Intersections: A newsletter of the Institute of Gender and Health

Fall/Winter 2011, Vol. 3, Issue 1

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Table of Contents

Message from the Scientific Director, Dr. Joy Johnson

Sexual and Reproductive Health: Improved Decision-Making

Sexual and reproductive health is a touchy subject. When we talk about sexual health, our discussions are often skewed in the negative—risky behaviours, infectious disease, unplanned pregnancy. But sex is a positive part of who we are and part of a healthy society. When we speak of reproductive health, we tend to focus exclusively on women and pregnancy and on healthy babies. But reproductive health has implications for both men and women, and extends to issues of societal expectations, personal control and access to appropriate services.

“Sexual and reproductive health is a lens to track changes in society,” as Christabelle Sethna so aptly comments inside this issue of Intersections. This is a field where gender and sex clearly factor into how we frame our research questions as much as they influence the phenomena of study. Our notions of what constitute important sexual and reproductive health issues are bound up with our social expectations and understandings of women and men of all ages. Indeed, studying sexual and reproductive health may require uprooting entrenched gendered stereotypes about people’s experiences and behaviours to get at the real evidence.

In focusing on sexual and reproductive health as one of our strategic research directions, the CIHR Institute of Gender and Health aims to support research that contributes to the evidence base for improved decision-making by taking gender and sex into account. Numerous questions specific to gender, sex and sexual and reproductive health remain unanswered; these gaps impede our capacity to develop the best possible interventions and policies to positively support the sexual and reproductive health of everybody.

The features inside this issue of Intersections highlight IGH-funded research and knowledge translation activities that are already making headway in this direction, raising questions such as: How is it that after 50 years of “the pill” for women, there is still no comparable contraception for men? Why do we see major gender disparities in sexually transmitted infections among young people? What about men when it comes to sexual pain? How can we reduce the gender-based stigma that some immigrant women encounter in prenatal care settings? We look forward to launching strategic funding opportunities to further support excellent research in this critically important domain, with priority announcements beginning in winter 2011.

The Forgotten Sex in Sexual Pain

Yitzchak M. Binik, Seth N. P. Davis, Serge Carrier & Samir Khalifé

Had you asked us 10 years ago about painful sexual intercourse in men, we probably would have said that it is very rare. If pushed, Dr. Carrier, a urologist, might have suggested that it was the result of prostate infection and treated it pharmacologically. Dr. Binik, a psychologist and sex therapist, might have assumed a psychosomatic problem and treated it accordingly. The truth is we had been taught that this kind of genital pain—medically termed dyspareunia—was a women’s problem. These views were reinforced by a variety of gender stereotypes. “Real men” were always ready for sex. “Real men” never talk about pain.

Our research and clinical work at the time reinforced these views. Together with Dr. Khalifé, a gynecologist, we had initiated a research program to investigate female dyspareunia. This prevalent women’s health problem, though recognized in ancient Egyptian papyri, was not being addressed in modern practice. It was conceptualized and treated as either a reflection of underlying disease or as a sexual problem resulting from inadequate arousal or early sexual abuse. Our approach was to reconceptualize female dyspareunia as a pain problem to be treated by multidisciplinary teams including physicians, psychologists and physical therapists, among others. In our lab and clinics, we tested and treated hundreds of women—but we forgot about men.

It took some “new blood” to remind us. In 2005, Seth Davis joined our research team to do a PhD in clinical psychology. He proposed to do his thesis on male dyspareunia. Our reaction was less than enthusiastic and we discouraged him, saying that he could be in graduate school forever trying to get a decent sized sample. Luckily for us, Seth had read the small literature on urological chronic pelvic pain syndrome or UCPPS in men. This literature pointed out that men also suffered from dyspareunia and that, most of the time, it had little to do with the prostate.

Once Seth educated us a bit, we began to read the literature and were struck by some of the parallels between UCPPS and female genital pain. For most cases, there was no known cause or treatment. For both, the descriptive and diagnostic literatures were poorly developed. Both female and male sufferers complained that health professionals “avoided” them and tended to refer them to others saying they didn’t know what to do.

