Integration of sex/gender and utilization of ecological Momentary assessment of cognition in clinical populations: A scoping review

Objectives: We aimed to describe the methods of smartphone-based cognitive ecological momentary assessment designs in clinical populations, with an intention to evaluate how the role of sex and/or gender has been considered in the design and analyses, particularly including female-specific physiology. Methods: This scoping review was conducted based on JBI scoping review methodology. On March 2nd, 2023, we searched for literature across four databases. Screening of the results and data extraction were conducted in duplicate according to the a priori methods in the pre-registered protocol. Results: 31 articles were included in this review. Participants ranged in age from 15-85 years old with various clinical disorders. Prompts were given between 1-7 times per day for 7-84 days. Executive function was the most frequently assessed cognitive domain. Over half the studies (n = 17, 55%) did not investigate the effects of sex and/or gender, and only one study considered the impact of hormonal therapy. Many studies (n = 14, 45%) used sex and gender interchangeably or incorrectly. Conclusions: Studies varied in design, with heterogeneity in the reporting of methodological information. The lack of attention to sex/gender on neuropsychological outcomes can lead to confusion and contradiction regarding its potential impact on cognition in clinical populations. This may hinder the identification of effective interventions for those assigned female at birth who have been overlooked or considered indistinguishable from their male counterparts. Given the well-documented impact of sex/gender on cognition, it is essential that future neuropsychological research, especially EMA-based studies, prioritize investigating sex/gender to ensure better outcomes for all.

Researchers' sex/gender identity influences how sex/gender question is investigated in neuroscience: an example from an OHBM meeting

Gender inequality and diversity in STEM is a challenging field of research. Although the relation between the sex/gender of the researcher and the scientific research practices has been previously examined, less interest has been demonstrated towards the relation between sex/gender of the researcher and the way sex/gender as a variable is explored. Here, we examine, from a neurofeminist perspective, both questions: whether sex/gender identity is related to the examination of sex/gender as a variable and whether different approaches towards examining sex/gender are being used in different topics of study within neuroscience. Using the database of submitted posters to the Organization of Human Brain Mapping 2022 annual conference, we identified abstracts examining a sex/gender-related research question. Among these target abstracts, we identified four analytical categories, varying in their degree of content-related complexity: (1) sex/gender as a covariate, (2) sex/gender as a binary variable for the study of sex/gender differences, (3) sex/gender with additional biological information, and (4) sex/gender with additional social information. Statistical comparisons between sex/gender of researcher and the target abstract showed that the proportion of abstracts from Non-binary or Other first authors compared to both Women and Men was lower for all submitted abstracts than for the target abstracts; that more researchers with sex/gender-identity other than man implemented analytical category of sex/gender with additional social information; and, for instance, that research involving cognitive, affective, and behavioural neuroscience more frequently fit into the sex/gender with additional social information-category. Word cloud analysis confirmed the validity of the four exploratorily identified analytical categories. We conclude by discussing how raising awareness about contemporary neurofeminist approaches, including perspectives from the global south, is critical to neuroscientific and societal progress.

White matter microstructure in transmasculine and cisgender adolescents: A multiparametric and multivariate study

Adolescence is a sensitive developmental period for neural sex/gender differentiation. The present study used multiparametric mapping to better characterize adolescent white matter (WM) microstructure. WM microstructure was investigated using diffusion tensor indices (fractional anisotropy; mean, radial, and axial diffusivity [AD]) and quantitative T1 relaxometry (T1) in hormone therapy naïve adolescent cisgender girls, cisgender boys, and transgender boys (i.e., assigned female at birth and diagnosed with gender dysphoria). Diffusion indices were first analyzed for group differences using tract-based spatial statistics, which revealed a group difference in AD. Thus, two multiparametric and multivariate analyses assessed AD in conjunction with T1 relaxation time, and with respect to developmental proxy variables (i.e., age, serum estradiol, pubertal development, sexual attraction) thought to be relevant to adolescent brain development. The multivariate analyses showed a shared pattern between AD and T1 such that higher AD was associated with longer T1, and AD and T1 strongly related to all five developmental variables in cisgender boys (10 significant correlations, r range: 0.21-0.73). There were fewer significant correlations between the brain and developmental variables in cisgender girls (three correlations, r range: -0.54-0.54) and transgender boys (two correlations, r range: -0.59-0.77). Specifically, AD related to direction of sexual attraction (i.e., gynephilia, androphilia) in all groups, and T1 related to estradiol inversely in cisgender boys compared with transgender boys. These brain patterns may be indicative of less myelination and tissue density in cisgender boys, which corroborates other reports of protracted WM development in cisgender boys. Further, these findings highlight the importance of considering developmental trajectory when assessing the subtleties of neural structure associated with variations in sex, gender, and sexual attraction.

