Recommendations for a Better Understanding of Sex and Gender in the Neuroscience of Mental Health.

There are prominent sex/gender differences in the prevalence, expression, and life span course of mental health and neurodiverse conditions. However, the underlying sex- and gender-related mechanisms and their interactions are still not fully understood. This lack of knowledge has harmful consequences for those with mental health problems. Therefore, we set up a cocreation session in a 1-week workshop with a multidisciplinary team of 25 researchers, clinicians, and policy makers to identify the main barriers in sex and gender research in the neuroscience of mental health. Based on this work, here we provide recommendations for methodologies, translational research, and stakeholder involvement. These include guidelines for recording, reporting, analysis beyond binary groups, and open science. Improved understanding of sex- and gender-related mechanisms in neuroscience may benefit public health because this is an important step toward precision medicine and may function as an archetype for studying diversity.

Research priorities and considerations for nutrition research: methods of sex and gender analysis for biomedical and nutrition research.

For some 20 years, science funding bodies have been asking for the integration of sex- and gender-related factors into the content of research and innovation. The rationale for those requirements has been the accumulated evidence that sex and gender are important determinants of health and disease. The European Commission (EC) has been the first, since 2002, to seriously ask for the integration of sex and gender into research and innovation in the context of their multi-annual framework programmes. When introduced, this condition was not immediately applauded by the research community, who perhaps lacked training in methods for the integration of sex- and gender-related factors. The EC Expert Group on Gendered Innovations sought to fill this gap. This review describes the work of this international collaborative project which has resulted in the development of general and field-specific methods for sex and gender analysis and 38 case studies for various research domains (science, health and medicine, environment, engineering) to illustrate how, by applying methods of sex and gender analysis, new knowledge could be created. Since 2010, science funding bodies in Canada, the USA and several EU member states have followed the example of the EC issuing similar conditions. Although the effects of nutritional patterns on a range of (physiological and health) outcomes may differ for men and women, sex and gender analyses are rarely conducted in nutrition research. In this review, we provide examples of how gender is connected to dietary intake, and how advancing gender analysis may inform gender-sensitive policies and dietary recommendations.

Best Practices in the Study of Gender.

Integrating sex- and gender-related aspects into research and innovation content has become an urgent requirement of major science funding bodies as f.e. the European Commission, the Canadian Institutes of Health Research and the US NIH/Office of Women's Health Research.It was the only right response in reaction to the documented failure of the 'one size fits all' approach in traditional biomedical research practices. Attention to sex differences seems to be taken up by researchers quite well, however integrating a gender analysis has met with difficulties. Of prime importance here is to consider gender as a multidimensional concept, covering gender norms, gender identities and gender relations. A research design should clarify from the outset whether gender norms, identities or relations are of relevance to the research question at hand. This chapter provides an overview of international policies insisting on integrating a sex, gender and intersectional analysis into research and innovation with a focus on the the gender equality policy of the European Union. Next, more in depth, a collection of best practices, to be understood as a coherent set of processes and activities, corresponding to the starting points, theories and evidence of the field concerned of which it can be expected to contribute to the intended results in a particular context is described. Finally some challenges ahead are identified.

The Integration of Sex and Gender Considerations Into Biomedical Research: Lessons From International Funding Agencies.

To improve the outcomes of research and medicine, government-based international research funding agencies have implemented various types of policies and mechanisms with respect to sex as a biological variable and gender as a sociocultural factor. After the 1990s, the US National Institutes of Health (NIH), the Canadian Institutes of Health Research (CIHR), and the European Commission (EC) began requesting that applicants address sex and gender considerations in grant proposals, and offering resources to help the scientific community integrate sex and gender into biomedical research. Although it is too early to analyze data on the success of all of the policies and mechanisms implemented, here we review the use both of carrots (incentives) and sticks (requirements) developed to motivate researchers and the entire scientific research enterprise to consider sex and gender influences on health and in science. The NIH focused on sex as a biological variable (SABV) aligned with an initiative to enhance reproducibility through rigor and transparency; CIHR instituted a sex- and gender-based analysis (SGBA) policy; and the EC required the integration of the "gender dimension," which incorporates sex, gender, and intersectional analysis into research and innovation. Other global efforts are briefly summarized. Although we are still learning what works, we share lessons learned to improve the integration of sex and gender considerations into research. In conjunction with refining and expanding the policies of funding agencies and mechanisms, private funders/philanthropic groups, editors of peer-reviewed journals, academic institutions, professional organizations, ethics boards, health care systems, and industry also need to make concerted efforts to integrate sex and gender into research, and we all must bridge across silos to promote systemwide solutions throughout the biomedical enterprise. For example, policies that encourage researchers to disaggregate data by sex and gender, the development of tools to better measure gender effects, or policies similar to SABV and/or SGBA adopted by private funders would accelerate progress. Uptake, accountability for, and a critical appraisal of sex and gender throughout the biomedical enterprise will be crucial to achieving the goal of relevant, reproducible, replicable, and responsible science that will lead to better evidence-based, personalized care for all, but especially for women.

