A conceptual muddle: an empirical analysis of the use of 'sex' and 'gender' in 'gender-specific medicine' journals

Association of pre-migration socioeconomic status and post-migration mental health in Syrian refugees in Lebanon: a descriptive sex-stratified cross-sectional analysis

BACKGROUND

Refugee populations present with high levels of psychological distress, which may vary among sociodemographic characteristics. Understanding the distribution across these characteristics is crucial to subsequently provide more tailored support to the most affected according to their specific healthcare needs. This study therefore seeks to investigate the association between pre-migration socioeconomic status (SES) and post-migration mental health separately for male and female Syrian refugees in Lebanon.

METHODS

In a cross-sectional study, a cluster randomized sample of 599 refugees from Syria were recruited between 2016 and 2019 within 12 months after they fled to Lebanon. Logistic regression was used to determine the association between self-reported pre-migration SES and levels of anxiety and depressive symptoms assessed on the Hopkins Symptoms Checklist-25 (HSCL-25) scale, both for the entire sample and stratified by sex. To assess the informative value of self-reported SES, its correlation with education variables was tested. All analyses were conducted in R version 4.3.

RESULTS

Using complete cases, 457 participants (322 female, 135 male) were included in the analyses. Females showed on average more symptoms of anxiety (Median: 2.5) and depression (Median: 2.4) than males (Median: 2.10 and 2.07, respectively). Below average SES was associated with significantly higher odds for mental illness compared to average SES (anxiety: OR 4.28, 95% CI [2.16, 9.49]; depression: OR 1.85, 95% CI [1.06, 3.36]). For anxiety, differences between SES strata were larger for males than females. The self-reported SES measure showed only a weak positive correlation with education.

CONCLUSIONS

This study adds additional descriptive data highlighting mental health differences in Syrian refugees in Lebanon, whereby below average SES is associated with worse mental health outcomes compared to average SES. These findings demand further research into the underlying mechanisms. Improving our understanding of the observed differences will provide valuable insights that can contribute to the future development of targeted measures.

The Effect of Sex on the Incidence, Latency, Duration and Perceived Burden of Adverse Events Following Seasonal Influenza Vaccination in the Netherlands

INTRODUCTION

The annual reformulation of the seasonal influenza vaccine results in fluctuating frequencies and severity of adverse effects following immunization (AEFIs), which stresses the importance of pharmacovigilance. Also, sex-related factors are known to influence the development of AEFIs. This study aims to describe the difference in incidence and course (i.e., time-to-onset, time-to-recovery, and perceived burden) of AEFIs between males and females after seasonal influenza vaccination.

METHODS

We assessed data from cohort event monitoring studies, which were performed over nine consecutive years (2013-2021), each covering several months during the seasonal influenza campaign in the Netherlands. Participants reported information about AEFIs over a 30-day period in three questionnaires. The effect of sex, age, body mass index, study year, and comorbidities on the incidence of any AEFI, local reactions, fever and the five most reported AEFIs was analyzed using logistic regression. The difference in time-to-onset, time-to-recovery, and perceived burden between males and females was analyzed by the Kruskal-Wallis test.

RESULTS

The cohort included 7789 participants (53.0% females). Females had around 2.5-fold (p < 0.001) higher odds of developing any AEFI compared with males. Some study years and comorbidities were positively associated with AEFI incidence, whereas age was negatively associated. An AEFI had a significant shorter time-to-onset, a longer time-to-recovery, and a higher perceived burden in females compared to males.

CONCLUSION

Overall, the results confirm that females experience AEFIs more often than males. Additionally, this study shows that the course of AEFIs only partially differs between the sexes.

Descriptive regression tree analysis of intersecting predictors of adult self-rated health: Does gender matter? A cross-sectional study of Canadian adults

BACKGROUND

While self-rated health (SRH) is a well-validated indicator, its alignment with objective health is inconsistent, particularly among women and older adults. This may reflect group-based differences in characteristics considered when rating health. Using a combination of SRH and satisfaction with health (SH) could capture lived realities for all, thus enabling a more accurate search for predictors of subjective health. With the combined measure of SRH and SH as the outcome we explore a range of characteristics that predict high SRH/SH compared with predictors of a low rating for either SRH or SH.

METHODS

Data were from the Canadian General Social Survey 2016 which includes participants 15 years of age and older. We performed classification and regression tree (CRT) analyses to identify the best combination of socioeconomic, behavioural, and mental health predictors of good SRH and health satisfaction.

RESULTS

Almost 85% of the population rated their health as good; however, 19% of those had low SH. Conversely, about 20% of those reporting poor SRH were, none-the-less, satisfied. CRT identified healthy eating, absence of a psychological disability, no work disability from long-term illness, and high resilience as the main predictors of good SRH/SH. Living with a spouse or children, higher social class and healthy behaviours also aligned with high scores in both self-perceived health measures. Sex was not a predictor.

CONCLUSIONS

Combining SRH and SH eliminated sex as a predictor of subjective health, and identified characteristics, particularly resilience, that align with high health and well-being and that are malleable.

Interventions for improving health literacy in migrants

BACKGROUND

Health literacy (HL) is a determinant of health and important for autonomous decision-making. Migrants are at high risk for limited HL. Improving HL is important for equitable promotion of migrants' health.

OBJECTIVES

To assess the effectiveness of interventions for improving HL in migrants. To assess whether female or male migrants respond differently to the identified interventions.

SEARCH METHODS

We ran electronic searches to 2 February 2022 in CENTRAL, MEDLINE, Embase, PsycInfo and CINAHL. We also searched trial registries. We used a study filter for randomised controlled trials (RCTs) (RCT classifier).

SELECTION CRITERIA

We included RCTs and cluster-RCTs addressing HL either as a concept or its components (access, understand, appraise, apply health information).

DATA COLLECTION AND ANALYSIS

We used the methodological procedures recommended by Cochrane and followed the PRISMA-E guidelines. Outcome categories were: a) HL, b) quality of life (QoL), c) knowledge, d) health outcomes, e) health behaviour, f) self-efficacy, g) health service use and h) adverse events. We conducted meta-analysis where possible, and reported the remaining results as a narrative synthesis.

