How Women Decide

Houghton Mifflin Harcourt Publishing Company

Contents

What Happens When a Woman Makes the Call?

From every direction lately, women are hearing a call to arms. Women have been told to lean in, ask for what they want, know their value, play big, don their bossypants, and close the confidence gap. These messages galvanize. They embolden women to take their proper seats at the table and they promise power to those who want it. If women work hard and raise their expectations, they're told, they will achieve the highest levels of success — and that means they will be making more of the big decisions.

But no one has talked about what happens to women when they make these big decisions. Is a woman's experience issuing a tough call, a decision with serious stakes, any different from a man's? That's the question that ignited my research and eventually caught fire as this book. I've found that when a man faces a hard decision, he only has to think about making a judgment, but when a woman faces a hard decision, she has to think about making a judgment and also navigate being judged.

What's a smart, self-respecting, and (let's face it) busy woman to do?

She needs to know how women decide and how to take the realities of the decision-making landscape into account when planning her own course of action. I'll share a secret with you: Women approach decisions in ways that are actually stronger than they realize. Men and women approach decisions differently, but not necessarily in the ways people have been led to believe. This isn't a "biology is destiny" or a pink brain / blue brain book. Society has been underestimating women's abilities to make astute choices for years, and this doubting, this routine questioning of a woman's judgment, drives many of the gender differences we see.

Often we don't realize that we're scrutinizing a woman's decision more than we would a man's; it can be hard to notice because there are very few scenarios where all factors other than gender are identical. Sometimes, though, a situation arises where we can see a clear parallel and a clear bias. Take, for example, the moment in February 2013 when Marissa Mayer made headlines for changing Yahoo's work-from-home policy. Yahoo announced that employees could no longer telecommute full-time, and the press lambasted Mayer. Pundits criticized the policy change, saying it would hurt women, and many of us, myself included, raised eyebrows about Mayer's controversial decision. But how many people heard about it when Best Buy's CEO, Hubert Joly, made the same decision about a week later? When he ended Best Buy's generous work-from-home policy, business reporters dutifully picked up the story, but his announcement didn't cause a public outcry the way Mayer's did. Joly popped up in headlines for his decision briefly in 2013, but as late as 2015, journalists were still talking about Mayer's decision, analyzing whether she made the right choice. So for making the same judgment call, a male CEO drew some sidelong glances for a few months, but a female CEO drew extensive scrutiny and censure for years.

At first, we tend to rationalize our reactions. Yahoo's decision must have impinged on more employees' schedules because it's a software company, and programmers can work in their pajamas at home at any hour of the day or night; Best Buy has stores, we reason, and employees need to appear fully clothed and on time. Their telecommuting pool must be tiny. But articles on the story indicated that Mayer's decision affected only two hundred employees, whereas Joly's decision reportedly changed the lives of nearly four thousand corporate employees who often worked from home. That's twenty times more workers touched by the Best Buy decision.

If the number of affected employees doesn't explain the outcry against Mayer and the complacency around Joly, what does? Had Mayer just taken the helm at Yahoo while Joly was a fixture at Best Buy? No. This is where the parallels become even more unsettling — both chiefs had been on the job roughly six months. One likely reason we keep fuming over Mayer's decision but ignore Joly's choice lies in a pattern that many of us unknowingly fall into: we're quick to question a woman's decision but inclined to accept a man's. Men and women don't have to act differently for us to see them differently.

This tendency has very real consequences. Consider the often-cited observation that businesses are eager to promote men but reluctant to promote women. Why? Your bookshelf may be full of answers to that question, but my research suggests a new one, one many people have overlooked. We trust men to make the hard choices. We are quick to accept a man's decisions, even the hard, unpleasant ones, as being what must be done. When a woman announces the same difficult decision, we scrutinize it with twice the vigor. We may not mean to, but we doubt the quality of her choices.

It may be hard to believe that decision-making has a gender component, that someone would give a man an understanding nod but give a woman a raised eyebrow for making the same call. We see ourselves as fair people with the best of intentions. I've never met a single person who has said, "I love to discriminate." If we want to understand how gender changes the decision-making process as well as the subtle and not-so-subtle ways we react to men's and women's choices, we need to ask some rigorous questions. Is there any real difference between men's and women's judgment? Might we ever exaggerate the gap? Where has popular culture exposed real disparities in the ways men and women decide, and where has popular culture actually manufactured the differences? In cases where women and men do take different approaches to the same choice, is the way women reach a decision ever an asset rather than a liability?

