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Sex, drugs and gender roles: mapping the use of sex and gender based analysis in pharmaceutical policy… Greyson, Devon; Becu, Annelies R; Morgan, Steven G Nov 19, 2010

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RESEARCH Open AccessSex, drugs and gender roles: mapping the use ofsex and gender based analysis in pharmaceuticalpolicy researchDevon L Greyson*, Annelies RE Becu, Steven G MorganAbstractBackground: Sex and gender sensitive inquiry is critical in pharmaceutical policy due to the sector’s historicalconnection with women’s health issues and due to the confluence of biological, social, political, and economicfactors that shape the development, promotion, use, and effects of medicinal treatments. A growing number ofresearch bodies internationally have issued laws, guidance or encouragement to support conducting sex andgender based analysis (SGBA) in all health related research.Methods: In order to investigate the degree to which attempts to mainstream SGBA have translated into actualresearch practices in the field of pharmaceutical policy, we employed methods of literature scoping and mapping.A random sample of English-language pharmaceutical policy research articles published in 2008 and indexed inMEDLINE was analysed according to: 1) use of sex and gender related language, 2) application of sex and genderrelated concepts, and 3) level of SGBA employed.Results: Two thirds of the articles (67%) in our sample made no mention of sex or gender. Similarly, 69% did notcontain any sex or gender related content whatsoever. Of those that did contain some sex or gender content, themajority focused on sex. Only 2 of the 85 pharmaceutical policy articles reviewed for this study were primarilyfocused on sex or gender issues; both of these were review articles. Eighty-one percent of the articles in our studycontained no SGBA, functioning instead at a sex-blind or gender-neutral level, even though the majority of these(86%) were focused on topics with sex or gender aspects.Conclusions: Despite pharmaceutical policy’s long entwinement with issues of sex and gender, and theemergence of international guidelines for the inclusion of SGBA in health research, the community ofpharmaceutical policy researchers has not internalized, or “mainstreamed,” the practice. Increased application ofSGBA is, in most cases, not only appropriate for the topics under investigation, but well within the reach of today’spharmaceutical policy researchers.BackgroundHealth researchers are increasingly investigating theways that social and biological factors interact as deter-minants of health. The influences of biological andsocial dimensions of sex and gender are important inthis regard. Although medical research has historicallyfocused on issues related to sex (the biological attributeslinked to the categories of male and female) rather thangender (the social constructs culturally linked to“maleness” and “femaleness”) [1,2], a growing body ofresearch suggests that health status, access to care, andmedical outcomes are influenced by an individual’s sta-tus in society, including one’s status as a sexed and gen-dered being [3]. Similar to race and ethnicity studies,high-quality sex and gender based analysis (SGBA) canhelp document inequities in health and health care,advance understanding of needs, and improve popula-tion and individual health outcomes. This potential for amore sophisticated understanding of health needs andoutcomes within and among identified demographicgroups - such as men and women - is greater still whenresearchers apply intersectional analysis techniques,* Correspondence: devon@chspr.ubc.caCentre for Health Services and Policy Research, School of Population andPublic Health, University of British Columbia, 201-2206 East Mall, Vancouver,BC, V6T1Z3, CanadaGreyson et al. International Journal for Equity in Health 2010, 9:26http://www.equityhealthj.com/content/9/1/26© 2010 Greyson et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.examining how various social categories combine andinteract to create difference.SGBA may be defined as, “an approach to research andevaluation which systematically inquires about biological(sex-based) and sociocultural (gender-based) differencesbetween women and men, boys and girls, without pre-suming that any differences exist” [4]. Sex