Intersections: A Newsletter of the Institute of Gender and Health
Fall 2010, vol. 2, no. 1
Special Issue: CIHR Institute of Gender and Health Celebrates 10 Years
Table of Contents
- Message from the Scientific Director
- How I Became a Fan of Sex Differences
- Songs of Silence
- Trans Pulse: Building Our Communities Through Research
- The Stress Between the Sexes
- Clearing the Smoke on Parents and Pregnancy: The FACET Journey
- Gender Inequities in Health Care: Physicians’ Contributions
- Who Smokes and Why: A Much Longer Way to Go, Baby!
- From Research to Policy: Improving Sexual Minority Health
- Gendering Medical Education
- Mentored into Sex and Health Research
- The IGH Cochrane Corner
What Was Unique is Still Unique
Gender and sex are 'every body's' business. The Institute of Gender and Health (IGH) was founded 10 years ago in recognition of this, and of major gaps in the study of the health of women, girls, men, and boys. IGH is the first—and remains—the world's only research funding institute with a specific focus on gender, sex, and health. What was unique is still unique.
Yet, so much has changed.
In the past decade, we have moved from building a research community to actively driving a cohesive field forward. Through our highly engaged relationship with a now robust research community, IGH has been a pivotal agent of these changes.
Canadian gender, sex, and health research has matured: our acclaimed women's health research community continues to thrive; more researchers are studying the biological bases of sex differences; the once nascent men's health research community has taken root; and, across organizations and disciplines, there is growing recognition of the scientific value of accounting for sex and gender in health research. We also have seen advances in emerging areas with theoretical and clinical relevance to gender, sex, and health research, such as transgender health. The overwhelming response to the call for abstracts for the first-ever Canadian conference on gender, sex, and health (November 2010), organized by IGH, is a testimony to the thriving state of the science in Canada.
Where once the role of gender and sex considerations in health policy and practice was questioned, researchers are now recognizing that pre-clinical studies cannot be confined to male animals only, that it cannot be assumed that a drug or device has similar functions for males and females, or that men and women access care in the same way. Because of the dedicated efforts of IGH, CIHR will now be instating two new questions in the certification section of the research module for all grant applications on sex and gender. The way we do health research in Canada is changing.
With a more established field, we are beginning to see that gender, sex, and health researchers are prioritizing knowledge translation in their work, a culture that IGH has helped to cultivate. Gender, sex, and health research evidence is making a difference.
The top 10 success stories profiled in our 10th anniversary special issue of Intersections paint a picture of how far we have come in the past 10 years. We are shifting paradigms, shaping policy, creating new knowledge, translating knowledge in innovative ways, and building capacity for the next generation of researchers. While IGH cannot lay sole claim to all of this work, these stories are revealing of a field that has not only come into its own, but is resonating throughout the health research community writ large. In celebrating our decennial, this special issue also features a 10-year overview of how gender and sex have been addressed in one of the most authoritative sources of health evidence—the Cochrane Library.
In going forward, we are building on the momentum of the past decade. By focusing on the development of new methods and measures, we are driving into cutting-edge areas. We are expanding our reach nationally through web-based technologies to further consolidate our Canadian research strengths, and internationally, through partnerships, to share our expertise and extend our leadership. Public engagement is high on our agenda as we continue to foster understanding about why gender and sex matter to health.
One key lesson learned over the past decade is that researchers, clinicians, and policy makers are open to the idea that sex and gender matter to health research, policy, and practice. Sometimes it just takes one simple question—"Do you know the sex of your cell line?"—to spark an awareness of these issues that grows into a way of doing research. As an institute and a community we need to continue to ask gender and sex questions of our colleagues, research partners, and wherever the opportunity presents itself.
Yves Tremblay, Université Laval
It was December 1999. As the turn of the millennium approached, I was driving home from skiing late one winter afternoon when I heard on the radio that a three-month-old baby boy died in his car seat without warning. The cause of death was Sudden Infant Death Syndrome (SIDS), the result of a gradual loss of the normal breathing reflex. "SIDS is more common in boys," said the voice on the radio, "because of high levels of androgens in the male lungs."
The flurry of information in this simple story was all it took. I was astounded—astounded that the disease was linked to the presence of androgens in the lungs. Androgens are active steroid hormones normally produced in the testes that affect the development of male sex characteristics. This information implied that the lungs might have the capacity to produce active steroids, a concept called intracrinology. Given my research background in steroids, the idea that baby boys' lungs were more sensitive to androgens than baby girls' was mind-boggling to me. Medically speaking, the lungs are considered an asexual tissue, meaning they perform the same function in both sexes: carrying out vital gas exchange. This radio newscast implied otherwise.
Over the following days, I tried to understand what this might mean. It even occurred to me that it might be some kind of a hoax, like the Y2K bug. I finally learned that, in this particular case, the cause of death of the baby was indeed SIDS, but that steroids, and particularly androgens, have nothing to do with SIDS. However, in the process of trying to understand what was going on, I came across another disease that affects babies in the neonatal period and where steroids were recognized as important contributing factors to the development of the lung: respiratory distress syndrome (RDS). RDS affects very premature infants and is the result of pulmonary immaturity that causes breathing difficulties due to insufficient production of "pulmonary surfactant," a complex mixture of fats and proteins that prevents the lungs from collapsing.
The scientific literature describes the incidence of RDS as being higher in males. Androgens in the lungs are cited as the cause. That got me thinking. Digging deeper, I found some studies from the late 1970s and early 1980s indicating that adult lungs had the ability to convert certain steroids into substances that were not well characterized at that time. Very excited about this information, I began a few preliminary experiments to investigate the potential of a cell line derived from lung cells to convert androgens. The results were very encouraging: this cell line did in fact metabolize androgens. As a result of these experiments, I proposed that the fetal lung might be regarded as a new type of organ, as an intracrine tissue with the ability to form steroids, and in which the biological factors differentiating the sexes could be expected to play an important role.
The next step was therefore to better define these dependent androgenic activities and clarify what role androgens played in creating sex differences in the incidence of RDS. The fascinating aspect of these new studies was that they seemed to promise rapid access to a therapeutic pathway that would specifically help premature boys. My impulse was to think that because only boys produce androgens during fetal development, only male lungs are exposed to them, and hence it would suffice to block or at least control this exposure. My vision was falling into place: the administration of an antiandrogen into the fetal lungs via amniotic fluid would be the miracle solution.
We first studied a male human cell line derived from cancerous pulmonary skin cells. These cells had the ability to express genes that produced androgens by transforming non-active steroids normally found in the circulatory system. We also characterized several normal human cell lines derived from healthy pulmonary tissue. These cells were taken from male and female lungs at various fetal and postnatal ages. An exhaustive analysis of these cells in terms of androgen production produced a surprising finding: all of these cells had the same steroidogenic characteristic—they inactivated the androgens. Even more surprising was that there was no correlation with the sex and/or age of the cells. The cells could, however, be classified into two categories: those with a low capacity to inactivate androgens, and those with a high capacity to do so.