Most important, if we do find that there are differences in how men's and women's decisions are received, what can we do about it? How do we become more aware of our favoritism and catch ourselves in the act? Partly, we need to educate ourselves about our hidden biases around decision-making. Both men and women must take stock and strategize, because no one person can do this alone. Certainly, reading this book can and should help improve the decisions you make regardless of your gender, but if we want to see more women take meaningful seats at the table, we ought to change how we, as a culture, talk about women's judgment. We need to make some structural changes, and these changes will improve not just the lives of women but the decisions being made for our world. If you gain only one insight from this book, I hope it's this: Having a greater number of women in the room when a crucial decision is being made is not only better for women, it's better for the decision. And that's better for everyone.

Whom Do We Ask to Make Decisions of Consequence?

It was January 1968 and a typical winter day in Seattle, cold enough to make you bundle up but not cold enough to snow. Barbara Winslow was twenty-three years old and a history major at the University of Washington, and she and her husband of less than a year were sitting in a doctor's office, not liking what they heard.

A few days earlier, Barbara had found a lump in her breast. The doctor explained he would sedate Barbara, take a slice out of her breast, run some tests while she was still under anesthesia, and, if the biopsy came back positive and the tissue was malignant, he would immediately perform a radical mastectomy. A radical mastectomy is aptly named. It entails removing the entire breast, the chest muscles underneath, and all the lymph nodes from a woman's underarm in one single, efficient, and slightly barbaric procedure. Barbara would fall asleep wondering if she had cancer, and she would wake up to either fantastic news or stitches where her breast had been.

After describing the operation, the doctor said they should schedule the biopsy immediately. Barbara protested. Could she go home and think about it? Why did this decision have to be made right then? The doctor explained that if he gave her a lot of time to think about this radical procedure, she would likely become too frightened and decide not to take the risk.

Barbara had been taught that you didn't question the authority of doctors, so she said: "Okay, that makes sense." "Good," said the doctor, and he handed the consent form to her husband. "Wait," Barbara said, "why should my husband sign my consent form?" She would never forget the doctor's reply. "Because," he said, "women are too emotionally and irrationally tied to their breasts."

Infuriating? Yes. But the exchange is also rather puzzling. Who was making this decision? Was it Barbara? We'd like to think so, but the doctor never actually asked her what she'd like to do. In fact, he said she was too emotional and irrational to be trusted with the choice. What does it mean to give someone the illusion of choice? If Barbara had said, "I don't want the biopsy," would the doctor have handed the consent form to her husband anyway?

"Looking back, I wish I had challenged that doctor," Barbara told me in 2015. "I wish I had torn up that office. I should have said, 'I wonder what part of the male anatomy men are irrationally attached to?'" She had many reasons to be angry, including the fact that the doctor doubted that women could make appropriate decisions under such stressful circumstances. But she didn't even question his presumption at the time. "I didn't think in those terms back then. Nobody did. That's what life was like for women."

This could just be a terrible moment in one woman's life, but as a decision-making researcher, I see larger concerns in this story. We would like to think that these sorts of things happened only in the past and that, at least in this very specific situation, the dynamic has improved. No doctor in the United States today would ask a woman's husband to make that decision. But how far have we really come? The temptation is to feel secure, to say such bias has disappeared. But how many of these biases about women as decision-makers have been fully erased and how many have merely gone underground, spoken of less often but still shaping who we want to lead? When making the wrong choice poses formidable risks, whether it's in the doctor's office or in a business meeting, are women seen as equals in the process or is there a creaking assumption that men are the ones with the superior decision-making powers, the gender that's unfettered by pesky emotions?

Almost half a century later, cancer treatment is a much more civilized process: women sign their own consent forms, surgery isn't scheduled until after the doctor and patient have discussed the biopsy results, and the radical mastectomy is largely a thing of the past. When Barbara tells this story now, everyone is appalled. But we have to ask ourselves, Are things all that different?

Richard Hoffman, a professor of medicine at the University of Iowa, finds that even today, there's cause to wonder what kinds of conversations take place between doctors and patients. What do doctors convey to their female patients and what do they suggest to the male ones about their roles in the decision-making process? Who gets asked, "What do you want to do?" Who doesn't? Are some patients treated as partners and others as dependents?

