Intersections: A newsletter of the Institute of Gender and Health
Volume 1, Issue 2, Summer 2010
Table of Contents
- Getting to the Heart of the Matter with Gender and Sex: IGH Holds Roundtable Meeting
- Gender, Sex, and Drugs in the "Real-World": Canada's Drug Safety and Effectiveness Network
- Let's Get Physical: Accounting for Sex Differences to Create Personalized Exercise Prescriptions
- KT in the City: Improving Access to Prenatal Care in Winnipeg
- The Right Time...The Right Reasons: Dads Talk about Reducing and Quitting Smoking
- Innovations in Gender, Sex, and Health Research: Every Cell is Sexed, Every Person is Gendered
- PreVAiL Unveils New Website
Message from Scientific Director Dr. Joy Johnson
When it comes to clinical interventions – the approaches we use to diagnose and treat people's health concerns – one size does not fit all. Clinical interventions have tended to be gender- and sex-blind, yet we know, for example, that gender and sex influence drug adherence, absorption, and side effects. Although important strides have been made, pharmaceuticals, devices, diagnostics, and clinical programs are often developed on the basis of male only data and uniformly applied to both men and women.
Enhancing the effectiveness of clinical interventions rests on whether they are equally accessible and effective for men and women. Sex matters in clinical interventions in terms of the biological differences between women's and men's bodies that may influence the efficacy of treatments like medications and joint replacements. Gender may shape the way that patients and health-care providers perceive heath and illness, as well as patient-provider interactions. By tailoring clinical interventions on the basis of sex and gender we are better equipped to address the unique needs of women and men and ever closer to ensuring that people receive the best possible care.
This issue of Intersections is dedicated to the Institute of Gender and Health's (IGH) strategic research direction "clinical interventions: enhancing effectiveness." By identifying this priority area, IGH is committed to ensuring that clinical interventions are accessible, appropriate, and effective. A roundtable meeting on the gender and sex dimensions of clinical interventions for cardiovascular disease, featured inside this issue, was our first initiative in this strategic direction. We focused on cardiovascular health as a starting point for advancing our clinical agenda because this is an area in which IGH and other research funders have made significant investment. Our aim is to build on this important work and over time expand to other clinical areas.
In the pages that follow we highlight some of the innovative ways in which IGH-funded researchers are contributing to enhancing the effectiveness of clinical interventions. The programs of research by Dr. Bill Sheel and Dr. David Hart on sex differences in pulmonary limitations and risk for knee injury and osteoarthritis, respectively, provide important insights into how exercise regimes and rehabilitation services can be customized to support better outcomes. We also profile the recently launched Drug Safety and Effectiveness Network (DSEN), which has important implications for how gender and sex are addressed in the Canadian clinical context.
Several new sections make their debut in this issue of Intersections that will be recurring across future newsletters. These include On the Spot with trainees focusing on the achievements and personalities of the next generation of gender, sex, and health researchers, a Knowledge Translation (KT) Monitor showcasing the KT activities of the gender, sex, and health community, the IGH Cochrane Corner that will direct our attention to relevant published systematic reviews, and News Briefs providing updates related to IGH initiatives and the endeavours of our research community.
The goal of Intersections is to showcase the best of Canadian gender, sex, and health research and to highlight how this research is improving health. In the articles that follow, we are proud to present key examples of this cutting-edge science and the researchers behind it.
Clinical Interventions: Enhancing Effectiveness
Gender and sex are not adequately considered in clinical interventions involving the use of pharmaceuticals, devices, diagnostics, and clinical programs. Although women report higher rates of disability related to knee pain, they are less likely to undergo joint-replacement surgery – and those who do are not necessarily given a replacement that suits their anatomy. When women and men seek health-care they may also receive different treatments because of gendered stereotypes that shape the way patients and health-care providers perceive heath and illness, as exemplified by the fact that men are less likely to report symptoms of pain.
There are a number of key issues related to enhancing the effectiveness of clinical interventions, including quality and safety, patient satisfaction, and care management and clinical pathways. To address these and other emergent issues, IGH is committed to supporting evidence-informed research in this area and the uptake of evidence by clinicians and policy makers.
