somewhat paradoxically, despite being Western medicine a science that should be impartial and replicable, in recent years it has become clear that there are substantial gender and sex biases in diagnosis and treatment for a wide range of medical disorders, especially neuropsychiatric conditions.
A few years ago, Maya underwent her seventh psychiatric evaluation in less than ten years. During the session, the professional asked her, among other questions, whether she could hear voices that others were unable to hear, to which she replied with a terse "Yes". Maya walked out with an inconclusive diagnosis and a battery of antipsychotics that would leave her mildly dysfunctional for years to come. What Maya had was a damn privileged hearing, and a severe communication impairment due to an undiagnosed autism.
As in Maya’s case, it has been noticed that autistic patients not fitting male cisgender criteria are frequently observed to be either misdiagnosed or overlooked by healthcare institutions.
The case of autism is particularly curious. Until a few years ago, it was commonly acknowledged that it affected more males than females, with a ratio of 4 to 1. However, it is becoming apparent that the overall ratio of males and females on the autistic spectrum is far more equal than diagnostic statistics might indicate. Recent evidence shows that, at comparable levels of severity, females are not only less likely than males to be diagnosed with autism, but also significantly later. Studies point to a number of underlying causes. For instance, it has been found that from an early age, girls learn to mask their symptoms more effectively than boys with matching patterns of behavior. Another reported factor is how caregivers and general public perceive autistic traits across the gender spectrum. Research show that from the age of 15, autistic behavioral patterns in female adolescents go unnoticed as sings of shyness, which are more socially tolerated than symptoms of male self-isolation that disrupt their gender stereotype of confidence and self-assuredness. By failing to address these differences, women and non-binary identities are systematically underrepresented in population-based and drug treatment research. A recent meta-analysis revealed that males were heavily over-represented in intervention studies, and while 82% of the other studies included both males and females, 17% were male-only compared to a tiny 0.49% that were female-only.
But this disregard of sex and gender differences is a hallmark across mental health research. As an example, out of 768 published clinical trials for depression treatments available on ClinicalTrials.gov a few years ago, 89% reported recruitment of male and female participants, yet less than 1% reported an intention to analyze results by gender. Furthermore, between 2012 and 2015, of the articles published in two leading journals in the psychiatric community, only 16% stratified analyses by sex, and none did so by gender. This sex- and gender-neutral perspective risks undermining scientific validity and efficacy and has been shown to cause health professionals to fail from providing effective mental health diagnosis and treatment.
Adequate population portrayal is an essential requirement if we are to conduct excellent and replicable research, and this would not possible if we continue to work according to outdated male-centered criteria. We all need to be represented in the studies that are supposed to cure the conditions that we suffer from, regardless of gender, race or class.
It is high time to turn some things around.