We also began to treat men suffering from UCPPS. These men shattered all of our stereotypes. First of all, there were many more men experiencing this condition than we had thought. Once we let it be known that we were interested, there was a deluge of men seeking help. The men who sought treatment were not afraid to talk about their pain or the difficulties this pain caused with their sex lives and relationships. They were also not afraid to complain about the medical system which did not know what to do with them. Most had been suffering for a number of years.

Although we were now attuned to the problem, we realized that we were inadequately prepared to deal with it. We began a research program to guide us. One of our starting points was to recognize that there might be more than one syndrome of male genital pain. In our work with women, we had focused on delineating different syndromes of female dyspareunia. For example, it was unlikely that a 25-year-old woman experiencing a burning, cutting vulvar pain during attempted penetration was suffering from the same problem as a 40-year-old woman with a dull, shooting pain felt over the right ovary during deep thrusting. Men seemed to experience similar variability. Although the most common symptom is pain associated with orgasm, there are a number of distinct locations, qualities and patterns of pain reported by men.

Think of a headache, for example. It is now commonly accepted that there are multiple kinds of headache. These different “types,” like migraine, tension, cluster and so on, are typically characterized by different pain locations, symptoms and patterns. The assumption is that that each of these syndromes is different and may require different treatment. We have made significant progress in demonstrating this in women and are now turning our attention to men. We are engaged in a study examining whether UCPPS can be phenotypically classified.

Based on our work with women and the chronic pain literature, we believe that the pain associated with male dyspareunia is multi-determined. Our biopsychosocial approach allows us to consider the different and interacting pathways which lead to this problem.

One avenue we have considered is pain threshold. Using an algometer (an instrument to measure pain sensitivity) and standard psychophysical procedures, Seth Davis recently demonstrated that pain thresholds in genital locations for men suffering from UCPPS were lower than those of men without UCPPS. While this may not be surprising, what was surprising was that lowered pain thresholds were evident in non-genital locations. This suggests that the locus of the problem may not be solely related to the reproductive organs and urinary system, but more central mechanisms may be involved.

For many chronic pain locations, the surrounding musculature becomes involved in exacerbating the pain (hence the popularity of physical therapy in relieving pain). In the case of genital pain, this surrounding musculature is housed in the pelvic floor—another focus of our work. One of the problems with assessing pelvic floor involvement is the unreliability and invasiveness of measuring pelvic floor function. Our team recently published a study on male UCPPS sufferers, showing that pelvic floor ultrasonography could reliably assess the pelvic floor function.

Specifically, men suffering from UCPPS displayed more acute anorectal and obtuse levator plate angles than controls. We are actively pursuing this work since it will provide guidance for physical therapy intervention to reduce pain, which has already been demonstrated in women.

We have also examined the psychosocial aspects of male dyspareunia. The existing studies of interference with sexuality had concentrated on disruption with ejaculation and erection. While this made sense, it went along with the male stereotype that sexual performance was crucial to men and that while pain might affect function, it would not affect desire. In fact, no one ever bothered to systematically ask men about their desire. We know that dyspareunia in women results in reduced desire—shouldn’t this occur in men, too? In addition, the existing studies of UCPPS and sexuality failed to take into account different pain locations and patterns. While it is logical that pain associated with ejaculation might greatly interfere with ejaculation, would a recurrent pain in the surrounding pubic area have the same effect?

One of the most reliable personality correlates of pain is catastrophizing or a tendency to ruminate about, magnify, and feel helpless when in pain. This results in increased pain reports and modified behaviour, an effect which has been demonstrated for numerous pain syndromes including female dyspareunia. We are currently investigating this in UCPPS. In addition, we are looking into other known personality correlates including trait anxiety and hypervigilance. Interestingly, it is not only individual characteristics that affect pain; since pain occurs in a sexual context, interpersonal interactions—not surprisingly—also have a strong effect. Paradoxically, having a “solicitous” spouse often results in increased pain. While this does not mean that spouses should disengage, it does highlight the importance of understanding more than the underlying pathophysiology.