Getting to the Heart of the Matter with Gender and Sex: IGH Holds Roundtable Meeting
On March 25 and 26, 2010, the Institute of Gender and Health convened an invitational roundtable in Vancouver, BC to identify gender and sex research gaps and ways forward for improving cardiovascular interventions. Participants included leading researchers, health professionals, and voluntary health sector representatives from diverse disciplines, specializations, and policy areas. This initiative, in partnership with CIHR's Institute of Circulatory and Respiratory Health and Knowledge Translation Branch, the Drug Safety and Effectiveness Network, the National Strategy on Patient Oriented Research, and the Heart and Stroke Foundation of Canada, was the Institute's first point of action to advance its clinical interventions strategic research direction.
The primary purpose of the roundtable was to identify priority foci for advancing multidisciplinary research on gender, sex, and clinical interventions for cardiovascular disease, including stroke, and the resources required to support this work. Through a collaborative, consensus-based process, roundtable participants identified five areas where accounting for gender and sex was deemed to be requisite for enhancing the effectiveness of clinical interventions for cardiovascular disease, including knowledge translation, cardiovascular risk, prevention, mechanisms of disease, and access to care.
The roundtable was a significant step in helping to enhance cross-theme and cross-sector linkages and networks in the cardiovascular disease research, policy, and health-care community at a national scale. Participants appreciated the opportunity to engage in strategic discussions in a multidisciplinary setting that provided, according to one participant, "a chance to see how common ideas in sex, gender, and health are being approached through different perspectives."
Dr. Chris Kaposy, who brought a health-care ethics standpoint to the table, found it valuable to interact with a multidisciplinary group holding "niche interests in related topics." Similarly, Dr. Alex Clark, associate professor in nursing at the University of Alberta, appreciated the "diversity and depth/breadth of expertise" and was intrigued by "the tensions and where they take us." Others found that through the roundtable discussions, they came to realize the extent of the gaps in research across disciplines. The roundtable format was an effective platform for joint priority-setting. As one participant explained, "The process worked. It was possible to see the development, in stages, of a concise research agenda that was inclusive but clearly sex/gender oriented."
IGH launched a Priority Announcement in clinical interventions for cardiovascular disease in the CIHR June 2010 Open Operating Grant competition as its first strategic funding mechanism to address this research direction. In moving forward on the outcomes of the roundtable, IGH will develop recommendations to inform the decision-making process of its Institute Advisory Board and begin work on developing the next funding opportunity to advance research on clinical interventions for cardiovascular disease tailored to the needs of women and men.
Gender, Sex, and Drugs in the "Real-World": Canada's Drug Safety and Effectiveness Network
In the field of drug safety it is widely recognized that there are many unknowns about the behaviour of drugs in women. Women experience tremendous metabolic and hormonal changes at menopause, specifically during the menopausal transition. These changes can trigger bodily responses to medications, elevating women's risk for adverse reactions to treatments that had previously been safe. At the same time, randomized controlled trials – studies generating the data used to determine safety and effectiveness – are typically male dominated. Most drug standards are de facto based on what is found to be safe and effective in men. Canada's Drug Safety and Effectiveness Network (DSEN) has a valuable role to play in addressing these gender and sex gaps in drug safety and effectiveness.
"The DSEN is positioned to improve information on drug safety because the research conducted will advance our knowledge of the real-world impact of pharmaceutical drugs on groups that have been typically under-represented in clinical research, such as women and girls," said DSEN Executive Director Dr. Robert Peterson. The DSEN stands to contribute to addressing adequate representation of women across their critical life periods such as puberty, menopause, and pregnancy. To date, several projects relevant to the safety and effectiveness of drugs used by pregnant and/or lactating women have already been funded as part of the Catalyst Grant: Post Market Drug Safety and Effectiveness, launched in 2009. According to Peterson, "Solely increasing the number of women participating in clinical trials that fulfill regulatory requirements for market authorization doesn't directly address sex-related differences in pharmacokinetics, side-effect profiles, and efficacy."
The DSEN is aligned with CIHR guidelines regarding the implementation of Gender and Sex-Based Analysis (GSBA) in health research and will encourage researchers to consider sex and gender in their studies of drug safety and effectiveness as appropriate. The focus of the DSEN is on marketed products and is therefore not likely to support basic research (such as animal models in rats and mice) in the study of sex-based differences in pharmacokinetics.
