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Better science with sex and gender: Facilitating the use of a sex and gender-based analysis in health… Johnson, Joy L; Greaves, Lorraine; Repta, Robin May 6, 2009

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ralInternational Journal for Equity in ssBioMed CentHealthOpen AcceResearchBetter science with sex and gender: Facilitating the use of a sex and gender-based analysis in health researchJoy L Johnson*1, Lorraine Greaves2 and Robin Repta1Address: 1NEXUS, School of Nursing, University of British Columbia, Vancouver, Canada and 2British Columbia Centre of Excellence for Women's Health, Vancouver, CanadaEmail: Joy L Johnson* - joy.johnson@nursing.ubc.ca; Lorraine Greaves - lgreaves@cw.bc.ca; Robin Repta - robin.repta@nursing.ubc.ca* Corresponding author    AbstractMuch work has been done to promote sex and gender-based analyses in health research and tothink critically about the influence of sex and gender on health behaviours and outcomes. However,despite this increased attention on sex and gender, there remain obstacles to effectively applyingand measuring these concepts in health research. Some health researchers continue to ignore theconcepts of sex and gender or incorrectly conflate their meanings. We report on a primer that wasdeveloped by the authors to help researchers understand and use the concepts of sex and genderin their work. We provide detailed definitions of sex and gender, discuss a sex and gender-basedanalysis (SGBA), and suggest three approaches for incorporating sex and gender in health researchat various stages of the research process. We discuss our knowledge translation process and sharesome of the challenges we faced in disseminating our primer with key stakeholders. In conclusion,we stress the need for continued attention to sex and gender in health research.Sex and gender in health researchIn the context of doing more sensitive, precise and rele-vant health research, there is an increasing emphasis onattending to issues of sex and gender. Much work has beendone to promote sex and gender-based analyses in healthresearch and to think critically about the influence of sexand gender on health behaviours and outcomes [1-10].This work is viewed as key to understanding and address-ing health inequities that exist throughout the world. Sev-eral journals have published special issues in recent years,emphasizing the scientific, methodological, and ethicalrationales for including sex and gender in health research[2,4,10,11]. Despite this increased attention on sex andgender, there remain obstacles to effectively applyingthese concepts in health research. Some health researcherstain disciplines are more familiar with these concepts thanothers; while gender has been a prominent concept in thesocial sciences for decades, and has therefore influencedsocial science health research, it has only relativelyrecently begun to enter the lexicon of biomedical and clin-ical health researchers. Thus, gender, which fundamen-tally refers to social and cultural influences, is oftenconflated or confused with sex, referring to the biologicalcategory of influences [9]. This conflation leads to confu-sion about the contributions of sex and gender to health,incomplete analysis and reporting in health research, andpotential missed opportunities for developing appropri-ate medical interventions and policy responses [9].To address these errors and omissions, researchers havePublished: 6 May 2009International Journal for Equity in Health 2009, 8:14 doi:10.1186/1475-9276-8-14Received: 12 March 2009Accepted: 6 May 2009This article is available from: http://www.equityhealthj.com/content/8/1/14© 2009 Johnson et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 11(page number not for citation purposes)continue to ignore the concepts of sex and gender or usethe terms synonymously and thus incorrectly [9,12]. Cer-begun to tackle the operational challenges of incorporat-ing sex and gender in health research, providing method-International Journal for Equity in Health 2009, 8:14 http://www.equityhealthj.com/content/8/1/14ological advice and realistic recommendations toresearchers [8,9,11-14]. For example, Prins et al. [8] dis-cuss the importance of developing methodologic stand-ards for pharmacogenetic studies on sex and genderdifferences and address key issues around study design,analysis and result reporting. They provide an excellentchecklist of issues to consider when studying the effect ofsex in research, but do not differentiate between sex andgender, nor do they provide concrete ways to incorporategender as a variable in health research. Phillips [13,14] onthe other hand, addresses gender in health research, espe-cially epidemiological approaches. She suggests the devel-opment of a proxy measure (or coefficient) for gender inwomen's health research, which could combine indica-tors of human rights, income, income distribution, andaccess to education and health care. Phillips acknowl-edges that this proxy measure of gender may not be rele-vant to men, and further development of the concept isrequired. Measurement techniques for addressing theeffects of gender are crucial; however, Phillips' approach issomewhat confounding as she merges the related but fun-damentally different concepts of sex and gender. TheWorld Health Organization (WHO) provides a review ofvarious gender tools, policies and guidelines designed tohelp measure the impact of gender on human healtharound the world [15]. This document identifies differentlayers of gender analysis, accounting for personal andcommunity-level impacts of gender, and identifies ques-tions to ask when investigating the interactions betweensex and gender and their dual impact on health. A valua-ble resource, this document's strength is in its breadth andlength, covering many NGO and aid organizations' gen-der policies. A condensed version of this 'tools' document,with more emphasis on incorporating sex and gender intoevery aspect of research design (particularly analysis)could better engage quantitative researchers and isneeded. Thus, while these reviews, guidelines and sugges-tions for better use of the concepts of sex and gender inhealth research are valuable contributions, more compre-hensive recommendations are needed for researchers tobe prepared to use the concepts in all stages of the researchprocess and in different fields and disciplines.This paper builds on previous publications and respondsto calls for additional guidelines on how to