Our research and clinical work concerning male dyspareunia is about 20 years behind the parallel work with women. This is a surprising gender twist, since traditionally women’s health concerns have been neglected. We are hoping to catch male dyspareunia sufferers up.

Yitzchak Binik received funding for “Male Dyspareunia: Vive La Différence?” through an IGH Priority Announcement in the CIHR Open Operating Grant Competition.

At the Crossroads: Healthcare Experiences of Women with Female Genital Cutting

Paula Migliardi, Bilkis Vissandjée & Gillian Einstein

What “makes” a girl, a girl—a woman, a woman? Gender is one of the fundamental ways that societies define us. Yet, what’s seen as feminine in one context may make a host of misunderstandings in another. Such tensions exacerbate the often precarious situation of transnational immigrants who may experience somatic and emotional disorders related to economic vulnerability and the processes of accommodating to new socio-cultural norms. Understanding where gender and immigration intersect, and the implications of this for the wellbeing of immigrants, is particularly important for an immigrant-receiving country like Canada. Perhaps nowhere do these factors coincide more to shape the health trajectory of some migrant women as in the case of female genital cutting (FGC) (also referred to as female genital circumcision or mutilation).

The World Health Organization defines FGC as procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs, whether for cultural or other non-therapeutic reasons. Immigration has increased awareness of FGC among native-born Canadian women and men, as substantial numbers of girls and women coming to all regions of Canada have undergone FGC in their natal country.

The origins of FGC practices lie in social conventions about what “makes” a woman. Some cultures view the clitoris as a masculine organ, and see its removal necessary to feminize the body and make a woman reproductively viable. It is also tied to moral codes of sexual behaviour that dictate women should be “pure” at marriage. Others believe it reduces sexual desire, making a woman more in control of her sexuality and enabling her to use this as a source of power in the household.

Research has documented the immediate harmful health effects of FGC in terms of uncontrolled bleeding and infection. The long term consequences are still not well understood and may vary depending on the healthcare infrastructure of the country in which a woman with FGC lives. Some of the poorer long term outcomes include vaginal infections, difficult second stage delivery, as well as menstrual and sexual pain. Ill-health outcomes may affect not only those new to Canada but also those who have been in Canada for a long time, but are slowly getting to know the healthcare system due to issues around access, lack of knowledge about how to use a healthcare system with an emphasis on prevention and a general discomfort projected by healthcare providers in caring for these patients.

Even if a pregnant woman with FGC, now a Canadian, surpasses all the steps and obstacles associated with accessing and using the healthcare system, the quality of pregnancy and reproductive health outcomes may be offset by her very interface with the system. It is not uncommon for women with FGC in Canada and other similar receiving countries to report difficult encounters including perceived negative judgements from healthcare providers. For example, a woman’s very identity, as a woman, may be questioned by shocked health workers who wonder aloud how an infibulated (procedure to narrow the vaginal opening) woman was able to become pregnant. Some pregnant women with FGC often decide not to attend pre-natal healthcare and may wait until the last minute to seek medical care services in order to avoid this distress.

Taken together, the taboo and the risk of stigma associated with FGC in Canada—not to mention its illegality under sections 267 or 268 of the Criminal Code—and women’s own cultural norms of “who goes and when to go to a doctor” severely impede access to the Canadian healthcare system for women with FGC. It has also been documented that women with FGC do not tend to avail themselves of other services such as sexual health clinics or pain management. In some of our research, we asked women with FGC about pain during daily experiences. They considered it to be negligible—just what is “normal,” what every woman has. However, when we tested these women for pain in the vulvar region, we found that all of our participants had at least one area of the vulva in which the pressure-pain threshold was lower than that for non-FGC Canadian women with vulvar vestibulitis, a chronic vulvar pain condition. This suggested to us that our FGC participants had chronic pain but to them it was considered a fact of life.