Using these findings, in my lab we developed a new model in which the lung's androgenic potential was assumed to result from a differing ability to inactivate androgens. Hence, certain lungs would be more or less exposed to androgens and more or less likely to develop RDS in cases of premature birth. But we still faced two major questions:
- How can tissue derived from female lungs have this ability if only male lungs produce androgens? and
- Was it possible that female lungs also produce androgens? To answer these questions, we turned to an animal model.
These animal studies modified our understanding of the role that androgens play during lung development. We found that not only does the fetal lung synthesize and inactivate androgens, but also that this characteristic belongs to both males and females. This phenomenon also coincides with the appearance of lung cells that specialize in the production of pulmonary surfactant, the fluid that allows for normal respiration. As a result of these studies, we introduced a new concept about the role of androgens in RDS. We showed that androgens had two different effects on lung development:
- a harmful effect that occurs only in males and whose origins could be traced to the production of androgens when the gonads develop in the male fetus, and
- a positive effect that is common to both sexes whereby the lung regulates its exposure to androgens by producing and inactivating androgens during the period when the cells that produce surfactant first appear.
As a direct result of these findings, we had to fundamentally modify our approach in subsequent research. Our goal was no longer to block the production of androgens by the lungs, but rather to target genes that are regulated by androgens and that are responsible for the male/female sex difference.
Throughout all these years I stood my ground that the current therapies for RDS, though effective, did not resolve everything—certainly not the difference between boys and girls in the incidence of the disease. My colleagues' opinions were divided. We not only had different understandings about the impact of sex, but also concerning the decision to begin, continue, or cease medical intervention with these infants when born on the threshold of viability. I realized that clinical beliefs regarding sex differences and the impact of fetal sex on clinical practice varied not only from one practitioner to another according to their culture and their workplace, but also sometimes from centre to centre within a given city. As a direct result, the information conveyed to parents is not uniform and varies depending on the context.
The bottom line is that for parents to be better informed, clinical practitioners must be better informed. And for that to happen, the first step must be to document the issue of premature birth from various disciplinary standpoints. The second will be to work toward consensus on how we understand and approach RDS and premature infant health. The third will be to formulate a statement of the best approach to date, based on the available evidence. To achieve this goal, researchers in the biomedical sciences, along with clinicians and various other professionals, will have to join forces and work together. Toward this end, after a year of preparation, we established the new MUltidisciplinary Scientists' Team (MUST), spanning the fields of medicine, biomedicine, psychology, and population health, supported by the Institute of Gender and Health. The team is dedicated to studying extremely premature infants and the impact of sex on their future. In the coming years, we hope to expand into other areas, including ethics and sciences such as speech therapy and audiology, all with a focus on the consequences of being born very prematurely and with a sex- and gender-based approach and analysis.
To learn more about MUST and the consequences of being born prematurely as a boy, please click here.
Colleen Anne Dell, University of Saskatchewan
Sharing academic research in a participant-created music video isn't standard practice—but it may be a breakthrough finding…'From Stilettos to Moccasins' sounds anthem of honour"
-Eagle Feather News, December 2009
There is scant research on how women's healing is impacted by the stigma linked with drug use, criminal involvement, and being of Aboriginal descent in Canada. Guided initially by the literature and practice-based expertise, our research team committed to undertaking a study in this area. Our community-based approach soon revealed the need to prioritize the often silenced voices of women with the lived experience of coping with this stigma. The members of our team included Aboriginal Elders, treatment providers, First Nations, Métis, and Inuit women who had been in drug treatment, treatment centre directors, academic researchers (including myself as principal investigator), community agencies working with criminalized women, and government decision makers. Our team's collective voice directed the study With funding support from the Canadian Institutes of Health Research Institute of Aboriginal Peoples Health, in 2006 our team began gathering stories with women from across the country at National Native Alcohol and Drug Abuse Program (NNADAP) addictions treatment centres, and with women who completed treatment, about their healing journeys. We established that to heal from drug abuse, there is a need for women to re-claim, and for some to claim for the first time, a healthy self-identity as an Aboriginal woman. This includes understanding the negative impacts of stigma. The women shared throughout their stories about experiences of having their voices silenced; they spoke about how they want to be heard and for others to "walk in their shoes." And so, it was decided that the most effective and appropriate way to share the study's findings was through a song and music video.
In February 2009, alongside community partners and some of the women interviewed, members of our team participated in a three-day song writing gathering. Guided by the findings of the study and the know-how of Violet Naytowhow, an award-winning Woodland Cree singer/songwriter, we drafted the lyrics of the song. The song has become a medium through which women's life experiences and wisdom about healing can be heard. It celebrates their voices.
Using song as a tool for translating the findings of the study served to break down the traditional hierarchical relationship between academic researchers and community members. Violet Naytowhow reflected, "I saw the hearts and minds of many reflecting holistically, sharing in a creative process with their lives in motion with others' lives... The song-writing process was a true testament of a respectful relationship amongst many human beings gathered to share the message of unified hope and supportive healing." Most significant is that song and music are traditionally recognized as a means to preserve culture and identity for First Nations, Métis, and Inuit peoples.
"From Stilettos to Moccasins" was released on May 13, 2009 at an Elizabeth Fry Society of Saskatchewan event that honoured community 'rebels' who work on behalf of criminalized women in the province. One of our team members with lived experience, Valerie Desjarlais, was recognized for her community leadership. Earlier that morning, Violet sung "From Stilettos to Moccasins" live on CBC's morning show, and Violet and I were interviewed about the team's unique approach to translating the findings of the study.
Our team soon after began working on a music video for the song. Partnering with director Angela Mae Edmunds from Mae Star Productions, we continued our commitment to prioritizing women's lived experiences in our research products. Team members, women we interviewed, and their relations are featured in the video. Similar to the song writing process, the video was a collaborative effort; it underwent several revisions until the final form was agreed upon.
The video officially first aired at the Canadian Centre on Substance Abuse, Issues of Substance (IOS) Conference in November, 2009 to over 500 conference delegates. It was shared by the women themselves and diverse representatives of our team: an Aboriginal Elder, social worker, researcher, non-governmental representative, and treatment provider. Reflecting on the experience of sharing her and the other women's collective voice, Anita Narvie explained, "It made me feel important, like I was somebody. Because for so long in my life I didn't feel like I was worth anything."