effectivelyincorporate sex and gender in health research [7-9]. Wereport on a primer that was developed by the authors tohelp researchers understand and use the concepts of sexand gender in their work [12]. The primer was publishedby the Women's Health Research Network (WHRN) inBritish Columbia, Canada in 2007 as a means of promot-ing sex and gender-based analyses in health research. Theprimer balanced some of the advanced theoretical discus-accessible. It was a practical starting point for healthresearchers across disciplines, involved in both humanand animal research, who were beginning to use sex andgender in their research. The primer is available online athttp://www.whrn.ca/better-science-download.php andcan be downloaded directly.In this paper, we discuss the conceptual work that was thefoundation for the primer, share the detailed definitionsof sex and gender that we developed, and describe a three-prong approach to sex and gender-based analysis (SGBA).We review the practical suggestions that we offered forapplying sex and gender in health research and share ourexperiences conducting 'knowledge translation' work-shops as a means of promoting the primer to key stake-holders. In describing the challenges we faced in ourknowledge translation process, we provide a case study onknee injuries that illustrates the benefit of applying SGBAto health research. Finally, we conclude by stressing theneed for all health fields and disciplines to incorporate sexand gender as a matter of science and ethics.The case for using sex and genderMany authors have written about the importance of usingthe concepts of sex and gender in health research [15-19].The inclusion of sex and gender not only guarantees morecomprehensive science, but can result in cost savings forthe health care system, more effective policies and pro-grams and is a matter of social justice [17]. For example,Aulakh and Anand discuss the importance of includingsex and gender properly: previous research on stroke andaspirin wrongly led researchers to believe that aspirin wasa useful preventative treatment for stroke in men only,and thousands of women likely missed this importanttherapy [18]. This emphasizes the ethical importance ofaccurately including sex and gender in health research, asomissions or the incorrect application of these concepts(e.g. errors in research design, analysis, reporting, etc. withrespect to SGBA) can affect rates of morbidity and mortal-ity [16-19]. Thus, it is critically important to understandand appreciate the impact of sex and gender, and attendto these concepts in health research correctly. However,the correct integration of sex and gender in researchdepends on consistent and clear definitions of the terms.DefinitionsUsing sex and gender accurately in health researchrequires a clear understanding of the two conceptsbecause, as Krieger [9] confirms, "...our science will onlybe as clear and error-free as our thinking" (p. 656). Whilemuch has been written about these concepts, we foundthat definitions varied, particularly across disciplines. Inorder to provide clear recommendations of how to usePage 2 of 11(page number not for citation purposes)sions of sex and gender with workable suggestions forhealth researchers, in order to make the concepts morethese concepts, we first scanned the literature to assesshow and where sex and gender are employed. Our initialInternational Journal for Equity in Health 2009, 8:14 http://www.equityhealthj.com/content/8/1/14scan produced a set of articles which we sorted into thefollowing six categories: gender-based analysis and theo-ries, policy and public health, tools/frameworks, interac-tion of gender and sex, masculinities/femininities, andexamples from research. From here we looked at specificjournals and reviewed the reference lists of these papers inorder to obtain additional resources. This categorizationsystem permitted us to generally review the issues andadvances in conceptualizing sex and gender and helped usto identify gaps in knowledge and obstacles to imple-menting these concepts in research. Furthermore, our ana-lytic process of assessing the field and reviewing thedifferent usages and definitions of the terms underpinnedour own definitions of sex and gender.In surveying the quantitative literature, we found that gen-der is often mistakenly used as a substitute for sex;researchers claim 'gender differences' with respect to biol-ogy when they are in fact reporting differences accordingto sex. In the social sciences, where the distinctionbetween sex and gender originated, the concepts are betterunderstood but have evolved theoretically in ways thatoften seem to defy measurement. The concept of gender inparticular has been thoroughly discussed and debated,with many definitions, sub-definitions, and theoriesoffered [20,21]. However, transferring the latest theoreti-cal developments into functional and operational modelsfor health research and policy has yet to happen, so theseimportant advances remain abstract and often unused inhealth research. To move forward, standardized defini-tions need to be accepted by all disciplines and amenableto both qualitative and quantitative research. We devel-oped our definitions in order to incorporate the theoreti-cal advancements in the social sciences in ways that basicscientists could appreciate and use. Our definitions belowborrow from the definitions we developed in our primerand are referenced here with permission [12].Sex is a multidimensional biological construct thatencompasses anatomy, physiology, genes, and hormones,which together affect how we are labelled and treated inthe world. Although conceptualizing sex usually relies onthe female/male binary, in reality, individuals' sex charac-teristics exist on a fluid and medically or socially con-structed continuum [22]. For example, research hasrevealed that while the "typical" sex chromosomes are XXfor females and XY for males, there are many variations inthis genetic chromosomal dichotomy, including XXY,XYY, XXX, and XO (no second chromosome). Thereforeour common binary understanding of sex (male/female)is limiting and unrepresentative of the breadth and varietythat exist with respect to human sex characteristics. Ourcommon assumption that animals and humans are com-Sex has an enormous impact on human health in waysnot previously understood [23]. For example, research hasdemonstrated that male and female bodies have innatephysiological and hormonal differences that result in dif-ferent responses to alcohol, drugs, and treatment [24]. Infact, the constitution of the typical female body has inher-ent differences when compared to the typical male body,from cellular metabolism to blood chemistry. Researchersnow claim that "every organ in the body – not just thoserelated to reproduction – has the capability to responddifferently on the basis of sex" [[19], p. 935]. There areimportant sex-based differences at the cellular level arisingfrom chromosomal dissimilarity. However, while weknow that a male liver cell is not the same as a female livercell, we do not know enough about the exact nature ofthese differences or whether these differences affect thedevelopment of disease or responses to treatment [16,17].It is increasingly clear, therefore, that these various cellulardifferences can potentially create different patterns in theprogression of disease in men and women and can lead todifferences in health status and outcomes. There is a needto include both female and male animals and women andmen in biomedical and clinical research in particular,because results from one group cannot be applied to theother [16-19]. Ignoring the influence of sex in researchcompromises the validity and generalizability of the find-ings and can be detrimental not just to the research enter-prise but also to the health of individuals [19].Gender is a multidimensional social construct that is cul-turally based and historically specific, and thus constantlychanging. Gender refers to the socially prescribed andexperienced dimensions of "femaleness" or "maleness" ina society, and is manifested at many levels [25]. The expe-rience of gender is always linked to the social and politicalcontext. As such, gender is also intimately connected tosocial and economic status in systems where maleness isalmost universally preferred over femaleness. The valua-tion of males over females is one way that "gender is a partof all human interactions" and "is a 'stable' form of struc-tured inequality" [[24], p. 329]. While there is continueddebate regarding the dimensions of gender, and its rela-tionships to aspects of diversity, it is widely recognisedthat gendered experiences and cultural values often resultin socially prescribed gender roles that dictate differentbehaviours, interests, expectations, and divisions oflabour for women and men, girls and boys [26-28]. Thesegender roles are further reinforced by practices, processesand rules that affect gender identity at the individual level,gender relations at the interpersonal or group level, andinstitutional gender at a macro level [26].Gender rolesreflect the behavioural norms applied toPage 3 of 11(page number not for citation purposes)prised of two sexes is reinforced by our limited languageand has implications for research tools and design [23].males and females in societies that influence their every-day actions, expectations, and experiences. They areInternational Journal for Equity in Health 2009, 8:14 http://www.equityhealthj.com/content/8/1/14expressed and enacted in a range of ways including dresscodes, mannerisms, posture, and societal opinions ofworthwhile contributions to make as a woman or a man.In some cultures, these roles are sharply defined and dif-ferentiated, allowing and disallowing women and men,girls and boys from certain tasks, jobs, opportunities, orspaces [22,23]. In other cultures, there is more genderequity and the lines between gender roles are moreblurred. Either way, gender roles often categorize individ-uals and control behaviour within institutions such as thefamily, the labour force, or the educational system [26].Gender identitydescribes how an individual sees them-selves on the continua of female or male (or as a "thirdgender" or "two-spirited"), and influences their feelingsand behaviours. All individuals develop their gender iden-tity in the face of strong societal messages about the "cor-rect" gender role for their presenting sex, but genderidentities are malleable and actively constructed over timeand culture, underpinning "an ongoing process of becom-ing" [[26], p. 309]. Gender identity is linked to socialroles, aspirations, social interactions, behaviours, traits,characteristics, and body image and is influenced by pre-scribed gender roles and the extent to which individualsaccept or resist them. Gender identity is evolving and notalways stable. For example, an infant presenting withambiguous genitalia is often assigned a gender by medicalpersonnel, and then socialized accordingly [27]. Someindividuals may experience disjunctions between theirapparent sex and their identification with the other gen-der, leading to transgenderism, and sometimes desires forreassignment (surgical or otherwise). Finally, there arecultural differences that either allow or prohibit expres-sions of gender identity, such as the "hijra" in India whousually act in feminine ways, but who can be male orintersexed, though they are considered neither male norfemale [28]. Growing up in a male or female body affectsthe gender identity individuals create/develop. For exam-ple, growing up female and being raised as members of aless desirable group can make it more difficult for girls todevelop positive senses of themselves, which is requiredfor good mental health [25].Gender relations refer to how individuals interact withand are treated by others, based on their ascribed gender.Gender relations have a profound effect at all levels ofsociety, and can restrict or open opportunities for individ-uals [29]. Gender relations interact with "race," ethnicity,class, ability, sexual orientation and other social locationsand reflect differential power between women and menand between more or less powerful groups [28]. Genderrelations affect personal relationships with others, andalso guide interactions within social units, such as theinfluence the interpersonal dynamics related to tobaccoreduction in pregnant and postpartum women [30]. Bot-torff et al.'s 2006 study revealed that partner's expecta-tions, support/pressure, and their personal tobaccoroutines influenced women's attempts to quit smokingduring pregnancy and into the postpartum period [30].Similarly, gendered and racialized relationships betweenworkers and customers affect sales of tobacco to children[31,32]. DiFranzi et al. found higher incidences oftobacco sales to minors among male clerks [31] whileLandrine et al. found that African-American and Latinochildren were asked about their age more often thanWhite children when attempting to purchase cigarettes[32]. Furthermore, compliance with smoke free policies