Gender minority stress and diurnal cortisol profiles among transgender and gender diverse people in the United States

The field of behavioral neuroendocrinology has only begun to explore the lived experiences of transgender and gender diverse (TGD) people exposed to stigma. In light of escalating attacks and legislation targeting TGD people in the United States, it is crucial to examine the physiological pathways through which gender minority stressors become embodied, impact health, and contribute to health inequities. The Trans Resilience and Health Study included baseline data collection from fall 2019 to spring 2020 from a sample of 124 TGD people, reflecting a diversity of gender identities (e.g., trans masculine, trans feminine, and nonbinary) and ages (range = 19-70 years old; M = 34.10), living in Michigan, Nebraska, Oregon, and Tennessee. These analyses examine experiences of gender-related enacted stigma in association with hypothalamic-pituitary-adrenal (HPA)-axis functioning. Among those experiencing the highest levels of enacted stigma, findings show a blunted cortisol awakening response and sluggish daily decline that resulted in elevated concentrations at bedtime compared to those experiencing less enacted stigma. These results of flattened diurnal activity are consistent with an emergent literature on discrimination as a social determinant of potential stress pathophysiology. In contrast, community connectedness was associated with a larger, more dynamic cortisol awakening response. These findings emphasize the importance of incorporating gender-minority stress and resilience measures when studying HPA-axis functioning among TGD people.

After the trans brain: a critique of the neurobiological accounts of embodied trans* identities

This paper critically analyses three main neurobiological hypotheses on trans* identities: the neurobiological theory about the origin of gender dysphoria, the neurodevelopmental cortical hypothesis, and the alternative hypothesis of self-referential thinking and body perception. In this study I focus then the attention on three elements: the issue of (de)pathologisation, the idea of the trans brain, and the aetiology of trans* identities. While the neurobiological theory about the origin of gender dysphoria and the neurodevelopmental cortical hypothesis claim the existence of the trans brain, each offering its own neurobiological depiction, the hypothesis of self-referential thinking and body perception doesn't postulate a distinctive neurobiological trait for all trans* people. I problematize both portrayals of the trans brain departing from the findings and conceptualizations of the paradigm shifting brain mosaicism. Unlike the hypothesis of self-referential thinking and body perception that keeps the question of causation open, both the neurobiological theory about the origin of gender dysphoria and the neurodevelopmental cortical hypothesis situate the origin of trans* identities in the neurobiological domain. I challenge the biological deterministic framework in which this aetiology is inscribed from a dynamic processual entanglement perspective. Finally, concerning the issue of (de)pathologisation of trans* identities, an evolution can be seen in each of the hypothesis and among them, from the least to the most depathologising. However, I question their complete departure from a pathologising framework.

Reflections on Neurofeminism and Intersectionality Using Insights From Psychology

Intersectionality contends that sex/gender is constituted of and with other social categories, and that the social structures giving rise to inequality should be addressed in research. This is a powerful and important perspective from which to investigate the processes and consequences of social group memberships, one which has been overlooked by most neuroscientific research. In particular, neurofeminism, a field of critical neuroscience that challenges neuroscientific assumptions, methods and interpretations of data that reinforce sexism, has ignored intersectionality to date. In contrast, research in the field of psychology has been engaging with intersectionality for more than a decade. In reflecting on how intersectionality has advanced feminist research in psychology, this paper provides a critical analysis of potential novel research avenues for neurofeminism. We identify three main research themes guided by intersectionality. The first theme involves research centered on understanding the socio-structural causes of health inequalities experienced by individuals with intersecting marginalized social identities; the second concerns research addressing the psychological processing of social group memberships that underlies the enactment of systemic discriminatory practices; and the third theme comprises intersectionality research that aims to challenge psychological epistemology. Drawing parallels between the fields of psychology and neuroscience, we explore the potential benefits and risks of advancing an intersectionality-informed neurofeminism.