The song and music video are available on our Facebook Group and on YouTube (with over 12,000 views to date) and are linked to other social networking spaces (e.g., Canadian Women’s Health Network, TurtleIsland.org). We have distributed over 6,500 DVDs at national and international conferences, to community organizations and treatment centres, and to all 800 NNADAP workers during National Addictions Awareness Week.
Unsolicited feedback has relayed both the range of use and impact of the song and music video—from a research facility in British Columbia, to a correctional institution in the Prairies, to a policing organization in Prince Edward Island. The organizer of a nursing conference, for example, recently shared the video at its closing, commenting to us in an email afterwards: "…we showcased 'From Stilettos to Moccasins' to an audience of 80 Community Health Nurses... To say that it was well received would be an understatement. It evoked a visceral response in many people. Dare I say that people left energized, and centred, knowing why they are here and who we serve."
In 2010, community partner Sharon Acoose, from the First Nations University of Canada, and I were awarded the Saskatoon YWCA Women of Distinction Award in the category of Science, Research and Technology. This honour reflects the efforts of the entire team, and most importantly, was another opportunity to share the findings of the study, and translate into practice the desire of the women who participated in it to have their voices heard.
For more information on the research project please click here.
Greta Bauer, University of Western Ontario
I had watched, and in some cases walked, a few trans (transgender, transsexual, or transitioned) friends through some pretty sticky health care situations. I had seen that getting a good pelvic exam can be difficult if you're a man, and that mental health providers often wanted to reduce every issue to one of gender identity, making it difficult to receive care for unrelated issues. Being new to Ontario in 2005 and not trans myself, I knew that I could not do a study on trans health without the involvement of trans community members and organizations. Through a very fortunate convergence of events, I soon met a group of trans community members and an ally that had already received seed funding to build a team for such a study.
The Research Team for the Trans Health Research Project—which was to become the Trans PULSE Project—was developed through a call-out for additional trans community members, and then a call for academic researchers. Community members interviewed and chose academic partners. As one of two academic researchers on the project, I recall my first meeting: I arrived and the agenda was written on a white-board: 1) Updates, and 2) Greta Bauer. For the entire evening I was asked questions about my potential involvement: What was my background and interest in trans communities? What skills would I bring to the project? Did my academic background meet the needs of the project? Would I be an ally in fighting transphobia? Given the history of pathologizing research on trans people, I was excited to be part of a team with a deep commitment to producing knowledge that would document the realities of trans lives that are so often invisible to those not part of, or closely connected to, trans people and communities. The Trans PULSE project developed into a mixed-methods community-based study on how social exclusion impacts the health and well-being of trans people, supported by grants from the Canadian Institutes of Health Research, the Wellesley Institute, and the Ontario HIV Treatment Network.
Until recently, most health research on trans people was driven by medical questions related to endocrinological or surgical treatment or academic concerns on the etiology of transsexualism. In contrast, Trans PULSE is heavily based in community concerns and focused on producing knowledge on the lived experiences of trans community members that has the potential to shape policies and practices across a broad range of areas including employment, housing, protection from violence, mental health, sexual health, and family medicine. Given community concerns and vast unmet knowledge needs, we broke many of the conventions of research, including in the development of a breathtakingly long (87-page) survey, and in nearly "real-time" release of survey results through electronic bulletins. These e-Bulletins allow for rapid uptake of results by community members and agencies, and establish community accountability, while more detailed peer-reviewed publications are prepared and reviewed. Our electronic mailing list has over 600 subscribers, including policy makers, community agencies, researchers, doctors, and of course many, many, trans community members.
The policy- and education-related uptake of our data has been significant. Our first publication on how erasure (the process that creates invisibility) impacts health care access for trans people has been used in university courses in nursing, health sciences and women's studies, and is currently ranked number five on the Journal of the Association of Nurses in AIDS Care's "Top 25 Hottest Articles." Our qualitative and early quantitative data were used by the Ontario Ministry of Health and Long-Term Care in the 2008 decision to relist sex reassignment surgeries (SRS) for public funding, and in a recently announced decision to decentralize the approval processes for publicly funded SRS, provide training on trans-related primary care to family physicians, and conduct an evaluation of trans health care in Ontario. Our data were also referenced in this year's parliamentary debate over Bill C-389, a measure to include gender identity and gender expression in the Canadian Human Rights Act and hate crimes provisions of the Criminal Code of Canada, and have been used in meetings with Ontario's Attorney General on incorporation of such explicit protections into the Ontario Human Rights Code. Statistics from Trans PULSE have also been used by a number of community and academic groups to provide support for funding applications for community programming and additional research.
Trans PULSE has become a model for community-based research. It is unique in that it was initiated and has always been controlled by trans community members. Of the 38 individuals who have served as investigators, staff, student research assistants, and Community Engagement Team (CET) members, all but 9 are trans. Our project Terms of Reference specifies that for all major project decisions, a majority of team members present must be trans. Our Community Engagement Team, a group of 16 trans people from around Ontario, also contributed countless hours to survey development and technical piloting, as well as promotion.
One of the biggest joys of working on such a community-intensive research project is building our collective capacity to do this kind of research. Trans PULSE has provided opportunities for community investigators to co-author papers and other research materials, to present at conferences, and to be involved as researchers in policy consultations. We have thus far trained eight graduate students, two of whom are trans and six of whom are cissexual (non-trans). Our project manager and graduate student Todd Coleman says, "I personally owe any achievements and milestones in my career to starting out as a research assistant on Trans PULSE. The skills and eye-opening knowledge that I have acquired in the areas of gender, sex and health over the last three years working for the project would likely not have occurred had it not been for Trans PULSE. It will continue to shape every piece of work in my career."
Trans PULSE is now made up of an experienced research team serving as stewards of the most comprehensive data resource on trans health in Canada. Our efforts—which will continue for years to come—are already having a real impact on policy and practice. Our work is contributing to the un-erasure of trans people in informational and institutional contexts. We have held ourselves to high standards of ethics and community accountability, and developed research processes and knowledge translation strategies that reflect those commitments. We are, as our project's tagline reads, "building our communities through research."
For more information, please click here.
Jens C. Pruessner, McGill University
I was a rather young graduate student when I first came across differences between men and women in their responses to stress. At the time, I didn't quite know whether these were due to sex (biological) or gender (social) factors. I was a research assistant in a laboratory that was performing stress studies using a public speaking scenario in front of an audience as a stressor, and measuring various physiological (blood pressure, heart rate) and endocrine (Adrenocorticotropic hormone, Cortisol) variables as outcomes. This type of performance task is both competitive and social; that is, you have to do a good job in front of peers. What was just being established at that time was that women showed a consistently lower stress response to this task than men, as measured by the major stress hormone Cortisol.