MAIN RESULTS

We included 28 RCTs and six cluster-RCTs (8249 participants), all conducted in high-income countries. Participants were migrants with a wide range of conditions. All interventions were adapted to culture, language and literacy. We did not find evidence that HL interventions cause harm, but only two studies assessed adverse events (e.g. anxiety). Many studies reported results for short-term assessments (less than six weeks after total programme completion), reported here. For several comparisons, there were also findings at later time points, which are presented in the review text. Compared with no HL intervention (standard care/no intervention) or an unrelated HL intervention (similar intervention but different information topic) Self-management programmes (SMP) probably improve self-efficacy slightly (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.50; 2 studies, 333 participants; moderate certainty). SMP may improve HIV-related HL (understanding (mean difference (MD) 4.25, 95% CI 1.32 to 7.18); recognition of HIV terms (MD 3.32, 95% CI 1.28 to 5.36)) (1 study, 69 participants). SMP may slightly improve health behaviours (3 studies, 514 participants), but may have little or no effect on knowledge (2 studies, 321 participants) or subjective health status (MD 0.38, 95% CI -0.13 to 0.89; 1 study, 69 participants) (low certainty). We are uncertain of the effects of SMP on QoL, health service use or adverse events due to a lack of evidence. HL skills building courses (HLSBC) may improve knowledge (MD 10.87, 95% CI 5.69 to 16.06; 2 studies, 111 participants) and any generic HL (SMD 0.48, 95% CI 0.20 to 0.75; 2 studies, 229 participants), but may have little or no effect on depression literacy (MD 0.17, 95% CI -1.28 to 1.62) or any health behaviour (2 studies, 229 participants) (low certainty). We are uncertain if HLSBC improve QoL, health outcomes, health service use, self-efficacy or adverse events, due to very low-certainty or a lack of evidence. Audio-/visual education without personal feedback (AVE) probably improves depression literacy (MD 8.62, 95% CI 7.51 to 9.73; 1 study, 202 participants) and health service use (MD -0.59, 95% CI -1.11 to -0.07; 1 study, 157 participants), but probably has little or no effect on health behaviour (risk ratio (RR) 1.07, 95% CI 0.91 to 1.25; 1 study, 135 participants) (moderate certainty). AVE may improve self-efficacy (MD 3.51, 95% CI 2.53 to 4.49; 1 study, 133 participants) and may slightly improve knowledge (MD 8.44, 95% CI -2.56 to 19.44; 2 studies, 293 participants) and intention to seek depression treatment (MD 1.8, 95% CI 0.43 to 3.17), with little or no effect on depression (SMD -0.15, 95% CI -0.40 to 0.10) (low certainty). No evidence was found for QoL and adverse events. Adapted medical instruction may improve understanding of health information (3 studies, 478 participants), with little or no effect on medication adherence (MD 0.5, 95% CI -0.1 to 1.1; 1 study, 200 participants) (low certainty). No evidence was found for QoL, health outcomes, knowledge, health service use, self-efficacy or adverse events. Compared with written information on the same topic SMP probably improves health numeracy slightly (MD 0.7, 95% CI 0.15 to 1.25) and probably improves print literacy (MD 9, 95% CI 2.9 to 15.1; 1 study, 209 participants) and self-efficacy (SMD 0.47, 95% CI 0.3 to 0.64; 4 studies, 552 participants) (moderate certainty). SMP may improve any disease-specific HL (SMD 0.67, 95% CI 0.27 to 1.07; 4 studies, 955 participants), knowledge (MD 11.45, 95% CI 4.75 to 18.15; 6 studies, 1101 participants) and some health behaviours (4 studies, 797 participants), with little or no effect on health information appraisal (MD 1.15, 95% CI -0.23 to 2.53; 1 study, 329 participants) (low certainty). We are uncertain whether SMP improves QoL, health outcomes, health service use or adverse events, due to a lack of evidence or low/very low-certainty evidence. AVE probably has little or no effect on diabetes HL (MD 2, 95% CI -0.15 to 4.15; 1 study, 240 participants), but probably improves information appraisal (MD -9.88, 95% CI -12.87 to -6.89) and application (RR 1.51, 95% CI 1.29 to 1.77) (1 study, 608 participants; moderate certainty). AVE may slightly improve knowledge (MD 8.35, 95% CI -0.32 to 17.02; low certainty). No short-term evidence was found for QoL, depression, health behaviour, self-efficacy, health service use or adverse events. AVE compared with another AVE We are uncertain whether narrative videos are superior to factual knowledge videos as the evidence is of very low certainty. Gender differences Female migrants' diabetes HL may improve slightly more than that of males, when receiving AVE (MD 5.00, 95% CI 0.62 to 9.38; 1 study, 118 participants), but we do not know whether female or male migrants benefit differently from other interventions due to very low-certainty or a lack of evidence.

AUTHORS' CONCLUSIONS

Adequately powered studies measuring long-term effects (more than six months) of HL interventions in female and male migrants are needed, using well-validated tools and representing various healthcare systems.

Sex and gender in infection and immunity: addressing the bottlenecks from basic science to public health and clinical applications

Although sex and gender are recognized as major determinants of health and immunity, their role is rarely considered in clinical practice and public health. We identified six bottlenecks preventing the inclusion of sex and gender considerations from basic science to clinical practice, precision medicine and public health policies. (i) A terminology-related bottleneck, linked to the definitions of sex and gender themselves, and the lack of consensus on how to evaluate gender. (ii) A data-related bottleneck, due to gaps in sex-disaggregated data, data on trans/non-binary people and gender identity. (iii) A translational bottleneck, limited by animal models and the underrepresentation of gender minorities in biomedical studies. (iv) A statistical bottleneck, with inappropriate statistical analyses and results interpretation. (v) An ethical bottleneck posed by the underrepresentation of pregnant people and gender minorities in clinical studies. (vi) A structural bottleneck, as systemic bias and discriminations affect not only academic research but also decision makers. We specify guidelines for researchers, scientific journals, funding agencies and academic institutions to address these bottlenecks. Following such guidelines will support the development of more efficient and equitable care strategies for all.

Sex-Based Differences in Clinical Profile and Complications among Individuals with Type 2 Diabetes Seen at a Private Tertiary Diabetes Care Centre in India

This study aimed to compare the clinical and biochemical profiles as well as the complications in males and females with type 2 diabetes (T2DM) presenting to a private tertiary diabetes care centre in India. This is a retrospective study, conducted between 1 January 2017 and 31 December 2019, and included 72,980 individuals with T2DM, aged ≥ 18 years (age and sex-matched-males-36,490; females-36,490). Anthropometric measurements, blood pressure, fasting plasma glucose (FPG), post-prandial plasma glucose (PPPG), glycated haemoglobin (HbA1c), lipids, urea, and creatinine were measured. Retinopathy was screened using retinal photography, neuropathy using biothesiometry, nephropathy measuring urinary albumin excretion, peripheral vascular disease (PVD) using Doppler, and coronary artery disease (CAD) based on the history of myocardial infarction and/or drug treatment for CAD and/or electrocardiographic changes. Obesity (73.6% vs. 59.0%) rates were significantly higher in females compared to males. FPG, PPPG, and HbA1c were higher among younger age groups among both sexes, with males having higher values compared to females. However, after the age of 44 years, control of diabetes was worse among females. In addition, only 18.8% of the females achieved glycemic control (HbA1c < 7%) compared to 19.9% in males (p < 0.001). Males had higher prevalence of neuropathy (42.9% vs. 36.9%), retinopathy (36.0% vs. 26.3%), and nephropathy (25.0% vs. 23.3%) compared to females. Males had 1.8- and 1.6-times higher risk of developing CAD and retinopathy compared to females. Hypothyroidism (12.5% vs. 3.5%) and cancers (1.3% vs. 0.6%) were significantly higher in females compared to males. In this large sample of T2DM seen at a chain of private tertiary diabetes centres, females had higher prevalence of metabolic risk factors and poorer diabetes control compared to males, emphasizing the need for better control of diabetes in females. However, males had higher prevalence of neuropathy, retinopathy, nephropathy, and CAD compared to females.

Consideration of sex/gender in publications of quantitative health-related research: Development and application of an assessment matrix

During the last years the need to integrate sex and gender in health-related research for better and fairer science became increasingly apparent. Various guidelines and checklists were developed to encourage and support researchers in considering the entangled dimensions of sex/gender in their research. However, a tool for the assessment of sex/gender consideration and its visualization is still missing. We aim to fill this gap by introducing an assessment matrix that can be used as a flexible instrument for comprehensively evaluating the sex/gender consideration in quantitative health-related research. The matrix was developed through an iterative and open process based on the interdisciplinary expertise represented in our research team and currently published guidelines. The final matrix consists of 14 different items covering the whole research process and the publication of results. Additionally, we introduced a method to graphically display this evaluation. By developing the matrix, we aim to provide users with a tool to systematically compare sex/gender consideration qualitatively between different publications and even different fields of study. This way, the assessment matrix represents a tool to identify research gaps and a basis for future research. In the long term, the implementation of this tool to evaluate the consideration of sex/gender should contribute to more sex/gender equitable health-related research.

