Sex and Gender Equity in Research Reporting (SAGER)

Full Transcript

Institute of gender and health webinar by:
Dr. Cara Tannenbaum; Dr. Jennifer Zelmer; Dr. Jackie Gahadan

Decembre 2016

Dr. Cara Tannenbaum: Great. So this is our agenda for today. My name is Cara Tannenbaum. I'm the Scientific Director of the Institute of Gender and Health for CIHR.

And joining me today to debate with me about why we should or should not adopt the SAGER guidelines are Jennifer Zelmer, whom you've just heard. Jennifer is Editor In Chief of healthcare policy and also affiliated with the University of Victoria.

And I also have Jackie Gahagan, who is joining me as the Policy Editor for the Canadian Journal of Public Health and she's calling in from Dalhousie University.

So Jackie, Jennifer, you're both online; correct?

Dr. Jennifer Zelmer: Yes.

Dr. Jackie Gahagan: Yes.

Dr. Cara Tannenbaum: Thank you for joining me.

Now we had a number of people confirm and I don't want to put people on the spot. I could certainly read out people who definitely said they were going to be here.

We often have more people call in, so if I don't mention you then you can speak up or you could sit quietly and let me know afterwards that you participated.

So we have representatives from CMAJ with us today, the Canadian Journal of Experimental Psychology, Health Promotion and Chronic Disease Prevention in Canada, the Canadian Association -- I think it's Nephrology Nurses and I'm not sure what the T is, the CANNT Journal, Journal of Medical Internet Research, Pain Research and Management, Journal of Psychiatry and Neuroscience, the Canadian Journal on Aging -- which is one of my favourites just because I was a Health Editor for that journal at one point in my life. We have the Clinical and Experimental Obstetrics and Gynecology Journal. We have a number of university delegates on the line and a number of other journals that told us that they would try to call in, but I'm not sure if they're on the line.

So thank you very, very much for joining us. This is our second webinar. Last week we had a number of other journals join us and I guess I would say congratulations to you. You were selected to join us.

Not all journals in Canada receive this invitation. We extended it to the top 50 Canadian medical science journals, so you got on our list. Congratulations. And that's why we are excited to be speaking to you first and foremost here today.

What I hoped we would accomplish is go over and make sure that you're aware of what the SAGER guidelines are, then maybe here an editor's view.

Jackie is going to talk to us about her successes and challenges in adopting the SAGER guidelines for the Canadian Journal of Public Health.

I think then Jennifer is going to ask some provocative questions about why it might be difficult and how you might want or not want to adopt the guidelines and then if anyone does decide to endorse or go ahead with us -- and I'll try to convince you why I think it would be fabulous if you did adopt these guidelines, we'll talk about steps you can take and then the last half hour will be reserved for questions and discussions.

So that's the agenda for today. Jennifer, should I let you maybe poll who's with us before we begin?

Dr. Jennifer Zelmer: Thanks very much, Cara. So we'd just like to get things started. We've got a number of polling questions throughout the webinar. The first one is really to give us a better sense collectively of who's on and joining the conversation today.

You'll the poll options on the right-hand side. Please click all that apply, because we know that many people actually have multiple hats that they wear and then when you're finished with checking all that apply, please click the submit button at the bottom right-hand side of your screen.

So we'll just give you a few seconds to identify all of the various roles that you hold.

Dr. Cara Tannenbaum: And of course you should mention, Jennifer, that this is completely anonymous and there's no way that we can track who says what.

Dr. Jennifer Zelmer: Thank you, Cara.

Dr. Cara Tannenbaum: So I think we're just on our final seconds' countdown and the result should be popping up in just a second. There they are.

Dr. Jennifer Zelmer: There we are. So we can see that we've got quite a mix of people on the call today. Definitely a preponderance of journal editors, but also folks who come from more than one environment, because definitely with the numbers on the screen that you can see we've got a mix. So we've got a number of people who also serve as peer reviewers and as authors.

So welcome to all of you, whichever role you're holding. Cara, back to you.

Dr. Cara Tannenbaum: Great. So the SAGER guidelines, the acronym stands for Sex and Gender Equity in Research.

I'm speaking to you today as the Scientific Director of the Institute of Gender and Health and Canada actually has a designated seat on the Gender Policy Committee of the European Association of Science Editors.

And we've been working with the Gender Policy Committee for a number of years now, actually, to produce the Sex and Gender Equity in Research guidelines and I'm pleased to report that as of this summer they are now included in the Equator Network Library.

So before I tell you what they are, Jennifer, I think you're going to ask who's heard of them before they received our invitation?

Dr. Jennifer Zelmer: I have -- I am indeed going to ask that and I will remind you of what Cara just said, which is that this is confidential.

So it's really to give us a sense of the current communication status around the guidelines and where we may already have communications out and where we may not.

So if you can help us by completing the polls I think we'll be showing the results in just a second.

Dr. Cara Tannenbaum: Yes, I think for some reason we have a timer on it. So we have 10 seconds left and I'm watching the countdown and we're almost there, so stay tuned guys. I'll see if I could make that countdown faster.