and gendersensitive inquiry is particularly critical in areas ofpharmaceutical policy due to the sector’s historicalconnection with women’s health issues and due to theconfluence of biological, social, political, and economicfactors that shape the development, promotion, use, andeffects of medicinal treatments [4,5]. The women’s healthmovement has successfully advocated for more researchon women’s health [6,7], and particularly for women’sinclusion in clinical trials [8,9], resulting in 1993 UnitedStates legislation [10] and 1997 Canadian guidelines [11]on inclusion of women in drug trials. A growing numberof research bodies internationally have also issued gui-dance and encouragement to support conducting “genderand sex-based analysis” [12] or “gender mainstreaming”[13] in all health related research.While the value of high-quality SGBA in pharmaceuti-cals has been established, it is as yet unclear whetherSGBA has permeated the field of pharmaceutical policyresearch. Have the attempts to mainstream SGBA trans-lated into sex and gender sensitive research practices inthe field of pharmaceutical policy? In order to addressthis question, we undertook a literature scoping exerciseto map the extent, range and nature of current practicesrelated to SGBA in a representative sample of Englishlanguage pharmaceutical policy research.MethodsWe employed methods of literature scoping and map-ping [14-16], beginning with a search of the MEDLINEdatabase (daily update, 1950-present, via Ovid SP inter-face) conducted by DG on July 16, 2009 for English lan-guage articles on pharmaceuticals and public policy thatwere published in 2008 (see Appendix 1 for search strat-egy). Abstracts of potentially relevant citations werescreened by DG for pharmaceutical policy relevance,defining pharmaceutical policy as, “the rules, processes,and structures that are put in place by governments andpublic agencies to manage problems related to the avail-ability of medicines and the role of medicine in healthcare” [17]. We excluded articles not directly related topharmaceutical policy (such as those on illicit drug pol-icy or environmental health) and non-policy articles onpharmaceuticals (such as clinical studies of a particulardrug), as well as articles not containing original researchor review content. After screening citations, we drew arandom sample of articles for detailed analysis andclassification.DG and AB coded the sample of included articlesusing a standardized extraction and classification tem-plate. This template was developed through an iterativeprocess in which themes from the literature on SGBAand pharmaceuticals were transformed into coding cate-gories applicable to a wide range of pharmaceutical pol-icy research, and pilot tested on a separate sample ofarticles from the core journal Health Policy in order toachieve >90% inter-rater reliability before proceedingthrough the included studies. Disagreements in codingof included studies were reconciled via discussionbetween the coders. The template allowed for categori-cal coding of each article’s research methods and datasources, binary coding of details about whether and howsex and/or gender was used in both the language andconcepts applied in the article, and categorical coding ofthe level of SGBA employed in the article. In addition,the template provided a free text section to captureadditional aspects of interest - ranging from contextualinformation that might lend insight into the SGBAchoices of the authors (for example, special attributes ofthe data or population studied), to notes on ways SGBAmight have been, but was not, included.We coded articles’ sex or gender language in terms ofthe use of words indicating sex or gender in the text ofthe article, for example a statement that “ male surveyrespondents were more likely to strongly agree “ or“46% of the study sample were women.” We also codedfor language that was related to, but not synonymouswith, sex and gender, such as sexual orientation andpregnancy status. We coded for sex or gender applica-tion referring to use of sex or gender concepts in theunderpinnings or research analysis of an article; forexample a statistical analysis using sex disaggregateddata, or the consideration of gender norms in a policyanalysis. The intent of this coding was to assess theextent to which any sex or gender language and conceptuse was taking