Digital Scarlet Letters: Sexually Transmitted Infections in the Electronic Medical Record.

ABSTRACT: The harms of implicit bias in clinical settings are acknowledged but poorly understood and difficult to overcome. We discuss how structural components of electronic medical record (EMR) user interfaces may contribute to sex and gender-based discrimination against patients via constant, duplicative presentation of stigmatizing sexually transmitted infection (STI) data irrespective of clinical significance. Via comparison with symbolism and representative quotes in Hawthorne's 1850 novel The Scarlet Letter, we propose a metaphor to examine how EMRs function as a platform for moral judgment, which may display an indelible "scarlet letter" for pregnant patients with STI history. We consider whether current depictions of STIs in EMRs are structurally unjust and may contribute to biased treatment by directing attention to violations of hegemonic sex/gender norms regarding sexual behavior and thus triggering moral judgments of maternal fitness. We conclude with recommendations for how to address these challenges to improve ethical stewardship of sensitive sexual/reproductive health data.