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

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.

Psychosocial Impact of Infertility Diagnosis and Conformity to Gender Norms on the Quality of Life of Infertile Spanish Couples

Epidemiological data show that human reproductive disorders are a common problem worldwide, affecting almost one in six people of reproductive age. As a result, infertility has been identified by the World Health Organization as a public health disease. Reproductive problems can take a heavy toll on the psychosocial well-being of couples suffering from infertility. This is especially true for women, who tend to be the ones who undergo the most treatment. The main objective of the present study is to find out whether a sex-based infertility diagnosis influences the quality of life of couples with infertility. Also, we aim to find out whether the degree of adherence to gender norms influences their quality of life. A cross-sectional study was conducted using the Fertility Quality of Life Questionnaire (FertiQoL) and the Conformity to Feminine and Masculine Norms Inventories in a sample of 219 infertile Spanish couples (438 participants). The results show that, in all cases, regardless of the degree of conformity to gender norms and whether the infertility diagnosis was of female or male origin, women have lower scores on the self-perceived quality of life. This suggests that being female is already a psychosocial risk factor when assessing the psychosocial consequences of infertility.

Impact of sex and gender on post-COVID-19 syndrome, Switzerland, 2020

BackgroundWomen are overrepresented among individuals with post-acute sequelae of SARS-CoV-2 infection (PASC). Biological (sex) as well as sociocultural (gender) differences between women and men might account for this imbalance, yet their impact on PASC is unknown.AimWe assessed the impact of sex and gender on PASC in a Swiss population.MethodOur multicentre prospective cohort study included 2,856 (46% women, mean age 44.2 ± 16.8 years) outpatients and hospitalised patients with PCR-confirmed SARS-CoV-2 infection.ResultsAmong those who remained outpatients during their first infection, women reported persisting symptoms more often than men (40.5% vs 25.5% of men; p < 0.001). This sex difference was absent in hospitalised patients. In a crude analysis, both female biological sex (RR = 1.59; 95% CI: 1.41-1.79; p < 0.001) and a score summarising gendered sociocultural variables (RR = 1.05; 95% CI: 1.03-1.07; p < 0.001) were significantly associated with PASC. Following multivariable adjustment, biological female sex (RR = 0.96; 95% CI: 0.74-1.25; p = 0.763) was outperformed by feminine gender-related factors such as a higher stress level (RR = 1.04; 95% CI: 1.01-1.06; p = 0.003), lower education (RR = 1.16; 95% CI: 1.03-1.30; p = 0.011), being female and living alone (RR = 1.91; 95% CI: 1.29-2.83; p = 0.001) or being male and earning the highest income in the household (RR = 0.76; 95% CI: 0.60-0.97; p = 0.030).ConclusionSpecific sociocultural parameters that differ in prevalence between women and men, or imply a unique risk for women, are predictors of PASC and may explain, at least in part, the higher incidence of PASC in women. Once patients are hospitalised during acute infection, sex differences in PASC are no longer evident.

Why and How to Account for Sex and Gender in Brain and Behavioral Research

Long overlooked in neuroscience research, sex and gender are increasingly included as key variables potentially impacting all levels of neurobehavioral analysis. Still, many neuroscientists do not understand the difference between the terms "sex" and "gender," the complexity and nuance of each, or how to best include them as variables in research designs. This TechSights article outlines rationales for considering the influence of sex and gender across taxa, and provides technical guidance for strengthening the rigor and reproducibility of such analyses. This guidance includes the use of appropriate statistical methods for comparing groups as well as controls for key covariates of sex (e.g., total intracranial volume) and gender (e.g., income, caregiver stress, bias). We also recommend approaches for interpreting and communicating sex- and gender-related findings about the brain, which have often been misconstrued by neuroscientists and the lay public alike.

How Can We Address What We Do Not Measure? A Systematic Scoping Review of the Measurement and Operationalization of Social Determinants of Health Research on Long-Acting Reversible Contraceptive among Adolescents in the US

Teen pregnancy is often considered an adverse health outcome that accentuates gender inequities, diminishes opportunities, and jeopardizes the safety of adolescent and young adult birthing people. Long-Acting Reversible Contraceptives (LARC) have been hailed as a panacea for teen pregnancy. However, adolescents and emerging adults intersect with multiple assaults on their health and well-being due to gender inequity and racism. To establish equitable care, it is imperative to discern all barriers that influence their reproductive autonomy. This study evaluates the measurement, operationalization, and quality of research conducted on adolescents and emerging adults that analyzed the use of LARC within the social determinant of health framework (SDOH) in the US. SDOH were assessed using the Dahlgren and Whitehead model, and reports were analyzed using a modified version of the Joanna Briggs Institute (JBI) Critical Appraisal tools. Nineteen articles were included in this study. Researchers found the insufficient measurement of race, ethnicity, sexuality, and gender among studies on LARC and SDOH in adolescents and emerging adults. Future studies must measure a full range of identities in data collection to generate knowledge on the impact of SDOH and LARC use among diverse populations.

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.

