Editorial: Bridging Gaps Between Sex and Gender in Neurosciences

Do Sex and Gender Have Separate Identities?

The largely binary nature of biological sex and its conflation with the socially constructed concept of gender has created much strife in the last few years. The notion of gender identity and its differences and similarities with sex have fostered much scientific and legal confusion and disagreement. Settling the debate can have significant repercussions for science, medicine, legislation, and people's lives. The present review addresses this debate though different levels of analysis (i.e., genetic, anatomical, physiological, behavioral, and sociocultural), and their implications and interactions. We propose a rationale where both perspectives coexist, where diversity is the default, establishing a delimitation to the conflation between sex and gender, while acknowledging their interaction. Whereas sex in humans and other mammals is a biological reality that is largely binary and based on genes, chromosomes, anatomy, and physiology, gender is a sociocultural construct that is often, but not always, concordant with a person' sex, and can span a multitude of expressions.

A step-by-step and data-driven guide to index gender in psychiatry

Beyond sex as a binary or biological variable, within-sex variations related to sociocultural gender variables are of increasing interest in psychiatric research to better understand individual differences. Using a data-driven approach, we developed a composite gender score based on sociodemographic and psychosocial variables showing sex differences in a sample of psychiatric emergency patients upon admission (N = 1708; 39.4% birth-assigned females; mean age = 40 years; age standard deviation = 14). This gender score was extracted from a confirmatory factor analysis (CFI = 0.966; RMSEA = 0.044, SRMR = 0.030) and could predict a person's birth-assigned sex with 67% accuracy. This score allowed the further identification of differences on impulsivity measures that were absent when looking solely at birth-assigned sex. Female birth-assigned sex was also associated with higher rates of mood and personality disorder diagnoses, while higher feminine gender scores were related to higher proportions of anxiety and mood disorder diagnoses. By contrast, male birth-assigned sex and higher masculine gender scores were associated with higher proportions of psychotic and substance use disorder diagnoses. Patients with undifferentiated gender scores (i.e., scoring between masculine and feminine threshold defined by terciles) were more represented in the psychotic disorder group. Considering both sex and gender in psychiatric research is essential and can be achieved even when using secondary data to index gender comprised of demographic and psychosocial variables.

“The two voices,” or more? Music and gender from myth and conquests to the neurosciences

Music is a unique phenomenon, constantly eliciting interest from a variety of viewpoints, several of which intersect the universal trait of musicality with sex/gender studies and the neurosciences. Its unparalleled power and physical, social, aesthetic, as well as cognitive, emotional and clinical ramifications make it a specially promising terrain for studies and reflections on sex and gender differences and their impact. This overview wishes to enhance awareness of such issues, also fostering an interdisciplinary exchange between the natural sciences, the humanities, and the arts. Over the centuries, different associations of music with the feminine gender have contributed to a pendulum between progressive recognition and stereotypical setbacks requiring to be overcome. Against this backdrop, music-related neurophysiological and psychological studies on sex and gender specificities are reviewed in their multiple approaches and results, exposing or questioning differences in structural, auditory, hormonal, cognitive, and behavioral areas, also in relation to abilities, treatment, and pedagogy. Thus, the bridging potential of music as universal yet diverse language, art, and practice, recommends its gender-aware integration into education, protective endeavors, and therapeutic interventions, to promote equality and well-being.