place in our sample. While language andcontent of an article are related, it is possible for an arti-cle to make mention of sex or gender yet not apply it inany way conceptually or analytically, or to use languagethat does not accurately represent the concepts beingapplied or investigated; therefore examination of bothamong articles in our sample was necessary.Beyond assessing language and conceptual inclusion ofsex and gender, we assessed whether the studies in oursample replicated themes commonly identified in the lit-erature as challenges to achieving “mainstreamed” gen-der and sex analyses. We coded whether “sex” or“gender” were defined, and whether sex and genderwere used interchangeably or otherwise conflated. Forarticles using quantitative research methods, we codedwhether sex and/or gender was a variable in analysis,whether the analysis was sex disaggregated, and - ifGreyson et al. International Journal for Equity in Health 2010, 9:26http://www.equityhealthj.com/content/9/1/26Page 2 of 8studying a phenomenon or condition that affectedwomen as well as men - whether at least 45% of thepopulation studied was female. For qualitative studies,we coded whether or not sex and/or gender were con-sidered by the study authors as a theme of the analysis.Finally, adapting Varcoe, Hankivsky, and Morrow’shierarchy of “Four approaches to thinking aboutwomen’s health” [18], we coded articles as to the levelof SGBA at which they functioned. Level 1 is the gen-der-neutral or sex-blind approach, in which sex andgender are ignored or seen as irrelevant to health. Level2 comprises approaches reliant on biological essential-ism or determinism. Level 3 is the level at which sexand/or gender based analysis is applied, and sex and/orgender are viewed as significant determinants of healthbeyond reproductive and sexual capacity alone. Level 4includes research in which sex and gender are incorpo-rated into intersectional analysis, which views sex andgender as interdependent with other social determi-nants, such as socio-economic status, culture, sexualorientation, age, and dis/ability. We flagged Level 1 arti-cles for which SGBA could reasonably be excludedbased on the study subject, for example economic stu-dies of competition between firms or policy analysesabout non-gendered phenomena. Studies with humandata and studies of drug or policy impacts on humanswere ineligible to be considered to appropriately func-tion in a gender-neutral and sex-blind manner.ResultsArticlesOur original search of the MEDLINE database produced1,346 unique citations published in 2008 and potentiallyrelated to pharmaceuticals and public policy. Title andabstract reviews reduced the list of potential articles forour study to 302. We drew a random sample of 151 ofthese (50%) for full text analysis. Upon full text analysis,66 further articles were excluded on the basis of beingoff-topic, not including original research, or being una-vailable in English. The remaining 85 original researcharticles about pharmaceutical policy were subject to fulldata extraction and classification; 14 of these articlesused qualitative research methodologies, 28 used quanti-tative methods, 40 were review articles, and 3 were the-ory pieces. Figure 1 illustrates the search and screeningprocess.Use of sex and gender languageTable 1 summarizes aspects of sex and gender languageand application in the 85 articles included in our study.Fifty-seven of the articles (67% of the total) made nomention of sex or gender. Of those containing some sexor gender language, 11 articles (13%) mentioned sex,8 articles (9%) mentioned gender, and 21 articles (25%)used language that was sex or gender related but notclearly one or the other. Of the 21 studies using sexand/or gender language that was ambiguous, the poten-tially related language focused on concepts such as preg-nancy, hormones, transsexuals, or women, withoutclarity on whether the concepts were intended to beunderstood in terms of the biology of sex, social dimen-sions of gender, or both. None of the papers in our sam-ple offered a definition of sex or gender, and 7 articles(8%) used the words sex and gender interchangeably orotherwise conflated their meaning.Application of sex and gender conceptsFifty-nine of the articles in our sample (69% of the total)contained no sex or gender related content whatsoever,not even a note that sex or