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Göttgens I, Darweesh SKL, Bloem BR, Oertelt-Prigione S. A multidimensional gender analysis of health technology self-efficacy among people with Parkinson's disease. J Neurol 2024; 271:6750-6760. [PMID: 39168866 DOI: 10.1007/s00415-024-12635-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/07/2024] [Accepted: 08/10/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND Digital health technologies (DHT) enable self-tracking of bio-behavioral states and pharmacotherapy outcomes in various diseases. However, the role of gender, encompassing social roles, expectations, and relations, is often overlooked in their adoption and use. This study addresses this issue for persons with Parkinson's disease (PD), where DHT hold promise for remote evaluations. METHODS We conducted a cross-sectional survey study in the Netherlands, assessing the impact of gender identity, roles, and relations on health technology self-efficacy (HTSE) and attitude (HTA). An intersectional gender analysis was applied to explore how gender intersects with education, employment, disease duration, and severity in influencing HTSE and HTA. RESULTS Among 313 participants (40% women), no significant correlation was found between gender identity or relations and HTSE or HTA. However, individuals with an androgynous (non-binary) gender role orientation demonstrated better HTSE and HTA. The exploratory intersectional analysis suggested that sociodemographic and clinical factors might affect the influence of gender role orientations on HTSE and HTA, indicating complex and nuanced interactions. CONCLUSION This study highlights the importance of investigating gender as a multidimensional variable in PD research on health technology adoption and use. Considering gender as a behavioral construct, such as through gender roles and norms, shows more significant associations with HTSE and HTA, although effect sized were generally small. The impact of gender dimensions on these outcomes can be compounded by intersecting social and disease-specific factors. Future studies should consider multiple gender dimensions and intersecting factors to fully understand their combined effects on technology uptake and use among people with PD.
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Affiliation(s)
- Irene Göttgens
- Research Institute for Medical Innovation, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Sirwan K L Darweesh
- Donders Institute for Brain, Cognition and Behavior, Center of Expertise for Parkinson & Movement Disorders, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Donders Institute for Brain, Cognition and Behavior, Center of Expertise for Parkinson & Movement Disorders, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sabine Oertelt-Prigione
- Research Institute for Medical Innovation, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands.
- AG 10 Sex- and Gender-Sensitive Medicine, Medical Faculty OWL, University of Bielefeld, Bielefeld, Germany.
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Bayram E, Rigler N, Wang KT, Tsai A, Flatt JD. Sexual Orientation, Gender Identity, and Experiences During, Awareness of, and Attitudes Toward Research for People With Parkinson Disease. Neurol Clin Pract 2024; 14:e200304. [PMID: 38808025 PMCID: PMC11129331 DOI: 10.1212/cpj.0000000000200304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/06/2024] [Indexed: 05/30/2024]
Abstract
Background and Objectives Presentation, progression, and treatment of Parkinson disease (PD) can differ based on sex and gender. However, knowledge on PD is limited by the characteristics of research participants, and most of the participants are men. In this study, we aimed to identify the attitudes toward and barriers to research participation for people with PD (PwP) based on their sexual orientation and gender identity. Methods Data were obtained from the Fox Insight on March 16, 2023, for PwP who completed the Attitudes and Beliefs Regarding Research and Genetic Testing for PD. Responses were compared between sexual and gender minorities (SGM) (n = 136), cisgender heterosexual women (n = 1,479), and cisgender heterosexual men (n = 1,445). Associations between age, socioeconomic variables, and the responses that differed between the groups were assessed with linear models. Results More than 68% of the participants were willing to participate in research; only 43.7% heard about research opportunities, and 52.3% knew where to find a study. Approximately 86.8% of the participants reported hearing about a study from their doctor would make them more likely to participate. A higher percentage of SGM were concerned about transportation and researchers not understanding or respecting their beliefs; a higher percentage of cisgender heterosexual women were concerned about transportation, data privacy, and their family's reaction to genetic results; and a higher percentage of cisgender heterosexual men were concerned about time required for research activities and complex forms. Age and socioeconomic variables were significantly associated with approach toward research that differed between the groups. Discussion PwP are willing to participate in research, and health care providers can facilitate their participation. Barriers to research participation related to sexual and gender identity exist and must be addressed to increase our understanding of PD in underrepresented populations.