Ties between reading faces, bodies, eyes, and autistic traits

While reading covered with masks faces during the COVID-19 pandemic, for efficient social interaction, we need to combine information from different sources such as the eyes (without faces hidden by masks) and bodies. This may be challenging for individuals with neuropsychiatric conditions, in particular, autism spectrum disorders. Here we examined whether reading of dynamic faces, bodies, and eyes are tied in a gender-specific way, and how these capabilities are related to autistic traits expression. Females and males accomplished a task with point-light faces along with a task with point-light body locomotion portraying different emotional expressions. They had to infer emotional content of displays. In addition, participants were administered the Reading the Mind in the Eyes Test, modified and Autism Spectrum Quotient questionnaire. The findings show that only in females, inferring emotions from dynamic bodies and faces are firmly linked, whereas in males, reading in the eyes is knotted with face reading. Strikingly, in neurotypical males only, accuracy of face, body, and eyes reading was negatively tied with autistic traits. The outcome points to gender-specific modes in social cognition: females rely upon merely dynamic cues while reading faces and bodies, whereas males most likely trust configural information. The findings are of value for examination of face and body language reading in neuropsychiatric conditions, in particular, autism, most of which are gender/sex-specific. This work suggests that if male individuals with autistic traits experience difficulties in reading covered with masks faces, these deficits may be unlikely compensated by reading (even dynamic) bodies and faces. By contrast, in females, reading covered faces as well as reading language of dynamic bodies and faces are not compulsorily connected to autistic traits preventing them from paying high costs for maladaptive social interaction.

Sex and gender differences in pain

Chronic pain affects 20% of adults and is one of the leading causes of disability worldwide. Women and girls are disproportionally affected by chronic pain. About half of chronic pain conditions are more common in women, with only 20% having a higher prevalence in men. There are also sex and gender differences in acute pain sensitivity. Pain is a subjective experience made up of sensory, cognitive, and emotional components. Consequently, there are multiple dimensions through which sex and gender can influence the pain experience. Historically, most preclinical pain research was conducted exclusively in male animals. However, recent studies that included females have revealed significant sex differences in the physiological mechanisms underlying pain, including sex specific involvement of different genes and proteins as well as distinct interactions between hormones and the immune system that influence the transmission of pain signals. Human neuroimaging has revealed sex and gender differences in the neural circuitry associated with pain, including sex specific brain alterations in chronic pain conditions. Clinical pain research suggests that gender can affect how an individual contextualizes and copes with pain. Gender may also influence the susceptibility to develop chronic pain. Sex and gender biases can impact how pain is perceived and treated clinically. Furthermore, the efficacy and side effects associated with different pain treatments can vary according to sex and gender. Therefore, preclinical and clinical research must include sex and gender analyses to understand basic mechanisms of pain and its relief, and to develop personalized pain treatment.

Environmental Contributions to Anhedonia

Anhedonia is a core feature of psychopathological conditions that have recent exposure to stress and trauma as central to their etiology. Indeed, evolutionary accounts of depression suggest that decreased motivation to pursue reward may be an adaptive strategy in the face of social stress, in particular, as it may serve to defuse interpersonal conflict. Through a review of rodent models and research with humans, we show that exposure to stress, particularly when it is chronic, repeated, and/or involves themes of social rejection or defeat, is consistently associated with reduced hedonic capacity ("liking"), motivation to pursue reward ("wanting"), and ability to learn from reward ("reward learning"). Further, across rodent and human research, there is evidence that females show greater stress-induced blunting of reward processing than males. In humans, this sex difference emerges most strongly when examining individual differences in the stress response rather than group differences in stress exposure. We discuss the implications of these findings for understanding the etiology of, and sex differences in, stress-related psychopathology, including depression and addiction.

Prenatal Progestin Exposure-Mediated Oxytocin Suppression Contributes to Social Deficits in Mouse Offspring

Epidemiological studies have shown that maternal hormone exposure is associated with autism spectrum disorders (ASD). The hormone oxytocin (OXT) is a central nervous neuropeptide that plays an important role in social behaviors as well as ASD etiology, although the detailed mechanism remains largely unknown. In this study, we aim to investigate the potential role and contribution of OXT to prenatal progestin exposure-mediated mouse offspring. Our in vitro study in the hypothalamic neurons that isolated from paraventricular nuclei area of mice showed that transient progestin exposure causes persistent epigenetic changes on the OXT promoter, resulting in dissociation of estrogen receptor β (ERβ) and retinoic acid-related orphan receptor α (RORA) from the OXT promoter with subsequent persistent OXT suppression. Our in vivo study showed that prenatal exposure of medroxyprogesterone acetate (MPA) triggers social deficits in mouse offspring; prenatal OXT deficiency in OXT knockdown mouse partly mimics, while postnatal ERβ expression or postnatal OXT peptide injection partly ameliorates, prenatal MPA exposure-mediated social deficits, which include impaired social interaction and social abilities. On the other hand, OXT had no effect on prenatal MPA exposure-mediated anxiety-like behaviors. We conclude that prenatal MPA exposure-mediated oxytocin suppression contributes to social deficits in mouse offspring.