Sex and gender aspects in diabetes mellitus: Focus on access to health care and cardiovascular outcomes

Aims

The aim of this study was to elucidate whether sex and gender factors influence access to health care and/or are associated with cardiovascular (CV) outcomes of individuals with diabetes mellitus (DM) across different countries.

Methods

Using data from the Canadian Community Health Survey (8.4% of respondent reporting DM) and the European Health Interview Survey (7.3% of respondents reporting DM), were analyzed. Self-reported sex and a composite measure of socio-cultural gender was constructed (range: 0-1; higher score represent participants who reported more characteristics traditionally ascribed to women). For the purposes of analyses the Gender Inequality Index (GII) was used as a country level measure of institutionalized gender.

Results

Canadian females with DM were more likely to undergo HbA1c monitoring compared to males (OR = 1.26, 95% CI: 1.01-1.58), while conversely in the European cohort females with DM were less likely to have their blood sugar measured compared to males (OR = 0.88, 95% CI: 0.79-0.99). A higher gender score in both cohorts was associated with less frequent diabetes monitoring. Additionally, independent of sex, higher gender scores were associated with higher prevalence of self-reported heart disease, stroke, and hospitalization in all countries albeit European countries with medium-high GII, conferred a higher risk of all outcomes and hospitalization rates than low GII countries.

Conclusion

Regardless of sex, individuals with DM who reported characteristics typically ascribed to women and those living in countries with greater gender inequity for women exhibited poorer diabetes care and greater risk of CV outcomes and hospitalizations.

Sex-disaggregated outcomes of adverse events after COVID-19 vaccination: A Dutch cohort study and review of the literature

Background

Albeit the need for sex-disaggregated results of adverse events after immunization (AEFIs) is gaining attention since the COVID-19 pandemic, studies with emphasis on sexual dimorphism in response to COVID-19 vaccination are relatively scarce. This prospective cohort study aimed to assess differences in the incidence and course of reported AEFIs after COVID-19 vaccination between males and females in the Netherlands and provides a summary of sex-disaggregated outcomes in published literature.

Methods

Patient reported outcomes of AEFIs over a six month period following the first vaccination with BioNTech-Pfizer, AstraZeneca, Moderna or the Johnson&Johnson vaccine were collected in a Cohort Event Monitoring study. Logistic regression was used to assess differences in incidence of 'any AEFI', local reactions and the top ten most reported AEFIs between the sexes. Effects of age, vaccine brand, comorbidities, prior COVID-19 infection and the use of antipyretic drugs were analyzed as well. Also, time-to-onset, time-to-recovery and perceived burden of AEFIs was compared between the sexes. Third, a literature review was done to retrieve sex-disaggregated outcomes of COVID-19 vaccination.

Results

The cohort included 27,540 vaccinees (38.5% males). Females showed around two-fold higher odds of having any AEFI as compared to males with most pronounced differences after the first dose and for nausea and injection site inflammation. Age was inversely associated with AEFI incidence, whereas a prior COVID-19 infection, the use of antipyretic drugs and several comorbidities were positively associated. The perceived burden of AEFIs and time-to-recovery were slightly higher in females.

Discussion

The results of this large cohort study correspond to existing evidence and contribute to the knowledge gain necessary to disentangle the magnitude of the effect sex in response to vaccination. Whilst females have a significant higher probability of experiencing an AEFI than males, we observed that the course and burden is only to a minor extent different between the sexes.

Effect Modification by Age and Gender in the Correlation Between Diabetes Mellitus, Hypertension, and Obesity

BACKGROUND

Literature has reported differences in the epidemiology or natural history of non-communicable diseases among both the male and female sexes. Stratification of multimorbidity burden based on sex is crucial to identify and implement targeted prevention and control interventions for chronic diseases.

OBJECTIVES

To determine the burden of hypertension, type-2 diabetes mellitus, and obesity; and to compare the related multimorbidity among male and female patients.

METHODS

The study was a retrospective analysis of 375 802 medical records from primary care centers. Data was extracted from March 2022 to March 2023. A multivariate probit estimation methodology was employed using a 3-equations multivariate multiple probit model to jointly estimate the association of a person's sex with the diagnosis of the 3 chronic conditions: obesity, diabetes, and hypertension. A multinomial logistic regression analysis was conducted to allow each unique combination of these 3 chronic diseases.

RESULTS

Females had a relatively higher proportion of obesity (58.1% vs 41.2%), obesity and diabetes only (58.9% vs 41.1%), obesity and hypertension (63.6% vs 36.4%), and joint diagnosis with 3 conditions (65.7% vs 34.3%). Females' participants consistently had a significantly higher likelihood of diagnosis compared with males except for diabetes (OR = 0.59, 95% CI: 0.56-0.62) and the combination of only diabetes and hypertension (OR = 0.67, 95% CI: 0.61-0.74). The likelihood of other combinations ranged from 1.04 (95% CI: 0.98-1.10) for only hypertension to 2.30 (95% CI: 2.10-2.53) for the joint diagnosis of all 3 conditions. An increased likelihood of a single or combined occurrence of 3 chronic conditions was observed with increased age.

CONCLUSION

The multimorbidity distribution for diabetes mellitus, hypertension, and obesity differs significantly among male and female patients. The overall burden of morbidity, and mortality, however, tends to rise after 46 years of age, with the highest burden among individuals above 60 years of age.

Addressing sex and gender to improve asthma management

Sex (whether one is 'male' or 'female', based on biological characteristics) and gender (defined by socially constructed roles and behaviors) influence asthma diagnosis and management. For example, women generally report more severe asthma symptoms than men; men and women are exposed to different asthma-causing triggers; men tend to be more physically active than women. Furthermore, implicit, often unintended gender bias by healthcare professionals (HCPs) is widespread, and may result in delayed asthma diagnosis, which can be greater in women than men. The sex and gender of the HCP can also impact asthma management. Pregnancy, menstruation, and menopause can all affect asthma in several ways and may be associated with poor asthma control. This review provides guidance for considering sex- and gender-associated impacts on asthma diagnosis and management and offers possible approaches to support HCPs in providing personalized asthma care for all patients, regardless of their sex or gender.

Gender-inclusive writing for epidemiological research on pregnancy

People who have a uterus but are not cisgender women may carry pregnancies. Unfortunately, to date, academic language surrounding pregnancy remains largely (cis) woman-centric. The exclusion of gender-diverse people in the language of pregnancy research in English is pervasive. In reviewing a random sample of 500 recent articles on pregnancy or pregnant populations across health research fields, we found that only 1.2% of articles used gender-inclusive language (none of them in epidemiology), while the remaining 98.8% used (cis) woman-centric language. First and foremost, recent recommendations highlight the need to include trans, non-binary and gender-diverse people in study design. Meanwhile, there remains a lack of awareness that all research on pregnancy can contribute to inclusiveness, including in dissemination and retroactive description. We explain how the ubiquitous use of (cis) woman-centric language in pregnancy-related research contributes to (1) the erasure of gender diversity; (2) inaccurate scientific communication and (3) negative societal impacts, such as perpetuating the use of exclusionary language by students, practitioners, clinicians, policy-makers and the media. We follow with recommendations for gender-inclusive language in every section (ie, introductions, methods, results, discussions) of epidemiological articles on pregnant populations. The erasure of gender-diverse people in the rhetoric of research about pregnant people can be addressed immediately, including in the dissemination of results from ongoing studies that did not take gender diversity into consideration. This makes gender-inclusive language a crucial first step towards the inclusion of gender-diverse people in epidemiological research on pregnant people and other health research more globally.