The DSEN represents an important opportunity for Canada to demonstrate leadership in drug safety and effectiveness and address significant gaps in the field, including those related to sex and gender. An integral feature of the research infrastructure supported by the DSEN will be the DSEN Collaborating Centres. Composed of researchers and team members from across universities and health organizations, these interprovincial centres will foster greater national coordination of research efforts in this critical area and enhance Canadian research capacity to respond in a timely manner to the drug safety and effectiveness questions of decision makers.
Let's Get Physical: Accounting for Sex Differences to Create Personalized Exercise Prescriptions
Can sex make you weak in the knees or short of breath, or are only some people at risk? When it comes to physical activity, IGH-funded researchers Dr. David Hart (University of Calgary) and Dr. Bill Sheel (University of British Columbia) have shown that the playing field is not necessarily the same for women and men. Women tear their anterior cruciate ligament (ACL) 5-10 times more than men in the same sports; once torn, the risk for developing osteoarthritis later in life increases. Women are also more prone to breathing limitations during exercise, even though they tend to outperform men in ultra endurance events like the 100 kilometre marathon. Hart's and Sheel's respective programs of research on knees and lungs reveal how accounting for the influence of biological sex on exercise risk and facility is key to determining which interventions may be most appropriate, for whom, and when.
Supported by an IGH new emerging team grant, Hart and his multidisciplinary team uncovered several surprising linkages between knees, hormones, and genes that help us to better understand susceptibility to knee injury and osteoarthritis. Through a series of studies of fit young women, Hart's team found that the degree of looseness of knee joint ligaments varies according to stages of the reproductive cycle, often peaking at ovulation. When the knee is at its loosest, risk for injury heightens due to corresponding changes in the mechanics of the knee during athletic activity. "When this happens," explained Hart, "the knee joint may not be positioned in the correct way. Some of this is style – how you run – but hormones also play a role." The precise stage in which the knee ligaments were loosest differed among women, indicating a possible genetic basis for injury risk. "These variations show that not everybody has the same risks of injuries, and not everyone has the same risks of disease development," said Hart.
While the incidence of osteoarthritis in younger males and females is identical, after menopause rates of knee and hip osteoarthritis are dramatically higher in women. Hart's team has attributed this sex difference to the ways that hormonal shifts in the menopausal period, as well as gene expression changes after menopause in genetically predisposed individuals, alter the way that women's knee joints fit together. "Genes do play a role, but hormones are definitely a major contributing factor," concluded Hart.
Research led by Sheel through a new investigator award in gender and health addressed how sex matters for exercise from another angle: "Breathing is harder work for healthy women than men," said Sheel. Healthy young and older women tend to be more susceptible to respiratory limitations during exercise. Sheel's work identified important sex differences in pulmonary structure and function, including an excessive work of breathing owing to narrow airways in women. The fact that healthy young women work harder in breathing during exercise has important implications for tailoring exercise regimes throughout the life course. "Understanding and establishing what is 'normal' in healthy older women is of even greater importance if we consider that many chronic diseases are manifest in older individuals and that current clinical comparisons may not necessarily be appropriate," explained Sheel.
The finding that women's airways are up to 22% smaller than men's, even when matched in lung size, was "a big surprise" for Sheel. This anatomical variation is a critical consideration in exercise performance and disease prevention and treatment. He explained: "We put people into pulmonary rehabilitation and exercise programs and we generally give men and women the exact same 'exercise prescription.' This approach may not appropriate for a number of reasons; one of them is related to the lungs."
By taking sex into account, we stand to develop better diagnostic and prognostic tools, preventive strategies, and interventions related to physical activity. Accounting for sex differences in knee injury and osteoarthritis supports the development of more personalized assessments of risk and monitoring of the factors that predispose people to injuries or decrease mobility later in life. Similarly, understanding the pulmonary physiology of exercise better equips us to design exercise prescriptions to keep people healthy as well as improve recovery. Minimizing risk and designing effective interventions will support an active and mobile life for both women and men across the lifespan.
On the Spot with Gender, Sex, and Health Trainees
Trainees share a bit about their academic lives and beyond.
IGH supports trainees by providing travel awards for graduate students and post-doctoral fellows to present their research at national and international conferences, and through awards of excellence for the best trainee papers. IGH also hosts an annual Summer Institute that provides participants with the opportunity to expand their understanding of methods and measures for gender, sex, and health research.