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Affiliation(s)
- Ece Bayram
- Parkinson and Other Movement Disorders Center (EB, KTW, AT), Department of Neurosciences; School of Medicine (NR), University of California, San Diego; and Department of Environmental and Occupational Health (JDF), School of Public Health, University of Nevada, Las Vegas
| | - Nicole Rigler
- Parkinson and Other Movement Disorders Center (EB, KTW, AT), Department of Neurosciences; School of Medicine (NR), University of California, San Diego; and Department of Environmental and Occupational Health (JDF), School of Public Health, University of Nevada, Las Vegas
| | - Kevin T Wang
- Parkinson and Other Movement Disorders Center (EB, KTW, AT), Department of Neurosciences; School of Medicine (NR), University of California, San Diego; and Department of Environmental and Occupational Health (JDF), School of Public Health, University of Nevada, Las Vegas
| | - Andrew Tsai
- Parkinson and Other Movement Disorders Center (EB, KTW, AT), Department of Neurosciences; School of Medicine (NR), University of California, San Diego; and Department of Environmental and Occupational Health (JDF), School of Public Health, University of Nevada, Las Vegas
| | - Jason D Flatt
- Parkinson and Other Movement Disorders Center (EB, KTW, AT), Department of Neurosciences; School of Medicine (NR), University of California, San Diego; and Department of Environmental and Occupational Health (JDF), School of Public Health, University of Nevada, Las Vegas
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Byer L, Orozco-Poore C, Rosendale N. Limitations and Future Directions in Sex, Sexuality, and Gender Diverse Research in Neurology. Ann Neurol 2024; 95:421-431. [PMID: 38112171 DOI: 10.1002/ana.26863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/16/2023] [Accepted: 12/09/2023] [Indexed: 12/20/2023]
Abstract
Sex, sexuality, and gender diversity is understudied and underserved in neurology. Neurology research inclusive of LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual) people is limited. Existing research struggles with a paucity of neurology studies collecting sex, sexuality, and gender diverse (SSGD) data, conflation of sex and gender, lack of precision in measures, neglect of younger and older populations, nebulous benefit to community, and absent intersectionality. Future directions in SSGD neurology research include precise and community-based measurements, respect for LGBTQIA+ colleagues, and the application of minority stress models. All patients stand to benefit from research that elucidates how SSGD variables influence neurological health. ANN NEUROL 2024;95:421-431.
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Affiliation(s)
- Lennox Byer
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Casey Orozco-Poore
- Department of Child Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nicole Rosendale
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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Maas BR, Göttgens I, Tijsse Klasen HPS, Kapelle WM, Radder DLM, Bloem BR, Post B, de Vries NM, Darweesh SKL. Age and gender differences in non-motor symptoms in people with Parkinson's disease. Front Neurol 2024; 15:1339716. [PMID: 38361642 PMCID: PMC10867965 DOI: 10.3389/fneur.2024.1339716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
Background Non-motor symptoms of Parkinson's disease (PD) are highly prevalent and heterogenic. Previous studies aimed to gain more insight on this heterogeneity by investigating age and gender differences in non-motor symptom severity, but findings were inconsistent. Furthermore, besides examining the single effects of age and gender, the interaction between them in relation to non-motor functioning has -as far as we know- not been investigated before. Objectives To investigate the association of age and gender identity -as well as the interaction between age and gender identity- with non-motor symptoms and their impact on quality of life. Methods We combined three large and independent studies. This approach resulted in a total number of unique participants of 1,509. We used linear regression models to assess the association of age and gender identity, and their interaction, with non-motor symptoms and their impact on quality of life. Results Older people with PD generally had worse cognitive functioning, worse autonomic functioning and worse quality of life. Women with PD generally experienced more anxiety, worse autonomic functioning and worse quality of life compared to men with PD, whereas men with PD generally had worse cognitive functioning. In interaction analyses by age and gender identity, depressive symptoms and anxiety were disproportionally worse with increasing age in women compared to men. Conclusion Our findings indicate that both age and gender -as well as their interaction- are differentially associated with non-motor symptoms of PD. Both research and clinical practice should pay more attention to demographic subgroups differences and possible different treatment approaches with respect to age and gender. We showed how combining datasets is of added value in this kind of analyses and encourage others to use similar approaches.
