Image Quality of MRI brain scans is strongly influenced by within scanner head movements and the resulting image artifacts alter derived measures like brain volume and cortical thickness. Automated image quality assessment is key to controlling for confounding effects of poor image quality. In this study, we systematically test for the influence of image quality on univariate statistics and machine learning classification. We analyzed group effects of sex/gender on local brain volume and made predictions of sex/gender using logistic regression, while correcting for brain size. From three large publicly available datasets, two age and sex-balanced samples were derived to test the generalizability of the effect for pooled sample sizes of n=760 and n=1094. Results of the Bonferroni corrected t-tests over 3747 gray matter features showed a strong influence of low-quality data on the ability to find significant sex/gender differences for the smaller sample. Increasing sample size and more so image quality showed a stark increase in detecting significant effects in univariate group comparisons. For the classification of sex/gender using logistic regression, both increasing sample size and image quality had a marginal effect on the Area under the Receiver Operating Characteristic Curve for most datasets and subsamples. Our results suggest a more stringent quality control for univariate approaches than for multivariate classification with a leaning towards higher quality for classical group statistics and bigger sample sizes for machine learning applications in neuroimaging.

False assumptions about sex and gender are deeply embedded in the medical system, including that they are binary, static, and concordant. Machine learning researchers must understand the nature of these assumptions in order to avoid perpetuating them. In this perspectives piece, we identify three common mistakes that researchers make when dealing with sex/gender data: "sex confusion", the failure to identity what sex in a dataset does or doesn't mean; "sex obsession", the belief that sex, specifically sex assigned at birth, is the relevant variable for most applications; and "sex/gender slippage", the conflation of sex and gender even in contexts where only one or the other is known. We then discuss how these pitfalls show up in machine learning studies based on electronic health record data, which is commonly used for everything from retrospective analysis of patient outcomes to the development of algorithms to predict risk and administer care. Finally, we offer a series of recommendations about how machine learning researchers can produce both research and algorithms that more carefully engage with questions of sex/gender, better serving all patients, including transgender people.

The terminology humans have conceived to explain and study our own brain may be mis-aligned with how these constructs are actually represented in nature. For example, in many human societies, when a baby is born either a "male" or a "female" box is checked on the birth certificate. Reality, however, may be less black and white. In fact, the assumption of dichotomic differences between only two sex/gender categories may be at odds with our endeavors that try to carve nature at its joints. Such is the case with a new paper, published recently in the journal Cerebral Cortex, where researchers argue that there are at least nine directions of brain-gender variation.