Gender differences of health literacy in persons with a migration background: a systematic review and meta-analysis

OBJECTIVE

To investigate gender differences of health literacy in individuals with a migration background.

DESIGN

Systematic review and meta-analysis. OVID/MEDLINE, PsycINFO and CINAHL were searched in March 2018 and July 2020.

SETTING

Studies had to provide health literacy data for adult women and men with a migration background, collected with a standardised instrument, or report results that demonstrated the collection of such data. Health literacy data were extracted from eligible studies or requested from the respective authors. Using a random-effects model, a meta-analysis was conducted to assess standardised mean differences (SMDs) of health literacy in men and women. Two researchers independently assessed risk of bias for each included study using the Appraisal Tool for Cross-Sectional Studies.

RESULTS

Twenty-four studies were included in this systematic review. Thereof, 22 studies (8012 female and 5380 male participants) were included in the meta-analyses. In six studies, gender-specific health literacy scores were reported. The authors of additional 15 studies provided their data upon request and for one further study data were available online. Women achieved higher health literacy scores than men: SMD=0.08, 95% CI 0.002 to 0.159, p=0.04, I2=65%. Another 27 studies reported data on female participants only and could not be included due to a lack of comparable studies with male participants only. Authors of 56 other eligible studies were asked for data, but without success.

CONCLUSION

Men with a migration background-while being much less frequently examined-may have lower health literacy than women. As heterogeneity between studies was high and the difference became statistically insignificant when excluding studies with a high risk of bias, this result must be interpreted with caution. There is a paucity of research on the social and relational aspects of gender in relation to health literacy among people with a migration background, especially for men.

PROSPERO REGISTRATION NUMBER

CRD42018085555.

Sex and gender terminology: a glossary for gender-inclusive epidemiology

There is increased interest in inclusion, diversity and representativeness in epidemiological and community health research. Despite this progress, misunderstanding and conflation of sex and gender have precluded both the accurate description of sex and gender as sample demographics and their inclusion in scientific enquiry aiming to distinguish health disparities due to biological systems, gendered experiences or their social and environmental interactions. The present glossary aims to define and improve understanding of current sex-related and gender-related terminology as an important step to gender-inclusive epidemiological research. Effectively, a proper understanding of sex, gender and their subtleties as well as acknowledgement and inclusion of diverse gender identities and modalities can make epidemiology not only more equitable, but also more scientifically accurate and representative. In turn, this can improve public health efforts aimed at promoting the well-being of all communities and reducing health inequities.

The Operationalisation of Sex and Gender in Quantitative Health-Related Research: A Scoping Review

Current trends in quantitative health research have highlighted the inadequacy of the usual operationalisation of sex and gender, resulting in a growing demand for more nuanced options. This scoping review provides an overview of recent instruments for the operationalisation of sex and gender in health-related research beyond a concept of mutually exclusive binary categories as male or masculine vs. female or feminine. Our search in three databases (Medline, Scopus and Web of Science) returned 9935 matches, of which 170 were included. From these, we identified 77 different instruments. The number and variety of instruments measuring sex and/or gender in quantitative health-related research increased over time. Most of these instruments were developed with a US-American student population. The majority of instruments focused on the assessment of gender based on a binary understanding, while sex or combinations of sex and gender were less frequently measured. Different populations may require the application of different instruments, and various research questions may ask for different dimensions of sex and gender to be studied. Despite the clear interest in the development of novel sex and/or gender instruments, future research needs to focus on new ways of operationalisation that account for their variability and multiple dimensions.

Considering sex and gender in Epidemiology: a challenge beyond terminology. From conceptual analysis to methodological strategies

Background

Epidemiologists need tools to measure effects of gender, a complex concept originating in the social sciences which is not easily operationalized in the discipline. Our aim is to clarify useful concepts, measures, paths, effects, and analytical strategies to explore mechanisms of health difference between men and women.

Methods

We reviewed concepts to clarify their definitions and limitations for their translation into usable measures in Epidemiology. Then we conducted methodological research using a causal framework to propose methodologically appropriate strategies for measuring sex and gender effects in health.

Results

(1) Concepts and measures. We define gender as a set of norms prescribed to individuals according to their attributed-at-birth sex. Gender pressure creates a systemic gap, at population level, in behaviors, activities, experiences, etc., between men and women. A pragmatic individual measure of gender would correspond to the level at which an individual complies with a set of elements constituting femininity or masculinity in a given population, place and time. (2) Main analytical strategy. Defining and measuring gender are not sufficient to distinguish the effects of sex and gender on a health outcome. We should also think in terms of mechanisms, i.e., how the variables are linked together, to define appropriate analytical strategies. A causal framework can help us to conceptualize “sex” as a “parent” of a gender or gendered variable. This implies that we cannot interpret sex effects as sexed mechanisms, and that we can explore gendered mechanisms of sex-differences by mediation analyses. (3) Alternative strategy. Gender could also be directly examined as a mechanism, rather than through a variable representing its realization in the individual, by approaching it as an interaction between sex and social environment.

Conclusions

Both analytical strategies have limitations relative to the impossibility of reducing a complex concept to a single or a few measures, and of capturing the entire effect of the phenomenon of gender. However, these strategies could lead to more accurate analyses of the mechanisms underlying health differences between men and women.

A pragmatic individual measure of individual gender would correspond to the level at which an individual complies with a set of elements constituting femininity or masculinity in a given population, place and time

Comparing outcomes by sex and gender is not sufficient, and even misleading, to understand the mechanisms underlying biological and health differences between men and women

Causal analysis framework is a powerful tool for refining hypotheses and identifying the effects that can and should be estimated to meet the objectives

Gender could also be measured at the populational-level as an interaction between sex and environment, which would be more compatible with the sociological concept of gender

Personalized Treatment of Asthma: The Importance of Sex and Gender Differences

An individual's sex (nominally male or female, based on biological attributes) and gender (a complex term referring to socially constructed roles, behaviors, and expressions of identity) influence the clinical course of asthma in several ways. The physiologic development of the lungs and effects of sex hormones may explain why more boys than girls have asthma, and after puberty, more women than men have asthma. Female sex hormones have an impact throughout the life span and are associated with poor asthma control. Gender may influence exposure to asthma triggers, and sex and gender can influence the prevalence of comorbidities and interactions with health care professionals. Despite widely reported sex- and gender-based differences in asthma and asthma management, these issues frequently are not considered by health care professionals. There is also inconsistency regarding the use of "sex" and "gender" in scientific discourse; research is needed to define sex- and gender-based differences better and how they might interact to influence asthma outcomes. This review outlines the impact an individual's sex and gender can have on the pathogenesis, clinical course, diagnosis, treatment, and management of asthma.