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Affiliation(s)
- Bart R. Maas
- Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Irene Göttgens
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hermina P. S. Tijsse Klasen
- Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willanka M. Kapelle
- Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Danique L. M. Radder
- Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Bastiaan R. Bloem
- Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Bart Post
- Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nienke M. de Vries
- Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sirwan K. L. Darweesh
- Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
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Göttgens I, Modderkolk L, Vermuë P, Darweesh SK, Bloem BR, Oertelt-Prigione S. Gender-aware Parkinson's care: a design-based study of patient perspectives on gender norms and gender-sensitive care. EClinicalMedicine 2023; 65:102285. [PMID: 37876997 PMCID: PMC10590864 DOI: 10.1016/j.eclinm.2023.102285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/04/2023] [Accepted: 10/04/2023] [Indexed: 10/26/2023] Open
Abstract
Background Gender dimensions are progressively recognised as a relevant social determinant of health in people with Parkinson's disease (PD). However, little is known about the impact of gender norms and stereotypes on illness experiences of men and women with PD and what they consider important focal points for gender-sensitive PD care. Methods We conducted two equity-centred design (ECD) sessions on December 7, 2022 and December 8, 2022, at the Radboud University Medical Centre in the Netherlands. This participatory multi-method approach includes patients in the research and design process and was used to explore the impact of gender norms and stereotypes in illness experiences and generate patient-driven recommendations for gender-aware Parkinson's care. Quantitative survey data and design-based data were descriptively analysed, and qualitative focus group discussions were thematically analysed. Findings This study included thirteen men and fifteen women with PD in the Netherlands. All participants were of Dutch descent, with a median age of 65.5 years and a median clinical disease duration of 4.2 years. The gendered stereotype that "people with PD are old men" affected both men's and women's perception of living with the disease and the perceptions of their social environment. Men described masculine stereotypes related to physical strength and provider roles, while women expressed those related to feminine physical appearance and caregiver roles, influencing their illness experiences. For some, these norms influenced personal behaviours, while for others, they affected experiences through societal attitudes. Interpretation Our findings suggested that several gender norms and stereotypes influence the illness experiences of men and women with PD, manifesting at ideological, interpersonal, and internalised levels. Some participants internalised these norms, affecting their coping behaviours, while others encountered them in broader ideological contexts that shaped societal attitudes and interpersonal relationships. To advance gender sensitive PD care, it's essential to explore the impact of gender roles and norms, especially regarding how they might impede coping strategies, care access and utilisation for individuals of diverse gender identities. Funding The Gatsby Foundation and co-funded by the PPP Allowance by Health∼Holland. Travel reimbursements for participants were made available through a Parkinson's Foundation grant (PF-FBS-2026).
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Affiliation(s)
- Irene Göttgens
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Linda Modderkolk
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Paula Vermuë
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Sirwan K.L. Darweesh
- Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Bastiaan R. Bloem
- Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Sabine Oertelt-Prigione
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
- AG 10 Sex- and Gender-sensitive Medicine, Medical Faculty OWL, University of Bielefeld, Bielefeld, Germany
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Olsson Hau S, Williamsson C, Andersson B, Eberhard J, Jirström K. Sex and gender differences in treatment intention, quality of life and performance status in the first 100 patients with periampullary cancer enrolled in the CHAMP study. BMC Cancer 2023; 23:334. [PMID: 37041522 PMCID: PMC10088105 DOI: 10.1186/s12885-023-10720-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 03/08/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Periampullary cancer is a term for cancers arising in or in close proximity to the pancreas. Pancreatic cancer is the 3rd leading cause of cancer death for both sexes and while surgery is the only option for cure, chemotherapy is given in both the adjuvant and palliative settings. The aim of this study was to investigate any sex and gender differences in patients with pancreatic and other periampullary adenocarcinomas enrolled in a prospective, observational trial. METHODS The study cohort consists of the first 100 patients, 49 women and 51 men, enrolled in the Chemotherapy, Host Response and Molecular dynamics in Periampullary cancer (CHAMP) study, an ongoing study of patients undergoing neoadjuvant, adjuvant or first-line palliative chemotherapy treatment. Twenty-five patients had surgery with curative intent and subsequent adjuvant treatment, and 75 patients were treated with palliative chemotherapy. Data regarding health-related quality of life (HRQoL, EORTC-QLQ-C30) at baseline, demographic and clinicopathological factors were examined and stratification by treatment intention according to sex. Overall survival (OS) was calculated through Kaplan-Meier analysis. RESULTS There was a statistically significant difference between male and female patients treated with curative intent, with fewer women having undergone surgery (18 vs 7, p = 0.017), also after adjustment for age, tumor location and performance status. No statistical differences were found between the sexes regarding age, comorbidities, or clinicopathological factors. Before start of chemotherapy treatment, health-related quality of life (HRQoL) was lower in female than in male patients. However, HRQoL was not associated with performance status in female patients, whereas in male patients several HRQoL indicators were significantly positively associated with poorer performance status at baseline. CONCLUSIONS This study shows no clear differences between the sexes regarding biological factors concluding that gender bias might be responsible for the discrepancy between men and women being offered curative surgery. The observed difference between women and men regarding the association between HRQoL and performance status is unprecedented. Altogether these findings underline the importance of taking gender into consideration when assessing eligibility for curative surgery in order to improve biological outcome and decrease suffering in both sexes. TRIAL REGISTRATION NCT03724994.