Dr. Jennifer Zelmer: There we are. So a few people had heard but the majority had not yet before the call.

So really glad that you're on the call today and hopefully even for those of you who have heard about them previously there will be some new information on the call as well.

Cara, back to you.

Dr. Cara Tannenbaum: So with everything that's going on at CIHR these days, why did CIHR think it was important to reach out to you today and talk about the Sex and Gender Equity in Reporting guidelines and the answer is of course because sex and gender matter.

And yet, sex and gender differences are often overlooked and underreported in scientific research design, implementation and reporting, as well as in scientific communication.

This not only limits the generalisability of research findings and their applications to clinical practice, in particular for women, but also for men and for gender diverse people.

So I guess the question is do we know why CIHR thinks this is important.

Now of course sex and gender has been a constitutional issue dating back to the 1980's here in Canada, but it was really in 2009 where the policy statement for the health portfolio of which the Canadian Institutes of Health Research is a part, was I guess released and encouraged to be implemented.

And you could all read on the slide that it's actually the policy of the Government of Canada's health portfolio to use sex and gender based analysis to develop, implement and evaluate the health portfolio's research, programs and policies that address the different needs of women and men.

The way CIHR operationalised this policy was by asking questions on, I guess, the proposals when people submitted grant applications.

And many of you, I'm sure, have submitted grants to CIHR. You may recognize the question are sex, biological considerations, taken into account in this study; and are gender, sociocultural considerations, taken into account in this study. If yes, please describe how they'll be considered and if no please justify why not.

And of course, we do have the "no" there, because there's some basic science research, as well as human studies, that are only performed in one sex.

And here I think for men if someone is researching prostate cancer or in women if someone is looking at ovarian cancer, then clearly it may not make sense to study both sexes.

However, even in sex specific studies, gender which are the sociocultural considerations around an issue -- and we'll talk a little bit about our definition in a second, can be considered and that's why that box is still there even if you're studying a sex specific condition.

So why are we holding this webinar today? We're holding this webinar because there's really been growing momentum on accountability for making sure that the publicly funded dollars that are invested in research truly yield results that are applicable to men, women, boys, girls and gender diverse people.

You'll see on the screen that we put a hodgepodge of different, I guess, journals, editorials and even public media accounts, of how the public is clamouring to make sure that we hold scientists accountable for conducting and reporting research appropriately.

So in the top left-hand corner you'll see the view point that I published with the Director of the Office of Research on Women's Health at the NIH about two weeks ago, where JAMA has now officially endorsed new guidelines and standards for reporting sex, gender and sometimes both in clinical research.

When we wrote this viewpoint we actually titled it "Table 1: Should you be reporting sex and gender", because people often conflate the terms male, female. Was it men/women who were studied, have you actually measured that, did you do karyotyping to see if they were genetically XX or XY, or was it self-report and how of course do we measure gender.

Sometimes there's a two question, sort of, protocol that's now being recommended, which is "what is the sex you were assigned at birth" and "how do you report your gender identity". So these are all issues that we debated in the JAMA viewpoint article.

The Lancet has also been a huge proponent of raising the bar on incorporating sex and gender to inform policy and practice, and this falls under their reducing waste in research policy.

For those of you who aren't aware of that, which is really, I guess, that highlighting that even if a study is not powered to look at differences, it's important that results be disaggregated so that meta-analyses can be used and that none of the data was wasted when humans especially were included in clinical trials.

You see the "do women ever respond differently than men to prescription drugs", this was in the Globe and Mail.

Chatelaine even published an article this year about how medical research has failed women and you could see CBC News and more articles from the Globe and Mail.

So not only in government, in science, but also the general public is really starting to ask the question are the drugs that I'm taking -- were they truly tested in men and women, do we know answers.

When we study dementia, we know that more women suffer from dementia, is the research that's being conducted applicable to both men and women.

These are the kind of questions that people are asking and which we feel at CIHR that we want to contribute to finding the answers for.

So, back to the SAGER guidelines. Who is the target of the guidelines? Well it's you, I guess, everyone on this call, editors, authors, reviewers, funding agencies -- and I'll go through them in a minute and tell you what the guidelines are.

And I've already told you that they were developed by consensus from representatives from 10 different countries and this webinar series is for Canada, but there are other webinar series that are currently being disseminated in Europe and elsewhere.

So the three main points of the guidelines, if you want me to distill it down to one slide, although I do encourage you to read them in their entirety, is that authors should use the terms "sex" and "gender" carefully to avoid confusing both terms and I'll walk you through some details later on in the webinar.

The second point is that where the subjects of research comprise organisms capable of differentiation by sex, including humans, the result -- the research should be designed and conducted in a way that can reveal sex related differences in the results, even if these were not initially expected, so disaggregation by sex.

And third, where we also can differentiate by gender the research should be conducted and reported at this additional level of distinction.

How? By making sure that authors use the correct terminology, by making sure that the methods for how sex and gender were reported are in the method section of the paper and to make sure that the raw data is disaggregated by sex and or gender where applicable.

In the guidelines, we go through recommendations for each section of the article. We have recommendations for editors, should they choose to screen submissions at the submission stage.