Gender-related variables for health research.

BACKGROUND: In this paper, we argue for Gender as a Sociocultural Variable (GASV) as a complement to Sex as a Biological Variable (SABV). Sex (biology) and gender (sociocultural behaviors and attitudes) interact to influence health and disease processes across the lifespan-which is currently playing out in the COVID-19 pandemic. This study develops a gender assessment tool-the Stanford Gender-Related Variables for Health Research-for use in clinical and population research, including large-scale health surveys involving diverse Western populations. While analyzing sex as a biological variable is widely mandated, gender as a sociocultural variable is not, largely because the field lacks quantitative tools for analyzing the influence of gender on health outcomes. METHODS: We conducted a comprehensive review of English-language measures of gender from 1975 to 2015 to identify variables across three domains: gender norms, gender-related traits, and gender relations. This yielded 11 variables tested with 44 items in three US cross-sectional survey populations: two internet-based (N = 2051; N = 2135) and a patient-research registry (N = 489), conducted between May 2017 and January 2018. RESULTS: Exploratory and confirmatory factor analyses reduced 11 constructs to 7 gender-related variables: caregiver strain, work strain, independence, risk-taking, emotional intelligence, social support, and discrimination. Regression analyses, adjusted for age, ethnicity, income, education, sex assigned at birth, and self-reported gender identity, identified associations between these gender-related variables and self-rated general health, physical and mental health, and health-risk behaviors. CONCLUSION: Our new instrument represents an important step toward developing more comprehensive and precise survey-based measures of gender in relation to health. Our questionnaire is designed to shed light on how specific gender-related behaviors and attitudes contribute to health and disease processes, irrespective of-or in addition to-biological sex and self-reported gender identity. Use of these gender-related variables in experimental studies, such as clinical trials, may also help us understand if gender factors play an important role as treatment-effect modifiers and would thus need to be further considered in treatment decision-making.

Gendered Innovation in Health and Medicine.

Excellence in research requires careful attention to sex and gender analysis. The Gendered Innovations project, initiated in 2009, develops state-of-the-art methods of sex and gender analysis for basic and applied research. This chapter reviews recent developments in cardiovascular disease for (1) analyzing sex, (2) analyzing gender, and (3) policy initiatives.

Implementation Strategies for Gender-Sensitive Public Health Practice: A European Workshop.

OBJECTIVES: Providing a robust scientific background for the focus on gender-sensitive public health and a systematic approach to its implementation. METHODS: Within the FP7-EUGenMed project ( http://eugenmed.eu ) a workshop on sex and gender in public health was convened on February 2-3, 2015. The experts participated in moderated discussion rounds to (1) assemble available knowledge and (2) identify structural influences on practice implementation. The findings were summarized and analyzed in iterative rounds to define overarching strategies and principles. RESULTS: The participants discussed the rationale for implementing gender-sensitive public health and identified priorities and key stakeholders to engage in the process. Communication strategies and specific promotion strategies with distinct stakeholders were defined. A comprehensive list of gender-sensitive practices was established using the recently published taxonomy of the Expert Recommendations for Implementing Change (ERIC) project as a blueprint. CONCLUSIONS: A clearly defined implementation strategy should be mandated for all new projects in the field of gender-sensitive public health. Our tool can support researchers and practitioners with the analysis of current and past research as well as with the planning of new projects.

A global call for action to include gender in research impact assessment.