Integrating Sex/Gender into Environmental Health Research: Development of a Conceptual Framework

There is a growing awareness about the need to comprehensively integrate sex and gender into health research in order to enhance the validity and significance of research results. An in-depth consideration of differential exposures and vulnerability is lacking, especially within environmental risk assessment. Thus, the interdisciplinary team of the collaborative research project INGER (integrating gender into environmental health research) aimed to develop a multidimensional sex/gender concept as a theoretically grounded starting point for the operationalization of sex and gender in quantitative (environmental) health research. The iterative development process was based on gender theoretical and health science approaches and was inspired by previously published concepts or models of sex- and gender-related dimensions. The INGER sex/gender concept fulfills the four theoretically established prerequisites for comprehensively investigating sex and gender aspects in population health research: multidimensionality, variety, embodiment, and intersectionality. The theoretical foundation of INGER's multidimensional sex/gender concept will be laid out, as well as recent sex/gender conceptualization developments in health sciences. In conclusion, by building upon the latest state of research of several disciplines, the conceptual framework will significantly contribute to integrating gender theoretical concepts into (environmental) health research, improving the validity of research and, thus, supporting the promotion of health equity in the long term.

Measurement of gender as a social determinant of health in epidemiology-A scoping review

Background

The relevance of gender as a social determinant of health and its role in the production of health inequalities is now broadly acknowledged. However, the plethora of existing approaches to capture gender, which often stem from disciplines outside of epidemiology, makes it difficult to assess their practicality and relevance for a given research purpose. We conducted a scoping review to 1) map the evidence of how gender can be operationalised in quantitative epidemiology and 2) design a tool to critically evaluate the measures identified.

Methods

We identified peer-reviewed articles in electronic databases (PubMed, Embase and PsycINFO). Eligible sources described the quantitative operationalisation of the social dimension of gender. With the help of a newly developed checklist, we assessed their relevance from an analytical perspective (e.g. intersectionality) and their potential for implementation in epidemiology.

Results

Gender measures principally assessed gender roles and norms, gender-based discrimination and violence, and structural gender (in)equality. Of the 344 measures included in this review, the majority lacked theoretical foundation, and tended to reinforce the binary understanding of gender through stereotypes of femininity and masculinity. Only few measures allowed for an intersectional approach and a multilevel understanding of gender mechanisms. From a practical point of view, gender measures demonstrated potential for use in varied populations and contexts.

Conclusions

A range of gender measures are readily available for epidemiological research, addressing different levels and dimensions of gender as a social construct. With our theory-informed, practice-driven scoping review, we highlighted strengths and limitations of such measures and provided analytical tools for researchers interested in conducting intersectional, gender-sensitive analyses.

A delicate balance between control and flexibility: Experiences of care and support among pre-teenage children with type 1 diabetes and their families

For children with type 1 diabetes, the period of adolescence is associated with higher blood glucose levels and increased psychological distress compared to other age groups. Focusing on pre-teens (9-12 years) with type 1 diabetes and their families has been suggested as key to understanding and reducing these challenges. The aim of this study was to explore: 1, how diabetes affects family life, 2, experiences of and needs for support and 3, how care responsibilities are negotiated among pre-teens with type 1 diabetes and their families. Data were obtained from four interactive workshops with pre-teens (n = 17), their parents (n = 26) and their siblings (n = 14). Dialogue tools, for example quotes and picture cards, were used to facilitate discussion and reflection concerning family life with type 1 diabetes. Data analysis resulted in three themes: 1, diabetes takes up 'a lot of space', 2, giving and receiving support and 3, balancing control and flexibility. While diabetes took up significant space in the families, family members protected each other from their respective frustrations. The findings point to the significance of considering all key family members and their interactions in diabetes interventions. This includes balancing control and flexibility, negotiating responsibilities and building trust.

Sex- and gender-sensitive public health research: an analysis of research proposals in a research institute in the Netherlands

Taking sex and gender into account in public health research is essential to optimize methodological procedures, bridge the gender gap in public health knowledge, and advance gender equality. The aim of this study was to evaluate the current status of sex and gender considerations in public health research proposals in a Dutch research institute. We screened a random sample of 38 proposals submitted for review to the institute's science committee between 2011 and 2016. Using the Canadian Institutes of Health Research' Gender and Health Institute criteria for gender-sensitive research and qualitative content analysis, we assessed if, and how sex and gender were considered throughout the proposals (background, research aim, design, data collection, and analysis). Our results show that in general, both sex and gender were poorly considered. Gender was insufficiently taken into account throughout most proposals. When sex was mentioned in a proposal, its consideration was often inconsistent and fragmented. Finally, we identified common methodological pitfalls. We recommend that public health curricula and funding bodies increase their focus on implementing sex and gender in public health research, for instance through quality criteria, training programs for researchers and reviewers, and capacity building initiatives.

Gender and palliative care: a call to arms

There has been a systematic and largely unconscious neglect of gender in palliative care research, practice and policy. This is despite significant, although previously uncollated, evidence that gender influences almost all aspects of end-of-life preferences, experiences and care. The social situations of women, transgender people and men often differ from one another while also intersecting in complex ways with sex differences rooted in biology. If palliative care is to meet its aspiration of providing universal benefit, it urgently needs to address a range of gender inequalities currently (re)produced at the level of the laboratory all the way through to government departments. In this call to arms, we spotlight specific instances where gender inequalities have been documented, for example, regarding end-of-life caregiving, end-of-life intervention and palliative care access and benefit. We highlight how gender inequalities intersect with other social determinants of health including ethnicity and economic status to exacerbate situations of marginality. We conclude by offering some practical steps that can be taken to support the discipline to adopt a more critical gender lens to support more equitable research, policy and practice.

Representation of gender in migrant health studies - a systematic review of the social epidemiological literature

Background

Gender as a social construct contributes to determine who migrates and which migration-related risks and opportunities emerge in all phases of the migration trajectory. Simultaneously, migration influences the individual as well as societal definition and perception of gender roles. An explicit gender perspective in migration-related epidemiological research can contribute to adequately analyse and interpret the health of migrants. This systematic review gives a comprehensive overview on how gender has been conceptualised, operationalised and measured in social epidemiologic studies aiming to assess the influence of gender on health among migrants.

Methods

We searched PubMed, Embase, CINAHL, the Cochrane Library, EconLit and PsycINFO and conducted backward reference searching. Reviewers independently selected studies, extracted data and conducted the quality assessment. Eligible studies actively aimed to understand, identify or explain the influence of gender on migrants’ health, whereby the role of gender can encompass a variety of mechanisms, processes or states of differentiation, discrimination and/or inequality.

Results

Almost all of the 43 studies were cross-sectional and focussed on health outcomes in the post-migration phase. The most common theme of research was the health of male migrants in the US, and in particular of men who have sex with men (MSM). All studies treated gender as a binary variable (men vs. women), without discussing additional types of gender identities. A minority of studies differentiated clearly between sex and gender. Gender was mostly operationalised through attitudes toward gender roles and gender-based discrimination, experienced at the individual level. Community and societal level gender measures capturing structural gender determinants were underrepresented.

Conclusions

The intersections of migration and gender suggested synergistic effects on health that only become visible when considering those two social determinants together. Future research needs to embrace a multilevel and non-binary understanding of gender and reflect on the influence of gender in the different phases of the migration journey.

Systematic review registration

PROSPERO CRD42019124698.