This could be interpreted in two ways. First, it could mean that women were less stressed because the public speaking stint did not get to them in the same way as men. Second, there was an equally feasible biological (sex) explanation, in that women had lower levels of stress hormones because these were inhibited by their higher presence of female hormones. We initially didn't know which was which but were intrigued by the apparent possibilities of both gender and sex playing a role.
My sense of intrigue was piqued a couple of experiments later when—still as a research assistant—I helped with an experiment investigating the effects of social support on stress. Participants had to speak in front of an audience either with or without their partner present. Our common sense notion (and everybody's expectation) was that when the partner was around, the stress response would be blunted because of the increased social support. As it turned out, this was true only for men. If accompanied by their female partner, men responded to the public speaking stress task by releasing less Cortisol. For women, however, the results were the opposite: they showed higher than average stress responses to the public speaking task when they confronted the audience in the presence of their male partner! This was absolutely unexpected and caused some raised eyebrows.
It was then that the importance of sex and gender in stress research crystallized for me. It also helped to clear up the initial question of whether hormones alone might explain the lower responses of the women to the earlier stress task. More than biology seemed to be at play here. Indeed, the different responses appeared to have more to do with the social than the biological: when the social relevance of the public speaking situation was amplified by the presence of the women's partners, women responded more strongly with the release of stress hormones.
Fifteen years have passed since my first entrée into stress research, and a lot has changed. Now it is officially accepted that men and women differ in the social roles and responsibilities with which they respond to stress, thanks in part to the work by Taylor et al. (2000) and Stroud et al. (2002). Taylor's seminal paper 'Tend and befriend, not fight or flight' officially introduced the notion that women might pursue different response strategies when stressed (and it is interesting to ponder whether that might be sex- or gender-based). Stroud, Salovey, and Epel (2002), in turn, demonstrated that the nature of stress might also be different for men and women. They documented differential responses in the sexes depending on the task used. To summarize it crudely: women respond more to the danger of social rejection, while men respond more to competitive aspects of the situation.
This brings us to the current line of stress research, and the adaptations that are taking place to acknowledge these sex- and gender-based differences. While earlier stress research was performed using a "one size fits all" approach—where men and women were exposed to the same stressors to study interindividual differences—we now realize that we might cause some of these differences by using stimuli that are biased toward one gender or the other. As a consequence, we are currently exploring tests that are either emphasizing female or male relevant situational aspects. It is hoped that these developments will in turn allow for a better assessment of sex- and gender-based differences in future stress research.
Joan L. Bottorff, John L. Oliffe, and Gayl Sarbit, University of British Columbia
Recognizing a missed opportunity gave "birth" to the FACET (Families Controlling and Eliminating Tobacco) program of research, dedicated to reducing and eliminating tobacco use in young families. During the course of our research, we became intrigued by the fact that many women "stop smoking" for pregnancy, only to return to cigarette use either during pregnancy or soon after the baby was born. This represented to us an important missed opportunity for intervention. Yet our own efforts, like those of others, to support successful and sustained smoking cessation by intervening directly with postpartum women only raised more questions than answers. We found that the theories guiding smoking cessation interventions did not fit with women's experiences. We were convinced that new parenthood provided a unique window for tobacco reduction. However, we believed that a much better understanding about how women's efforts to reduce and stop smoking were influenced by everyday life, household dynamics, and gender roles was needed to develop new approaches.
For over eight years, we have been generating new insights into the roles of family gendered relations in shaping smoking behaviours, with support from the Canadian Institutes of Health Research. This new knowledge has enabled our work to move from the initial phases of describing the gendered nature of the problem to designing and developing innovative gender-specific tobacco reduction interventions. As the FACET research program has evolved to focus on evidence-based solutions, our research team has increasingly incorporated a range of multidisciplinary researchers, health professionals, and community partners committed to connecting critical pieces of the tobacco reduction puzzle in pregnancy and the postpartum.
Our focus in the first phase of FACET was on couple interactions around tobacco during pregnancy. We discovered how tobacco-related dynamics between couples created challenges for women's tobacco reduction efforts. These findings underscored the need to support women by taking into account the role partners play in their tobacco use, as well as the realities of women's everyday lives. This led us to identify fathers' smoking as a potentially important way to assist mothers' efforts and this became an important focus in the next phase of the FACET research.
We learned that despite repeated requests and sometimes nagging, women were largely unsuccessful in getting their partners to stop smoking. As a result, they worked hard to regulate men's smoking to fulfill their role as "good" mothers. We found that the smoking issues faced by new fathers were different than those associated with expectant and postpartum mothers. Fathers rationalized and defended their continued smoking by linking it to masculine characteristics of strength and risk-taking. It became apparent that the stress associated with being a new dad reinforced the need for stress relief through smoking. Although expectant fatherhood prompted men to re-think and sometimes modify their smoking habits, few quit or substantially changed their tobacco consumption by the time of the birth of their child.
It was clear from the early stages of FACET that interventions needed to address how tobacco was interlinked with couple dynamics, gender roles, and the experiences of becoming a new parent. We set out to develop new approaches to support tobacco reduction in families with this in mind. The first intervention was a booklet, entitled "Couples and Smoking: What you Need to Know When You are Pregnant," designed to complement other smoking cessation resources for pregnant/postpartum women. The booklet is unique in that it situates women's smoking and tobacco reduction in the context of realistic everyday interactions and relationships with intimate partners.
We also focused on translating our new understandings about fathers and smoking. We designed a booklet geared specifically towards new and expectant fathers who want to become smoke-free, "The Right Time… The Right Reasons… Dads Talk about Reducing and Quitting Smoking." This new resource fills the gap in available resources to assist men in their tobacco reduction and quit efforts. It is men-centred and focuses on the significant changes and challenges associated with becoming a new father. Our latest intervention, a tobacco reduction program called "Dads in Gear" is an integrated 8-week program, tailored for expectant and new fathers. The program is unique in the way that it engages directly with men about fathering, tobacco reduction, and exercise/healthy eating. The program will be pilot tested this year. To our knowledge, this is the first Canadian tobacco reduction program to target fathers and, as such, will provide a basic foundation on which to develop men-centred interventions dedicated to reducing the health effects of tobacco in young families.
As we move forward, we are focusing our efforts on diverse modes of knowledge translation. Our project is on Twitter, Facebook, and MySpace. We anticipate a FACET video on YouTube in the very near future.
Examining a missed opportunity to support women’s tobacco reduction efforts during pregnancy to enable long term cessation has led us to novel approaches to support both women’s and men’s tobacco reduction. The focus on gender took us down a new path—one that we think is key to shifting the discourse on, and practices supporting, smoking cessation, and ultimately the health of families.
For more information please click here.