Global investment in biomedical research has grown significantly over the last decades, reaching approximately a quarter of a trillion US dollars in 2010. However, not all of this investment is distributed evenly by gender. It follows, arguably, that scarce research resources may not be optimally invested (by either not supporting the best science or by failing to investigate topics that benefit women and men equitably). Women across the world tend to be significantly underrepresented in research both as researchers and research participants, receive less research funding, and appear less frequently than men as authors on research publications. There is also some evidence that women are relatively disadvantaged as the beneficiaries of research, in terms of its health, societal and economic impacts. Historical gender biases may have created a path dependency that means that the research system and the impacts of research are biased towards male researchers and male beneficiaries, making it inherently difficult (though not impossible) to eliminate gender bias. In this commentary, we - a group of scholars and practitioners from Africa, America, Asia and Europe - argue that gender-sensitive research impact assessment could become a force for good in moving science policy and practice towards gender equity. Research impact assessment is the multidisciplinary field of scientific inquiry that examines the research process to maximise scientific, societal and economic returns on investment in research. It encompasses many theoretical and methodological approaches that can be used to investigate gender bias and recommend actions for change to maximise research impact. We offer a set of recommendations to research funders, research institutions and research evaluators who conduct impact assessment on how to include and strengthen analysis of gender equity in research impact assessment and issue a global call for action.

Applying a gender lens on human papillomavirus infection: cervical cancer screening, HPV DNA testing, and HPV vaccination.

BACKGROUND: Our aim is to provide a state-of-the-art overview of knowledge on sex (biological) and gender (sociocultural) aspects of Human papillomavirus (HPV) and cervical cancer for educational purposes. Considerable disparities exist in cervical cancer incidences between different subgroups of women. We provide an outline on the crucial issues and debates based on the recent literature published in leading gender medicine journals. Intersectionality was applied in order to help categorise the knowledge. METHODS: Key terms (HPV, cervical cancer) were screened in Gender Medicine, Journal of Women's Health and Women & Health from January 2005-June 2012. Additional searches were conducted for topics insufficiently mentioned, such as HPV vaccination of boys. In total, 71 publications were included (56 original papers, four reviews, six reports, three commentaries, one editorial and one policy statement). RESULTS: Research reveals complexity in the way various subgroups of women adhere to cervical screening. Less educated women, older women, uninsured women, homeless women, migrant women facing language barriers, women who have sex with women and obese women participate in Pap smears less frequently. A series of barriers can act to impede decisions to vaccinate against HPV. CONCLUSIONS: Both male and female controlled preventive methods and treatment measures should be developed in order to tackle HPV infection and different strategies are needed for different subgroups. A substantial discussion and research on alternative methods of prevention was and is lacking. In future research, sex and gender aspects of HPV-related diseases of boys and men as well as subgroup differences in HPV risk need to be addressed.

Mainstreaming sex and gender analysis in public health genomics.

BACKGROUND: The integration of genome-based knowledge into public health or public health genomics (PHG) aims to contribute to disease prevention, health promotion, and risk reduction associated with genetic disease susceptibility. Men and women differ, for instance, in susceptibilities for heart disease, obesity, or depression due to biologic (sex) and sociocultural (gender) factors and their interaction. Genome-based knowledge is rapidly increasing, but sex and gender issues are often not explored. OBJECTIVE: To explore the implications of a sex and gender analysis for PHG. METHODS: We explore genome-based knowledge in relation to sex and gender aspects using depression as an example, gender equality, and the intersection of sex and gender with other social stratifiers such as ethnic background or socioeconomic status. RESULTS: We advocate a sex- and gender-sensitive genomics research agenda alongside studies that provide sex-disaggregated data rather than controls based on sex. Such a research agenda is needed to guide research on how genomics is understood and perceived by men and women across groups, and for the equitable and responsible translation of such knowledge into the public health domain. CONCLUSIONS: Including sex and gender analysis in PHG research will not only shed more light on phenomena such as diseases with a higher prevalence in either men or women, but will ultimately lead to gendered innovations by way of exploring how gendered and cultural environments increase or safeguard genetic predispositions.

Process evaluation of a diversity training program: the value of a mixed method strategy.

Patients' health and health needs are influenced by categories of difference like sex, gender, ethnic origin and socioeconomic status (SES). To enhance awareness of this diversity among patients and to provide holistic care for them, health professionals should first be aware of the relation between dimensions of diversity and patients' health and health demands. This paper presents a formative process evaluation of a diversity sensitivity training programme for healthcare professionals. The training was implemented in three healthcare settings (mental healthcare, nursing home and hospital care). Mixed methods were used to monitor the implementation of the training and its effects after three years. Findings demonstrate that the training stimulated participants' awareness, knowledge and critical attitudes towards diversity. Their motivation and willingness to take action regarding diversity was also enhanced. Yet these developments were less apparent among nursing home participants who felt less satisfied and did not develop a critical perspective on this issue. Qualitative data were helpful to explain differences between the settings. By means of the combination of quantitative and qualitative data, we can conclude that individual learning was not enough to guarantee a sensitive approach to diversity at the organizational level.