Sex/Gender Differences in the Association between Residential Green Space and Self-Rated Health-A Sex/Gender-Focused Systematic Review

Though sex/gender is an important social determinant of health, sex/gender inequalities have not been considered comprehensively in environmental health research thus far. The aim of this systematic review was to clarify whether sex/gender theoretical concepts were addressed in studies on the impact of residential green space on self-rated health and whether effect modification by sex/gender was observed. Three electronic databases were searched to identify epidemiological studies on perceived or objective residential green/blue space and self-rated health. Necessary for study inclusion was mentioning at least one keyword for sex/gender in title or abstract, adult study participants and data on self-rated health and on availability and/or use of green/blue spaces. Decisive for study inclusion was consideration of sex/gender differences in the impact of perceived or objective residential green/blue spaces on self-rated health in the analysis and presentation of results. Seven studies were included. They presented an overall positive impact of green space on self-rated health. No consistent sex/gender differences in the impact of green space on self-rated health were found in these studies. However, all studies used a binary operationalization male/female without further theoretical foundation. Research quality could be enhanced by integrating sex/gender-theoretical concepts into study design and interpretation of results.

Are Sexist Attitudes and Gender Stereotypes Linked? A Critical Feminist Approach With a Spanish Sample

This study aims to verify the psychometric properties of the Spanish versions of the Social Roles Questionnaire (SRQ; Baber and Tucker, 2006), Modern Sexism Scale (MS), and Old-Fashioned Sexism Scale (OFS; Swim et al., 1995; Swim and Cohen, 1997). Enough support was found to maintain the original factor structure of all instruments in their Spanish version. Differences between men and women in the scores are commented on, mainly because certain sexist attitudes have been overcome with greater success in the current Spanish society, while other issues, such as distribution of power in organizational hierarchies or distribution of tasks in the household, where traditional unequal positions are still maintained. In all cases, it was found that men showed greater support for sexist attitudes. The correlations between the three instruments were as expected in assessing sexist attitudes that tend to relate to each other. Eventually, we found no empirical evidence for the postulated link between sexist attitudes and traditional gender stereotypes. Our results call for the validity and effectiveness of the classic theories of gender psychology, such as gender schema theories (Bem, 1981; Markus et al., 1982) and the notion of a gender belief system (Deaux and Kite, 1987; Kite, 2001).

Challenges of the heterogeneous nutrition response: interpreting the group mean

Extensive research demonstrates unequivocally that nutrition plays a fundamental role in maintaining health and preventing disease. In parallel nutrition research provides evidence that the risks and benefits of diet and lifestyle choices do not affect people equally, as people are inherently variable in their responses to nutrition and associated interventions to maintain health and prevent disease. To simplify the inherent complexity of human subjects and their nutrition, with the aim of managing expectations for dietary guidance required to ensure healthy populations and individuals, nutrition researchers often seek to group individuals based on commonly used criteria. This strategy relies on demonstrating meaningful conclusions based on comparison of group mean responses of assigned groups. Such studies are often confounded by the heterogeneous nutrition response. Commonly used criteria applied in grouping study populations and individuals to identify mechanisms and determinants of responses to nutrition often contribute to the problem of interpreting the results of group comparisons. Challenges of interpreting the group mean using diverse populations will be discussed with respect to studies in human subjects, in vivo and in vitro model systems. Future advances in nutrition research to tackle inter-individual variation require a coordinated approach from funders, learned societies, nutrition scientists, publishers and reviewers of the scientific literature. This will be essential to develop and implement improved study design, data recording, analysis and reporting to facilitate more insightful interpretation of the group mean with respect to population diversity and the heterogeneous nutrition response.

Evaluation of Metabolic Syndrome and Its Associated Risk Factors in Type 2 Diabetes: A Descriptive Cross-Sectional Study at the Komfo Anokye Teaching Hospital, Kumasi, Ghana

Background. Metabolic syndrome (MS) is a collection of cardiovascular risk factors comprising insulin resistance, dyslipidemia, obesity, and hypertension, which may cause further complications in diabetes. Although metabolic syndrome (MS) is increasing in incidence in diabetics and leading to significant cardiovascular diseases and mortality, there is dearth of data in Ghana. This study investigated metabolic syndrome, its prevalence, and its associated risk factors in type 2 diabetes at the Komfo Anokye Teaching Hospital, Kumasi, Ghana. Methods. The study involved 405 diabetic patients attending the Diabetic Clinic of the Komfo Anokye Teaching Hospital (KATH) Kumasi, in the Ashanti Region of Ghana. A well-structured questionnaire was used to obtain demographic background such as their age and gender. Anthropometric measurements were obtained using the Body Composition Monitor (Omron ® 500, Germany) which generated digital results on a screen and also by manual methods. Fasting venous blood was collected for the measurement of biochemical parameters comprising fasting plasma glucose (FPG), glycated haemoglobin (HbA1c), high density lipoprotein cholesterol (HDL-c), and triglyceride (TG). Metabolic syndrome was defined according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III). Results. Out of the total of 405 participants, 81 were males and 324 were females, and the estimated mean age was 58.5 ± 9.9 years. The female patients exhibited higher mean waist circumference (WC) and mean hip circumference (HC) as well as an approximately higher body mass index than males (28.3 ± 5.1, 26.5 ± 4.2 for the female and male respectively). Overall, the prevalence of metabolic syndrome observed among the study population was 90.6%. Conclusions. The prevalence of metabolic syndrome observed among the study population was 90.6%, with a higher percentage in females than males. High triglyceride levels and high waist circumference were the main risk factors for MS in the diabetic population.

Role of sex in post-transplant diabetes mellitus development: Are men and women equal?

INTRODUCTION

Sex differences are defined as biology-linked differences between women and men that occur through the sex chromosomes and their effects on organ systems.

MATERIAL AND METHODS

The objective of this prospective study was to determine risk factors for post-transplant diabetes mellitus (PTDM) in men and women.

RESULTS

A total of 417 patients (271 men and 146 women) were included in the monitored group. Age at the time of kidney transplantation (KT) >60 years and hypovitaminosis D at the time of KT (<20 μg/l) were identified as independent risk factors for PTDM in both men and women. It was further confirmed as an independent risk factor for men a waist circumference at the time of KT >94 cm, C-peptide at the time of KT >5 ng/ml, HOMA-IR >2 and triacylglycerols at the time of KT >1.7 mmol/l. In case of women, the dominant factor was BMI at the time of KT >30 kg/m2 and menopause at the time of KT. A significant decrease in C-peptide was recorded in women with PTDM.

CONCLUSION

It was confirmed that there are gender differences with regard to the development of PTDM after KT. Women show pancreas β cell dysfunction, whereas insulin resistance and metabolic syndrome are dominant in men.

A Guide to Applying the Sex-Gender Perspective to Nutritional Genomics

Precision nutrition aims to make dietary recommendations of a more personalized nature possible, to optimize the prevention or delay of a disease and to improve health. Therefore, the characteristics (including sex) of an individual have to be taken into account as well as a series of omics markers. The results of nutritional genomics studies are crucial to generate the evidence needed so that precision nutrition can be applied. Although sex is one of the fundamental variables for making recommendations, at present, the nutritional genomics studies undertaken have not analyzed, systematically and with a gender perspective, the heterogeneity/homogeneity in gene-diet interactions on the different phenotypes studied, thus there is little information available on this issue and needs to be improved. Here we argue for the need to incorporate the gender perspective in nutritional genomics studies, present the general context, analyze the differences between sex and gender, as well as the limitations to measuring them and to detecting specific sex-gene or sex-phenotype associations, both at the specific gene level or in genome-wide-association studies. We analyzed the main sex-specific gene-diet interactions published to date and their main limitations and present guidelines with recommendations to be followed when undertaking new nutritional genomics studies incorporating the gender perspective.