To address the disconnect between the experiences of women with FGC, the knowledge of healthcare providers and current research, the Sexuality Education Resource Centre in Winnipeg held a multidisciplinary and intersectoral workshop. The goal of the “Symposium on Female Genital Cutting (FGC): Focus on Canadian Approaches to Addressing FGC” was to move the current knowledge base forward. The workshop highlighted that despite research work and interventions which have been implemented with community partners at different levels across Canada, gaps remain with regards to more sensitive models of perinatal care for women with FGC, the specific understandings of sexual and reproductive issues among women with FGC, the benefits and consequences of the FGC legislation as it stands in Canada, the role of “harm reduction” as a strategy for FGC care and women’s own shifts in their gender roles due to immigration to a country that does not condone the practice of FGC. All of these issues were discussed and consensus is ongoing that these can be addressed only with a respectful and participatory approach linking community members, healthcare providers and researchers.

Because of Canada’s widespread immigration policies and multicultural perspective, the experience of women and their families with FGC in Canada is unique. It is in some ways more positive that in other Western countries, and in other ways disappointing, perplexing, and challenging to their sexualities, gender identities and simply their overall wellbeing.

“Symposium on Female Genital Cutting (FGC): Focus on Canadian Approaches to Addressing FGC” (principal investigators: Lisa Shannon Avery and Paula Migliardi) was funded by an IGH Meetings, Planning and Dissemination Grant. “From Body to Brain: Whole Body Experiences of Female Genital Cutting” (principal investigator: Gillian Einstein) was funded through an IGH Priority Announcement in the CIHR Open Operating Grant Competition.

Married to the Pill: Negotiating a Fifty-year Relationship

This year marks the 50th birthday of oral contraception, or “the pill”, as we know it. In 1961, when Canada’s Health Protection Branch first approved the pill for use as a prescription contraceptive, most politicians, doctors, family planning groups and pharmaceutical companies intended the pill for married women. It was supposed to help space childbirth in developed countries and control population growth in the developing world. Yet, as University of Ottawa health historian and professor Christabelle Sethna notes, since 1980, the birth control pill has been the top contraceptive used by single females aged 18-24 in Canada—so much so that awareness of other birth control methods, besides the condom, has actually decreased in this population over time.

She asks: “How did a contraceptive intended originally for married women at home and abroad become a lifestyle drug for so many young, single women in Canada?” Sethna shines a light on how history holds important contemporary lessons for women’s and men’s sexual and reproductive health. Five decades on, the pill’s influence on the reproductive lives of Canadian women, on sexual relationships between men and women and on gender relations in the economic, social and cultural realms is profound. “The pill was a lightning rod for issues such as population control, single female sexuality, unwanted pregnancy, abortion, the medicalization of women’s bodies, the impact of the pharmaceutical industry, the relationship of women to medical professionals, differences in the sexual and reproductive health needs of women around the world and the role of men in contraception. We continue to struggle with these issues today,” says Sethna.

On July 3, 2011, Sethna convened “Great Expectations: A 50-Year Retrospective on Oral Contraception,” marking the anniversary of the introduction of the birth control pill in Canada as a prescription contraceptive. The symposium was designed to coincide with an international conference, Women’s Worlds 2011. The symposium’s keynote speaker, Dr. Carl Djerassi, is credited with being one of the first scientists to synthesize the necessary hormones for the pill. Historians from Canada, the United States and England, as well as local Ottawa lawyers, doctors, social workers and community activists, explored the pill’s varied meanings and assessed whether and how the pill had fulfilled its expectations over the past 50 years.

The verdict was decidedly mixed. As Sethna and other researchers have noted, while the pill has undoubtedly afforded women greater sexual and reproductive control and fueled the transformation of gendered roles (especially in work and education), it has not reduced rates of unwanted pregnancy, population growth, or divorce to the extent predicted, and the evidence regarding hormonal side effects is anything but clear cut. Moreover, new challenges have emerged, including the ethical implications of the lifestyle marketing of the pill that emphasizes less acne and fewer periods over its contraceptive purposes.

For Sethna, history is the way forward: “The history of sexual and reproductive health is a lens to track changes in society.” Only in retrospect can we fully understand the fundamental societal transformations linked to a medical innovation such as the pill. These lessons are invaluable, Sethna contends, in helping us to forecast the impact of other health interventions and understand them in context.