inbars has been found to be correlated with bartender gen-der, where patrons are more likely to comply when servedby male staff [33]. The nature and details of these gen-dered interactions were not always explored; however,these examples illustrate the ways that gender operatesrelationally and in social contexts.Institutionalized gender reflects the distribution of powerbetween the genders in the political, educational, reli-gious, media, medical, cultural and social institutions inany society. These powerful institutions shape the socialnorms that define, reproduce, and often justify differentexpectations and opportunities for women and men andgirls and boys, such as social and family roles, job segre-gation, job limitations, dress codes, health practices, anddifferential access to resources such as money, food, orpolitical power. These institutions often impose socialcontrols through the ways that they organize, regulate,and uphold differential values for women and men [34].These restrictions reinforce each other by relaying socialprocesses of discrimination, inclusion and exclusion, cre-ating cultural practices and traditions that are difficult tochange and often come to be taken for granted. There arenumerous examples of unequal and differential access forwomen and girls in particular, to resources that directlyaffect health and well-being. For example, girls are lesslikely than boys to be provided with health care, food, oreducation in many parts of the world [35]. Women areoften malnourished due to the priority of feeding otherfamily members first [36]. Even in developed countries,women are less likely than men to have an adequateincome, and racialized women even less so, directly affect-ing their opportunity to achieve good health [34]. Thus, asLorber and Farrell recognize, "Gender is built into thesocial order...The major social institutions of control –law, medicine, religion, politics – treat men and womendifferently" [[37], p. 1–2].Gender, Sex and Health ResearchPage 4 of 11(page number not for citation purposes)family or the workplace. These relationships have a directbearing on health [29]. For example, the gendered rela-tionships between men and women have been found toGender and sex, while separate concepts, are inextricablylinked and reciprocally influence each other. For example,a person's secondary sex characteristics (whether theyInternational Journal for Equity in Health 2009, 8:14 http://www.equityhealthj.com/content/8/1/14have a penis or vagina or breasts) will influence how theyare treated by others and will shape their life experiences(i.e., they will move through the world as a woman, man,intersexed or transsexual person). Gender also affects sex:men who view themselves as ultra-masculine and partici-pate in high-risk sports and activities experience increasesin their testosterone levels [38]. These examples illustratethe interconnectedness of sex and gender and help toexplain why, in research, when people are asked to reporttheir "sex" or their "gender" (when offered response cate-gories "male" and "female") researchers are likely captur-ing both social and biological elements. For example, aperson may report their gender based on both how theyappear (secondary sex characteristics) and/or how theyfeel: masculine or feminine. It is this realization that likelyled Prins et al. to suggest that "there is no difference in theuse of the binary variables of sex and gender. The distinc-tion between the two terms is usually relevant only whenthe mechanisms of influence are being studied" [[11], p.S107]. The binary variable "male" and "female" that isderived from most questionnaires and databases is usefulfor a beginning exploration of difference between malesand females. Once established, we need to move beyonddescription and ask about whether the observed differ-ence is caused by biological or social factors. It is in thisexploration of the causal mechanism of difference anduniqueness where more refined definitions of sex andgender are required.Sex and gender are multidimensional concepts, whichmeans that any given individual is affected by multiplefactors, including genetics, physiological characteristics,physical characteristics, gender identity, gender relations,and institutional gender. Additionally, sex and gender-related factors can interact and change as individualsmove through the lifespan [3].Given the complexity of understanding the effects of gen-der and health, what advice can be given to the researcherwho wants to better incorporate and acknowledge themany issues related to sex and gender and health? Whilethere are many ways to incorporate a sex and gender-based analysis (SGBA) in health research, in developingthe primer we suggested three basic approaches in thehope that they would provide an entrée into a confusingfield for a wider array of researchers. We deliberately wrotethe primer in a simple manner in order to appeal toresearchers who might not otherwise consider these con-cepts. Below we describe these approaches and reflect onour experience in trying to encourage others to use oursuggestions. These approaches are meant to apply to allrealms of health research: biomedical, clinical, health sys-tems, social/cultural, and health policy, as well as allthan simply adding men or women to a sample andinstead requires changes throughout the research process.For this reason, we developed three options to enableresearchers to use SGBA at various stages of the researchprocess. Option one involves revisiting an original studywhere data has already been collected and retroactivelyapplying SGBA, reanalyzing or performing a secondaryanalysis. Option two helps researchers enhance an exist-ing study with SGBA, making minor additions andchanges to the research design. Option three encouragesresearchers to incorporate SGBA at the beginning of astudy, and is therefore designed for projects that are ableto make substantial changes or are still in the initial plan-ning phase. We discuss these three options in detailbelow.Revisit an original study by applying SGBA, and or reanalyzing the dataThe first of our three options is designed for researchprojects where data collection is complete, rendering afull-fledged SGBA difficult without additional andlengthy time investments. It is still possible to incorporateand account for sex and gender in these instances by criti-quing and reanalyzing previously collected data. Forexample, researchers can disaggregate research results bysex, to explore whether differences exist, which