Cornelia M. Borkhoff & Gillian A. Hawker, Women’s College Hospital James G. Wright, The Hospital for Sick Children
Total joint arthroplasty (TJA) surgery of the hip or knee is one of the most impressively effective medical discoveries of the last century, and is considered the definitive treatment for relieving pain and restoring function in individuals with moderate to severe osteoarthritis for whom medical therapy has been tried and failed. Numerous studies indicate substantial and sustained improvement in patients' quality of life with low complication and revision rates following TJA. Why then isn't everyone who needs this highly effective treatment and deemed an appropriate surgical candidate, getting TJA? This is the story of how gender bias may inappropriately influence physicians' clinical decision making regarding TJA and what this evidence means for reducing gender inequities in osteoarthritis care.
Research regarding the rates of use of TJA began in 1990 with early research focused on the phenomenon of area variation (i.e., if whether you get TJA depends on where you live). Our research included the first attempt in exploring the appropriateness of rates of utilization for a surgical or medical procedure using a population-based approach. We surveyed all individuals over the age of 55 years in a county with high rates of TJA being performed and a county with low rates of TJA in Ontario, Canada to determine the population need for TJA. We defined "unmet need" as candidates medically appropriate for TJA who, when advised of the risks and benefits of TJA, were still willing to consider TJA. We found an unmet need for TJA in both counties and that the degree of unmet need was greater in the high- compared with the low-rate utilization county. These findings shifted our attention away from area variation, towards the underutilization of TJA.
Our prior population-based study also established the presence of unmet need for TJA by gender and socioeconomic status. This finding indicates that unmet need varies by identifiable segments of the population, an issue that has been labelled as disparity. Previously documented disparities were largely based on analyses of administrative data that told us only about who is getting care, not about who is not. Although we found that TJA was underused in all segments of the population, the degree of underuse was more than three times greater for women (5.3 vs. 1.6/1000 for women and men, respectively) and those of lower socioeconomic status. For comparable levels of osteoarthritis, women in our sample expressed equal willingness to have surgery. Disparities in this highly effective procedure are a matter of major concern because they may adversely affect the health of vulnerable population subgroups.
Our recent research focused on subtle or overt gender biases potentially affecting physicians' treatment recommendations regarding TJA. Biased care occurs when non-clinical factors such as stereotypes or social attitudes based on gender guide physicians' clinical behaviour. When surveyed, referring physicians and orthopaedic surgeons indicated that a patient's gender does not affect their decision to refer for, or perform, total knee arthroplasty (TKA). A ground-breaking study by our group published in the Canadian Medical Association Journal using standardized patients, also known as "mystery patients"—one male and one female with moderate knee osteoarthritis and otherwise identical clinical scenarios—demonstrated that the odds of an orthopaedic surgeon recommending TKA to a man was 22 times that for a woman. The odds of a family physician recommending TKA to a man was 2 times that for a woman. Furthermore, shared decision making was more problematic for women with physicians including fewer shared decision making elements when the standardized patient was a woman compared to a man. Specifically, physicians provided less medical information and less encouragement to participate in the decision to undergo TKA to a woman compared with a man. Physicians also seldom discussed her role in decision making, explored whether she understood the decision, or elicited her preferences.
The results of this study suggest that physicians may be at least partially responsible for the gender disparity in TKA utilization. Our study is important as it is the first to demonstrate that patients' gender affects physicians' clinical decision making in actual clinical practice and provides some of the most conclusive evidence to date of a significant provider contribution to gender disparity in health care. In addition, no study has previously addressed whether physicians are less participatory with women compared with men for patients presenting with the same chief complaint, suggesting that gender bias may also influence physicians' interpersonal behaviour.
In addition, no study evaluating the effect of patients' gender on physicians' clinical decision making had previously compared actual behaviour with physician responses to matching written case vignettes. Unlike their treatment recommendations for standardized patients, the same physicians' treatment and referral decisions for matching "paper" patients were not influenced by patients' gender. While paper patients (or written case vignettes) may be useful in the assessment of clinical competency, they are not a sensitive method of assessing gender bias among physicians.
Addressing the physicians' contribution to gender disparity in treatment is likely to require a multiple intervention approach, such as shared decision making and communication skills programs for physicians and decision support tools that facilitate shared decision making between patients and their practitioners. However, because these educational interventions are likely to target physicians' explicit (conscious) beliefs rather than implicit (unconscious) stereotypes about patients, they are probably not sufficient to address physicians' biases and eliminate gender disparity in treatment. Our findings support the need for additional skills that increase physicians' acceptance and awareness of the unconscious biases that may be influencing their clinical decision making and provides physicians with the capacity to consciously replace automatically activated stereotypes.
This research was supported by grants from the Canadian Institutes of Health Research and the Arthritis Society of Canada.
Lorraine Greaves, British Columbia Centre of Excellence for Women’s Health
Over 20 years ago, I took the plunge into the issue of women's tobacco use. It all started when I was asked to write the "Background Paper on Women and Tobacco" for Health Canada (1990). At the same time, I met Bobbie Jacobson, a physician in the UK who had artfully exposed the sexism and oversights in the tobacco control movement, alongside the now well-known exposés of tobacco marketers. I quickly realized how much work there was to do on reducing tobacco use among girls and women, and how little (appropriate) attention had been paid to it. Furthermore, a pattern of relentless attention to pregnant women smokers had created a victim-blaming, fetus-centric scenario that needed changing. I privately vowed to never work on pregnancy and smoking, and never on men's smoking, as a way to try and right these imbalances.
I have long since broken those promises. The story of how this happened is all about gender and health.
My overarching intention has been to shine a light on the underside of tobacco use. My research has demonstrated that this requires the use of a gender and diversity analytical lens, and more recently, that biological sex-related factors interact with gender to explain the effects of tobacco on different groups of women and men. For example, women have smaller airways and lungs than men. These sex differences, coupled with higher rates of using gendered products such as "light" cigarettes, which promote deeper inhaling, cause more and different kinds of lung disease in women. These types of observations, have fuelled my larger efforts in bringing considerations of sex, gender, and diversity into all health research and policy, and in integrating sex and gender into health research design.
I started by looking at what smoking actually means to women in a book, Smoke Screen: Women's Smoking and Social Control (1996). This book illustrated both the costs and benefits of smoking to women, and how smoking functions to facilitate women's social roles and locations. In the context of the British Columbia Centre of Excellence for Women's Health, colleagues and I built the first research team on girls, gender, women and tobacco in the world. Among many topics, we considered how tobacco policies are differentially experienced by sub populations, a phenomenon that remains under-researched. These investigations raised ethical questions about blunt, "comprehensive" policies and their inability to be truly comprehensive and equitable for all groups. They have also laid the groundwork for more nuanced approaches to prevention and intervention.