Beyond sex and gender difference in funding and reporting of health research

BACKGROUND

Understanding sex and gender in health research can improve the quality of scholarship and enhance health outcomes. Funding agencies and academic journals are two key gatekeepers of knowledge production and dissemination, including whether and how sex/gender is incorporated into health research. Though attention has been paid to key issues and practices in accounting for sex/gender in health funding agencies and academic journals, to date, there has been no systematic analysis documenting whether and how agencies and journals require attention to sex/gender, what conceptual explanations and practical guidance are given for such inclusion, and whether existing practices reflect the reality that sex/gender cannot be separated from other axes of inequality.

METHODS

Our research systematically examines official statements about sex/gender inclusion from 45 national-level funding agencies that fund health research across 36 countries (covering the regions of the EU and associated countries, North America, and Australia) and from ten top-ranking general health (the top five in "science" and the top five in "social science") and ten sex- and/or gender-related health journals. We explore the extent to which agencies and journals require inclusion of sex/gender considerations and to what extent existing strategies reflect state of the art understandings of sex/gender, including intersectional perspectives.

RESULTS

The research highlights the following: (a) there is no consistency in whether sex/gender are mentioned in funding and publishing guidelines; (b) there is wide variation in how sex/gender are conceptualized and how researchers are asked to address the inclusion/exclusion of sex/gender in research; (c) funding agencies tend to prioritize male/female equality in research teams and funding outcomes over considerations of sex/gender in research content and knowledge production; and (d) with very few exceptions, agency and journal criteria fail to recognize the complexity of sex/gender, including the intersection of sex/gender with other key factors that shape health.

CONCLUSIONS

The conceptualization and integration of sex/gender needs to better capture the interacting and complex factors that shape health-an imperative that can be informed by an intersectional approach. This can strengthen current efforts to advance scientific excellence in the production and reporting of research. We provide recommendations and supporting questions to strengthen consideration of sex/gender in policies and practices of health journals and funding agencies.

If there's a penis, it's most likely a man: Investigating the social construction of gender using eye tracking

In their foundational work on the social construction of gender, Kessler and McKenna (1978) investigated the relationship between gender attribution and genital attribution. We used digital reproductions of the original stimuli to replicate their findings in the current social context. To further investigate the underlying decision processes we applied eye tracking. The stimuli shown varied in the composition of gender cues: from those more commonly associated with maleness to associated with femaleness. Applying the ethnomethodological approach originally used, participants were asked to decide for each stimulus whether they saw a man or a woman and to indicate subjective confidence with the decision. In line with the original results we found that the genital attribution contributed immensely to the gender attribution. Also, male gender was ascribed more often when the penis was present than was female gender when the vulva was shown. Eye tracking revealed that overall most dwell time as a proxy for important information was dedicated to the head, chest and genital areas of all the stimuli. Total dwell time depended on whether the gender attribution was made in line with the depicted genital, if the genital was a penis. Attributing female gender when a penis was present was associated with longer total dwell time, unlike attributing male gender with a vulva shown. This is indicative of higher cognitive effort and more difficulty ignoring the penis as opposed to the vulva. We interpret this finding in context of the persistent male dominance as well as to the socio-cultural understanding of the vulva as a concealed and therefore seemingly absent organ. In summary, we were able to show that the gender attribution is still closely linked to genital attribution when having a binary forced choice task and that the penis is a special cue in this attribution process.

"Brave Men" and "Emotional Women": A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain

Background

Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity.

Methods

A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach.

Results

The included studies demonstrated a variety of gendered norms about men's and women's experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional's treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity.

Conclusions

Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.

Sex and gender matters : A sex-specific analysis of original articles published in the Wiener klinische Wochenschrift between 2013 and 2015

BACKGROUND

The variables sex and gender are significantly related to health and disease of women and men. Aiming at quality research, biomedical publications need to account for the key variables sex and gender.

METHODS

All original articles published in the Wiener klinische Wochenschrift between 2013 and 2015 were extracted into a database. As a result, the 195 published articles were selected for review led by the Sex and Gender Equity in Research Guidelines (SAGER) by the European Association of Science Editors (EASE). The slightest indications of mentioning sex and/or gender were assessed by two reviewers independently from one another.

RESULTS

Of the 195 publications 4 specified sex and/or gender in the title, and 62 in the abstract. None of the authors reported whether the variables sex and/or gender may have relevance and were taken into account in the design of the study. Of the 195 publications 48 mentioned the potential implications of sex and/or gender on the study results.

CONCLUSION

In the time span studied most of the selected articles of this journal did not account for the variables sex and/or gender systematically or adequately. For future research the existing guidelines can help authors and editors to overcome gender bias due to inadequate methods. Applying sex and gender-sensitive methods to biomedical and health research is necessary for high quality and as a precondition for results which are generalizable and applicable to both women and men.

Article Commentary: Sex- and Gender-Based Medicine: The Need for Precise Terminology

As our knowledge of sex- and gender-based medicine (SGBM) continues to grow, attention to precision in the use of related terminology is critical. Unfortunately, the terms sex and gender are often used interchangeably and incorrectly, both within and outside of the typical binary construct. On behalf of the Sex and Gender Women's Health Collaborative (SGWHC), a national organization whose mission is the integration of SGBM into research, health professions education, and clinical practice, our objective was to develop recommendations for the accurate use of SGBM terminology in research and clinical practice across medical specialties and across health professions. In addition, we reviewed the origins and evolution of SGBM terminology and described terms used when referring to individuals outside the typical binary categorization of sex and gender. Standardization and precision in the use of sex and gender terminology will lead to a greater understanding and appropriate translation of sex and gender evidence to patient care along with an accurate assessment of the impact sex and gender have on patient outcomes. In addition, it is critical to acknowledge that SGBM terminology will continue to evolve and become more precise as our knowledge of sex and gender differences in health and disease progresses.

Unintended Consequences of Gender Equality Promotion in Swedish Multicultural Contraceptive Counseling: A Discourse Analysis

In this article, we explore how reproductive health care providers in Sweden, a country often described as one of the most gender-equal countries in the world, incorporate gender equality ideals in multicultural contraceptive counseling. In the tension between gender equality promotion on one hand and respect for cultural diversity and individualized care on the other, we will demonstrate that values of gender equality were often given priority. This is not necessarily undesirable. Nevertheless, our proposal is that the gender equality ideology may inhibit providers' ability to think differently about issues at stake in contraceptive counseling, which may negatively influence women's possibilities to obtain adequate support. At the end of the article, we suggest how health care providers' reflexivity might be used as a working tool for increased awareness about the taken-for-granted cultural norms that exist in their clinical milieu.

Examples of sex/gender sensitivity in epidemiological research: results of an evaluation of original articles published in JECH 2006-2014

BACKGROUND

During the last decades, sex and gender biases have been identified in various areas of biomedical and public health research, leading to compromised validity of research findings. As a response, methodological requirements were developed but these are rarely translated into research practice. The aim of this study is to provide good practice examples of sex/gender sensitive health research.

METHODS

We conducted a systematic search of research articles published in JECH between 2006 and 2014. An instrument was constructed to evaluate sex/gender sensitivity in four stages of the research process (background, study design, statistical analysis, discussion).

RESULTS

In total, 37 articles covering diverse topics were included. Thereof, 22 were evaluated as good practice example in at least one stage; two articles achieved highest ratings across all stages. Good examples of the background referred to available knowledge on sex/gender differences and sex/gender informed theoretical frameworks. Related to the study design, good examples calculated sample sizes to be able to detect sex/gender differences, selected sex/gender sensitive outcome/exposure indicators, or chose different cut-off values for male and female participants. Good examples of statistical analyses used interaction terms with sex/gender or different shapes of the estimated relationship for men and women. Examples of good discussions interpreted their findings related to social and biological explanatory models or questioned the statistical methods used to detect sex/gender differences.