When asked what to expect of the pill at its 100th birthday, University of Ottawa undergraduate student, Emma Burgess, who volunteered at the symposium, predicts that the development of a male contraceptive pill may shake matters up even more: “Though pharmaceutical companies seem to have no interest in a male pill, I believe it may be able to break through many barriers. The female pill is seen as “unnatural” since women are always expected to be fertile. If men were given the pill, the unnatural quality associated with the female pill might fade.”

The question now is, will the pill as we know it continue its transformative path into the next half century, or not?

The symposium “Great Expectations” and the history of the pill virtual exhibit are part of a knowledge translation initiative led by Christabelle Sethna with funding from an IGH Meetings, Planning and Dissemination Grant.

Who Really Gets Chlamydia?

Rod Knight

Numbers don’t lie—or do they? At least, they may not tell the whole story. Statistics from the British Columbia Centre for Disease Control (BCCDC) show that more young women get chlamydia, a sexually transmitted infection (STI), than men—twice as many (1,701.5 cases per 100,000 women, compared to 787.6 cases per 100,000 men). Yet, there is more happening here than meets the eye.

Popular portrayals about young people’s lives often use such differentials to validate a variety of gendered stereotypes. Youth we spoke with in our study about young people’s experiences with STI testing told us that these statistics probably represent something “well-known” in our society: a small number of (“lucky”) men are infecting a whole bunch of (“easy”) women. Many of these assumptions are grounded in a misogynistic rationale: “Women don’t know how to take care of themselves” and “Young women are having too much sex with older men.” Surely, there are other explanations.

The BCCDC explains in their most recent report on STI surveillance data that the higher chlamydia rates for women may be largely due to asymptomatic cases in men, which therefore remain unreported. As well, there are situations in which men treated for chlamydia may not necessarily have been tested and, again, remain unreported within their surveillance data. In other words, these data are likely over representing women’s infections, while missing the men. So the question is not, why are young women getting chlamydia more than young men, but why are young women’s infections being tested, reported and counted, while men’s are not?

Chlamydia symptomatology differs by biological sex

Biologically, there are differences in how STIs, including chlamydia, are transmitted based on an individual’s biological sex. A young woman’s cervix, for example, represents a particularly vulnerable part of her anatomy for STI infection. Symptomatically, STIs also manifest differently depending on one’s biological sex. For example, prevalence studies have shown that about 25% of male urethral infections versus 75% of female cervical infections are asymptomatic. With this three-fold difference in rates of asymptomatic infection, we would expect to see more men than women presenting to clinics with symptoms for testing and treatment, and yet this is hardly the case.

Different gendered sexual health-seeking behaviour

Some of our recent research details the ways in which young men and women seek sexual health services differently. For example, we found that when young men experience symptoms (e.g., urethral discharge), they often engage in reactive self-care, including medium- to long-term self-monitoring, coupled with some form of self-treatment. This work has also identified some of the barriers men face with testing services, frequently characterizing STI testing as a potentially sexualized encounter (e.g., fears of getting an erection during genital exams). These findings generally contrast with the views expressed by the young women in our studies who often suggest that accessing sexual health services is “just part of being a woman.”

Different routine testing opportunities

Most sexual health clinics report that just 5-10% of youth clientele are men. Critics have pointed to structural deficiencies within healthcare services and systems that focus on women’s sexual and reproductive health, while generally ignoring the needs of men. For example, annual PAP smears—an opportunity in which many practitioners will often encourage sexually active women to consider testing—are promoted from the onset of puberty with women. As a result, ongoing concerted efforts from public health frequently engage women with sexual and reproductive health services. Men, on the other hand, do not seem to be afforded similar opportunities to engage with sexual health services.