In other words, if you immediately turn to table 3, which is usually where you report the results of the study, if there's no disaggregation by sex would it be up to the editor at that point to return the article to the person who submitted it to and say please read our instructions to authors. We only publish papers that disaggregate by sex or gender, or please explain in your letter to the editor why this has not been done.

So those are the kind of things that we, you know, recommend in the SAGER guidelines. There's other options, but those were just some examples of how you might want to operationalize the guidelines.

I think I told you that obviously, we're going to be promoting the guidelines not only at the scientific reporting stage, but also they're going to be posted on the CIHR website for those submitting protocols because, of course, what editors tell me when I have this conversation, is how could they possibly insist that scientists disaggregate by sex, or if we were looking at biomedical researchers, include males and female animals, if they didn't receive funding in the first place.

How to find out more? We'd be happy to send you the link for the full article. There is a flyer. You can check the EQUATOR Network.

We also have a number of editorials that have been published. And to indicate your support for the guidelines, if you haven't done it already, we're looking at worldwide endorsement for, you know, I guess improvement of equity in scientific reporting in this area and we would encourage you to do that.

So I think Jennifer is going to go over these in a little bit more detail further on in the call, but we want Canada to be a leader.

We really would like, when push comes to shove, the Canadian editors are insisting, and supporting, and encouraging disaggregation by sex and gender in scientific reporting.

We would love for the guidelines to be adopted in the instructions to author section. We would love to showcase the efforts that you see, if this is something that you're interested in doing. And we have a number of tips and tricks as we progress on the call and we debate how you could actually do that and how you could bring everyone on board on your editorial team, to work together in a way that's adapted to and that would work for your journal.

So I think that takes us to the -- well how does this work in practice. Jackie, can I pass it over to you and you can tell us a little bit about your experience?

Dr. Jackie Gahagan: Yes, absolutely. I'd like to start by thanking Cara and her team for inviting me to be part of this CIHR Institute of Gender and Health webinar on the SAGER guidelines. I think this is a very important and timely discussion.

As many of you may know, the Canadian Journal of Public Health is dedicated to fostering excellence in public health research, through scholarship, policy and practice.

And it does this in part through publishing current evidence in public health, which is meant to help inform public health policy and practice responses.

So as a member of the Canadian Journal of Public Heath Editorial Board I was invited by CIHR Institute of Gender and Health to their conference in 2012, to speak about the sex and gender editorial policy of the Canadian Journal of Public Health, which is interesting because at that time we didn't actually have one.

So while we didn't have an editorial policy formalised at that point, following the conference I did develop one in conjunction with members of our journal editorial board and I'm pleased to note that the Sex and Gender Editorial Board has now been formally adopted by the Canadian Journal of Public Health, so a little success story.

The key challenges, however, in making this shift happen was really around the perception of the additional work that this might cause staff of the journal, the potential burden on reviewers, the need for training of editorial staff and reviewers on exactly how to implement the new policy.

And an additional concern in the case of the Canadian Journal of Public Health was in re-formatting the online submission system to include the required questions on sex and gender in order to mirror the questions that CIHR currently ask in their applications for funding.

So I'm using the bookend analogy. The idea is essentially to close the gap between the formulation and funding of research studies that look at sex and gender and the peer reviewed published journal articles to emerge from this research in such a way that it takes into account, again as Cara pointed out, where applicable, the sex and gender based differences in research findings.

So if we understand the evidence based in published health journals, such as the Canadian Journal of Public Health, as an important way of informing healthcare decisions such as healthcare policies and practices, I think we can all agree that including sex and gender considerations where applicable simply makes sense for better scientific evidence in which to inform our decisions in advancing public health.

And now I will turn it back over to the straw poll number 3; Jennifer?

Dr. Jennifer Zelmer: Thanks so much and thanks for sharing your experiences.

We just wanted to get a sense at this point in the call, in terms of where everybody on the call is at, in terms of supporting the adoptions of SAGER guidelines. Basically, whether we've convinced you already or whether there's more work yet to do.

So if you have a chance to complete the poll that's on your screen that would be very helpful.

So "yes" to support, "no", or "not sure yet", "need some more information", "need to think about it". And I believe Rachel will be bringing up the responses in just a few seconds.

There we are. So overall -- and our numbers in the denominator have also gone up, because we've got a couple people who joined us along the way, so welcome to all those who have joined.

A number of people are already convinced and a number are not sure and the fortunate thing is there's nobody in the not convinced column, so that's great.

Cara, back to you.

Dr. Cara Tannenbaum: Great. So I guess the question is why not adopt and the answer I get when I ask that question is because does sex and gender really matter in health research and more specifically does it really matter in the discipline area or, I guess, expertise that my journal reports on.

So to make sure we're on the same page, the Institute of Sex and Gender has clear definitions for what is "sex" and what is "gender".

That every cell is sexed and every person is gendered. And here by "sex" we mean the biological attributes of humans and animals including physical features, chromosomes, genes, hormones and anatomy.

And when we talk about "gender" we talk about socially constructed roles, behaviours, expressions and identities of girls, women, boys, men and gender diverse people.