is a neces-sary first step to engaging in sex and gender-sensitiveresearch [39]. We do recognize that if sex was not a varia-ble in the original data set, that reanalyzing by sex maynot be possible. However, it is still possible to review andcritique the way that sex and gender were used or omittedin a study, regardless of what specific data were collected.Researchers can critique and challenge the way that sexand gender were theorized, operationalized, and dis-cussed in the literature review, and acknowledge if theywere overlooked or confused [39]. Reanalyzing data byasking supplementary questions of previously collecteddata or further probing results in an attempt to explain sexor gender differences is constructive and can improve theapplicability of research results. Performing a secondaryanalysis is another useful way of reanalyzing data that didnot originally consider the concepts of sex and gender. Asecondary analysis provides the opportunity to explorepreviously unexamined dimensions of the research, askadditional questions, compare data from other studies, orperform different statistical analyses [40]. Above all, assuggested by Eichler, asking the following questions ofany work is always relevant and useful and can apply toany stage of the research process [39]. We paraphraseEichler's questions below [39]:1. Does the research question take one sex or gender asPage 5 of 11(page number not for citation purposes)stages of the research process. It is important to recognizethat integrating sex or gender into a study means morethe norm, rather than stating explicitly who theresearch is applicable to? Make sure to avoid general-International Journal for Equity in Health 2009, 8:14 http://www.equityhealthj.com/content/8/1/14izing the findings to groups other than the one beingstudied.2. Does the research question assume that women andmen are uniform within their sex/gender groups? If so,consider that there are multiple differences betweenindividuals of the same sex or gender and be mindfulwhen reporting the findings to acknowledge the differ-ences among groups of women or groups of men.3. Revisit the literature review and examine how sexand gender are used in these studies. Are the terms sexand gender used accurately? How can your studypresent a more precise portrayal of sex and gender? Ifinaccuracies or omissions exist in the literature, makenote of this in your own research to avoid perpetuat-ing the confusion.4. Are your measures for both sex and gender appro-priate? If not, acknowledge this limitation and con-sider modifying your instruments if possible.5. How were your data collected and how does thisaffect your results?6. Does your analysis account for differences betweenthe sexes and genders, and also within these groups? Ifnot, reconsider how you can analyze the findings toaccount for these differences.While research on the differences between the sexes isimportant and necessary, it is essential to move beyondthe level of differences to explore how sex and genderoperate in tandem to influence health outcomes andbehaviours. Once differences between the sexes have beenestablished, additional research is needed to explorewhether sex, gender or both contribute to the differences.Krieger [9] provides an excellent table showing examplesof the differential roles of gender relations and sex-linkedbiology on health outcomes. She identifies whether onlygender, only sex-linked biology, neither, or both, areinvolved in the production of sex differences in case stud-ies such as HIV/AIDS needle-stick injury among healthcare workers and parity among men and women withincreased risk of melanoma [9]. This type of research illus-trates the challenges of analysing sex and gender on sev-eral levels. For researchers new to the concept of gender,understanding and applying the many layers of gendercan be a difficult task. A solution might be to begin withone layer of gender (e.g. gender identity or gender rela-tions) in the analysis and move from there. Furthermore,as O'Brien et al. [41] have asserted, "Whilst the presenta-tion of sex-disaggregated data (and explanations forof reifying differences between men and women, andhomogeneity within gender classes" (p. 504). This dangeris real and must be responded to with more reflection onwithin group differences and experiences and the socialprocesses that affect them in achieving health. In this way,it is important to explain sex differences in ways that donot endorse stereotypes or use binary thinking, norassume that all members of a sex or gender group experi-ence risks to or opportunity for health equitably.Augment an existing research plan with SGBAThe second option is intended for research studies that arein the initial stages where data collection has not endedand where amendments and modifications are possible.This option encourages adding samples of men to a studyon women, or samples of women to a study on men, toenable more rigorous and complete analyses. Dividing asample by sex is also valuable, as this immediately con-tributes to more comprehensive findings than research onundifferentiated samples. Further dissecting samples by,or providing information about, age, ethnicity, socioeco-nomic status and other variables enables researchers tofurther investigate important health determinants.Adding sex and gender-sensitive measures allows fordeeper analysis of complexities in research. While addinga measure of sex or gender is usually only possible whiledata collection is still in progress, doing so can help toreveal and/or explain sex or gender differences, and alsoquantifies differences in ways that are often not possibleotherwise. Measures that adopt a global perspective withrespect to sex and gender can provide an additionaladvantageous lens. Examples of sex measures include ana-tomical measurements, like height, weight, and musclemass, physiological measurements like sex hormones,and metabolism, and genetic sex chromosomes. Measuresof gender include the Bem Sex Role Inventory [42], theMasculine Gender-Role Stress scale [43], and the KobeWomen's Health Indicators [44], to name just a few. Allmeasures should be reviewed in light of recent theoreticaland clinical progress made on sex and gender to ensurethat measures are sensitive to the latest developments andaccurately measuring the issue at hand (see our Option 1checklist). Current measures may not be sufficient but are,for now, a means of addressing the issues. Acknowledgingthe limitations of a chosen measure is one way of circum-venting this