CONCLUSIONS

The identified good practice examples may inspire researchers to critically reflect on the relevance of sex/gender issues of their studies and help them to translate methodological recommendations of sex/gender sensitivity into research practice.

Searching for sex- and gender-sensitive tuberculosis research in public health: finding a needle in a haystack

Despite broadening consideration of sex- and gender-based issues in health research, when seeking information on how sex and gender contribute to disease contexts for specific health or public health topics, a lack of consistent or systematic use of terminology in health literature means that it remains difficult to identify research with a sex or gender focus. These inconsistencies are driven, in part, by the complexity and terminological inflexibility of the indexing systems for gender- and sex-related terms in public health databases. Compounding the issue are authors’ diverse vocabularies, and in some cases lack of accuracy in defining and using fundamental sex–gender terms in writing, and when establishing keyword lists and search criteria. Considering the specific case of the tuberculosis (TB) prevention and management literature, an analysis of sex and gender sensitivity in three health databases was performed. While there is an expanding literature exploring the roles of both sex and gender in the trajectory and lived experience of TB, we demonstrate the potential to miss relevant research when attempting to retrieve literature using only the search criteria currently available. We, therefore, argue that for good clinical practice to be achieved; there is a need for both public health researchers and users to be better educated in appropriate usage of the terminology associated with sex and gender. In addition, public health database indexers ought to accept the task of developing and implementing adequate definitions of sex and gender terms so as to facilitate access to sex- and gender-related research. These twin advances will allow clinicians to more readily recognize and access knowledge pertaining to systems of redress that respond to gendered risks that compound existing health inequalities in disease management and control, particularly when dealing with already complex diseases. Given the methodological and linguistic challenges presented by the multidimensional and highly contextual nature of definitions of sex and gender, it will be important that this review task be undertaken using a multidisciplinary approach.

Sex and Gender Roles in Relation to Mental Health and Allostatic Load

OBJECTIVES

Beyond male/female binaries, gender roles represent masculine and feminine traits that we assimilate and enact throughout life span development. Bem proposed that "androgynous" individuals adeptly adapt to different contexts by alternating from a strong repertoire of both masculine and feminine gender roles. By contrast, "undifferentiated" individuals may not adapt as well to social norms because of weak self-endorsed masculinity and femininity.

METHODS

Among 204 adults (mean [standard error] age = 40.4 [0.9] years; 70% women) working in a psychiatric hospital, we hypothesized that androgynous individuals would present better mental health and less physiological dysregulations known as allostatic load (AL) than undifferentiated individuals. AL was indexed using 20 biomarkers using the conventional "all-inclusive" formulation that ascribes cutoffs without regard for sex or an alternative "sex-specific" formulation with cutoffs tailored for each sex separately while controlling for sex hormones (testosterone, estradiol, progesterone). Well-validated questionnaires were used.

RESULTS

Independent of sex, androgynous individuals experienced higher self-esteem and well-being and lower depressive symptoms than did undifferentiated individuals. Men manifested higher AL than did women using the all-inclusive AL index (p = .044, ηP = 0.025). By contrast, the sex-specific AL algorithm unmasked a sex by gender roles interaction for AL (p = .043, ηP = 0.048): with the highest AL levels in undifferentiated men. Analysis using a gender index based on seven gendered constructs revealed that a greater propensity toward feminine characteristics correlated only with elevated sex-specific AL (r = 0.163, p = .025).

CONCLUSIONS

Beyond providing psychobiological evidence for Bem's theory, this study highlights how sex-specific AL formulations detect the effects of sociocultural gender.

Sex and Gender Differences in Risk, Pathophysiology and Complications of Type 2 Diabetes Mellitus

The steep rise of type 2 diabetes mellitus (T2DM) and associated complications go along with mounting evidence of clinically important sex and gender differences. T2DM is more frequently diagnosed at lower age and body mass index in men; however, the most prominent risk factor, which is obesity, is more common in women. Generally, large sex-ratio differences across countries are observed. Diversities in biology, culture, lifestyle, environment, and socioeconomic status impact differences between males and females in predisposition, development, and clinical presentation. Genetic effects and epigenetic mechanisms, nutritional factors and sedentary lifestyle affect risk and complications differently in both sexes. Furthermore, sex hormones have a great impact on energy metabolism, body composition, vascular function, and inflammatory responses. Thus, endocrine imbalances relate to unfavorable cardiometabolic traits, observable in women with androgen excess or men with hypogonadism. Both biological and psychosocial factors are responsible for sex and gender differences in diabetes risk and outcome. Overall, psychosocial stress appears to have greater impact on women rather than on men. In addition, women have greater increases of cardiovascular risk, myocardial infarction, and stroke mortality than men, compared with nondiabetic subjects. However, when dialysis therapy is initiated, mortality is comparable in both males and females. Diabetes appears to attenuate the protective effect of the female sex in the development of cardiac diseases and nephropathy. Endocrine and behavioral factors are involved in gender inequalities and affect the outcome. More research regarding sex-dimorphic pathophysiological mechanisms of T2DM and its complications could contribute to more personalized diabetes care in the future and would thus promote more awareness in terms of sex- and gender-specific risk factors.

Sex and gender matter in health research: addressing health inequities in health research reporting

Attention to the concepts of 'sex' and 'gender' is increasingly being recognized as contributing to better science through an augmented understanding of how these factors impact on health inequities and related health outcomes. However, the ongoing lack of conceptual clarity in how sex and gender constructs are used in both the design and reporting of health research studies remains problematic. Conceptual clarity among members of the health research community is central to ensuring the appropriate use of these concepts in a manner that can advance our understanding of the sex- and gender-based health implications of our research findings. During the past twenty-five years much progress has been made in reducing both sex and gender disparities in clinical research and, to a significant albeit lesser extent, in basic science research. Why, then, does there remain a lack of uptake of sex- and gender-specific reporting of health research findings in many health research journals? This question, we argue, has significant health equity implications across all pillars of health research, from biomedical and clinical research, through to health systems and population health.

Central gender theoretical concepts in health research: the state of the art

Despite increasing awareness of the importance of gender perspectives in health science, there is conceptual confusion regarding the meaning and the use of central gender theoretical concepts. We argue that it is essential to clarify how central concepts are used within gender theory and how to apply them to health research. We identify six gender theoretical concepts as central and interlinked-but problematic and ambiguous in health science: sex, gender, intersectionality, embodiment, gender equity and gender equality. Our recommendations are that: the concepts sex and gender can benefit from a gender relational theoretical approach (i.e., a focus on social processes and structures) but with additional attention to the interrelations between sex and gender; intersectionality should go beyond additive analyses to study complex intersections between the major factors which potentially influence health and ensure that gendered power relations and social context are included; we need to be aware of the various meanings given to embodiment, which achieve an integration of gender and health and attend to different levels of analyses to varying degrees; and appreciate that gender equality concerns absence of discrimination between women and men while gender equity focuses on women's and men's health needs, whether similar or different. We conclude that there is a constant need to justify and clarify our use of these concepts in order to advance gender theoretical development. Our analysis is an invitation for dialogue but also a call to make more effective use of the knowledge base which has already developed among gender theorists in health sciences in the manner proposed in this paper.