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Gender Bias and the Medical Establishment

In order to understand the misdiagnosing of women within specific learning disorders, it’s important to understand the ways in which gender bias has developed throughout the history of medicine.

The Greek philosopher, Aristotle believed that females are in essence mutilated males(Cole, 1944). This belief centered on the anatomical differences between women and men. This perception continued for hundreds of years. Until fairly recently, scientists, anthropologists and doctors believed that because women have smaller skulls than men in general, women also have less intellectual capacity. For a long time, medical texts have described the male body as superior to the female body.

Contradictions

At the same time as these differences were being emphasized, there was a de-emphasis on other biological differences. Seeing women as smaller, weaker and inferior versions of men implied that the anatomy (with the exception of reproductive anatomy) was essentially the same. These ideas have resulted in the lack of understanding of women’s health and ineffective, and harmful ‘treatments’ for women with physical and mental health challenges (Young, 2015).

When, in the early 1900s women started to advocate for more research specifically looking at female anatomy, the medical and scientific establishments were resistant. They believed it would be a potential risk for the fertility and reproductive ability of women to expose them to clinical trials involving the intake of drugs and other medicine. In Europe and the United States, it is only since the early 1990’s that women are allowed to participate in clinical trials and research focused on disease within women. (LBS)

The Development of our Understanding of ADHD

The first mention of the observed characteristics of Attention Deficit Hyperactivity Disorder (ADHD) can be traced back to a book, written in the late 1700s, by a Scottish physician, Sir Alexander Crichton. In this book, he writes specifically about me (Lange, Reichl, Lange, Tucha, and Tucha, 2010). This is where the diagnostic bias of the gender specific behavioral characteristics of ADHD may have started.

The narrative continues in 1844, with the release of the book Fidgety Phil, which although written as a children’s poem, was authored by a doctor who also founded a mental hospital in Frankfurt. The book popularized the representation of hyperactivity as the main characteristic of attention ‘disorders’ .

In the early 1900s,  scientific research being done about ADHD (which was not called ADHD yet) was established by Still’s study, where ADHD was defined as being a “defect of moral control” (Still, 1902, p. 1077). This study explored cases of hyperactivity in 15 males and 5 females and it concluded that this ‘moral control defect’ could be identified and diagnosed by the expression of anger, frustration, hostility and aggression. (Ibid., 1902). All these emotions are the kind we typically assign to and expect to see in men, and actively teach women and girls to suppress. The study itself is an early example of the biased nature of researching and diagnosing ADHD/ADD; remember the 3:1 male to female ratio as the timeline continues, as it may surprise you how little has changed.

For the next few decades, the disorder was given many names, eventually leading to Attention Deficit Hyperactivity Disorder. The 1990s presented more conclusive research on AD(H)D, and laid the foundation for the field’s understanding of the disorders. In this decade, ADD found its stationary position in the DSM, characterised as a more inward sense of hyperactivity, and presenting as daydreamy, rather than disruptive (Ibid., 2010)

Gender bias in diagnosing learning disorders

The historical belief that ADHD occurs more often in males has not only affected the way ADHD has been diagnosed, but also who tends to get diagnosed. Teachers tend to be referred to as a point of contact, identifying who may need extra support in their classrooms; a study in 1997 showed that young boys were more likely to be referred for special education services than girls with the same profile because they exhibited more disruptive behaviours (Anderson, 1997).

It is theorised that ADHD is more widely recognised than ADD. As a hyperactivity disorder it is more noticeable, especially as boys are likely to be more prototypical and girls have traditionally been taught to suppress those characteristics (Bruchmuller, Margraf, and Schneider, 2012).

This chart shows the male to female ratio of ADHD diagnoses in countries around Europe in 2006. A large imbalance in the gender of those diagnosed is clearly noticeable.

Teachers are often the first to notice learning issues and/or challenges and learning specialists and psychologists observe and assess the child (with parental permission).  Specialists around the world compare what they observe and assess to the the references and symptoms listed in the the DSM-5.

This diagnostic process is considered to be the international standard for diagnosis. However, medical gender bias resulted in diagnostic standards that are based on research focused on the male gender. Because of this, girls’ learning issues are often overlooked. This results in an underrepresentation of girls in special education, which eventually leads to a prioritization of research to boys and men with learning disabilities (Anderson, 1997). This process leads to a vicious cycle that is hard to break.