challenge. Additional work is needed todevelop more precise and reflexive ways to operationalizeand measure sex and gender.Mixing qualitative and quantitative research methods canprovide valuable considerations of sex and gender andcan utilize the unique contributions that each approachPage 6 of 11(page number not for citation purposes)apparent differences) is an important starting point forresearch on gender and health, it has the inherent dangeroffers. Supplementing a quantitative study with qualita-tive interviews or focus groups can further explain certainInternational Journal for Equity in Health 2009, 8:14 http://www.equityhealthj.com/content/8/1/14phenomena. Similarly, qualitative approaches can pro-vide an initial examination of the issues to be further stud-ied using quantitative methods. While not all studies needto use both qualitative and quantitative research methods,there are benefits to combining these two perspectives andcan be a means of including sex and gender at a later stageof the research process.The inclusion of female animals in preclinical research iscrucial as every animal cell is also sexed [3,16], thereforeexcluding female animals has potentially extensivehuman health ramifications. The exclusion of female ani-mals typically occurs as a means of controlling for hormo-nal variation. However, these hormonal variations are oneof the key differences that deserve to be studied; thereforeresearchers need to learn to incorporate hormonal varia-tions into study design to understand their importantinfluence.Incorporate SGBA from the outsetRefocusing and reconceptualising a proposed study canincorporate concepts of sex and gender (and diversity)from the outset. As previously discussed, there is heteroge-neity in relation to sex and gender within women [14,16].For example, women have variance in their hormone lev-els and can have a range of gender identities. It is thereforeimportant to incorporate concepts of gender and sex instudies that are relevant to women only (e.g., maternalmortality and reproductive health). Using SGBA in studiesfocused on women exclusively is not only possible butalso important, as this type of study can examine issues ofdiversity among women (e.g., how race and socioeco-nomic status affect the health of women). Researching dif-ferences in susceptibility to diseases and conditions andresponses to treatment among and between groups ofwomen is a crucial dimension of single-sex studies that isoften overlooked. These types of studies benefit from theapplication of SGBA models that are sensitive to issues ofdiversity. When beginning a study on women/femalesonly, it is important to review the theoretical frameworkand methodology to confirm that they are appropriate forstudying females, as research methodologies impact thetype of questions that are asked, the process of data collec-tion, and the analytical work that is done. Quantitativeresearchers need to be mindful of sample size when stud-ying women only and take care not to over generalizetheir results to populations outside of the group(s) athand.Comparison studies can illuminate differences betweenand among groups of men and women, particularly withrespect to variability in age, income, ability, socio-eco-nomic status, geography, ethnicity, etc. Using a longitudi-uncover important gaps and differences. For example,research has shown that smoking rates among subgroupsof men and women have changed over the last 20 years,and that specific groups of people are particularly vulner-able to tobacco addiction, including Aboriginal people,youth, and individuals with low-incomes [45]. Thesefindings can provide insight and direction for futurehealth policies and prevention efforts.Multilevel studies make the simultaneous examination ofmultiple layers of sex and gender (and diversity) possible.Multilevel approaches, where the interplay and contribu-tions of many sex, gender and diversity variables are stud-ied, are becoming more important as ecological and othergroup-level health determinants are linked to individualfactors [46]. Hierarchical linear models (HLM) are a mul-tilevel approach that characterizes individuals and ani-mals as nested within groups (e.g. according to sex, racialbackground, or occupation) as a means of investigatingthe interaction between individual-level and group-levelvariables [46]. This method is useful when exploringwhether health outcomes for individuals or groups arecorrelated.These three basic suggestions for improving healthresearch were designed to appeal to new or establishedresearchers, animal or human researchers, and thoseassessing already collected data or setting out to acquirenew data. They provided some basic choices and sugges-tions in a field where new and established researchersalike often steer away from integrating considerations ofsex and gender into health research because of discipli-nary practices, a lack of will or a lack of understanding ofthe concepts and variables. While it is an emerging andconstantly changing field where the concepts, theoriesand methods are constantly being improved and mademore sophisticated, there is an urgent need to begin toinvolve more health researchers in the enterprise, utilizingbasic approaches such as these.The Knowledge Translation ProcessKnowledge translation (KT), defined as moving "knowl-edge to action" [[47], p. 22], has been identified as animportant aspect of health research that is typically over-looked by researchers [47,48]. The importance of ensur-ing that research results are shared with stakeholders,particularly in health research, cannot be overstated: theconsequences of ignoring this transfer of knowledge canrange from less effective programming to increased mor-bidity and mortality in health research contexts [48]. Withthis in mind, there is increasing recognition among healthresearchers that KT must be incorporated into researchprojects from the outset and should involve users ofPage 7 of 11(page number not for citation purposes)nal approach, or investigating trends over time, can research whenever possible.International Journal for Equity in Health 2009, 8:14 http://www.equityhealthj.com/content/8/1/14As part of the knowledge translation strategy for theprimer [12], the Women's Health Research Network(WHRN) organized and conducted workshops withresearchers, students, clinicians and policy-makers acrossthe province of British Columbia, Canada. The goal ofthese workshops was to introduce the primer and to breakdown the concepts of sex and gender so that participantswould