Measures of self-reported identity associated with sex and gender: Relations with collegiate drinking

OBJECTIVE

Quantitative research has typically relied on categorical measures of sex assigned at birth (SAAB) and gender, with heterogeneous findings in terms of their associations with alcohol-related behavior. This investigation examined continuous indices of self-identification as an alternative to categorical operationalizations in alcohol research.

METHOD

Eight hundred ninety-three undergraduate students (74.6% cisgender women, 20.3% cisgender men, 3.9% nonbinary, and 1.2% transgender), recruited from the Midwest and Pacific Northwest of the United States, completed online measures of SAAB (male/female), gender (categorical), continuous indices of identification (femaleness, maleness, and bidirectional), and alcohol consumption (Cahalan Indices; Daily Drinking Questionnaire-Revised; Alcohol Use Disorders Identification Test [AUDIT]).

RESULTS

Novel continuous measures of identification were associated with categorical indices of SAAB and gender as predicted. While none of the self-identification indices (continuous or categorical) predicted current drinking (consumption in the past 30 days), they evidenced relatively consistent, albeit small effects, across quantity-frequency of drinking and AUDIT scores for current drinkers. Higher scores on maleness and bidirectional indices of identification were associated with greater consumption, while greater endorsement of femaleness and being a cisgender woman (vs. a cisgender man) were related to less drinking.

CONCLUSIONS

Continuous self-reported identification items performed well when describing drinking behavior in college students. The inclusion of dimensional scales of identity broadens our ability to capture differing self-conceptualizations in research.

Operationalization of a multidimensional sex/gender concept for quantitative environmental health research and implementation in the KORA study: Results of the collaborative research project INGER

Background

In environmental health research, sex and gender are not yet adequately considered. There is a need to improve data collection in population-based environmental health studies by comprehensively surveying sex/gender-related aspects according to gender theoretical concepts. Thus, within the joint project INGER we developed a multidimensional sex/gender concept which we aimed to operationalize and to test the operationalization for feasibility.

Methods

In an iterative process, we created questionnaire modules which quantitatively captured the requirements of the INGER sex/gender concept. We deployed it in the KORA cohort (Cooperative Health Research in the Region of Augsburg, Germany) in 2019 and evaluated response and missing rates.

Results

The individual sex/gender self-concept was surveyed via a two-step approach that asked for sex assigned at birth and the current sex/gender identity. Additionally, we used existing tools to query internalized sex/gender roles and externalized sex/gender expressions. Adapted to the KORA population, we asked for discrimination experiences and care and household activities contributing to explain structural sex/gender relations. Further intersectionality-related social categories (e.g., socio-economic position), lifestyle and psychosocial factors were covered through data available in KORA. We could not identify appropriate tools to assess the true biological sex, sexual orientation and ethnic/cultural identity, which have yet to be developed or improved. The response-rate was 71%, the evaluation of 3,743 questionnaires showed a low missing rate. Prevalence of marginalized groups regarding sex/gender identity and definable by experiences of discrimination was very low.

Conclusion

We have shown how the multidimensional INGER sex/gender concept can be operationalized according to an European and North American understanding of sex/gender for use in quantitative research. The questionnaire modules proved feasible in an epidemiologic cohort study. Being a balancing act between theoretical concepts and its quantitative implementation our operationalization paves the way for an adequate consideration of sex/gender in environmental health research.

Breaking the binary: Gender versus sex analysis in human brain imaging

Despite decades of pursuit, human brain imaging has yet to uncover clear neural correlates of male-female behavioral differences. Given that such behavior does not always align with sex categories, we argue that neuroimaging research may find more success by partitioning subjects along nonbinary gender attributes in addition to sex. We review the handful of studies that have done this, several of which find as good or better association between brain measures and "gender" as they do with "sex." Recent advances in operationalizing "gender" as a multidimensional variable should facilitate such studies, along with discovery-based approaches that mine brain imaging data for gender-associated attributes, independent of sex.

Operationalization and Reporting Practices in Manuscripts Addressing Gender Differences in Biomedical Research: A Cross-Sectional Bibliographical Study

Historically, authors in the biomedical field have often conflated the terms sex and gender in their research significantly limiting the reproducibility of the reported results. In the present study, we investigated current reporting practices around gender in biomedical publications that claim the identification of "gender differences". Our systematic research identified 1117 articles for the year 2019. After random selection of 400 publications and application of inclusion criteria, 302 articles were included for analysis. Using a systematic evaluation grid, we assessed the provided methodological detail in the operationalization of gender and the provision of gender-related information throughout the manuscript. Of the 302 articles, 69 (23%) solely addressed biological sex. The remaining articles investigated gender, yet only 15 (6.5%) offered reproducible information about the operationalization of the gender dimension studied. Followingly, these manuscripts also provided more detailed gender-specific background, analyses and discussions compared to the ones not detailing the operationalization of gender. Overall, our study demonstrated persistent inadequacies in the conceptual understanding and methodological operationalization of gender in the biomedical field. Methodological rigor correlated with more nuanced and informative reporting, highlighting the need for appropriate training to increase output quality and reproducibility in the field.