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.


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.


gender diagnoses and ADD
Figure 11: (Novik et al., 2006).

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.

IT”S YOUR TURN: Is there gender bias in other diagnosed learning disabilities?
  1. Create a two-column list. Take no more than 3 minutes and list some traditional gender expectations and characteristics. Share with a partner, and broaden your list.
Boys/Men Girls/Women

2. Using a research method of your choice, look up the characteristics of a learning disability of interest to you (not ADHD or ADD). List at least five characteristics.

3. Compare what you have written for steps 1 and 2.  Were the traits of this learning disability indicative of a male or female centred research or diagnostic process?

4. Discuss your results with a partner or a group.  Compare your findings.

The Nature vs. Nurture Debate

The nature-nurture debate refers to an ongoing discussion in the field of social sciences and education as researchers and theorists discuss whether biological or environmental factors play a more significant role in human development (Pennington, 2002). Nature refers to biological factors, including genetics, while nurture describes all the environmental variables (e.g. social relationships, culture, upbringing) (Ibid., 2002).

Quick think! What qualities of the nurture debate might affect gender bias issues in diagnosis?

The table below displays a few of the research claims made about the diagnosis of various disorders.

  1. Can you identify whether the claims fall into the nature or nurture category of debate?
  2. Do you see any relationships between the year that a claim was presented, and where it falls along the timeline of diagnosis explored on the previous page? 




Substantiated or Refuted?


Acute forms of brain injury (such that implicate the neurological structure) contribute to several learning and behavioural disorders.

(Pasamanick and Knoblock, 1960)


The behavioural and cognitive faculties of children with ADHD and mild traumatic brain injury (MTBI) are similar, but experiencing an MBTI does not necessarily predict ADHD (Konrad, Gauggel, Manz & Scholl, 2000).


Adverse reactions to artificial food additives are responsible for over 50% of ADHD diagnoses.

(Feingold, 1975)

Refuted: The contribution of food dyes on ADHD diagnosis is minor (Ferguson & Rapaport, 1983).


Neurochemical imbalances or deficiencies (e.g. serotonin, dopamine, norepinephrine) may play a role in the underperformance of people with learning disorders, especially ADHD.

(Anastopoulos and Barkley, 1988)

Substantiated: There is an association between the performance of children with ADHD and a genetic variation (Kieling, Genro, Hutz & Rohde, 2008).


Maternal exposure to alcohol and nicotine through pregnancy increases incidents of ADHD among the children of the pregnancy.

(Anastopoulos and Barkley, 1988)

Substantiated/Refuted: Maternal smoking is significantly associated with elevated symptoms related to ADHD in children, however these children were not officially diagnosed with ADHD (Nomura, Marks & Halperin, 2010).


Children who experienced severe maternal deprivation displayed increased symptoms of autism spectrum disorder.

(Rutter et al., 1999)

No conclusive studies yet.


Higher rates of anxiety and depression are a result of undiagnosed ADHD in adult females.

(Quinn, 2005)

Substantiated: Not only is that statement true, but symptoms of ADHD in women can be misdiagnosed as anxiety or depression (Quinn & Madhoo, 2014).


Around 50% of children diagnosed with ADHD have a parent who presents with ADHD or ADD.

(Starck, Grunwald and Schlarb, 2016)

No conclusive studies yet.


Women are twice as likely to suffer from mental illness than men as a consequence of social inequalities and living standards.

(Yu, 2018)

Substantiated: Similar claims have been made in the past; Yu (2018) is the most recent source.

Key Takeaway

The drawback of the nature versus nurture debate is that by focusing on the dichotomies, classical theorists have ignored the roles of variables such as gender or diversity as an origin. (Harding, 2005).

Why does it seem like ADHD is more prevalent in boys? It has been normalised for boys to grow up being rough, aggressive, and loud, while girls are raised to be polite, quiet, and delicate. As a result, boys are more recognisable when exhibiting the characteristics related to ADHD than girls (Quinn & Wigal, 2004), as they are taught not to mask those behaviours. This is not to suggest that biology does not affect the development of ADHD, ASD, etc. When referring to the table, it is noticeable that there seems to be a biological correlation.

However, while biology plays a role, it is not explicit that sex does. The research into sex was completely discarded until recently, as the ideas of gender norms are being revisited and criticised.

As a result of this historical lack of diagnosis in females, girls with undiagnosed ADHD or with ASD are reported to have issues with self-esteem and are often either misdiagnosed with depression or anxiety, or develop those mental issues as a consequence of their self-esteem issues (Quinn & Wigal, 2004; Giarelli et al., 2010).

Time to Reflect: Are you contributing to gender bias?

Explore the activity Anti Biased Education (ABE), under the Supportive Strategies section of this chapter, to gain a better understanding of your own biases about gender, and how they may affect the students in your classroom. If possible, compare experiences with a group



Icon for the Creative Commons Attribution-NonCommercial 4.0 International License

Inclusive Perspectives in Primary Education Copyright © 2021 by room305 and Inclusive Education Class 2020-2021 is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

Share This Book