gender data was unavailablefor that study. This number is slightly higher than thenumber without sex or gender language, as two of thesearticles had used sex or gender language somewhere inthe article but did not actually apply any sex or genderconcepts in any part of the article. Of those containingsome level of sex or gender concept application, 18 arti-cles (21%) included some form of sex-based content,6 articles (7%) included some form of gender-based con-tent, and 9 (11%) incorporated related concepts. Someof these articles applied SGBA to the research that wasthe primary focus of the article, whereas others onlyincluded it as part of the article’s conceptual back-ground or literature review section. Methods andapproaches to applying sex and gender concepts variedwidely within and across study types.SGBA was the main focus of none of the 5 qualitativepapers [19-23] that considered some aspect of sex,Potentially relevant articles identified and screened by titlen = 1430Articles to be randomly sorted for scoping n=302Full articles retrieved for more in-depth evaluationn = 151Articles mapped according to coding rubric n = 85Total articles excluded n = 1128Duplicate records n=84Not pharmaceutical policy n=1044Articles excluded via random sortn = 151 (50%)Total articles excluded n = 66Descriptive or no original data n = 48Not pharmaceutical policy n = 16Not available in English n=2Review n=40Qualitative n=14Quantitative n=28Theory n=3Figure 1 Search and screening process for literature mapping.Greyson et al. International Journal for Equity in Health 2010, 9:26http://www.equityhealthj.com/content/9/1/26Page 3 of 8gender or related concepts. Of the 6 quantitative articlesthat included some degree of sex content, just 1 [24]included sex-disaggregated analysis; 3 others [25-27]used sex as a variable for adjusting/controlling for sex-related effects (often unspecified). Only 3 [24,25,27] ofall 28 quantitative articles clearly included study popula-tions that were known to be >45% female, although sev-eral either did not know or did not disclose the sexbreakdown of human populations studied, so this issueis difficult to assess in our sample.Only 2 of the 85 pharmaceutical policy articlesreviewed for this study were primarily focused on sex orgender issues. Both of these were review articles: one onthe topic of transsexuality treatment options andanother on medical abortion drug approval [28,29].A third review article [30], focusing on clinical trialspolicy, contained a significant focus on sex and genderissues. All other sex or gender analyses were minor por-tions of the main articles.Levels of SGBAAs illustrated in Table 2, 69 (81%) of the studiesincluded in our analysis conducted research at Level 1, agender-neutral or sex-blind approach. Fifty of these arti-cles (59% of all included studies) took such an approacheven when focusing on topics with possible sex or gen-der aspects. Quantitative research articles were mostlikely to be gender-neutral or sex-blind; however, ahigher proportion of the qualitative studies that took aLevel 1 approach did so when SGBA could reasonablybe expected of the subject matter (79% of Level 1 quali-tative studies vs. 75% Level 1 quantitative studies).Ten of our study articles (12%) took a Level 2approach, either assuming sex and gender by virtue offocusing on a sexual or reproductive-related topic, or byequating men or women’s health with gendered bodyparts, conditions or therapies (e.g., breasts, pregnancy,or sildenafil). Six of our study articles (7%) took a Level3 approach, employing some sort of SGBA in the workreported. None of the articles employing qualitativeresearch methods - the methods with perhaps the great-est potential for capturing rich gender data and concepts- conducted sex or gender based analysis at this thirdlevel. No articles in our sample employed intersectionalanalysis (Level 4).Data SourcesWhile the data types and sources utilized by articles inour sample were diverse (table 3), there did not appearto be any particular type of data that corresponded withincreased or improved SGBA. Among the qualitativearticles, the three that employed a Level 2 approach toSGBA, rather than Level 1, utilized all three data types:legal documents, policy documents, and interviews. Thequantitative article that used a Level 2 approach linkedclinical trial data with drug adverse