CommentaryMethods for prospectively incorporating gender into health sciences research
Introduction
To fully understand and improve human health, it is important to incorporate sex and gender in health sciences research. Sex is a biological variable that distinguishes individuals as male or female (or intersex) based on their genetics, anatomy, and hormones [1]. Gender, on the other hand, is a social construct. It encompasses the identities, expressions, roles, norms, behaviors, and perceptions of men, women, boys, girls, and gender-diverse people [1]. It may also include the institutionalization of these norms, and how individuals are treated by society based on their identified or perceived gender, as well as relations between individuals based on identified or perceived gender [2]. A growing body of evidence demonstrates that both sex and gender may independently influence both disease risks and outcomes [[3], [4], [5], [6], [7]] and that further investigation of the role of both is necessary [5,8]. Indeed several major funding agencies now require the consideration of these variables into research proposals [1,9,10]. Nevertheless identifying methods for the incorporation of sex and gender remains difficult for many researchers, who often conflate these terms [11,12]. Despite increasing inclusion of female participants in clinical research and recognition of sex as an important variable, gender factors often remain neglected [13,14].
Gender, distinct from sex, has proven elusive from both a collection/measurement perspective as well as the relatively low frequency of its incorporation into health sciences research, despite long-standing recognition of its importance in the social sciences. The definition of gender changes with time and varies across cultures, disciplines, and among public health organizations and often includes imprecise, vague language [1], making the identification of appropriate scientific methods for measurement and analysis unclear. Because of these difficulties, few clinical researchers have attempted to quantify “gender” as a psychosocial construct and measure its impacts on health [4].
The objective of this study is to provide clarification on how to incorporate gender into the design of prospective clinical and epidemiological studies as well as methods for statistical analysis.
Section snippets
The integration of sex and gender into the research question
There are several ways in which sex and gender may influence the outcomes and/or the relationships of interest in human health studies. For example, although sex may influence an individual's biological susceptibility to an infectious disease or likelihood of developing a chronic condition, gender may influence an individual's likelihood of exposure to the disease or developing the condition through differences in social roles, responsibilities, occupation, and/or risk-taking behaviors.
Identifying gender-related variables
The Canadian Women's Health Research Network identifies four domains that encompass gender: gender identity, gender roles, gender relations, and institutionalized gender [2]. Gender identity refers to the way an individual self-identifies, which may impact their behaviors and expression of gender, as well as how others treat them. Gender roles refer to the norms and behaviors typically associated with gender. Gender relations refer to the way in which people may interact with each other based
Gender as an explanatory variable: individual vs. composite measure
If collecting many variables, researchers may investigate them in univariate and multivariate analyses or they may wish to reduce or consolidate them into a composite score of all gender domains or a score that reflects the individual gender domains they have investigated. This step would reduce the number of variables necessary to include in statistical models by creating one or a few metrics for gender rather than many intercorrelated gender-related variables [21,32,33]. Specifically, a
Discussion
Although numerous researchers and funding agencies have required the consideration of sex and gender in research designs, many researchers are struggling with how to operationalize the collection of these factors, particularly given that there is no standardized definition or measurement for gender. This commentary provides concrete examples of variables that can be collected to incorporate gender into prospective study design as well as strategies for analysis, while providing flexibility to
References (37)
- et al.
Sex versus gender-related characteristics: which predicts outcome after acute coronary syndrome in the young?
J Am Coll Cardiol
(2016) Violence, control, romance and gender equality: young women and heterosexual relationships
Women's Stud Int Forum
(2005)- et al.
The gendered system of academic publishing
Lancet
(2018) - et al.
Factors mediating and moderating the relationship between gender and utilization of health care among Puerto Rican drug users in New York
Drug Alcohol Depend
(2009) Science is Better with Sex and Gender; Strategic Plan 2018-2023 Ottawa ON: Canadian Institutes of Health Research Intitute of Gender and Health
- et al.
Better science with sex and gender: A primer for health research
- et al.
Sex and gender matter in health research: addressing health inequities in health research reporting
Int J Equity Health
(2015) Genders, sexes, and health: what are the connections—and why does it matter?
Int J Epidemiol
(2003)Sex and gender differences in health
EMBO Rep
(2012)- et al.
Sex differences in acute coronary syndrome symptom presentation in young patients
JAMA Intern Med
(2013)
Sex and gender analysis improves science and engineering
Nature
How Sex/Gender Influence Health & Disease (A-Z) National Institutes of Health Office of Research on Women's Health
Promoting Gender Equality in Research and Innovation Horizon 2020
Gender norms and health: insights from global survey data
Lancet
Investigating gender within health research is more than sex disaggregation of data: a Multi-Facet Gender and Health Model
Psychol Health Med
Gender differences in clinical registration trials: is there a real problem?
Br J Clin Pharmacol
Sex is not enough: the need for gender-based analysis in health research
Health Care Women Int
Structured methods: interviews, questionnaires and observation
Research Soc Cult
Cited by (0)
Declaration of interest: none.
Funding: The GOING-FWD Consortium is funded by the GENDER-NET Plus ERA-NET Initiative (project ref. number: GNP-78): The Canadian Institutes of Health Research (GNP-161904), La Caixa Foundation (LCF/PR/DE18/52010001), The Swedish Research Council (2018-00932), and The Austrian Science Fund (FWF, I 4209). V.R. is funded by the Scientific Independence of Young Researcher Program of the Italian Ministry of University, Education and Research (RBSI14HNVT).
This manuscript was conceptualized by C.P.T., V.R., L.P., and C.M.N. The initial draft was written by C.P.T., with all other authors contributing to editing.
Conflict of interests: We declare no competing interests.