Gender could be related to healthcare seeking. I know we have some people from Psychiatry on the call today, so I always like to ask the question are, you know, are women diagnosed more frequently than men with depression and of course the answer is yes, women are diagnosed more frequently but four times as many men commit suicide.

So just because they're diagnosed and seek care for that doesn't mean that they necessarily suffer from depression more than men.

Again, that would be possibly a gender related, I guess stigmatisation for men about seeking mental health, I guess, care.

So in genetics this plays a role because the X chromosome has 1,669 genes. I like to say the little Y chromosome only has 426 genes and there was a publication a few years ago, which talked to a number of researchers where only 33 percent of -- genome wide association publications included the sex chromosome, because of the different sizes it was actually harder to include them in the essay and look for associations. Which means that two thirds of our research in genetics actually wasn't looking at sex specific associations.

In terms of obstetrics and gynecology, in terms of maternal fetal transmission or developmental origins of chronic disease, we now know that what's transmitted through sperm, both genetically and epigenetically plays an important role in outcome. So here's where genetics would definitely play a role.

In terms of biology I have on this slide the landmark paper from Mike Salter and Jeff Mogil's group, which showed for the first time in history that chronic pain was actually mediated by different immune cells in the body, which is simply ground-breaking in my mind, because it means that maybe we should be developing different therapies for men and women to treat pain.

And here's a paper by Louise Pilote's group where she asked, you know, is it really sex or gender that leads to early heart disease and poor outcomes after heart disease in men and women.

And she was able to show in the Journal of the American College of Cardiology, that gender was more predictive than sex in acute coronary syndrome outcome.

Now you could say well how do you measure gender? Well she very innovatively -- and there's been a number of research -- researchers who have been looking into how to do this, created a gender score using the following seven variables that correlated with sex, but actually represented gender.

So status of the household primary earner, this might be a gender role, personal income, number of hours per week doing household chores, status of the primary person responsible for doing the housework, the level of stress at home and again sexual inventory calculating your masculinity score, are you more aggressive, assertive, typically or stereotypically masculine traits, and a femininity score, are you nurturing, are you supportive.

Again, this is stereotyped and a lot of people, you know, think there's a better way of measuring gender, but this is how this research group did it and what they showed number one, is here on the Y axis you see the proportion of men and women who on the X axis distributed according to feminine characteristics, masculine characteristics or both, and as you could see there's no one to one correlation between the two.

Which meant that in multivariant analysis it was possible to actually look at sex and gender differently.

And on the left side of the slide here, what this group showed was that there was no difference in outcomes after acute coronary syndrome, such that 3 percent of men and 3 percent of women -- it should probably actually say males and females here, had poor outcomes.

And yet when they looked at recurrent acute coronary syndrome symptoms by gender, they were able to show that gender, feminine gender, increased the risk of poor outcomes almost two-fold compared to masculine characteristics, which is fascinating and opens up the question of well why is that.

Is it the way we metabolize stress and how of course do you then -- do messaging knowledge translation and interventions around gender, but in a personalized health approach this is something that we need to be asking and we're therefore, just so you know, at the Canadian Institutes of Health Research, now encouraging researchers to learn how to appropriately measure gender.

Even if you're using an administrative database we have three online training modules, which allow researchers and reviewers to familiarize themselves with different methods for measuring and analyzing gender and I think what we'll find is that the results will be fascinating and will lead to better evidence based practice and policy.

So I definitely think it matters. There's an entire institute at the Canadian Institutes of Health Research dedicated to this, so hopefully I've convinced you this matters too. Jennifer, you want to take question number 2?

Dr. Jennifer Zelmer: Sure, thanks, Cara.

So this is a question that came up. I'm Editor of healthcare policy and the realities is -- the reality is that many of us are undertaking these roles with other things on our plate, let's just say.

And so one of the questions that's come up is look I'm busy, how can we make this easier to do.

There are a number of tools and resources that have been developed to try and simplify the implementation process. There's a model statement that you can see on your screen that's also available, part of the electronic tool kit that can be inserted into instructions for authors, or instructions for reviewers.

The tool kit overall also includes a number of other resources. So there's a one page flyer to provide an overview of the guidelines, there's a bunch of journal editorials, the ones that Cara mentioned earlier and some others, to give you some starting points in terms of what was the thinking of other editors who have moved down this path.

And in addition to the model statement for the instructions for authors, instructions for reviewers, there's also other lengths to the full guidelines and other resources.

In addition, there have been some questions around well, you know, does everybody either on my editorial board or all of the reviewers have the background to actually be able to appropriately provide thoughtful commentary or appropriately judge whether the guidelines are being followed, and fortunately there's a series of free online training modules from CIHR, the links are in the tool kit, that provide that foundational knowledge.

So things like sex and gender in biomedical research, if your journal is more focused that way, sex and gender in primary data collection of humans, some of the kinds of issues that Cara was talking about in terms of how do you measure what kind of approaches might you use. And also, sex and gender in the analysis of data from human participants. How might you think about and present data in a meaningful and useful way.

And you can see the -- what the bottom of that screen that provides you the link to all of those resources.