be able to understand the theoretical differencesbetween sex and gender and recognize the importanceand relevance of these concepts in their own research andprogramming. Above all, the workshops were meant toinspire participants to continue thinking about sex, gen-der and diversity in relation to health and to their ownwork.The workshops assumed different forms, with someorganized and led by the authors of the primer, and mostcoordinated and led by two staff members of the WHRN,Drs. Elana Brief and Colleen Reid. Workshops took placein various locations across the province of British Colum-bia, and were free of charge to participants and host insti-tutions/organizations. At the time of writing thismanuscript, 22 workshops have taken place since theprimer was launched in April, 2007. Of these 22 work-shops, 4 were for provincial health authorities, 12 were foracademic departments at universities and colleges, and 6were for government-funded research networks andresearch groups, all within British Columbia, Canada. Theprimer itself has been downloaded over 650 times by peo-ple all around the world who have found it useful forteaching, grant writing, and manuscript preparation pur-poses.The workshops typically used a multi-method presenta-tion format that involved a talk by the facilitators on thebasic concepts of sex and gender, an illustrative powerpoint presentation, activities to engage participants withthe concepts, and both small and large group exercises tohelp participants incorporate sex and gender in their ownwork. Participants analyzed health issues like cardiovascu-lar disease, tobacco use, and diabetes using sex and gen-der-based analyses in order to expand how theypreviously thought about these specific health issues. Par-ticipants were encouraged to create research strategies andapproaches that could better account for sex and gendereffects. These practical sessions provided hands-on train-ing in the hopes that participants would be encouragedand prepared to use SGBA in the future. Facilitators foundthat kinaesthetic exercises were helpful, particularly inbringing the amorphous and fluid concept of gender tolife. For example, one popular activity that facilitatorsused involved having participants construct a continuumof gender identities using pictures of well-known celebri-masculinity. With the image of the celebrity in mind, par-ticipants were asked to stand somewhere on the genderline-up between 100% masculine and 100% feminine.Participants then revealed their image and explained whythey stood in that particular spot. Inevitably, explanationsranged from notions of gender identity, gender roles, andgender relations, to, in some instances, institutionalizedgender. By moving gender from its complicated andabstract theoretical origins to a tangible "hands-on" andembodied group activity, participants were able to con-nect with the concept and became more comfortable withthe idea of integrating gender into their work.While we have enjoyed some success introducing theseconcepts to researchers across British Columbia, the proc-ess of sharing the primer with others has allowed us toappreciate how difficult it can be to incorporate sex andgender into research. Despite our best intentions to keepthe format of the workshops simple and the concepts easyto understand, we often worried that participants hadn'tfully grasped the concepts, or would be unable to inte-grate sex and gender into their work after they left theworkshop.One of the most difficult aspects of conducting the work-shops was the limited measurement tools available to sug-gest to participants for use in their research and programs.Compounding this lack of resources was the varied levelof experience with, and prior knowledge of, sex and gen-der. Thus, the facilitators were, ironically, often uncom-fortable dealing with the issue of measurement directly,even though the measurement of sex and gender was acore concept within the primer. There is a dearth of appro-priate and concrete tools to measure sex and gender, espe-cially to suggest to an assorted mix of participants, so itwas instead easier to provide a framework of key issues toconsider and tailored case study examples for each group.Sharing the primer with others has illustrated to us theneed for accurate and reflexive measures, particularly ofgender, so that the field of gender and health can moveforward and beyond the use of sex and gender as analytictools. The development of concrete and accurate measureswill also help to extend the conversation about sex andgender and health beyond those who are already familiarwith these concepts. Concrete measures will better enableresearchers to adopt SGBA.Perhaps most useful in teaching about the health effects ofsex and gender was the provision of case examples, whichtook participants through the process of applying SGBAand illustrated the impact of considering sex and genderin particular research instances. These examples were tai-lored to be specific to each audience so that while the con-Page 8 of 11(page number not for citation purposes)ties to illustrate pictorially the ideas of femininity and cepts of sex and gender were new, the material wasInternational Journal for Equity in Health 2009, 8:14 http://www.equityhealthj.com/content/8/1/14familiar and provided realistic examples of improvementsthat could be made. We provide a case study below toillustrate this method of KT that we found effective:Case Study: Knee InjuryKnee injuries are a curiously and sometimes controver-sially gendered phenomenon which, when investigatedusing a sex and gender-based analysis, reveal a number ofimportant differences between men and women that haveconsequences for prevention, diagnosis, treatment, andpatient care. Here, we illustrate how the application ofSGBA could benefit studies related to knee injury at vari-ous stages of the research process, like in our 'threeoptions' listed above:1. Revisit an original study by applying SGBA, reanalyzing or performing a secondary analysisSex-disaggregating previously collected data on anteriorcruciate ligament (ACL) tears reveals that women aremore likely than men to sustain an injury [49], morelikely to report pain than men [50], and more likely to suf-fer from osteoarthritis [51]. Establishing that sex differ-ences exist with respect to ACL injury should signal theimportance of accounting for sex and gender in futureACL research, as the factors associated with ACL injuryrisk may not be the same for men and women. This differ-ence would be