Getting treated, but not getting tested and counted

But there are also men, as indicated in the BCCDC report, who are treated for chlamydia without being tested and therefore not counted in surveillance data. How are these men being treated without being tested and reported? Again, healthcare service provision and young people’s gendered sexual health practices likely interact to influence these outcomes. While clinical practice guidelines require a test to confirm positivity for clients presenting in-person at a clinic, some youth and clinicians report instances in which antibiotics are dispensed to confirmed positive clients to bring to their sexual partners, thereby bypassing a positive count in the surveillance data. The impact that this practice may play on sex-based surveillance data is unclear; however, considering the fact that far more women are accessing testing services, it is not surprising that their partners, whether male or female, are receiving treatment through their partners, rather than engaging directly with the public health system. Our research has shown that young women often conceptualize taking care of their own sexual health (e.g., accessing STI testing services) as also representing an opportunity to take care of the sexual health of their male partners.

Re-writing the story

In exploring the gendered sexual health practices of young people, we can better understand the statistics without explanations based on stereotypes and other unhelpful assumptions. And, it would be naïve to suggest that the “actual” male-to-female chlamydia rates would align in parity. Indeed, the complexities of these sex differences in infection rates also apply to STIs in which the reverse occurs: young men experience higher reported rates compared to women (e.g., gonorrhoea, which public health largely attributes to men who have sex with men). By examining the interactions between the multiple biological, gendered and structural influences on young people’s sexual health, research can provide direction for improving access to sexual health services (e.g., improve access to STI testing for men) and/or opportunities to create more equitable gender relations for men and women (e.g., remove the responsibility for women to get tested on behalf of their male partners).

Rod Knight is a doctoral student in the interdisciplinary studies program at the University of British Columbia and a core member of the IGH co-funded Youth Sexual Health Team (principal investigator: Jean Shoveller). Research discussed in this article is drawn primarily from the Young Men and Sexually Transmitted Infections Study funded by IGH (principal investigator: Jean Shoveller).

News Briefs

Second Biannual Gender, Sex and Health Research Conference

The Institute of Gender and Health will host an international conference, Advancing Excellence in Gender, Sex and Health Research, in Montreal from October 29-31, 2012. This multidisciplinary conference will showcase leading research, feature interactive poster sessions and workshops and provide valuable networking opportunities with leaders in the field. Visit the conference website for details!

IGH Gender, Sex and Health Research Casebook

This peer-reviewed casebook will present a range of research-based accounts that illustrate how attending to gender and sex in health research contributes to advancing knowledge, strengthening science and improving knowledge translation. Written from a critically reflective vantage point, chapters will share health researchers’ experiences in how they came to understand and engage gender and sex in their work. The collection will demonstrate that there is much to be gained from the routine integration of gender and sex across the health research spectrum. Look for the IGH casebook in January 2012.

KT Monitor

Locker Room Low-down: Symposium is a Launchpad for Addressing Boys’ Body Image

Michael Kehler

The male physical body has long been emblematic of a particular valued and valorized masculinity. Often considered taboo, boys rarely speak of insecurities about the body. The current culture of masculinity and climate of homophobia in schools contributes to the suppression and silencing of anxieties about body image among men and boys. For adolescent boys, school locker rooms and gyms become masculinizing sites in which body privilege is negotiated. Those who do not “measure up” routinely compensate for this by engaging in other perceived masculine activities that often involve risky behaviours such as drinking.

With growing concerns about inactivity among youth and an apparent “obesity epidemic,” my collaborators and I organized an international symposium to address national and international responses to a relatively under-examined and misunderstood area of inquiry at the intersection of health, education, body image and gender. We wanted to bring to the public foreground an awareness of the complex and troubling concerns underlying body image issues for boys. Our goal was to coordinate an international research focus that would support and encourage future research networks responding to concerns about how body image issues in school contexts affects boys’ health.

On June 4-8, 2011, fifty researchers, teachers, health practitioners and graduate students gathered in Ottawa for the international symposium“Speaking the Unspoken: Masculinities, Bodies and Body Images in Health and Education.” This was the first event of its kind to bring together a truly international cross section of participants examining masculinities and body images in health and education. In addition to researchers in the field, the exchange of ideas encompassed a range of stakeholder perspectives including teachers from the Ottawa Catholic School Board, a presentation by the Crescent School linking research to school design and practices, as well as private agency attendees from the National Eating Disorder Information Centre (NEDIC) and the Media Awareness Network.