And Cara, back to you. This is also another question that has come up. Why is this the job of journals.

Dr. Cara Tannenbaum: I think it's the job of everyone.

You know, we have a scientific ecosystem here in Canada and that includes researchers, funding agencies, research ethics' boards, journals and science editors, the reviewers and the users of evidence.

So at CIHR we're doing what we can. We are asking researchers to justify and explain how sex and gender are being included, but -- and I'm just going to say this frankly, except for the end of grant report CIHR just has no way of holding researchers accountable for actually conducting the research and reporting what they said they would do.

So that's where the research ethics boards come in. We've been in conversation with a number of different ethics boards, including the Combined Health Canada and Public Health Agency of Canada Ethics Boards. And working together that ethics board has now made a submission form to make sure that sex and gender considerations are being considered when researchers submit to ethics.

And this could include well how are you going to recruit sufficient numbers of men and women to the study, because of course recruitment is sometimes different.

How are you going to do the messaging, are you taking into account gender related factors such as who is going to be conducting the interviews if it's qualitative research and in animal research are you studying both sexes.

In terms of the journal and science editors, we have a number of journals already that have really cracked down on this and it makes for better science.

I recall one story from an editor of a journal in the United States where -- I can't remember exactly, I think it was a cancer related study where the author used mutated immortal cell lines and the editor wrote back and said well what sex of the cells did you study and the author wrote back and said well we buy our cell lines and because they're mutated I can't really tell you and -- but this is common practice just to say where we got the cell lines from.

And the editor wrote back and said well I think we want you to report what the sex of the cell was and they said are you serious, you know, I can't -- the company can't tell me and the editor said so why don't you just karyotype the cells, look under a microscope and see what the chromosomal content is and in the end the author actually went and did that and came back.

So the -- you know, I don't want to pass the buck, but in a way journal editors have the most power over what actually gets reported and used out in clinical practice.

And, of course, tongue in cheek, the reviewers for journals are probably the same people who sit on the research ethics boards, who are probably the same people who review for CIHR, who are probably the same people who submit and do research in the first place at some point in their life.

So I would say that increasing capacity across the board would serve everyone all together.

We're very committed to working with you and I'm hoping to hear some questions from you about how we can help, but this is a team effort. If we don't work together then we won't be as successful, than if we work individually on this in Canada.

What about implementation issues? Jackie, I don't know if you want to tackle this one.

Dr. Jackie Gahagan: Yes, sure. Thank you, Cara.

So just a couple of things to think about around implementation issues and as Cara pointed out it's kind of everyone's job -- or everybody has a role to play, rather, in making sure that sex and gender are reported.

So just as I mentioned earlier there are some practical issues to consider when implementing sex and gender editorial policies that even includes things such as whether or not the parent journal already has such a policy.

Where this is not the case it may require some discussion with the editor in chief, as well as the editorial board, about current guidelines to authors and how best to phase in a sex and gender requirement.

It's also important to note that there are a variety of sex and gender modules, as Cara has pointed out, and related information that is freely available from the Canadian Institutes of Health Research, Institute for Gender and Health on their website, and those certainly can be used for training purposes including the development of a reviewer template.

So while some people may suggest that sex and gender reporting and health research is not relevant for their particular journal or to their particular field of study it can be argued, as Cara has nicely done, that every cell is in fact sexed and every person is gendered, so clearly discussions with editorial board members about the possibilities and the parameters of their journals is a key place to start in implementing a sex and gender editorial policy.

And as indicated in the SAGER guidelines, the initial screening of submissions to determine if sex or gender is relevant to the topic is a great place to -- a great place to start.

And I'm going to just turn it over to Jennifer to see if there's anything else that she'd like to add around the issue of implementation.

Dr. Jennifer Zelmer: I think one of the other questions that came up when we were implementing was how can we make sure we're being true to what we say.

So where were the places in our process that we needed to insert either information or checkpoints.

So things like for us the reviewer template was a great place to be able to do that. We've also made some changes in our work flow as a journal to make sure that we were following through on the implementation of the guidelines. That was another sort of very practical question that came up for us.

So maybe this is a good segue into so what can you actually do, beginning right now, if you're sitting at your computer and you wish to take those initial steps.

As Cara mentioned there's an international site that's being compiled of leading journals who are indicating their support. It can either be you as an individual, as an editor, as a publisher or on behalf of your journal at this stage. And you can see the website there. It's a very easy click and submit type of a process.

It's also, obviously, we hope that people will move forward and adopt the guidelines.

One of the obvious places to do that is in your instructions for authors in terms of the actual implementation process, but depending on the journal you may have other sources, other approaches that you maybe also be able to use to reinforce the implementation of the guidelines.

We encourage you to tell us as a community. Specifically, to tell CIHR who is also interested in sharing the news about Canadian journals who are leading the way in adoption and you can see Rachel's e-mail on the screen here, so please slip a note as you proceed down this path.

And we're also interested in your experiences, so were there are things that would have made it easier or maybe that got in the way of your adoption. What can we learn from your experiences in moving down this path to be able to share with others.

There are opportunities in the practical process of both screening initial submissions and looking at how to encourage peer reviewers.