Along the way, I did turn my attention to intervening on tobacco use during pregnancy and postpartum, but my focus was addressing the inadequacies in existing interventions and making them more respectful of women. I joined with international partners to share Canadian better practices on cessation for pregnant and postpartum women with Spanish, French, English, and Portuguese audiences around the world. In the context of understanding tobacco use and the high relapse rates for postpartum women, it became clear that men had a lot to do with these patterns. I became involved with a program of research focused on understanding how gender relations and couple dynamics shape tobacco use and quitting, and how power dynamics between male and female partners need to be a key consideration for health providers when intervening with pregnant women and mothers who smoke.
Still, 20 years on, there remains an enormous challenge in undoing the axiom of the tobacco industry that has linked women's liberation with smoking, embodied in the Phillip Morris slogan: "You've come a long way, baby", the tag line that introduced Virginia Slims to the American market in 1972. This campaign, like much of the tobacco industry campaigns from 1928 onwards, has evolved and now uses a sophisticated diversity lens that has visually targeted women of all races in all world regions, with a new slogan: "Find your voice".
On the surface, Canada has significantly changed its smoking scenario, but underneath, gender and diversity and disadvantage tell the real story of who smokes and why. The bigger question remains as to whether tobacco control efforts can assist in transforming gender norms to improve women's status, as opposed to just accommodating, or even reinforcing them. In short, there is a long way to go in solving the smoking problem.
A central question that now occupies my research is: how do we prevent women's smoking and enhance women's status at the same time? This has led me to global advocacy on these issues. The International Network of Women Against Tobacco (www.inwat.org), of which I was a co-founder in 1990 and now serve as President, is a key channel through which gender-specific approaches to tobacco use have been advanced.
Women's global smoking rates are on the rise in low income countries with large populations, causing a huge epidemic that is just beginning to unfold. To address how tobacco control can respond in a gendered fashion to these critical trends at a global level, and do so much earlier than we did in Canada and other developed countries, I have written a policy brief and a background paper on gender issues in tobacco use, cessation, and policy responses for the World Health Organization.
And yes, I still had to suggest that there be less attention to pregnancy and smoking and more attention to women and girls' health. And, no I did not ignore men, but rather pointed to the huge influence they have on exposing women and children to second hand smoke, and in shaping cessation efforts among women. And, yes, I suggested that the world develop gender-sensitive interventions for men as well as women, and intervene in a women-centred manner with pregnant women. I managed to break all those early promises, as gender and health research broadened the way in which I have viewed tobacco use and how it has been responded to, both in Canada and abroad.
Danielle Julien, Université du Québec à Montréal
If ever there was a fortuitous time when social necessity met academic preparedness and combined to create an effective, practical response to a vexing condition, it was in Quebec in June 2005. It happened during an intense social debate about homosexuality in Canada, a month before the legalization of same sex marriages.
The Ministry of Justice was under pressure from gay and lesbian community leaders to find solutions to the problem of homophobia in Quebec and address the well-being of sexual minorities. Recognizing that little was known about the current state of homophobia in Quebec, the Ministry called for a marshalling of knowledge as Quebec society progressed toward new human rights realities.
The task was charged to the Commission des droits de la personne et des droits de la Jeunesse (CDPDJ) to produce a report. A mixed working group, under the guidance of Monik Audet, included representatives of different ministries, public sectors (e.g. unions), community organizations, and academic researchers in the field of sexual minorities.
Into this propitious time, two researchers, professors Line Chamberland (UQAM) and Bill Ryan (McGill), were invited to be representatives of the academic research sector. As the principal investigator of the Sexual diversity, Vulnerability and Resilience (SVR) research team, I knew Line and Bill as members of our team. I saw then that "academic preparedness" had met "social necessity".
Years of dedicated research and activism regarding homophobia uniquely positioned Line and Bill to be ambassadors in this role. I was sure their combined knowledge would guarantee that scientific evidence would be highlighted in the report. This would guide the ultimate policy to be determined by the Ministry of Justice. Both Line and Bill were involved in several of the ad hoc thematic committees as a consequence of their long-time previous research. Hence, other SVR researchers were invited to provide ad hoc testimony based on their respective expertise in the field.
Two years later, the mixed working group published its report on specific issues regarding sexual minorities such as aging, education, family, and homophobic experiences. The report acknowledged the gains in civil rights over the previous ten years and, importantly, provided a progress report on combating homophobia and made recommendations to the Ministry of Justice for the needed changes in government policies and action.
The report impressed the need for supporting further research. One of the stipulations was to support the establishment of a chair devoted to research on homophobia and to evaluate interventions geared to reduce homophobia in Quebec. Specific significance was attached to gender and health. It stated the need to support research to fill gaps in knowledge about sexual minority women relative to sexual minority men, and recommended the creation of a gender-specific database. In addition, the report advocated support of educational initiatives to counter homophobia and the adoption of targeted public services, especially health and education.
A few months before the Quebec government announced its policy against homophobia, nearly three years later, the CDPDJ published a document assessing the impact of its initial report. It was apparent that the imperatives of the report had already been adopted by multiple civic and public sectors, professional groups, and academic researchers. In particular, I was heartened at the time when in May 2009 the Quebec Human Rights Court of Justice used information from the report to arrive at three decisions in favour of plaintiffs pleading human rights discrimination based on sexual orientation. Further, the court upheld the plea of a plaintiff in a case of sexual harassment in the workplace.
One month after the announcement of the policy, the government mandated an inter-ministerial committee to create a plan of action to combat homophobia in Quebec. It is hoped the plan of action will be a profound endorsement of the findings of the commission. The final plan is expected to be announced in December 2010.
From proposal to the final established policy, in terms of research and parliamentary procedure, it was like watching a fast horse on a fast track. The Quebec initiative is unquestionably the result of converging concerns, maturity of development, opportunities and the actions of several social sectors, including the research sector and the growth and work of the SVR research team over the past six years.
But, I must reiterate the role of who I see as the two leading actors of this success story: Line and Bill. Their many years of study on the subject, initially done with little help from formal funding, contributed profoundly to the early achievement of this social progress. At the time they started their research, most funding for studying sexual minorities targeted HIV and men having sex with men. I was delighted when funding expanded to other dimensions of sexual minorities, notably the experience of homophobia. Funding from the CIHR Institutes of Gender and Health and Population and Public Health enabled us bring expertise in this area together for the first time in the SVR team. Because of this, the team was recognized by the CDPDJ as a source of credible knowledge.
My estimation of this "opportunity meets chance" experience in the field of research and changes in social policy is that it is an indelible example confirming what funding for research outside mainstream studies could do to create new knowledge and ultimately to form efficient ways of transferring that knowledge for the betterment and health of society.