effect and medicalservices data, while the one functioning at the thirdlevel was based on survey data. Use of aggregate datathat prohibited sex- or gender-disaggregated analysiswas common in our sample. The aggregate data phe-nomenon was especially prominent within the articlesemploying quantitative methodologies.DiscussionLimitations and InterpretationResults from this scoping and mapping study are notnecessarily representative of all pharmaceutical policyresearch. MEDLINE is an incomplete index of theworld’s pharmaceutical policy research, both geographi-cally and in terms of subject coverage. We further lim-ited our scope by including only English-languagearticles, and only articles from 2008. While this limitedTable 1 Sex and gender language and application by research type among articles included in studyQualitative articles(n = 14)Quantitative articles(n = 28)Review articles(n = 40)Theory articles(n = 3)Total (n = 85)Sex/gender conflation 0% (0) 7% (2) 10% (4) 33% (1) 8% (7)LanguageGender 7% (1) 7% (2) 10% (4) 33% (1) 9% (8)Sex 0% (0) 14% (4) 18% (7) 0% (0) 13% (11)Related/Ambiguous* 36% (5) 11% (3) 30% (12) 33% (1) 25% (21)None 64% (9) 75% (21) 63% (25) 67% (2) 67% (57)ApplicationGender 7% (1) 0% (0) 10% (4) 33% (1) 7% (6)Sex 21% (3) 21% (6) 20% (8) 33% (1) 21% (18)Related/Ambiguous** 14% (2) 4% (1) 13% (5) 33% (1) 11% (9)None 64% (9) 75% (21) 68% (27) 67% (2) 69% (59)* Related/Ambiguous language focused on concepts such as women, pregnancy, hormones, and transsexuals.** Related/Ambiguous application included such concepts as: pregnancy, sex hormones, gender identity, sexuality, and sexual orientation.Greyson et al. International Journal for Equity in Health 2010, 9:26http://www.equityhealthj.com/content/9/1/26Page 4 of 8date range ensured the most recent complete sampleavailable, the time-limited sample will necessarily reflecttrends and events of current interest in 2006-2008. Byapplying data abstraction and mapping, rather than in-depth qualitative content analysis, our assessment maynot reflect nuances of the discourse around sex andgender in the articles we sampled. An in-depth qualita-tive content analysis of articles in this discipline mightshed further light on the nature of inclusion or exclu-sion of SGBA in this body of research. Likewise, a largerstatistically-based study might be able to test for differ-ences among methodological approaches, study coun-tries of origin, or other article attributes, in order tofurther assess the status of SGBA in the field.Nonetheless, our results reinforce previous assess-ments that SGBA implementation has not been terriblysuccessful to date [31,32], even in areas of medicine inwhich sex and gender have emerged as significant fac-tors [33,34]. They also highlight windows of opportunityfor implementing better SGBA in pharmaceutical policyresearch. In some cases, incorporating SGBA on thethird level of the four-approaches model is fairly “lowhanging fruit.” Examples of article types that may movefairly easily from a sex and gender blind approach to aSGBA approach include qualitative and quantitative stu-dies that draw on interview, focus group or survey datacollected for the purpose of the project. Yet, we foundno indication that uptake of SGBA was higher amongarticles utilizing these data types. Similarly, quantitativestudies relying on administrative data that presumablycontained an individual-level sex field were not particu-larly likely to conduct sex-stratified analysis.A minority of pharmaceutical policy issues and researchquestions do not necessarily tie in with sex and genderissues. Studies distanced from human impacts - e.g., aboutattributes of published articles, about drug firm beha-viours, or about economic incentives for drug develop-ment - may be legitimately considered unlikely to havesex- or gender-specific effects that should be examined inthe same article. However, studies with human data, stu-dies of human reactions to drugs, and studies of policyimpacts on humans can all be reasonably expected toinclude SGBA. We found many such articles in the Level1 category lacking SGBA despite discussing a topic knownto have sex and/or gender effects, determinants or dispro-portionate impacts. Thus, it appears that the field of phar-maceutical policy has not fully integrated SGBA guidelinesand recommendations into current research practice. Insome cases, it