There's the resources available in the tool kit to help you to support you in doing that, including training the editorial staff in your community.

Some will already be well up to speed and well involved, others may just need a little help to be comfortable and confident in assessing articles relative to the guidelines.

So with that overview we welcome any thoughts, questions, discussions -- discussion points that you may have. Either feel free to send a message to everyone on the chat, you can do that in the bottom right-hand corner of your screen, or I think there's probably not so many people on the phone today that we can't also just have people jump in.

But Cara, I mean you probably have some questions and comments come in as we've been talking so you may want to start off the process.

Dr. Cara Tannenbaum: I mean one question is how do you get everyone on board, especially in Canada there's often a virtual editorial team, where different associate editors are located across the country and there may or may not be regular Skype calls or phone calls.

Jennifer, I think you had an experience with your annual editorial meeting about raising this. Do you want to maybe tackle that question? How do you get the entire editorial team on board?

Dr. Jennifer Zelmer: Sure, so for us it was a natural opportunity. Once a year we do either get together well as a quasi combination of physical and virtual as an editorial team and so it was an opportunity for us to circulate information about the guidelines before hand, give some options for how to address.

We had a really meaty conversation amongst us in terms of what this would mean for the journal, different considerations in terms of how we might implement and we were also actually able to drive feedback back to the overall process in terms of some of that conversation as well. So it was a great opportunity for us to have a policy discussion as an editorial team.

Another journal I'm involved in will probably need to do it more on an even virtual basis, because we don't have that same kind of opportunity. So I think there's a variety of approaches that may work depending on the journal and how you tackle these kinds of questions.

Dr. Cara Tannenbaum: Anyone on the line want to ask a question or raise an issue?

MS.PATRICIA BOX: It's Patricia Box here. So I'm a little bit new to these guidelines, so I'm just wondering so in the journal instructions to authors what would be the minimal requirements that you think would be the important points to ask of people for, you know, with regard to their submissions, to follow these guidelines?

What are the major points again, if you could -- I'm just trying to think of then what would be the practicalities of implementing those.

Dr. Cara Tannenbaum: Sure, I could review those. So I think that -- well if I could come back to the three principals.

One is to use the terms "sex" and "gender" correctly. And here, for instance, in a lot of biomedical research we see an abstract thing like, I don't know, the CD4 count of the, you know, male mice was higher in response to, you know, the vaccine than the female animals, so gender differences were quite significant.

Well I don't think the mice had genders. So right away the term "sex" and "gender" was not used correctly there and we would, you know, ask reviewers to say please correct the term in the abstract to read sex differences. So correct use of the terms "sex" and "gender", number one.

MS.PATRICIA BOX: And then -- then for humans then in differentiating sex and gender would you -- would you require that they actually had differentiated by that two-question definition that you had, you know, talked about about what were you assigned at birth and then what do you identify as or do you just always use gender for humans? I'm not sure what you would be looking for there.

Dr. Cara Tannenbaum: That's a great question. Certainly, if we were talking about gender identity, for instance if someone submitted a paper on transgender youth and the risk of suicide in this population, then we would ask well how did you measure gender identity and I think it will be up to the reviewers to look at the method by which gender identity had been measured.

So gender identity is if you, you know, if you were born female that you feel more along a continuum of being male at certain times in your life that would be gender identity.

Do I think that needs to be defined for every article? Absolutely not. And is -- do we always have to use gender in humans? Absolutely not.

If we were looking at creatinine clearance in men and women, we know that creatinine clearance or kidney function actually differs by sex. There's even an equation showing that, you know, that reflects the fact that women have smaller kidneys and fewer nephrons and you need to adjust for sex because it's biologic when you talk about creatinine clearance.

So I think that number one use the term "sex" and "gender" correctly. Sometimes "sex" would be appropriate. If you are looking at sex hormone differences, if you're looking at body size, if you're looking at other, you know, estrogen and testosterone and the fact that, I don't know, testosterone adds – you know opioids suppress testosterone. That's a sex difference in men, but not in women.

And then gender if you were measuring different constructs of gender like gender identity, gender roles, gender norms and institutionalised gender.

And this is why we actually recommend that people go take the courses so that they feel comfortable and confident when they use the terms "sex" and "gender".

That would be the first thing that we would operationalise in the instructions to authors, though it might just say please use the terms sex and gender correctly and then maybe have a link to the IGH webpage where we would give different definitions.

Then of course it's in the reporting of results. Did they disaggregate the results differently for males and females or according, you know, to different disaggregation where sex was a factor or for gender.

You know, you could talk about -- remember the study I showed you? How Louise Pilote disaggregated by gender and said that feminine gender was associated with poor outcome after heart disease? So in the results they actually disaggregated by gender.

So, use the terms correctly. Disaggregate by sex where appropriate, disaggregate by gender and in the method, explain how you define sex and gender as different characteristics.

Was that too much of a confusing answer?

MS.PATRICIA BOX: No, I just have one supplemental and I'll let it go to somebody else.