missed without separating samples accord-ing to sex.2. Augment an existing research plan with SGBAUsing the knowledge that sex differences exist with respectto injury, researchers could attempt to explain this differ-ence by examining different causal factors. By dividing asample into men and women (or adding a sample ofwomen), prospective studies examining risk factors forACL injury in both men and women could focus on spe-cific factors to see if and how they differ between the sexesand might contribute to injury. Researchers could also ret-rospectively compare injured individuals, male andfemale, to control cases to try and isolate specific factorsthat could place women at risk of injury. Studies such asthese have confirmed many differences between men andwomen that could be causes of women's greater risk ofACL injury. For example, researchers have found that kneelaxity, limb alignment, knee notch dimensions, and liga-ment size differ between the sexes and all have been theo-rized to cause women's greater risk of ACL injury [52].Because of these anatomical differences, sex-specific kneereplacements have been developed for men and womenseeking knee replacements [53].Adding a measure of hormonal influence in studiesalready designed to investigate casual factors wouldhormonal factors are also believed to impact women'sgreater risk of injury [52].Supplementing a quantitative study focused on the neu-romuscular and biomechanical aspects of ACL injury witha qualitative investigation examining the impact of ACLinjury in participants' daily lives, the process of negotiat-ing treatment options or the experience of ACL repaircould provide insight into this gendered subject. Forexample, qualitative research examining adherence torehabilitation regimes has reported environmental, phys-ical and psychological reasons that individuals are suc-cessful or unsuccessful in their rehabilitation attempts[54]. This type of qualitative research would benefit froma gender analysis that could consider the impact of genderroles on men and women's risk of injury and daily lives inways that promote or impede rehabilitation (e.g. differentwork schedules, responsibilities at work and at home, andamount and type of physical exercise, etc).3. Incorporate SGBA from the outsetWhile it is now widely accepted that women are moreprone to ACL tears than men due to the importantresearch on sex differences in knee structure and function,research has not yet identified the specific mechanismsthat lead to these sex differences. More research is neededto pinpoint the underlying factors that lead to discrepan-cies, and to document which factors lead to an increasedrisk for women in particular [49]. These types of studieswill need to account for sex and gender from the outset.For example, studies focused specifically on women's ACLinjuries have identified that sex hormones are likely onefactor contributing to women's greater risk for ACL injury[55,56] and that women are more likely to suffer an injuryduring a particular phase of their menstrual cycles [55,56].Research is still needed on the sex-based mechanisms thatcause women's high rate of ACL injury so that preventionefforts can be developed.Studies that incorporate SGBA from the outset are betterequipped to investigate the impacts of gender. For exam-ple, Borkhoff et al. [57] examined gender at the institu-tional level and found that twice as many men thanwomen were referred for total knee arthroplasty (kneereplacement) in an Ontario-based study, despite similarsymptoms and level of disability. This startling findinghas led researchers to speculate that gender biases mightbe at play, where physicians consciously or unconsciouslyactivated stereotypes about which gender is more likely toneed total knee arthroplasty (TKA), and/or succeed withTKA [57]. Furthermore, there has been speculation thatgender roles positively influence the way that men interactwith physicians when seeking help for injured knees, andPage 9 of 11(page number not for citation purposes)immediately provide more comprehensive findings, as that women's narrative speaking style is not as effective inInternational Journal for Equity in Health 2009, 8:14 http://www.equityhealthj.com/content/8/1/14health care appointment settings as men's factual and to-the-point style [57].These examples illustrate the benefit of utilizing a SBGA inhealth research and illustrate the 'value-added' of such anapproach. Examples such as these proved helpful for theparticipants in our workshops and we hope that they areuseful in this context as well as a means of understandinghow SGBA might function. Above all, the process of SGBAmeans asking questions and thinking creatively abouthow aspects of sex and gender might influence the issue athand. The workshops affirmed that more work is neededin this area, so that researchers are not only aware of sexand gender, but comfortable with the concepts and profi-cient in using them.ConclusionThe current landscape of sex, gender and health researchwill undoubtedly shift as more work is done in this area.We have suggested three main ways to use sex and genderin health research as a catalyst and starting point to helpresearchers think about these concepts in relation to theirown work and interests. Introducing sex and gender in acomprehensive manner into health research heralds anew era, one that holds great promise for increasing ourunderstanding of the origins of health and illness. Weexpect new developments in our understandings of sexand gender as research continues in these areas and moreattention is paid to theoretical developments, questionsof research design and the measurement issues related tosex and gender. We look forward to the articulation ofmore complex theories and measures of diversity, andgrowing insights into how all elements interact to producehealth. Above all, recognizing sex and gender in healthresearch is a necessity, in order to produce more accurate,rigorous, and valid results. Incorporating sex and genderinto health research equals better science.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsJJ and LG developed the conceptual background andframework for the primer and paper. RR managed theproject. JJ, LG and RR wrote and edited the paper.AcknowledgementsWe thank the Women's Health Research Network and the Michael Smith Foundation for Health Research for supporting this work and publishing the primer, Better Science with Sex and Gender: A Primer for Health Research. 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