In 2011, Hoffman and his team analyzed survey data from eleven hundred adults across the United States, looking at patients' reports of recent conversations they'd had with their doctors about cancer screenings. Hoffman focused on adults over fifty because doctors normally recommend some types of regular cancer testing after that age. If physicians saw men and women as equally capable of making good choices, their decision-making conversations should have been the same regardless of the patient's gender. But they weren't. "Do you want to have this test?" was a question doctors reportedly asked 70 percent of men when discussing men's prostates but only 43 percent of the women when the visit was about women's breasts.

Why this discrepancy? Why are men given more say in their testing options than women are when both are facing choices about cancer screening for sexual organs? There have been, it's worth noting, controversies around the effectiveness of prostate cancer screening. Initial screening for prostate cancer is usually done with a blood test, and approximately three out of four men who test positive don't actually have prostate cancer, meaning there's a high rate of false positives. Prostate cancer blood tests are considered so problematic that the U.S. Preventive Services Task Force gives the test a D rating, indicating it does more harm than good, whereas mammograms, which aren't perfect either, are at least given a B rating. The prostate test can cause a lot of unnecessary worry, not to mention unnecessary procedures and risks from those procedures, which may be why doctors might give more men the option of whether they want to undergo this potentially misleading and upsetting screening process.

Okay. So how about comparing apples to apples? Hoffman then looked at screening for an organ found in both sexes. He focused on a test that's received an A rating by the U.S. Preventive Services Task Force because it's such a reliable way to detect cancer in both men and women. The test? The dreaded colonoscopy. Colon cancer is the third most common cause of death from cancer for both men and women in the United States, so it poses a high risk for both sexes. When doctors talk with their patients about having a colonoscopy, do they simply say, "You need to do this," or do they present the options and then ask, "Do you want to do this?" Hoffman's results were revealing. Doctors asked 71 percent of the men whether they wanted a colonoscopy, but they asked only 57 percent of women. The numbers are better, true, but why aren't they identical? Why do more men get a choice? The men and women were in the same age range; most were between fifty and seventy years old, and the recommended age for the first colonoscopy is fifty. Men in the United States are at a slightly higher risk of developing colon cancer; one in twenty-one men faces it at some point in his life, compared to one in twenty-two for women. But does that mean more men should have the option to decide for themselves, that men should be asked more often (rather than told) to take the test? A lower cancer risk for women suggests that if any gender should be given the option to skip the screening, it's women. And were female doctors more likely to ask women what they wanted (as opposed to telling them what to do)? We don't know. The data set didn't include information about the sex of the doctor.

When I first read this research report, I didn't know what to think. Maybe doctors were acting differently with men and women in some effort to be more effective. Physicians see hundreds of patients a year, and observing subtle patterns is part of any good professional's skill set. Could it be that physicians saw that men who weren't given a choice were offended and never came back? Or did doctors find that alarge proportion of women avoided cancer screening initially and then later regretted it, so they gave fewer women a choice? Or is something less benevolent going on? Even though doctors no longer ask a man to approve his wife's surgery, they consistently seem to trust his good judgment (and their own) more than they trust hers.

The United States has a relatively short history of giving women the power to make decisions of consequence. Women in the United States weren't given the right to vote until 1920, after almost a dozen other countries had passed laws allowing women to participate in those civic decisions. In 1968, when Barbara watched her husband reluctantly sign the consent form, doctors weren't the only ones who thought men had better judgment. Most of the professional world did. The women's liberation movement had just begun. Divorced women who tried to start their lives over in the late 1960s typically couldn't buy their own homes. A divorcée had two options: she could rent an apartment or, if she insisted on buying, she had to persuade a male in her life, often her ex-husband, to sign her mortgage. When women with plenty of income applied for lines of credit in the early 1970s, they were often denied. Take Billie Jean King, the world champion tennis player who won three Wimbledon titles in a single year and supported her family on her winnings. She tried to get a credit card in her own name but couldn't. She discovered the only way she could secure a credit card was if her husband's name was listed first on the account; once it was clear to lenders that a man backed the financial decisions, she could be a secondary cardholder. If her husband had had an income, this might have made some sense, but he didn't. Billie Jean King was putting him through law school.