So but I think -- well ours is an international journal and I don't know that these are being taken up where we get a lot of studies coming from, but I think most people are not actually differentiating sex and gender. I think they just might ask on their form are you male or female, which -- so it's -- you know they're not doing anything with, you know, when the study is initiated to kind of differentiate anything like that I don't know how we can request them to, you know, and I think we'd be rejecting a lot of the papers on that basis if ---

Dr. Cara Tannenbaum: So here's where I think it's transparency and reproducibility in reporting and in fact the NIH actually applies this under their reproducibility policy, clearly journal editors can't make researchers re-do a questionnaire where they might have asked are you male or female, but they can say can you please specify in your method that sex was determined by self-report in a questionnaire asking "male", "female". So that's great. Then it's transparent.

MS.PATRICIA BOX: M'hm.

Dr. Cara Tannenbaum: It is reproducible. We know what we've measured. We know maybe how we need to measure differently and just by asking questions and raising awareness it may be that you might prompt the researchers to think for their next study they might want to ask the question differently.

MS.PATRICIA BOX: Okay.

Dr. Cara Tannenbaum: Is that a good answer maybe?

MS.PASTRICIA BOX: Yes, yes. That's useful.

Dr. Cara Tannenbaum: Is that comfortable?

MS.PATRICIA BOX: M'hm, thanks.

Dr. Cara Tannenbaum: Great.

So I do have another question that someone sent. It says:

"Most if not all of the examples provided in the presentation were related to biomedical or clinical research. There was a sense in our editorial board that this is an issue created by inadequacies of medical research but not necessarily as relevant for the social scientist who might wonder why they would need to justify in multiple places in their manuscript their focus on, for instance, grand-mothers or widows."

Now my quick answer to that is that gender is very much a social determinant of health. In fact, there's even an acronym PROGRESS that talks about you need to talk about place of residence, you need to talk about religion, you know it's recommended that you talk about socioeconomic status, gender, educational status and that as a, I guess, social determinant of health gender is extremely important.

But maybe, Jackie, I think you cover a lot of social science research in your journal? Do you want to maybe give an answer to that question?

Dr. Jackie Gahagan: Yes. Thank you, Cara.

So then the idea about, you know, lumping and splitting, I guess, is the concern. So are all grandmothers widows, are all widows grandmothers.

So from my perspective as a social scientist, having a level of specificity that allows you to disentangle the sex and gender implications in the research is really important because for the purposes of the work that I do, that evidence base then becomes an integral part of the decision-making process for example, health and social care policies or programs.

So, you know, I'm thinking about this in terms of the work I've done with HIV positive women, sort of a biological component of that is failure of positive women to anti-retroviral therapies, because the pharmacokinetics of those drugs have not been -- have not been tested on women and the data had been extrapolated from a male population to young -- to women who are living with HIV.

There's also a gender component. So what we found that contributed to lack of adherence, in addition to toxicity issues, was the social construction of gender, which meant that women who were mothers and HIV positive didn't want their HIV status to be known and therefore they might forfeit pills in the course of the day so that they didn't have to be seen taking pills.

So I think the sort of disentangling sex and gender where possible just adds to a more robust evidence base from which we, as social scientists, can inform appropriate health and social care policies.

Dr. Cara Tannenbaum: I guess, Jennifer, did you want to add to that or ---?

Dr. Jennifer Zelmer: It's certainly a question that came up around our discussions and we did also acknowledge that for some papers considerations would not be relevant and the guidelines allow for that.

And so it goes back to your comment, I think, Cara, in terms of transparency and openness of reporting.

To be clear, that in a particular case, maybe through studying policy around critical infrastructure in the health sector that was much more of a macro question, you know, in a particular study there may be a need to just say it wasn't relevant in this particular context. We expected the majority of cases it would be, but in some cases, it won't.

Dr. Cara Tannenbaum: I guess the only thing I would add to that is that there's some evidence emerging that gender dynamics and gender relations have a role to play in decision-making.

So if you are looking at decisions that are being taken by boards, if you're looking at decision that are being taken when there's a woman or a man as the head of a team, both within research as well as within companies, then it may start to become helpful to know who's taking the decisions and how those gender dynamics play out.

Some of you may have heard that Thomson Reuters, which is an index for business -- for businesses really, just added the composition of the leadership team in terms of male/female distribution as part of their new index.

There is some evidence actually coming out that when there's more women on the leadership team the company brings in greater revenue.

And again, obviously, in the social sciences if -- I'm not a social scientist but if I had one next to me they would be sitting here talking to me about feminist theory and putting a masculine or a feminine lens on the phenomenon under study and what the sociohistorical context around that would be.

And, I mean, you just have to look south of the border to see how gender relations and gender dynamics in large scale changes socially in the world.

So I don't know if that helps but there's definite a feeling that this, if given the attention it deserves, could really inform the -- and make a contribution to the knowledge and generation of knowledge in a certain area.

Good, I have -- were there any other questions? If not, maybe I'll end with the last one that came up from the previous webinar. Anyone?

MS.PATRICIA BOX: It's Patricia Box here. I have one other supplemental question.