would seem that a higher awareness of sexand gender issues among pharmaceutical policy research-ers could make such inclusions second nature. However,given that discussions of mainstreaming gender and sexissues into research have been ongoing for many yearsnow, and major research funders offer guidelines on howto conduct such research, it is clear that simple “aware-ness” is not the only thing lacking.Disciplinary Culture Change OpportunitiesBy failing to consistently apply SGBA in pharmaceuticalpolicy research, we risk incomplete or inaccurate researchconclusions about this important component of healthcare. However, the field of pharmaceutical policy (andhealth policy studies more generally) might borrow frompatient safety literature and frame this as a “systems” defi-ciency [35]. Rather than blaming individual researchersTable 2 Levels of SGBA found among articles in study sampleLevel 4:Inter-sectionalLevel 3:SGBAappliedLevel 2:Biologicalessentialism/determinismLevel 1: Gender-neutral or sex-blindLevel 1: SGBAreasonably excludedLevel 1: SGBAreasonably expectedQualitative articles 0 (0%) 0 (0%) 3 (21%) 11 (79%) 0 (0%) 11 (79%)Quantitative articles 0 (0%) 1 (4%) 1 (4%) 26 (93%) 5 (18%) 21 (75%)Review articles 0 (0%) 4 (10%) 6 (15%) 30 (75%) 13 (33%) 17 (43%)Theory articles 0 (0%) 1 (33%) 0 (0%) 2 (67%) 1 (33%) 1 (33%)Total 0 (0%) 6 (7%) 10 (12%) 69 (81%) 19 (22%) 50 (59%)Table 3 Data sources, by research method of articleQualitative data sourcesLegal and/or policy documents (n = 10)Focus groups or interviews (n = 4)Quantitative data sources *Administrative prescription database (n = 10)Drug approval data (n = 7)Survey data (n = 5)Clinical study/trial data (n = 4)Drug safety/adverse event data (n = 3)Other medical services data (n = 2)Other data source (n = 4)*** Categories are not mutually exclusive.** Other sources include: drug promotion spending, mathematical models,and various types of drug and drug company information.Greyson et al. International Journal for Equity in Health 2010, 9:26http://www.equityhealthj.com/content/9/1/26Page 5 of 8who are not following SGBA guidelines, perhaps the focusshould be placed upon changing the culture of pharma-ceutical policy researchers. Such an approach of targetingthe culture of researchers, in order to create a social shift,is supported by Rogers’ Diffusion of Innovation theory[36], which posits that awareness is merely the beginningstage of acceptance of a new way of functioning. Beyondawareness, individuals must be persuaded before decidingto implement change.How can pharmaceutical policy researchers be per-suaded to implement change? Creating a peer culturethat expects to see evidence of SGBA in any paper mayprovide “checks” for SGBA in the peer review processfor papers and presentations. Adoption of SGBA as aroutine element in pharmaceutical policy research couldbe further facilitated by transforming current healthresearch funder guidelines and policies, which may beignored with little consequence to researchers, into fir-mer requirements for grant support or renewal. Finally,were journals, or the International Committee of Medi-cal Journal Editors, to require SGBA unless inappropri-ate, this could significantly impact the frequency withwhich SGBA appears in the published literature, asacceptability for publication has been identified as amotivating factor for other study attributes [37].In order to illustrate common approaches to SGBAwithin contemporary pharmaceutical policy research, weturn our lens inward by critiquing a selection of papersproduced by our own team. As a coordinating centre ofa national pharmaceutical policy research network, weconduct studies on a wide variety of policy questionsusing varied methods in our work. The following fourselected studies illustrate areas of opportunity for SGBAand, in some cases, areas where SGBA will be acceptablylimited. In reflecting on our own research and reportingpractices, we find ourselves no less “guilty” of neglectingSGBA than our colleagues: we have failed to either per-form or report on sex-disaggregated analyses in quanti-tative studies, conflated our terminology and failed tolook for gendered aspects of policy phenomena.The first of our papers is an example of a topic forwhich sex and gender aspects are not apparent, as wasthe case with a minority of the papers mapped for thisstudy of the literature. This