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Affiliation(s)
- Sofie Olsson Hau
- Division of Oncology and Therapeutic Pathology, Department of Clinical Sciences, Lund University, SE-221 85, Lund, Sweden.
| | - Caroline Williamsson
- Division of Surgery, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Bodil Andersson
- Division of Surgery, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jakob Eberhard
- Division of Oncology and Therapeutic Pathology, Department of Clinical Sciences, Lund University, SE-221 85, Lund, Sweden
| | - Karin Jirström
- Division of Oncology and Therapeutic Pathology, Department of Clinical Sciences, Lund University, SE-221 85, Lund, Sweden
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Göttgens I, Modderkolk L, Jansen C, Darweesh SKL, Bloem BR, Oertelt-Prigione S. The salience of gender in the illness experiences and care preferences of people with Parkinson's disease. Soc Sci Med 2023; 320:115757. [PMID: 36738652 DOI: 10.1016/j.socscimed.2023.115757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023]
Abstract
RATIONALE In recent years, interest in sex characteristics and gender dimensions of Parkinson's disease (PD) has increased. Yet, much remains to be understood about how gender-related aspects specifically impact the illness and experiences of care in persons living with PD. OBJECTIVE The purpose of this study was to explore the salience of gender-related aspects in the illness experiences and care provision preferences of people with PD. METHODS A descriptive qualitative study including semi-structured life story interviews was conducted with men and women living with PD in the Netherlands. Between September 2020 and February 2021, forty people with PD (20 men and 20 women) participated in digital interviews of which thirty-one (18 men and 13 women) were included in the thematic analyses for this specific study. RESULTS Overall, most participants did not consider gender-related aspects salient towards their illness experiences. However, when prompted, a number of participants described several stereotypical views about gender as related to the visibility of PD, emotional experiences, help seeking, role patterns and physical appearance. While most men and women with PD did not express specific gender-related preferences for their healthcare providers, those that did, all preferred women as healthcare providers. These preferences were generally related to attributed feminine traits which are considered relevant in routine, particularly sensitive, physical examinations of people with PD. CONCLUSION This study demonstrates that although every person has a gender identity, the salience attributed to gender varies with illness experiences and in care provision preferences between people with PD. These findings highlight the need for precise and personalized methodologies to capture more nuanced insights into the impact of gender dimensions on PD. Furthermore, drivers behind gender-related preferences in care provision are multifactorial and warrant further investigation among people with PD.
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Affiliation(s)
- Irene Göttgens
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Linda Modderkolk
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Sirwan K L Darweesh
- Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Bastiaan R Bloem
- Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sabine Oertelt-Prigione
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands; AG 10 Sex- and Gender-sensitive Medicine, Medical Faculty OWL, University of Bielefeld, Bielefeld, Germany.
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van den Hurk L, Hiltner S, Oertelt-Prigione S. Operationalization and Reporting Practices in Manuscripts Addressing Gender Differences in Biomedical Research: A Cross-Sectional Bibliographical Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14299. [PMID: 36361177 PMCID: PMC9653596 DOI: 10.3390/ijerph192114299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 06/16/2023]
Abstract
Historically, authors in the biomedical field have often conflated the terms sex and gender in their research significantly limiting the reproducibility of the reported results. In the present study, we investigated current reporting practices around gender in biomedical publications that claim the identification of "gender differences". Our systematic research identified 1117 articles for the year 2019. After random selection of 400 publications and application of inclusion criteria, 302 articles were included for analysis. Using a systematic evaluation grid, we assessed the provided methodological detail in the operationalization of gender and the provision of gender-related information throughout the manuscript. Of the 302 articles, 69 (23%) solely addressed biological sex. The remaining articles investigated gender, yet only 15 (6.5%) offered reproducible information about the operationalization of the gender dimension studied. Followingly, these manuscripts also provided more detailed gender-specific background, analyses and discussions compared to the ones not detailing the operationalization of gender. Overall, our study demonstrated persistent inadequacies in the conceptual understanding and methodological operationalization of gender in the biomedical field. Methodological rigor correlated with more nuanced and informative reporting, highlighting the need for appropriate training to increase output quality and reproducibility in the field.
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Affiliation(s)
- Lori van den Hurk
- Department of Primary and Community Care, Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| | - Sarah Hiltner
- Department of Primary and Community Care, Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| | - Sabine Oertelt-Prigione
- Department of Primary and Community Care, Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
- AG10 Sex- and Gender-Sensitive Medicine, Medical Faculty OWL, University of Bielefeld, 33615 Bielefeld, Germany
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