One of the major successes of this meeting was piquing public awareness of boys’ body image issues. The orchestration of a media outreach effort by our team heightened the profile of this symposium and the research questions addressed by our panels. From a front page story by The Ottawa Citizen to CBC coverage on 16 rolling morning show interviews across Canada to National Post coverage, one of our primary goals of opening up a dialogue about masculinities, body images and education was quickly realized. While our “media moments” strategy was aimed at initiating, disrupting and motivating the public to engage with this topic, we certainly did not anticipate the overwhelming response—especially the 6:00am spot on CBC starting with Tim Belford in Quebec City, followed by Thunder Bay, Corner Brook and Whitehorse on the first morning of the symposium! There was no better way imaginable to launch our symposium than speaking across Canada hours before our first keynote, Michael Messner from the United States, took the podium. From the morning flurry of cross-country interviews to the CBC All in a Day afternoon program with Alan Neal, we were thrilled with the media response.

The symposium provided a rich context in which to further develop a scholarly community as well as forge new relationships with teachers and health professionals on the national and international scene. New collaborative work is emerging with scholars from Australia, the UK, and the US with upcoming grant applications and a book proposal in the works. We are confident this initiative has jumpstarted the momentum—in the public psyche, on the research front and across sectors—that will challenge boundaries, limitations and freedoms that are routinely misunderstood at the intersections of boys, bodies, health and education.

“Speaking the Unspoken” was funded by an IGH Meetings, Planning and Dissemination Grant (principal investigator: Michael Kehler).

Trainee Spotlight

4 Questions for Lyndsay Hayhurst

International development initiatives are increasingly becoming “girled.” Recent global campaigns such as the “Girl Effect” and “Because I am a Girl” are examples of crusades that promote “the girl” as the next tenable solution for the development problems of our time. Under this banner, interventions, often funded by multinational corporations, use physical activity and sport to build girls’ potential as “agents of development.” University of Ottawa postdoctoral fellow Lyndsay Hayhurst critically explored the impacts of the Girl Effect for her recently completed doctoral research on one such program with young women in Eastern Uganda. Lyndsay was a participant at the 2011 IGH Summer Institute.

In Brief:
  • Hometown: Toronto, ON
  • Last book I read: A Fine Balance by Rohinton Mistry
  • Favourite food: Hummus
  • My motto is: “Life is not a dress rehearsal” and “Stay hungry, stay foolish”
  • A little-known fact about me is: I love to sing.
  • When I am not at my computer, I’m most likely: running/biking/swimming/walking my yellow Labrador puppy with my husband.
  • Something I would like to try once is: Climbing the Seven Summits of the world!
What is the logic behind the Girl Effect?

The Girl Effect is becoming a growing global movement that assumes young women are catalysts capable of bringing social and economic change to their families, communities and countries, particularly in the Global South. For example, proponents argue that investing in a girl’s health and education will increase her family and her country’s economic prosperity, using statistics such as, “when an educated girl earns income she reinvests 90 percent in her family, compared to 35 percent for a boy.”

How did you first become interested in this topic?

While working as a consultant at the United Nations Development Programme before I started my PhD I noticed how multinational corporations were increasingly gaining more authority and power over how international development interventions are governed, including those promoting the Girl Effect. I immediately became interested in what the implications of Girl Effect programs were for the presumed “targeted beneficiaries”—that is, the girls themselves.

What are the health implications of the Girl Effect?

They are clearly gendered. In the program I studied, for example, the onus seemed to be on these young women to change their behaviours, actions and attitudes in order to achieve gender equality, while ignoring the need to enlist men and boys in accomplishing this same feat. There was minimal attention, for instance, paid to the ways that shifting gendered dynamics and gendered expectations were both limiting and expanding opportunities for the girls due to their participation in the program. I also think that Girl Effect programs tend to ignore the myriad structural constraints that operate in the lives of the girls (for example, poverty) that may prevent them from fully benefiting from its intentions, namely improved health and wellbeing. The general assumption remains that girls have the “simple choice” to participate in these programs: actively participate, and the benefits will follow. But this ignores the fact that such choices are being made under oppressive (and highly gendered) social structures and institutions. On a positive note, the sport, gender and development program I studied seemed to successfully encourage the girls to become educated, employable and confident young leaders ready to take on responsibility for their own development and health. It’s important to highlight the positive gains made by this program, while also recognizing ways that it might be improved.