was a study of the correla-tion between drug pricing policy and research anddevelopment (R&D) spending [38]. While there may bedefinite gendered forces directing R&D expendituresand dictating reactions to pricing policies, the primaryfocus of the study and the data involved do not providegrounds for necessarily conducting or commenting onsex and/or gender themes. Thus, while this article worksat Level 1 of the four approaches to SGBA, such anapproach is not inappropriate.The second example illustrates analysis of sex-specificconcerns without in-depth SGBA. Published as a medi-cal journal “research letter,” the article examined theimpact of media reports about drug risks on purchasesof a hormonally-based drug by Canadian women [39]. Itreported findings of an empirical analysis of a sex-specific concern (potentially dangerous off-labelprescribing), but did so without any critical analysis ofgender dynamics. Since the article did not reach beyondusing women’s data to study a women’s health issuerelated to female reproductive capacities, it might beconsidered a Level 2 approach (biological essentialism).However, we can report from our experience in writingthis article (and others for like journals) that medicaljournal articles have strict word limits and must focuson the (generally clinical) interest of the readership. ALevel 4 (intersectional) study of this topic could be done- and would be a valuable contribution to scholarshipabout gendered dynamics related to medicine use, pro-motion, risks and harms - but it would not likely bepublishable in a general medical journal.The third example drawn from our work illustratesmissed opportunities to conduct meaningful SGBA. In arecent paper published in a health services journal,researchers compared cost-related nonadherence(CRNA) to prescription drugs in the United States andCanada [40]. Findings were adjusted for sex, but analysiswas not sex-stratified. While sex differences in CRNAwere not the primary outcome of interest, given themixed evidence on sex or gender as determinants ofnonadherence [41], it would have been ideal to havealso examined this potential phenomenon in this study.While the study concluded that there is a “Canadianadvantage” in prescription adherence, it would havebeen preferable to know if this advantage is gender andsex neutral or whether it applies more for women ormen. Intersecting sex and income (another factor thatwas adjusted for, rather than stratified in the paper),would go further yet in adding valuable knowledgeabout CRNA. Although the survey used for this studywould not have powered the intersectional ideal, thefact remains that this paper is an example of a studythat should have moved beyond a Level 1 approach or,if sample size prohibited, commented on the need to doso in future research.Power considerations are less likely to be a problemfor research with administrative data, as our final exam-ple illustrates. In an examination of outpatient prescrip-tion drug spending, researchers sex-disaggregated thedata but did not explore the interpretation of that analy-sis [42]. The term “gender” was used throughout thestudy but the discussion of results reveals that the studyconflated terms by using “gender” as a euphemism for“sex.” While this paper met our minimal criteria for aGreyson et al. International Journal for Equity in Health 2010, 9:26http://www.equityhealthj.com/content/9/1/26Page 6 of 8Level 3 approach, given that it sex-disaggregated theresults, a fuller SBA would have required additionaltables of the major finding by sex. Moreover, althoughthe paper explored the effects of sex, income, age, andhealth status on financial burdens, it was not a Level 4approach to SGBA because, like most statistical analyses,it assessed the individual contributions of these charac-teristics to the outcome of interest rather than intersect-ing them.ConclusionsVia a literature mapping method, we investigated theuse of sex and gender-related language, inclusion of sexand gender-related concepts, and level of sex and genderbased analysis (SGBA) in a sample of contemporaryEnglish-language pharmaceutical policy research. Wefound that the majority of articles could have reasonablybeen expected to include SGBA but did not. Despitepharmaceutical policy’s long entwinement with issues ofsex and gender, and the emergence of internationalguidelines for