Matt Numer: Merging Academia and Activism to Make a Difference in Men's Health
Matt Numer is doctoral candidate in the Interdisciplinary PhD Program in the Dalhousie University School of Health and Human Performance under the supervision of Dr. Jacqueline Gahagan. His research examines the relationships between HIV policy and programming and the sexual practices and experiences of gay men, with particular attention to the influence of gender in sexual relationships. In April 2010, Matt was awarded the inaugural Institute of Gender and Health Award for Excellence in Gender, Sex, and Health Research for his paper 'The sexual health of gay men in the post-AIDS era', published in the International Journal of Men's Health. As chair of the Nova Scotia Rainbow Action Project, Matt leads general advocacy on behalf of the lesbian, gay, bisexual, and transgender communities, as well as focused efforts to support particular groups, such as seniors. In between his scholarship and activism, Matt can be found outdoors jogging with his two dogs, an amstaff/mastiff and a husky shepherd. Matt is originally from Pittsburgh, Pennsylvania, USA.
What first sparked your interest in gender and health?
As a public school teacher, I recognized that the differences in achievement, behaviour, etcetera, were more complex than simple sex differences. It was at this time that I began to think about gender in a more academic way. During my master's degree in counselling, I saw that there were social norms at work that greatly influenced young men and the way they experienced emotions and many other things. This was the beginning of my interest in gender and health; from there I began to think about my doctoral work, which led me to where I am today.
How do your activist and academic roles relate?
I actually see my doctoral work as an extension of my activist agenda. I am able to bring additional insight into my work by having done the research to support activist claims. My activism also puts in me in places that I would otherwise not have access to in my academic work. Recently, I was invited to speak at a CIHR Café Scientifique regarding hepatitis C and HIV and was able to share and discuss some of what I have learned. I believe that the two components, academia and activism, are essential for influencing change in our society.
How does a gender lens expand understanding of HIV risk behaviour?
Gender, sex, sexual orientation, and sexual practice are all concepts that are invariably intertwined. While some distinction can be made, my work on HIV risk in gay men would be incomplete without an analysis of the complex ways they intersect within society. Gender is particularly relevant to gay men's sexual health and practice because in many ways gender is often the basis upon which gay identity is constituted.
Where do you envision your research having impact?
The means and methods of HIV policy and programming in Nova Scotia and elsewhere. I would also hope it might contribute to the growing body of literature surrounding gay men's sexual health and HIV, particularly in relation to the idea of "barebacking" (unprotected anal sex).
What does receiving the IGH award for excellence mean to you?
It is often difficult to measure a paper's value beyond acceptance for publication. The IGH award is very meaningful for me because I have been involved with the Institute since the beginning of my doctoral work. I have attended a number of the sessions that IGH produces and last year I attended the first summer institute. I believe that IGH is extremely valuable in its contribution to the larger body of health research.
What's the story behind your award-winning paper?
It was initially developed for a philosophy course and was later adapted for publication. The aim was to introduce a multi-faceted theoretical lens to gay men's sexual health in relation to gender and masculinity. This paper attempts to provide a perspective on how identity is constituted and how identities/subjectivities interact with sexual practice. The goal was not to reconcile the theoretical foundations; rather, to illustrate how these perspectives might be helpful for further investigation of gay men's sexual health and HIV prevention.
What profession other than your own would you like to attempt?
Being a musician. I have a background in music but have not pursued it further over the years due to limits in time.
Which talent would you most like to possess?
I wish I could juggle.
If you could live anywhere in the world, where would it be?
New Zealand – always thought that would be fun!
What human quality do you most admire?
Empathy brings together caring, compassion, understanding and host of other really great qualities so I would say this is the most admirable to me. It also requires an understanding of the human condition that transcends location, culture, and so on.
If you had a motto, what would it be?
I guess I'd go with Ghandi on this one: "Be the change you want to see in the world."
Gender, sex, and health researchers in action
At the core of the IGH mission is a commitment to evidence-informed solutions to improve health. IGH is dedicated to advancing knowledge translation (KT) by strengthening the KT capacity of gender, sex, and health researchers and facilitating the translation of gender, sex, and health research evidence. IGH develops resources to enrich the KT training environment, fosters the development of collaborations and partnerships for KT, enhances the accessibility of research findings for diverse audiences, and undertakes public outreach initiatives, among other approaches.
