EQUITRIAGE: A Fairness Audit of Gender Bias in LLM-Based Emergency Department Triage

We investigate whether large language models produce different medical triage recommendations for identical neurological symptoms when only the patient's stated gender and age vary. Using three model families--Gemini 3.5 Flash, Claude Sonnet 4.6, and GPT-5.4-mini--we present a standardized symptom profile (persistent headache, blurred vision, morning nausea, visual disturbances) across seven demographic conditions: three age groups (25, 38, 65) x two genders (male, female), plus a gender-unspecified baseline (n = 30 per condition per model, 630 total trials). We find a stark, systemic gender-dependent triage disparity: young women receive significantly lower emergency room (ER) referral rates than age-matched men (Gemini: 0% vs. 23.3%; Claude: 6.7% vs. 96.7%; GPT: 6.7% vs. 66.7%, all p < 0.001). The disparity disappears at age 65 for all models. The primary mechanism is diagnostic substitution: the models anchor on a gender-associated diagnosis, preferentially classifying young women with Idiopathic Intracranial Hypertension (IIH)--a condition epidemiologically linked to women of childbearing age--while diagnosing men with generic increased intracranial pressure with space-occupying lesions in the differential. This diagnostic closure routes female patients to lower-urgency care (outpatient doctor appointments) despite comparable severity ratings (7-9/10). Our findings demonstrate that clinical LLMs replicate documented human clinical biases by using epidemiological priors to suppress triage urgency, suggesting that AI triage engines must decouple urgency assessment from probabilistic diagnostic priors. We release all code, prompts, and raw results.

Large language models (LLMs) are rapidly being integrated into high-stakes public safety systems, including emergency call triage and dispatch decision support, yet their demographic fairness in this context remains largely untested. Here we introduce a cross-lingual audit framework that operationalizes the Police Priority Dispatch System as a five-level ordinal classification task and applies a controlled minimal-pair design to isolate the effect of demographic cues. Across 19,800 model outputs spanning 11 frontier models, 15 scenario pairs, three demographic categories (religious appearance, gender, and race), and two languages (English and Mandarin Chinese), we find that demographic bias emerges systematically when incident severity is ambiguous but largely disappears when the operational priority is clearly determined by call content. Bias magnitude varies by demographic axis, with the largest effects observed for religious appearance, followed by gender and race. Critically, bias does not transfer consistently across languages: gender bias is substantially amplified in Mandarin Chinese, whereas race bias is more pronounced in English, revealing cross-lingual asymmetries that aggregate analyses obscure. In several scenarios, demographic cues produce counter-directional effects, challenging simple stereotype-amplification accounts of model behavior. These findings suggest that bias in LLM-based dispatch is not a fixed property of models alone, but arises from the interaction between demographic signals, contextual ambiguity, and language. Beyond these empirical results, the proposed framework provides a scalable audit infrastructure that enables deploying agencies to evaluate candidate models on jurisdiction-relevant scenarios prior to real-world adoption.

Prior benchmarking work has shown that a single large language model (LLM), forced to make life-or-death resource-allocation decisions, exhibits measurable demographic bias. Real deployments, however, rarely use a single agent: they use pipelines, with review steps meant to catch exactly this kind of failure. We study what happens to bias when the same decision is distributed across a role-differentiated multi-agent pipeline (assessment, allocation, independent audit) instead of made and checked by one model alone. Using a synthetic disaster-triage simulator with paired cases that are clinically identical except for one demographic attribute, we run 192 episodes (2,304 resolved case pairs) on GPT-4o-mini comparing a single-agent control condition to a nine-agent pipeline under three independently varied pressure dimensions. We find no measurable difference in how often biased outcomes occur between the two conditions (6.9% vs. 6.1%, p = 0.498). We do find a large and significant effect of audit capacity on whether bias is caught: 30.0% of biased outcomes go entirely undetected, rising to 43.8% when the auditor is overloaded and falling to 18.4% when it is not. Decomposing this effect shows it is driven almost entirely by coverage (whether a case is reviewed at all, which collapses from 100.0% to 65.6% under load, p < 0.001) rather than by degraded judgment on the cases that are reviewed (81.6% vs. 85.7%, p = 1.000, direction reversed). A follow-up experiment shows that reordering the audit queue by estimated risk, rather than first-come-first-served, recovers most of the lost coverage under the same capacity constraint (65.6% to 91.7%, p = 0.028). We discuss the implications for any system that adds independent oversight to an LLM agent pipeline under resource constraints, and report the study's limitations honestly: one model, modest sample sizes, and no adversarial replication.