Shayna Watson, Queen’s University
In early 2000, the Deans of the Ontario medical schools, through Council of Ontario Faculties of Medicine (COFM), began to explore the possibility of collaborating on curriculum development. There was a growing sense that schools were duplicating efforts to meet emerging curricular needs and that technology might help schools consolidate efforts.
Gender and health was the testing ground. The undergraduate education deans of COFM and the Gender Issues Committee of COFM (GIC-COFM; later called the Equity, Diversity and Gender Committee, EDG-COFM), jointly initiated the Gender and Health Collaborative Curriculum Project in 2002. The collaboration attracted the attention and generous support of the Ontario Women's Health Council. The project team included an executive with representatives from the two COFM committees, a site coordinator from each of the six participating schools, a central project coordinator, and undergraduate medical students from all of the schools for three summers.
Today, the Gender and Health Collaborative Curriculum Project (genderandhealth.ca) is a freely available web resource that includes thirteen self-learning modules, three in both French and English. The site provides a 'portfolio' that allows students to track their work. This is accompanied by a set of gender competencies in the CanMEDS framework—the guidelines for essential physician competencies in Canada. The website is used by medical schools provincially, nationally, and internationally and across a range of health disciplines and social sciences. The project has provided a Canadian perspective on gender and health that is not biologically focused nor just a reframing of women's health.
Perhaps the biggest success of the project is that we actually did it. When students told us that the project allowed them to address topics they feared would not be part of their medical education, we knew we on the right track. Students still tell us that genderandhealth.ca gives them perspectives and content that they are not getting elsewhere. When a fourth year gender studies class used the poverty module as a consolidation exercise, we knew we were providing students with content that was able to bridge the medical and the social.
When we started, we did not even really know what gender and health was. Compared to similar educational projects we went about things backwards. Other projects start with a defined and familiar subject area with an established place in the medical school curriculum, and begin by defining a set of competencies and a content framework. We had to start by grappling with what gender and health meant to us and what it could mean to medicine.
We were generalists and specialists, some academically based and others firmly rooted in the community. We were tech savvy and tech naïve. We were in six different corners of the sizable province of Ontario.
We began with World Health Organization (WHO) and Health Canada definitions of gender, both of which tell us that gender is socially constructed and relational. We wanted to have congruence between our subject, our process, and our product. Gender and health is about the opportunities and privileges that flow from society to an individual and how they impact on health. It did not make sense then to create an educational resource that was limited or locked down; that would be limited by proprietary software or passwords. We opted for open source software and made our product freely available on the internet. We chose not to erect any barriers, be they passwords, fees, or membership.
The series of modules created mirrors our process: small steps to understanding the components and then applying that understanding and summarizing it before moving on. The introductory module starts with definitions of health and gender, and builds to what is gender and health. In other modules, we examine how gender fits with other social determinants. The curriculum then turns to specific areas in medicine and asks how gender is considered.
The educational material is grounded in the literature and presents latest findings in an interactive way that aims to engage the student with the material but also to change the way students understand sex and gender and the effects that these have on health and access to health care. The core of this project has been knowledge translation and perspective shift. The reflective exercises are constructed with transformative intent and to challenge learners to become aware of their own assumptions and biases.
The choice of topics was primarily based on allowing students to work in areas of their interest. If we had not followed the lead of our summer students, we would not have our module on Gender and Sexual Diversity, or the module on Gender, Globalization and Health, or the varied collection of topics that we now offer. We were able to include content on career choice and streaming, medical student well-being, sexuality and depression—taboo topics that students might not encounter elsewhere within their programs.
Along the way, there were many centrifugal forces, trying to pull us apart, but in the balance, there was a centripetal force: we were drawn together in gender and health by our shared belief that it mattered academically and personally. Gender and health spoke to us as physicians and as people; it spoke to us as gendered beings. We had a common desire to make things better for students, to change the way people think, and to make health care more open and accessible for all people. It was from this common ground that we were able to collaborate. Like moving water shapes, and is shaped by, the landscape, our understanding of gender and health was shaped by our gendered lives in this collaboration.
It was at the end of our wanderings that we understood what gender and health meant to medicine. We could look to the series of learning modules for medical students and know that they demonstrated what gender and health meant to us. We were able to clearly define what gender competencies were and recorded them in the CanMEDS framework.
Jordan Guenette, Queen’s University
I was in the third year of my undergraduate degree in the School of Human Kinetics at the University of British Columbia. I was a typical student achieving mediocre grades and realizing that I had no idea what I wanted to do with my life and career. All I knew is that I was passionate about endurance sports and that I loved to learn about exercise physiology. Unfortunately, I had no idea how to turn these passions into a career. A friend suggested that I look into undergraduate research opportunities so I could study exercise physiology in more detail. In searching on the web, I came across a faculty member named Dr. Bill Sheel, a CIHR Institute of Gender and Health New Investigator who was studying sex differences in exercise physiology. Coincidently, Bill also happened to be my statistics instructor at the time.
I reluctantly sought out Bill after class one day to inquire about possible research opportunities in his lab. My hesitation was in large part because I had absolutely no clue what research was all about and because my grades weren't particularly impressive. Fortunately, Bill was very approachable and he decided to give me a chance, despite my modest grade point average and lack of research experience. I think he recognized my enthusiasm for exercise physiology and that I was willing to work hard. After discussing some research ideas we decided to explore studies on the respiratory response to exercise in men and women.
After helping with a review article on sex differences in respiratory physiology, we recognized a major gap in the literature. Most exercise scientists exclusively use male subjects in their research and assume the responses will be the same in women. And so it was that Bill and I decided to carry out research on sex differences in how humans breathe during exercise. Bill gave me the confidence and independence to run with my ideas. Rather than giving me the answers to my questions, he would point me in the right direction and he allowed me to struggle. He created a research environment where I felt like his colleague rather than one of his subordinates. Bill instilled in me a passion for science and encouraged me to pursue graduate studies and a career in sex and gender research.
I became very motivated and ended up publishing my undergraduate research and presented at national and international conferences. This newfound desire to pursue graduate studies encouraged me to persevere for the remainder of my undergraduate degree, resulting in my selection to give the valedictorian address at my convocation. My confidence as a student shifted in a positive direction because I had a role model that believed in my potential.
Following graduation, I immediately started my master's with Bill. My master's dealt with sex differences in breathing mechanics during exercise in elite endurance athletes. We demonstrated that women may be more susceptible to breathing limitations and that the respiratory muscles work much harder in women than men during exercise. We received formal recognition for this research from the Canadian Society for Exercise Physiology and I was very fortunate to be the first Human Kinetics student at UBC to win the Governor General's Academic Gold Medal. During my master's, Bill encouraged research collaboration and allowed me to take part in many studies that were independent of my thesis research, including the opportunity to do high altitude medical research in Nepal. Many of these collaborations had no direct benefit to Bill but he recognized the importance of these opportunities in my development as a scientist. This selfless attitude towards student mentorship and my growing interest in sex-based research made it very easy for me to decide to continue with Bill for my Ph.D.