KT in the City: Improving Access to Prenatal Care in Winnipeg
Canada fares worse in terms of infant mortality than most developed countries, despite a universal healthcare system. One way to improve the scenario for maternal and infant health is to ensure equity in access to high quality prenatal care. Dr. Maureen Heaman, IGH Chair in Gender, Sex, and Health and professor in the University of Manitoba Faculty of Nursing, is taking action to develop solutions for inner city women in Winnipeg, Manitoba.
Over the past decade, Heaman has built a comprehensive program of research on maternal health and prenatal care in the Winnipeg context. In 2006, she embarked on an integrated knowledge translation (KT) project to better understand the factors associated with inadequate prenatal care among inner city women in Winnipeg funded by CIHR. The research team incorporated a range of knowledge users in all stages of the project, including planning the study design and methods, guiding its implementation, and reviewing preliminary results.
Part of the team's KT strategy included a cumulative, end-of-grant KT workshop that brought together health-care providers, community outreach workers, nutritionists, Aboriginal women's groups, substance abuse workers serving inner city women, policy makers, representatives of the regional health authority, and researchers to examine the team's research findings and strategize future applications and directions. Seventy participants attended the May 6, 2010 event, supported by a CIHR Meetings, Planning, and Dissemination Grant.
The day-long workshop was highly charged with energy to move the research evidence into practice and program improvements. Participants interactively developed approaches for engaging the study findings to help reduce prenatal care barriers and facilitate access and utilization. The group formulated concrete suggestions for enhancing access and utilization of prenatal care, and for initiating alternate models of care. Participants also generated several research themes and accompanying research questions to address gaps in prenatal care programming and service.
This KT initiative was a major success, described by one participant as a "great workshop that built on existing evidence, effectively engaged the diverse audience, and led to valuable outcomes." Attendees noted that the "breadth of participants was fantastic" and that they took away "ideas to use the research results to change how we deliver prenatal care." The event clearly created a catalytic effect; in a mere two weeks following the conclusion of the workshop, Heaman received three invitations to present research results at different service delivery meetings.
The research team is drawing on key recommendations from the workshop to advance the application of their research findings and to develop a future project that will incorporate an intervention component.
The Right Time...The Right Reasons: Dads Talk about Reducing and Quitting Smoking
Becoming a father is a life-changing experience for most men, a significant transition period whereby masculine independence and self-reliance give way (at least in part) to more formally taking on protector and provider roles. These shifts can unsettle new dads who smoke. The many challenges that can emerge are underscored in an innovative print based intervention, "The Right Time...The Right Reasons." This resource draws on the six year CIHR-funded Families Controlling and Eliminating Tobacco (FACET) research program, led by Drs. Joan Bottorff and John Oliffe at the University of British Columbia, and was developed with the assistance of other members of the research team and community partners. In this publication, launched on Father's Day 2010, men's testimonials about fatherhood along with their desires to reduce or quit smoking as a means to being a better dad and role model for their children take centre stage. Honest and forthright, the content is strength-based in describing men's connections to their babies amid self-talk and determination to reduce or quit smoking. This resource is the first Canadian intervention to target dads' smoking.
Focusing on fathers is an especially important strategy because in addition to the negative effects on men's health and the impact of second hand smoke, men's smoking is known to increase their partners' potential to smoke in pregnancy and the postpartum period. Despite the connectedness of fathers' smoking to family health, up until now men have attracted little attention in terms of targeted tobacco reduction supports and interventions. This innovative intervention begins to fill that gap in making available a resource to assist men in their tobacco reduction and quit efforts. This is the second resource developed from the FACET program; the first focused on couples and smoking and was released in 2008. For electronic copies of both resources and more information about the FACET research program please visit FACET website.
