Putting gender into sex- and gender-sensitive medicine

The case for sex- and gender-sensitivity in (bio)medicine and health is becoming more and more compelling. Funding agencies in Europe [[1]Commission E. Promoting gender equality in research and innovation. 2014. https://ec.europa.eu/programmes/horizon2020/en/h2020-section/promoting-gender-equality-research-and-innovation.Google Scholar], Canada [[2]Johnson J.L. Greaves L. Repta R. Better science with sex and gender: facilitating the use of a sex and gender-based analysis in health research.Int J Equity Health. 2009; 8: 14Crossref PubMed Scopus (192) Google Scholar] and the USA [[3]Clayton J.A. Collins F.S. Policy: NIH to balance sex in cell and animal studies.Nature. 2014; 509: 282-283Crossref PubMed Scopus (889) Google Scholar] are requesting that sex and/or gender be considered in grant applications. Scientific journals [[4]Gogos A. Langmead C. Sullivan J.C. Lawrence A.J. The importance of sex differences in pharmacology research.Br J Pharmacol. 2019; 176: 4087-4089Crossref PubMed Scopus (3) Google Scholar,[5]Schiebinger L. Leopold S.S. Miller V.M. Editorial policies for sex and gender analysis.Lancet. 2016; 388: 2841-2842Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar] increasingly embrace the need to publish sex-disaggregated data. Even scientific societies are supporting the subject [[6]Wagner A.D. Oertelt-Prigione S. Adjei A. et al.Gender medicine and oncology: report and consensus of an ESMO workshop.Ann Oncol. 2019; Summary Full Text Full Text PDF Scopus (29) Google Scholar]. Yet, our everyday practice is still very far from being sex-sensitive, let alone gender-sensitive. Sex- and gender-sensitive medicine (SGSM) focuses on the role that biological differences (sex) and socio-cultural power structures (gender) play in healthcare. How both sex and gender affect health behavior, the development of diseases, their diagnosis, management and long-term effects. Furthermore, SGSM can focus on the structure of the healthcare system, on how traded traditions impact the make-up of the workforce and its opportunities. This, in turn, reflects on the care that is being provided and the research that is being conducted. SGSM has emerged over the last twenty to thirty years. Initially its focus was on differences in incidence of mortality between females and males [[7]Vaccarino V. Krumholz H.M. Berkman L.F. Horwitz R.I. Sex differences in mortality after myocardial infarction. Is there evidence for an increased risk for women?.Circulation. 1995; 91: 1861-1871Crossref PubMed Scopus (283) Google Scholar], or, more precisely, on filling the gap of knowledge about female symptoms and needs in a medical world focused on male standards [[8]Legato M.J. Beyond women's health the new discipline of gender-specific medicine.Med Clin North Am. 2003; 87 (vii): 917-937Summary Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Next came sex-specific basic research with the objective to identify the causes of sex differences in disease development and progression. And while scholars in the social sciences already talked about gender in health in the 1970s, medicine discovered the concept much later. Unfortunately, translating a concept from the social sciences into the medical field is not easy. The first attempts at introducing gender in (bio)medicine frequently simply meant the interchangeable use of the terms sex and gender. Although the knowledge and methods are increasing [[9]Tannenbaum C. Ellis R.P. Eyssel F. Zou J. Schiebinger L. Sex and gender analysis improves science and engineering.Nature. 2019; 575: 137-146Crossref PubMed Scopus (94) Google Scholar], we are still lacking sound and systematic instruments for the analysis of gender in medicine. It does not help that gender can be broken down into numerous sub-categories; such as gender identity, gender norms, gender relationships just to name a few. Developing these methods often means walking a fine line between perpetuating stereotypes and distilling health-relevant information. Which leads to the question: which aspects of gender do we need to know to improve people's health? The answer to this question takes us back to what we consider health. Is it solely the absence of sickness, the development of increasingly individualized diagnostic tests that will guide our choice of targeted drug therapies? Or do we choose the WHO's definition of “a state of complete physical, mental and social well-being” [[10]WHOBasic Documents. WHO, Geneva2020Google Scholar] placing an emphasis on the structural, social and global drivers of people's lives? In sex- and gender-sensitive medicine these questions could be provocatively translated into: How do we transcend from research focused primarily on privileged realities to include topics and scholars that can address the impact of gender on health in all its breadth? The present collection of articles in EClinicalMedicine is a very good representation of this complex reality. Gender affects access to healthcare, social dynamics, health behaviors, and it shapes the work environment we find ourselves in. Gender impacts our chances of survival, in single families according to birth order and gender representation (Raj et al., in this collection) or at the population level, where gender equity appears to reduce mortality not just in women but also in men (Gadoth et al., in this collection). To change unequal practices, which generally disadvantage women, approaches should be participatory and include knowledge rooted in communities (Hazra et al., in this collection). Health promotion interventions should target structural barriers to transform gender stereotypes rather than focusing solely on individual behavior (Bhan et al., in this collection). Gender congruence among users and healthcare providers can influence the uptake of maternal health services (Bhan et al., in this collection) and gender discrimination can significantly impact mental health (Stepanikova et al., in this collection). Last, gender does not just affect the populations and patients we care for, it also impacts the careers of women researchers in the academic world (Raj et al., in this collection). Gender is not a unidimensional variable; it is complex, intertwined with our lived realities and affects all aspects of our health. Including gender into our work is essential to achieving that “state of complete physical, mental and social well-being” for all; it's time to make it a priority. Sabine Oertelt-Prigione has written the present manuscript. Dr. Oertelt-Prigione reports research funding from the German Ministry of Education and Research (BMBF), the German Ministry of Health (BMG), the Netherlands Organization for Health Research and Development (ZonMW), the Charité Foundation , the Hans-Böckler Foundation , the Equal Opportunity Fund of the City of Berlin .

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