Beyond sex differences and a male-female continuum: Mosaic brains in a multidimensional space

In the last two decades, the 60 years old view that in utero exposure to testosterone irreversibly masculinizes the brain of males away from a default female form has been replaced by a complex scenario according to which sex affects the brains of both females and males via multiple mechanisms, which are susceptible to internal and external factors. These observations led to the "mosaic" hypothesis-the expectation that the degree of "maleness"/"femaleness" of different features within a single brain would not be internally consistent. Following a short review of the animal studies providing the basis of the mosaic hypothesis, I describe three studies conducted in humans that assessed internal consistency in regional volume, cortical thickness, and connectivity as revealed by magnetic resonance imaging (MRI); in neuronal numbers in the postmortem hypothalamus; and in changes in regional volume and cortical thickness (assessed with MRI) following exposure to extreme real-life stress. The conclusion from these studies, that human brains are largely composed of unique mosaics of female-typical and male-typical features, was supported by recent findings that the brain "types" typical of women are also typical of men, and vice versa. Lastly, I discuss criticism of the mosaic hypothesis and suggest replacing the framework of a male-female continuum with thinking about mosaic brains residing in a multidimensional space.

A Dynamic Systems Framework for Gender/Sex Development: From Sensory Input in Infancy to Subjective Certainty in Toddlerhood

From birth to 15 months infants and caregivers form a fundamentally intersubjective, dyadic unit within which the infant's ability to recognize gender/sex in the world develops. Between about 18 and 36 months the infant accumulates an increasingly clear and subjective sense of self as female or male. We know little about how the precursors to gender/sex identity form during the intersubjective period, nor how they transform into an independent sense of self by 3 years of age. In this Theory and Hypothesis article I offer a general framework for thinking about this problem. I propose that through repetition and patterning, the dyadic interactions in which infants and caregivers engage imbue the infant with an embodied, i.e., sensori-motor understanding of gender/sex. During this developmental period (which I label Phase 1) gender/sex is primarily an intersubjective project. From 15 to 18 months (which I label Phase 2) there are few reports of newly appearing gender/sex behavioral differences, and I hypothesize that this absence reflects a period of developmental instability during which there is a transition from gender/sex as primarily inter-subjective to gender/sex as primarily subjective. Beginning at 18 months (i.e., the start of Phase 3), a toddler's subjective sense of self as having a gender/sex emerges, and it solidifies by 3 years of age. I propose a dynamic systems perspective to track how infants first assimilate gender/sex information during the intersubjective period (birth to 15 months); then explore what changes might occur during a hypothesized phase transition (15 to 18 months), and finally, review the emergence and initial stabilization of individual subjectivity-the period from 18 to 36 months. The critical questions explored focus on how to model and translate data from very different experimental disciplines, especially neuroscience, physiology, developmental psychology and cognitive development. I close by proposing the formation of a research consortium on gender/sex development during the first 3 years after birth.

Beyond the binary: Rethinking sex and the brain

The paper reviews the relations between sex and brain in light of the binary conceptualization of these relations and the challenges posed to it by the 'mosaic' hypothesis. Recent formulations of the binary framework range from arguing that the typical male brain is different from the typical female brain to claiming that brains are typically male or female because brain structure can be used to predict the sex category (female/male) of the brain's owner. These formulations are challenged by evidence that sex effects on the brain may be opposite under different conditions, that human brains are comprised of mosaics of female-typical and male-typical features, and that sex category explains only a small part of the variability in human brain structure. These findings led to a new, non-binary, framework, according to which mosaic brains reside in a multi-dimensional space that cannot meaningfully be reduced to a male-female continuum or to a binary variable. This framework may also apply to sex-related variables and has implications for research.

The Complex Relationships between Sex and the Brain

In the past decennia, our understanding of the sexual differentiation of the mammalian brain has dramatically changed. The simple model according to which testosterone masculinizes the brain of males away from a default female form, was replaced with a complex scenario, according to which sex effects on the brain of both females and males are exerted by genetic, hormonal, and environmental factors. These factors act via multiple partly independent mechanisms that may vary according to internal and external factors. These observations led to the "mosaic" hypothesis-the expectation of high variability in the degree of "maleness"/"femaleness" of different features within a single brain. Here, we briefly review animal data that form the basis of current understanding of sexual differentiation; present, in this context, the results of co-analyses of human brain measures obtained by magnetic resonance imaging or postmortem; discuss criticisms and controversies of the mosaic hypothesis and implications for research; and conclude that co-analysis of several (preferably, many) features and going back from the group level to that of the individual would advance our understanding of the relations between sex and the brain in health and disease.