My doctoral thesis determined some of the physiological consequences associated with breathing limitations in women during exercise. For example, we demonstrated that women have smaller airways than men resulting in an increase in airflow resistance while breathing. Despite this observation, we found that female respiratory muscles were more resistant to developing fatigue relative to their male counterparts during exercise. Bill continued to provide me with opportunities to pursue independent research during my Ph.D. in an effort to further diversify my academic training. He also recognized some of the limitations a student might experience when doing all of their degrees at the same institution and with the same supervisor. So I ended up spending several months in Europe doing additional research at the Copenhagen Muscle Research Centre and in the Department of Critical Care Medicine and Pulmonary Services at the University of Athens. This research resulted in the first successful attempt at measuring blood flow to respiratory muscles in conscious humans. Few supervisors would allow their students to spend several months doing independent research with other principal investigators—another example of how Bill holds his trainees' interests above his own.
Bill's CIHR Institute of Gender and Health New Investigator Award afforded him the time to focus his attention on mentoring his research trainees. His mentorship model has trained me as a health researcher and has given me the tools to one day mentor my own students and to continue exploring the important role that sex and gender have in human health. I decided to write this story to acknowledge Bill for being such an outstanding role model, supervisor, friend, and colleague. It is my goal that I will one day be able to offer my students the same quality of mentorship that I received from Bill.
I recently defended my doctoral thesis and I am now a post doctoral fellow in the Department of Medicine at Queen's University. I have taken the knowledge that I acquired about elite athletes with Bill and I am now applying similar models to understand sex and gender differences during exercise in chronic diseases. My goal is to eventually run an independent research program focusing on sex and gender differences during exercise in both health and disease with the long term objective of generating optimal exercise interventions designed to prevent, treat, and manage chronic diseases.
Sex and Gender in the Cochrane Library: Looking back, moving forward
Erin Ueffing and Jordi Pardo Pardo, Campbell and Cochrane Equity Methods Group
In the ten years since the inception of the Institute of Gender and Health, there have been increasing calls from policy makers, practitioners, and researchers for the integration of gender and sex in health research.1 At the same time, there has been a movement toward evidence-based health care; that is, using available research evidence to guide the decision making affecting health care practices and patient care.2 International groups such as the World Health Organization's Commission on Social Determinants of Health have identified systematic reviews as one form of evidence that meets these needs. The Cochrane Collaboration publishes systematic reviews of health interventions in The Cochrane Library.
Looking back over the past decade, three studies have investigated how reviews produced through the Cochrane Collaboration have considered the applicability of the research evidence assessed with regards to differences by sex or gender. Two of these surveys focused exclusively on sex or gender,3,4 while the third also assessed other sociodemographic factors such as race/ethnicity, socioeconomic status, and education.5
The first survey, conducted by Johnson et al., examined 30 Cochrane reviews on heart, hypertension, and peripheral vascular diseases in 2001. Of these reviews, only three considered whether gender played a role in the effectiveness of interventions. Of the 196 studies that recruited both men and women and were included in these reviews, 65 (33%) examined outcomes by gender. Of the 65 trials that performed a gender-based analysis, 13 (20%) reported significant differences in cardiovascular-related outcomes by gender.3
In their 2010 update of Johnson's study, Doull et al. examined 38 randomly selected reviews on heart, hypertension, and peripheral vascular diseases published since 2001. As with the Johnson study, Doull et al. found that differences between men and women were rarely considered; only two of the 38 reviews presented results disaggregated by sex or gender. The authors further noted that the terms "sex" and "gender" were used interchangeably, and that reviews often reported on the populations included in primary studies in terms of "% male", without describing the remaining participants.Tugwell and colleagues examined how sex, gender, and a range of sociodemographic characteristics were accounted for in reviews on rheumatoid arthritis. The authors included all 14 reviews published between 2003 and 2008, which collectively reported on 147 primary studies. Five reviews (35.7% of the 14) and 131 primary studies (89.1% of the 147) reported the proportion of men and women included as participants at the start of the primary studies. Notwithstanding the share of primary studies reporting this information, Cochrane reviews on rheumatoid arthritis did not assess whether the effects of interventions for rheumatoid arthritis differed for men and women. The authors concluded that important differences might be missed and that systematic reviews can help to identify evidence gaps to guide future research.5
These surveys show that across different time periods and subject areas, sex and gender are not considered or reported consistently in Cochrane reviews related to heart, hypertension, and peripheral vascular diseases and rheumatoid arthritis. Future work is needed to determine how Cochrane reviews on interventions in other areas of health fare in accounting for sex and/or gender. Moreover, these studies demonstrate that there are gaps in understanding sex and gender, from the definition of the concepts to the implementation of the review methods to analyze sex and gender. Cochrane reviews have not been sufficiently sensitive to results from gender- and sex-based analyses and may have underreported relevant findings.
Moving forward to tackle these knowledge gaps, the Campbell and Cochrane Equity Methods Group develops methods for adequately addressing sex- and gender-based analysis in systematic reviews. These methods help to determine when and how sex and gender should be considered in Cochrane reviews, and ways to address them in the analysis. The Equity Methods Group also works with Canadian and international colleagues to build the evidence base on the differential effects of interventions on the basis of sex and gender.
Visit the IGH Cochrane Corner.
- Sen, G. and Östlin, P. (2008) 'Gender inequity in health: why it exists and how we can change it', Global Public Health, 3:1, 1 - 12
- Dawes M, Summerskill W, Glasziou P et al. Sicily statement on evidence-based practice. BMC Med Educ 2005; 5: 1– 7.
- Johnson SM, Karvonen CA, Phelps CL, Nader S, Sanborn BM. Assessment of analysis by gender in the Cochrane reviews as related to treatment of cardiovascular disease. J Womens Health (Larchmt ) 2003;12(5):449-57. Available: PM:12869292.
- Doull M, Runnels VE, Tudiver S, Boscoe M. Appraising the evidence: applying sex- and gender-based analysis (SGBA) to Cochrane systematic reviews on cardiovascular diseases. J Womens Health (Larchmt ) 2010;19(5):997-1003. Available: PM:20384450.
- Tugwell P, Maxwell L, Welch V, Kristjansson E, Petticrew M, Wells G, et al. Is health equity considered in systematic reviews of the Cochrane Musculoskeletal Group? Arthritis Rheum 2008;59(11):1603-10. Available: PM:18975366.