Scientific excellence in applying sex- and gender-sensitive methods in biomedical and health research.

Despite regulations, the attention paid to sex and gender in biomedical and health research is far from optimal. Researchers often recognize the importance of incorporating sex and gender issues in general but fail to see the applicability to their own research. This can have severe consequences and impedes gender equity in healthcare. More hands-on approaches are needed that stimulate scientists to integrate sex and gender aspects into their research. The present work is based on the contents of a workshop developed by the authors that serves as such a hands-on method. It aims at familiarizing a broad range of scientists in the field of biomedical and health research with the basics of conducting sex- and gender-sensitive research. In addition to clarifying concepts, it serves to provide a general introduction to sex- and gender-sensitive methods. To this end, challenges in pitfalls conducting sex- and gender-sensitive research, originally identified in the social sciences, are translated to the practice of biomedical and health research. Implications and applicability to all areas of biomedical and health research are shown by providing illustrative examples. Finally, a tool is presented that allows for the detection of sex and gender bias throughout all phases of the research process and shows how this bias can be overcome through sex- and gender-sensitive (1) relevance checking, (2) literature search, (3) formulation of research questions and hypotheses, (4) research methods and sample, (5) data analysis and interpretation, (6) reporting, and (7) conclusions and recommendations.

Maintaining gender sensitivity in the family practice: facilitators and barriers.

OBJECTIVE: This study aims to identify the facilitators and barriers perceived by General Practitioners (GPs) to maintain a gender perspective in family practice. METHODS: Nine semi-structured interviews were conducted among nine pairs of GPs. The data were analysed by means of deductive content analysis using theory-based methods to generate facilitators and barriers to gender sensitivity. RESULTS: Gender sensitivity in family practice can be influenced by several factors which ultimately determine the extent to which a gender sensitive approach is satisfactorily practiced by GPs in the doctor-patient relationship. Gender awareness, repetition and reminders, motivation triggers and professional guidelines were found to facilitate gender sensitivity. On the other hand, lacking skills and routines, scepticism, heavy workload and the timing of implementation were found to be barriers to gender sensitivity. CONCLUSION: While the potential effect of each factor affecting gender sensitivity in family practice has been elucidated, the effects of the interplay between these factors still need to be determined.

Gender perspectives in European research.

BACKGROUND: Attention to sex and gender aspects in biomedical and health-related research has been a major initiative of the EU gender equality policy for research. The EU funded GenderBasic project (2005-2008), conceived to stimulate this attention to sex and gender and to provide practical tools to researchers, resulted in the publication of 10 reviews by high-level scientists in a Supplement to Gender Medicine in December 2007: "Bringing Gender Expertise to Biomedical and Health-Related Research". METHODS: Four commissioned reviews covered methodological aspects of addressing sex and gender in biomedical research--ranging from basic, molecular to public health research--next to six reviews that addressed sex and gender aspects relevant to selected health areas: anxiety disorders, asthma, metabolic syndrome, nutrigenomics, osteoporosis and work-related health. RESULTS: The review articles, that were discussed at an expert meeting, attended - upon invitation - by a mixed audience of basic and clinical researchers, epidemiologists, social scientists and gender researchers, came up with excellent state of the art data, solutions to methodological and conceptual problems, practical tools and interesting questions for further research. CONCLUSION: The expert meeting created great enthusiasm among the participants and a real exchange took place among researchers from various backgrounds. Most life sciences researchers were familiar with the concept of sex differences but confessed that the effects of socially constructed gender until now, had received too little attention. The GenderBasic project yielded three major achievements for European research: (1) it stimulated and promoted research into sex differences; (2) it stimulated research into the workings of gender, illustrated by useful examples in particular in understanding masculinity and its effects on the health of individual men; (3) it highlighted sex-gender interaction and granted gender a prominent place on the research agenda that resulted from GenderBasic. A final conclusion of the project was that it is not differences per se that are interesting but rather how, as a result of the interaction between sex and gender, differences develop. The European Commission selected the GenderBasic project itself as an excellent example of the positive impacts EU research can achieve and the project will be featured in a catalogue of 6th Framework Success Stories.

Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems.

OBJECTIVE: Highly educated Dutch women experience more work related mental health disability than their male counterparts, and yet little is known regarding the process. Using the theory of symbolic interactionism, we examined how women interpret their roles at work, during sick leave, and upon their return to work. METHODS: Semi-structured interviews focusing on role perceptions and interactions with other actors were conducted with 13 women (aged 29-41 years) on sick leave or off work for periods ranging from half a year to 8 years. RESULTS: The women worked overtime because of work aholism, or to meet supervisors' expectations. This led to mental health problems and social isolation. Taking sick leave aided recovery, but further isolated the women. Insufficient support from the workplace and social insurance professionals intensified negative feelings. Psychological counselling provided alternatives whereby work and private roles could become more balanced. However, their reintegration into the workplace failed because the women could not implement these strategies when the organizational culture failed to change. CONCLUSIONS: A long lead-up time preceded sickness absence and sick leave allowed for recovery and value adjustment. However, a variety of interpretations reinforced the women's individualized focus, thereby hampering their successful reintegration. PRACTICE IMPLICATIONS: Given the importance of implementing effective sick leave prevention measures in the workplace, psychological treatment should focus on women's interactions with their work environment.

Gender sensitivity among general practitioners: results of a training programme.

BACKGROUND: Gender differences contribute to patients' health and illness. However in current healthcare practices attention to gender differences is still underdeveloped. Recognizing these differences and taking them into account can improve the quality of care. In this study we aimed to investigate whether GPs' gender sensitivity can be stimulated by a training programme. The focus was on three diseases: angina pectoris, depression and urinary incontinence. METHODS: This study had a quantitative, explorative and descriptive design. By means of a training programme 18 GPs were trained to focus on gender-sensitive recommendations for the three diseases. With standardised registration forms, data were collected during a 6-month period. During the registration period, the GPs were visited by the study team to discuss the process of data collection. RESULTS: The GPs filled in registration forms for 100 patients: 39 with angina pectoris (31 women and 8 men), 40 with depression (26 women and 14 men), and 21 with urinary incontinence (20 women and 1 man). The results show that gender sensitivity can be stimulated among trained professionals. The combination of the training programme, clear and practical recommendations, daily discussion of relevant cases between the GP couples, feedback and support during registration by the study team probably contributed to the outcome. CONCLUSION: GPs' gender sensitivity was stimulated by the training programme and the supporting visits. Ideally, structural attention could be realised by embedding gender issues in existing organisational structures of general practices.

Implementation of diversity in healthcare practices: barriers and opportunities.

OBJECTIVE: The aim of this study is to investigate to which extent diversity is part of current healthcare practices and to explore opportunities and barriers in the implementation of diversity dimensions in healthcare practices. METHODS: Nine in-depth, semi-structured interviews and three focus groups were conducted in three healthcare settings (mental health, hospital, nursing home care). RESULTS: Results demonstrate that (the potential of) diversity is an ambiguous issue; diversity is said to be important, but this has not led to adjustments of the neutral, disease-oriented approach of patients. If recognized at all, diversity is reduced to one dimension (sex). Barriers in the implementation of diversity relate to: (a) lacking awareness and knowledge of diversity, (b) poor information and communication, and (c) organizational constraints. Opportunities to implement diversity in healthcare include: (d) an emerging sense of urgency to attend to diversity, (e) the development of good practices, and (f) the political climate. CONCLUSION: Various barriers and some opportunities for the implementation of diversity in healthcare practices have been identified. There is an ambiguity in how professionals deal with diversity. As a result, the neutral approach remains dominant in practice and policy. PRACTICE IMPLICATIONS: In order to raise the awareness and enhance the competence of professionals, educational programmes and learning networks are required.

The policy implications of gender mainstreaming for healthcare research in the EU.

Scientific and technological progress in the life sciences and modern biotechnology is continuing at a breathtaking pace. At the same time, the potential implications for individuals and society are giving rise to intense debate. This article gives a background to the European Institute of Women's Health (EIWH) and the work of the organisation in contributing to and developing policy at a European level. We will identify the policy issues related to gender-based healthcare research arising from the EU 6th Framework Programme for Research, which was introduced this year, and the implications for the EU Public Health Strategy. Additionally, the issues of personalized medicine and the promise of biotechnology for improved medicines and healthcare will be addressed from a gender perspective. What are the prospects in the medium and long term? How can we best address the ethical and socio-economic implications?