So I'm finding the concept of gender kind of confusing in that, you know, you gave us an example where it was defined in a certain way by a certain researcher and, you know, given its kind of fluidity I'm kind of finding it a little difficult how to, kind of, implement that in the journal.

For example, in that example that you gave, I have a lot of those masculine characteristics, so I would probably, you know, I would probably be considered masculine there, but I don't identify -- if you ask me the question what did I -- what do I identify myself as, I don't identify myself as a man; you know?

So I'm finding it kind of a difficult concept to try to implement; you know?

Dr. Cara Tannenbaum: It is a difficult concept. Yes. It's a difficult concept because gender is really multidimensional.

MS.PATRICIA BOX: M'hm.

Dr. Cara Tannenbaum: And my 101 course is to divide the word gender into four different constructs.

The first construct is the gender role in society and I best explain this in a stereotypical kind of way, which is the man at the head of the household who earns, you know, is the breadwinner, primary breadwinner, and women are taught to, in some societies, to have to take care of children and clean the house.

That was very stereotypical and I'm not saying it's right or wrong, but that's what gender roles in a given time and place might be dictated by society. So that's gender roles.

Then there's gender identity and that has to do with how you feel. If you feel more masculine, feminine, transgender comes into this conversation and that would really come under gender identity.

It is an absolute fluid context -- construct and sometimes you might feel -- I mean I love to say, you know, I'm a woman with balls. I've got to be. I sit around the science council table at CIHR with 11 other scientific directors who are men. So that's okay and it could change depending on time and place.

The third construct is what we call gender relations or gender interactions and here is where I was talking about a leadership team for a journal. You know, are -- is it more of an autocratic style, is it more of a collaborative style, how does that play out in terms of who speaks up when and then maybe the fourth construct is what I call institutionalised gender, which is how the media portrays gender, which is your perfectly skinny, beautiful woman, you know, Barbie versus Ken, and that's sort of how we define institutionalised gender.

It is a fluid concept. I'd be happy to take this conversation offline with you if you'd like.

I would actually recommend that you take the course, the online course, and then see how it could be operationalised.

For purposes of being an editor, I think just was sex accounted for, was gender accounted for, if yes how and if not then please justify. I think that that's the role of the editor here.

MS.PATRICIA BOX: M'hm, m'hm. Okay.

Dr. Cara Tannenbaum: I see that we're getting to the end of our time. Was there another question or should we wrap up, Jennifer?

Dr. Jennifer Zelmer: I don't hear anyone jumping in so perhaps we can move to our last question for everybody.

So we have one final polling question, in terms of the options that you intend to take after this call.

So if you could just help us to understand what steps you might take moving forward at the end and feel free to check "other".

If you do please send us a quick message in the chat to let us know what other steps you might want to take, because we want to understand what some of the options are that you may be considering as well.

And I think we've closed the poll so Rachel will bring up the answers momentarily.

Dr. Cara Tannenbaum: We have 10 more seconds left.

Dr. Jennifer Zelmer: Oh ---

Dr. Cara Tannenbaum: I guess I would just say, as we near the end, thank you to everyone.

We're calling out to you to be part of the solution. I think this will take baby steps, but what I'm hoping for is that in 5 or 10 years we'll be so much more advanced than we are today. So there's your results; Jennifer?

Dr. Jennifer Zelmer: Perfect. Thanks very much.

So great that so many people are interested are finding out more. If there's anything we can do to help you with that process, please let us know.

Hopefully the toolkit will be a useful starting point in terms of moving forward and also great to see that so many people are also interested in some concrete actions for their journals and the journals they're affiliated with.

Again, if there's anything we can do to help in that process, please let us know, and as you adopt the guidelines please also e-mail Rachel so that we can make sure to add you to the list that CIHR is celebrating.

UNKNOWN: Hi, this is Joleen. Just one question. When will the webinar be available for viewing?

Dr. Cara Tannenbaum: I think in the next two days we're going to try to get it up.

UNKNOWN: Okay.

Dr. Cara Tannenbaum: Should we send you -- should we send everyone the link when it's up?

MS. PATRICIA BOX: Yes.

Dr. Cara Tannenbaum: Okay, perfect. We could send it as a file to anyone who wants. Just contact Rachel and then we will post the link for everyone.

And yes, I mean the beginning of the conversation might be to have others around you visualize this or you could -- you could listen to the other webinar. There were other questions that were asked.

I guess I just feel really grateful that everyone took time out of their busy schedules to participate today.

I know that a lot of people do their editor role fairly pro-bono; not everyone, but a lot of us.

(LAUGHTER)

Dr. Cara Tannenbaum: And like I said being part of the solution and trying to raise the bar on science is a big responsibility, but it is a powerful way that journal editors could actually improve health and knowledge here in Canada.

So perhaps I'd conclude by saying thank you to Jennifer, thank you to Jackie. Thanks for everyone for taking that time.

You can reach out to me personally or we could -- you could reach out to Rachel or I'd be happy to speak to you individually and we'll be following up to hear about your successes and challenges as we move forward on this new, I guess, quest and initiative to make sure that sex and gender are properly reported.

So thank you very much and have a great afternoon for those of you in the snow like I am. Bye, bye.

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