Gender/Sex, Sexual Orientation, and Identity Are in the Body: How Did They Get There?

In this review, I explore theoretical and empirical approaches to the development of gender/sex and sexual orientation (SO). Leaving behind the nature versus nurture opposition, I look at both identities as deeply embodied. My approach intertwines sex, gender, orientation, bodies, and cultures without a demand to choose one over the other. First, I introduce basic definitions, focusing on how intertwined the concepts of sex and gender really are. I affirm recent trends to consider a new term-gender/sex-as the best way to think about these deeply interwoven bodily traits. I introduce several literatures, each of which considers the processes by which traits become embodied. These points of view offer a basis for future work on identity development. Specifically, and selectively, I provide insights from the fields of phenomenology, dyadic interaction and the formation of presymbolic representations in infancy, and dynamic systems in infant development. I consider how thinking about embodied cognition helps to address intersubjectivity and the emergence of subjective identity. Next, I review what we currently know about the development of complex sexual systems in infancy and toddlerhood. Finally, I discuss the few existing theories of SO development that consider the events of infancy and childhood.

VIII. Captured in terminology: Sex, sex categories, and sex differences

Swayed by the clear distinction between male and female genitalia, the question of how far these categories extend into human biology has attracted humans for centuries. This question is sometimes being framed as whether the effects of sex are restricted to the genital organs or penetrate the entire organism. Here I argue that the two questions are not equivalent and that whereas the answer to the question, how far sex penetrates the body, is – deep down to the level of every cell, the answer to the question, how far the categories, “male” and “female”, do, is – probably nowhere beyond the genitals. That the two questions are often used interchangeably reflects the prevailing conceptualization of sex as a dichotomous system or process that exerts profound effects on other systems (e.g., the brain), leading to sexual dimorphism (i.e., two forms, male versus female) also of these systems. Here I discuss the question of whether the effects of sex result in dimorphic systems, focusing on the case of sex effects on the brain. I show that although there are sex/gender differences in brain and behavior, humans and human brains are comprised of highly variable ‘mosaics’ of features, some more prevalent in females, others more prevalent in males.

Neural Correlates of Sex/Gender Differences in Humor Processing for Different Joke Types

Humor operates through a variety of techniques, which first generate surprise and then amusement and laughter once the unexpected incongruity is resolved. As different types of jokes use different techniques, the corresponding humor processes also differ. The present study builds on the framework of the 'tri-component theory of humor,' which details the mechanisms involved in cognition (comprehension), affect (appreciation), and laughter (expression). This study seeks to identify differences among joke types and between sexes/genders in the neural mechanisms underlying humor processing. Three types of verbal jokes, bridging-inference jokes (BJs), exaggeration jokes (EJs), and ambiguity jokes (AJs), were used as stimuli. The findings revealed differences in brain activity for an interaction between sex/gender and joke type. For BJs, women displayed greater activation in the temporoparietal-mesocortical-motor network than men, demonstrating the importance of the temporoparietal junction (TPJ) presumably for 'theory of mind' processing, the orbitofrontal cortex for motivational functions and reward coding, and the supplementary motor area for laughter. Women also showed greater activation than men in the frontal-mesolimbic network associated with EJs, including the anterior (frontopolar) prefrontal cortex (aPFC, BA 10) for executive control processes, and the amygdala and midbrain for reward anticipation and salience processes. Conversely, AJs elicited greater activation in men than women in the frontal-paralimbic network, including the dorsal prefrontal cortex (dPFC) and parahippocampal gyrus. All joke types elicited greater activation in the aPFC of women than of men, whereas men showed greater activation than women in the dPFC. To confirm the findings related to sex/gender differences, random group analysis and within group variance analysis were also performed. These findings help further establish the mechanisms underlying the processing of different joke types for the sexes/genders and provide a neural foundation for a theory of sex/gender differences in humor.