The IGH Cochrane Corner
Taking stock of the state of research evidence on topics in gender, sex, and health
Introducing the IGH Cochrane Corner
As a partner on the CIHR Cochrane Collaboration Funding Opportunity, IGH has made a five-year commitment to the Canadian Cochrane Network and Centre. One of the first outputs from this collaboration will be the development of an IGH "Cochrane Corner," to be spearheaded by the Campbell and Cochrane Equity Methods Group and launched in the fall of 2010. The Cochrane Collaboration produces the 'gold-standard' in systematic reviews of health evidence in formats accessible to a range of knowledge users including researchers, policy makers, health-care providers, and patients, among others, to inform health decision-making. The IGH Corner will serve as a resource to highlight those reviews pertinent to the gender, sex, and health community.
The Corner will be accessible through the IGH website and will provide links to relevant reviews in the Cochrane library and summary podcasts where available. Each review will be accompanied by structured indications of the particular gender and sex considerations of interest. Given the breadth of the Cochrane Library at over 4,000 reviews, the IGH Corner will focus initially on recently released reviews and eventually include older syntheses; the Corner will thus be a living resource and expand over time. A standing column in the Intersections newsletter will also spotlight specific reviews or collections of reviews on critical topics from the IGH Corner. By creating a focused collection of systematic reviews relevant to gender, sex, and health, the IGH Cochrane Corner will be a valuable tool for knowledge translation in the field.
What's new at IGH and in the research community
Innovations in Gender, Sex, and Health Research: Every Cell is Sexed, Every Person is Gendered
In celebration of ten years of the Institute of Gender and Health, IGH will host Innovations in Gender, Sex, and Health Research, a multidisciplinary conference on November 22-23, 2010, in Toronto, Ontario. The conference will showcase excellence and innovations across all domains of gender, sex, and health research, including but not limited to biomedical, clinical, health services and policy, population and public health, and social science research. Plenary speakers and panels, along with concurrent poster sessions, oral presentations, symposia, and workshops, will highlight how accounting for gender and sex leads to improvements in health interventions, policies, and outcomes. Bringing together a multidisciplinary group of researchers with a shared interest in gender, sex, and health, the conference will explore advances and challenges related to ethics and knowledge translation in gender, sex, and health research. It aims to promote networking and collaborative engagement among these researchers, as well as health care providers, policy makers, community groups, and others with an interest in this topic as well as foster training and educational opportunities for emerging gender, sex, and health researchers. Conference streams include new discoveries, methodological innovations, emerging issues, changing policy and practice, working with communities, integrating gender and sex in research, knowledge translation, and ethics. The conference promises to be a landmark opportunity in the field of gender, sex, and health.
Please visit the conference website for more information.
PreVAiL Unveils New Website
The PreVAiL (Preventing Violence Across the Lifespan) Research Network, one of the three Centres for Research Development in Gender, Mental Health, and Addictions funded by IGH, launched its website in April 2010. PreVAiL is an international collaboration of over 50 researchers and partners from Canada, the US, the UK, Asia, Europe, and Australia with a mandate to bring together researchers and decision-maker partners to produce and share knowledge that will help children, women, and men exposed to child maltreatment and intimate partner violence. PreVAiL's remarkable breadth and disciplinary diversity is depicted in a diagrammatic mapping of the network structure provided on the site, accessible via the sidebar under "researchers." The website details the centre's three themes, provides regular updates about ongoing projects, profiles researchers and partners, and offers access to reports, research briefs, and other products intended to translate PreVAiL findings and exchange information with a range of stakeholders.
The website is also a collaborative resource to bridge the geographic and disciplinary diversity of centre members. A range of collaborative tools to facilitate ongoing work and to catalyze new projects are under development in a secure workspace available to members' through a login section. A searchable online database, or "Dataset Repository", will allow members to search existing datasets related to violence, gender, and mental health. With an aim to surface other collaborative opportunities, a "Project Inventory" is in preparation where members can post descriptions of other projects they may be involved with also related to PreVAiL's topic areas. Finally, a "Deliverables Reporting Tool" will enable members to report back on various types of KT and networking, as well as traditional academic products, and streamline evaluation of these outcomes.
About the Institute of Gender and Health (IGH)
IGH is one of the 13 institutes that make up the Canadian Institutes of Health Research (CIHR), the government agency responsible for funding health research in Canada. IGH is the only organization in the world with the mandate to fund research on gender, sex, and health.
IGH supports research excellence regarding the influence of gender and sex on the health of women and men throughout life and the application of these research findings to identifying and addressing pressing health challenges.