Sex and Gender in the Perioperative Period: Wake Up to Reality

There was a time when it was considered inappropriate, even offensive, to suggest that there were biological or health differences between men and women that could necessitate differences in medical management. Increasingly, however, it is understood that there are indeed many biological and social differences between women and men, and these now play an important role in medical research and patient care.1–4 Although it is clear that these differences imply neither inferiority nor superiority of one sex over another, in all areas of health care practice these differences must be acknowledged and addressed.1,4 The shift from dismissing to acknowledging sex and gender as affecting health care beyond reproduction has occurred increasingly over the past decade, though it is still relatively early in its acceptance and integration into practice. This is exemplified by the fact that the World Health Organization 2003 determinants of health do not explicitly consider sex and gender as key determinants, whereas the determinants of health outlined by the Public Health Agency of Canada do consider gender to be a key health determinant.3,5 Further exemplifying this shifting valuation is a more recent World Health Organization publication entitled Unequal, Unfair, Ineffective, and Inefficient Gender Inequity in Health: Why it exists and how we can change it.4 This article draws attention to the reality that sex and gender are critical to both acknowledge and address in medical practice and broader health initiatives. The complexities of treating and considering sex difference in any field cannot be discussed without acknowledging that the terms gender and sex are intertwined and often confused in meaning. Gender refers to the social constructs, norms, and practices of maleness and femaleness. As a social construct, the meaning of gender, its values and implications, is always tied to the social world. Sex refers to the “multidimensional biological construct that encompasses anatomy, physiology, genes, and hormones that together create a human ‘package.’”2 Because we are biological entities in a social world, neither element can be addressed in isolation. Unfortunately, in the biological sciences, it is common to use “gender” and “sex” interchangeably. However, sex and gender should not be considered synonymous, nor confused with one another.1 This nuanced use of language has notable implications for previous and future health research. The current issue of Anesthesia & Analgesia contains 14 articles—reviews, editorials, pro–con debate, and original research—that relate to sex and gender in the perioperative period.6–19 The majority of these articles deal with sex differences and draw extensively on experimental work and limited and occasionally conflicting clinical data. What emerges is that differences between men and women go beyond the colloquial notion of “hormones” and “anatomy” as all encompassing explanations. Differences represent complex interactions and heterogeneity involving every aspect of the person, from genes to the integrated whole. The information presented in these articles and the directions suggested are important to the practice of anesthesia and perioperative medicine. Although the implications from the current, often confusing and contradictory literature may not always be clear, there are fundamental biological similarities and differences that may influence choice of drug, dose, overall management strategy, and surgical treatment. New therapeutic approaches should account for differing biological responses of men and women to devastating diseases such as stroke, myocardial infarction, trauma, and sepsis. As we further examine sex and gender in anesthesia, we must be cautious in extrapolating from one disease or organ to another, and continue to base practice on the outcomes of good clinical trials. Currently, one of the major problems with clinical trials in this field is that sample sizes are too small for the heterogeneity of the studied population, especially in relation to easily identifiable factors such as age and hormonal status. Another challenge in current clinical trials is addressing the semantic confusion alluded to above. This is apparent in many of the articles in this issue where sex and gender are used interchangeability. However, the difficulty of clearly separating the roles of sex and gender is demonstrated, for example, in relation to pain. Many rodent studies show sex differences in pain thresholds. Similar sex differences in pain thresholds to animals have been found in human studies, but in humans one needs to also consider the entire experiential component: the tolerance and responses to pain that are influenced by diverse and intersecting factors including for example age, emotion, coping skills, behavioral expectations, and gonadal status. Academic status is one area where sex and gender clearly interlink to create distinct challenges to increasing women’s involvement and advancement in the academic echelons. Wong and Stock17 analyze the changes that have taken place over the past 20 yr in the status of women in academic anesthesiology. The good news, perhaps, is that the status of women in anesthesiology is not much different from other medical specialties. The bad news is that the progress of women into senior leadership roles and academic ranks remains abysmal. The simplistic explanation is that biological differences, namely child bearing, combine with social norms, values, and expectations, including child rearing, to create a loaded situation for women; time to have baby = lost publications and opportunities for academic advancement. It is a positive advancement that maternity leave has become the norm. However, we need to be more proactive in creating mother-friendly residency and career pathways. Among other considerations is the fact that departments and institutions still value and reward traditionally male approaches. Highly competitive work environments with short time-frames to achievement as primary measures of success perpetuate structural barriers for women in academic careers. The more stereotypically female approaches to work, such as collaboration rather than competition in the work environment, combined with time constraints linked to both child bearing and child rearing, limit women’s involvement and advancement in anesthesiology. In reflecting on the implications of sex and gender on different elements in anesthesiology, on both the patient and the practitioner, it is worth noting that many of the sex differences in the perioperative period have been identified due to pressure from external funding agencies to attend to sex as a variable in all research studies. Through this pressure, we have become aware of many of the interesting findings presented in the articles within this issue of Anesthesia & Analgesia. However, this raises the question: if sex differences in studies are only coming to the foreground due to external pressures, how will we become aware of and responsive to different sex and gender considerations in the academic and leadership tracks, where no external agency is forcing a critical perspective? The articles in this issue of Anesthesia & Analgesia review the substantial but confusing body of literature relating to sex, gender, and the perioperative period. How best to apply this information in clinical practice is a challenge that is addressed in many of the articles and debated by Fox and Koch.8,9 Despite the lack of clear clinical implication in many circumstances, we need to wake up to the reality that sex and gender are integral to clinical and academic perioperative medicine.

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