Who needs to know about the results of your research?

I am writing reports that summarize my findings for each of the organizations and the young women involved in my research. I also hope to organize a webinar as a starting point for disseminating my findings across multiple audiences and stakeholders, including staff from the UN, private sector, non-governmental organizations and academics. I am continuing to explore the Girl Effect and its health implications through a postdoctoral fellowship at the University of Ottawa, and hope to use participatory video and photography to engage young women in the research processes and outcomes.

IGH Cochrane Column

Sensitizing Systematic Reviews for Sex/Gender, Equity and Bias: Some Challenges

Vivien Runnels, Marion Doull, Sari Tudiver and Madeline Boscoe

Systematic reviews are designed to evaluate the effectiveness of interventions in health and policy by gathering and analyzing evidence from multiple primary studies. Patients, practitioners and others consult systematic reviews for evidence-based recommendations that are applicable and context specific. However, systematic reviewers encounter challenges in acquiring and synthesizing data in relation to sex and gender, which in turn have implications for methods bias and equity in outcomes. We report here on some of these challenges synthesized from responses to a questionnaire developed by our Working Group on Sex and Gender in Systematic Reviews that was circulated to colleagues with interest and expertise in systematic reviews prior to the meeting “Combining Forces to Improve Systematic Reviews: Gender, Equity and Bias” (Ottawa, ON, May 2011).

Conceptual challenges

How a problem is framed, conceptualized and ultimately researched is determined by decisions made early in the systematic review process. Upstream decisions shape the production of knowledge including determining when to investigate sex and gender differences, when to factor in questions of equity and how to address potential issues of bias in trial design. However, these decisions can only be made on the basis of pre-existing knowledge. Conceptual challenges include lack of understanding the distinct, but interrelated concepts of sex and gender, lack of awareness about potential sex/gender-based differences and the importance of equity for health interventions, research and outcomes.

Methodological challenges

Assessing sex, gender, equity and bias in systematic reviews presents numerous methodological challenges. These include: poor quality protocols; lack of transparency of clinical trials and the resultant inability to determine whether outcomes and analyses were specified a priori; difficulties in completing robust subgroup analysis when there is under-representation of those from disadvantaged groups in the trial population and when published studies do not provide sex-disaggregated data. These limitations suggest a need for appropriate guidance and training for researchers, systematic reviewers and the broader research community (e.g., journal editors, publishers, funders).

From concepts to methods

Overall, colleagues emphasized that a lack of conceptual clarity is interconnected to, and iteratively feeds, methodological challenges. This laid the basis for discussions at the “Combining Forces” meeting where we identified a need for indicators for gender and other health determinants, and for guidelines for how to achieve quality sex/gender analysis within reviews and for theorizing how to interpret generalized data for diverse individuals and groups. Together, we pointed to the value of highlighting gaps in evidence even if appropriate sub-group analyses cannot be carried out and noted that a lack of tools, checklists, and/or outlines for conducting sex/gender analysis in systematic reviews creates a challenge for methodologists unfamiliar with the concepts of sex and gender in particular.

The conceptual and associated methodological challenges that the inclusion of sex, gender, equity and bias can present for systematic reviewers have limited the uptake of these issues and their associated analyses into reviews. Addressing the challenges by developing methods and tools to facilitate and build critical capacity has significant potential for enhancing the applicability and the quality of the evidence to achieve better health outcomes for all.

The authors thank the participants at the “Combining Forces” workshop whose thoughtful input allowed them to contribute this column. “Combining Forces” was funded through an IGH Meetings, Planning and Dissemination Grant.