Reporting and misreporting of sex differences in the biological sciences

As part of an initiative to improve rigor and reproducibility in biomedical research, the U.S. National Institutes of Health now requires the consideration of sex as a biological variable in preclinical studies. This new policy has been interpreted by some as a call to compare males and females with each other. Researchers testing for sex differences may not be trained to do so, however, increasing risk for misinterpretation of results. Using a list of recently published articles curated by Woitowich et al. (eLife, 2020; 9:e56344), we examined reports of sex differences and non-differences across nine biological disciplines. Sex differences were claimed in the majority of the 147 articles we analyzed; however, statistical evidence supporting those differences was often missing. For example, when a sex-specific effect of a manipulation was claimed, authors usually had not tested statistically whether females and males responded differently. Thus, sex-specific effects may be over-reported. In contrast, we also encountered practices that could mask sex differences, such as pooling the sexes without first testing for a difference. Our findings support the need for continuing efforts to train researchers how to test for and report sex differences in order to promote rigor and reproducibility in biomedical research.

Biomedical research has a long history of including only men or male laboratory animals in studies. To address this disparity, the United States National Institutes of Health (NIH) rolled out a policy in 2016 called Sex as a Biological Variable (or SABV). The policy requires researchers funded by the NIH to include males and females in every experiment unless there is a strong justification not to, such as studies of ovarian cancer. Since then, the number of research papers including both sexes has continued to grow.

Although the NIH does not require investigators to compare males and females, many researchers have interpreted the SABV policy as a call to do so. This has led to reports of sex differences that would otherwise have been unrecognized or ignored. However, researchers may not be trained on how best to test for sex differences in their data, and if the data are not analyzed appropriately this may lead to misleading interpretations.

Here, Garcia-Sifuentes and Maney have examined the methods of 147 papers published in 2019 that included both males and females. They discovered that more than half of these studies had reported sex differences, but these claims were not always backed by statistical evidence. Indeed, in a large majority (more than 70%) of the papers describing differences in how males and females responded to a treatment, the impact of the treatment was not actually statistically compared between the sexes. This suggests that sex-specific effects may be over-reported. In contrast, Garcia-Sifuentes and Maney also encountered instances where an effect may have been masked due to data from males and females being pooled together without testing for a difference first.

These findings reveal how easy it is to draw misleading conclusions from sex-based data. Garcia-Sifuentes and Maney hope their work raises awareness of this issue and encourages the development of more training materials for researchers.

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.

The impact of sex and gender on heart-brain axis dysfunction: current concepts and novel perspectives

The heart-brain axis (HBA) recapitulates all the circuits that regulate bidirectional flow of communication between heart and brain. Several mechanisms may underlie the interdependent relationship involving heterogeneous tissues at rest and during specific target organ injury such as myocardial infarction, heart failure, arrhythmia, stroke, mood disorders, or dementia. In-depth translational studies of the HBA dysfunction under single-organ injury should include both male and female animals to develop sex- and gender-oriented prevention, diagnosis, and treatment strategies. Indeed, sex and gender are determining factors as females and males exhibit significant differences in terms of susceptibility to risk factors, age of onset, severity of symptoms, and outcome. Despite most studies having focused on the male population, we have conducted a careful appraisal of the literature investigating HBA in females. In particular, we have (i) analyzed sex-related heart and brain illnesses, (ii) recapitulated the most significant studies simultaneously conducted on cardio- and cerebro-vascular systems in female populations, and (iii) hypothesized future perspectives for the development of a gender-based approach to HBA dysfunction. Although sex- and gender-oriented research is at its infancy, the impact of sex on HBA dysfunction is opening unexpected new avenues for managing the health of female subjects exposed to risk of lifestyle multi-organ disease.