Recommendations for sex/gender neuroimaging research: key principles and implications for research design, analysis, and interpretation

Neuroimaging (NI) technologies are having increasing impact in the study of complex cognitive and social processes. In this emerging field of social cognitive neuroscience, a central goal should be to increase the understanding of the interaction between the neurobiology of the individual and the environment in which humans develop and function. The study of sex/gender is often a focus for NI research, and may be motivated by a desire to better understand general developmental principles, mental health problems that show female-male disparities, and gendered differences in society. In order to ensure the maximum possible contribution of NI research to these goals, we draw attention to four key principles-overlap, mosaicism, contingency and entanglement-that have emerged from sex/gender research and that should inform NI research design, analysis and interpretation. We discuss the implications of these principles in the form of constructive guidelines and suggestions for researchers, editors, reviewers and science communicators.

Matters of sex and gender in F. J. Gall's Organology: a primary approach

The originator of phrenology, F. J. Gall (1758-1828), saw himself as a natural scientist and physiologist. His approach consisted of brain anatomy but also of palpating skulls and inferring mental faculties. Unlike some of the philosophical principles underlying Gall's work, his conception of sex/gender has not yet been examined in detail. In this article, I will focus on Gall's treatment of men and women, his idea of sex differences, and how far an assumed existence of dichotomous sexes influenced his work. In examining his primary writings, I will argue that Gall held some contradictory views concerning the origin and manifestation of sex/gender characteristics, which were caused by the collision of his naturalistic ideas and internalized gender stereotypes. I will conclude that Gall did not aim at deducing or legitimizing sex/gender relations scientifically, but that he tried to express metaphysical reasons for a given social order in terms of functional brain mechanisms.

Neurofeminism and feminist neurosciences: a critical review of contemporary brain research

To date, feminist approaches to neurosciences have evaluated the debates surrounding practices of knowledge production within and research results of contemporary brain research. Consequently, neurofeminist scholars have critically examined gendered impacts of neuroscientific research. Feminist neuroscientists also develop research approaches for a more gender-appropriate neuroscientific research on several levels. Based on neurofeminist critique feminist neuroscientists aim to enrich neuroscientific work by offering methodological suggestions for a more differentiated setup of categories and experimental designs, for reflective result presentations and interpretations as well as for the analysis of result validity. Reframing neuro-epistemologies by including plasticity concepts works to uncover social influences on the gendered development of the brain and of behavior. More recently, critical work on contemporary neurocultures has highlighted the entanglements of neuroscientific research within society and the implications of ‘neurofacts’ for gendered cultural symbolisms, social practices, and power relations. Not least, neurofeminism critically analyses the portrayal of neuro-knowledge in popular media. This article presents on overview on neurofeminist debates and on current approaches of feminist neurosciences. The authors conclude their review by calling for a more gender-appropriate research approach that takes into account both its situatedness and reflections on the neuroscientific agenda, but also questions neurofeminist discourse in regards to uses and misuses of its concepts.

Genetic-gonadal-genitals sex (3G-sex) and the misconception of brain and gender, or, why 3G-males and 3G-females have intersex brain and intersex gender

The categorization of individuals as "male" or "female" is based on chromosome complement and gonadal and genital phenotype. This combined genetic-gonadal-genitals sex, here referred to as 3G-sex, is internally consistent in ~99% of humans (i.e., one has either the "female" form at all levels, or the "male" form at all levels). About 1% of the human population is identified as "intersex" because of either having an intermediate form at one or more levels, or having the "male" form at some levels and the "female" form at other levels. These two types of "intersex" reflect the facts, respectively, that the different levels of 3G-sex are not completely dimorphic nor perfectly consistent. Using 3G-sex as a model to understand sex differences in other domains (e.g., brain, behavior) leads to the erroneous assumption that sex differences in these other domains are also highly dimorphic and highly consistent. But parallel lines of research have led to the conclusion that sex differences in the brain and in behavior, cognition, personality, and other gender characteristics are for the most part not dimorphic and not internally consistent (i.e., having one brain/gender characteristic with the "male" form is not a reliable predictor for the form of other brain/gender characteristics). Therefore although only ~1% percent of humans are 3G-"intersex", when it comes to brain and gender, we all have an intersex gender (i.e., an array of masculine and feminine traits) and an intersex brain (a mosaic of "male" and "female" brain characteristics).