inclusion of sex and gender in healthresearch, the community of pharmaceutical policyresearchers appears not to have internalized, or “main-streamed,” gender and sex analyses. While research fun-ders have adopted SGBA policies, medical journals,which might have greater influence, have not yet fol-lowed suit. Increased application of SGBA is, inmost cases, not only appropriate for the topics underinvestigation, but well within the reach of today’s phar-maceutical policy researchers. However, this requiresconsideration of sex and gender factors in researchdesign in order to ensure adequate data sources andanalytical frameworks. Fully intersectional analysis,examining the interactions between sex and gender andother social determinants of health, is rarely approachedin today’s pharmaceutical policy literature. While this isunsurprising, given the relative novelty of intersectionalapproaches, it should not be seen as prohibitive forpharmaceutical policy research to begin to employmethods that grapple with multiple and overlappingissues of diversity and difference.Appendix: Search StrategyMEDLINE 1950-present with daily update (Ovid)13 July, 20091. public policy/or health policy/2. legislation, drug/or “drug and narcotic control"/ordrug approval.mp.3. 1 or 24. Pharmaceutical Services/or Insurance, Pharmaceuti-cal Services/or Technology, Pharmaceutical/or Pharma-ceutical Preparations/or Pharmaceutical Solutions/5. (Pharmaceutical$ or Prescription or PrescriptionDrug$ or Drug$ or Medicine$ or medication$).mp.6. 4 or 57. 3 and 68. limit 7 to yr="2008”9. limit 8 to english languageAuthors’ contributionsAll authors were involved in conceptual development of the project. DGconducted the literature search. DG and AB created the abstracting templateand conducted the literature mapping. DG and SM were primarilyresponsible for writing up the research. All authors approved the finalmanuscript.Competing interestsThe authors declare that they have no competing interests.Received: 4 May 2010 Accepted: 19 November 2010Published: 19 November 2010References1. Institute of Gender and Health: Gender matters: IGH strategic plan 2009-2012Ottawa, ON; 2009.2. Johnson J, Greaves L, Repta R: Better science with sex and gender: a primerfor health research Vancouver. BC: Women’s Health Research Network of BC;2007.3. Health Canada: Exploring concepts of gender and health Ottawa, ON; 2003[http://www.hc-sc.gc.ca/hl-vs/pubs/women-femmes/explor-eng.php].4. Spitzer DL: Gender and sex-based analysis in health research: A guide for CIHRresearchers and reviewers Ottawa, ON; 2007.5. Fuller C: Women and adverse drug reactions reporting in the Canadiancontext Toronto, ON: Women and Health Protection; 2003 [http://www.whp-apsf.ca/pdf/fullerReport.pdf].6. Boscoe M, Basen G, Alleyne G, Bourrier-Lacroix B, White S: The women’shealth movement in Canada: looking back and moving forward.Canadian Woman Studies/les cahiers de la femme 2004, 24(1):7-13.7. Boston Women’s Health Book Collective, Norsigian J: Our Bodies, Ourselves:A New Edition for a New Era New York, NY: Simon & Schuster; 2005.8. Ford AR, Saibil D: The push to prescribe: women & Canadian drug policyToronto, ON: Women’s Press/Canadian Scholars’ Press; 2009.9. Lippman A: The Inclusion of Women in Clinical Trials: Are We Asking the RightQuestions? Toronto, ON: Women and Health Protection; 2006.10. U.S. Congress: National Institutes of Health revitalization act of 1993.Washington, DC; 1993 [http://history.nih.gov/research/downloads/PL103-43.pdf].11. Health Canada: Therapeutic products programme guidelines: inclusion ofwomen in clinical trials Ottawa, ON: Health Canada; 1997 [http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/clini/womct_femec-eng.php].12. Canadian Institutes of Health Research: Gender and sex-based analysis inhealth research: a guide for CIHR researchers and reviewers Ottawa, ON: CIHR;2007 [http://www.cihr-irsc.gc.ca/e/32019.html].13. World Health Organization: WHO gender mainstreaming strategy Geneva,Switzerland; 2007 [http://www.who.int/gender/mainstreaming/strategy/en/index.html].14. Arksey H, O’Malley L: Scoping studies: towards a methodologicalframework. Int J of Soc Research Methodol 2005, 8(1):19-32.15. Davis K, Drey N, Gould D: What are scoping studies? A review of thenursing literature. Int J Nurs Stud 2009, 46(10):1386-1400.16. Anderson S, Allen P, Peckham S, Goodwin N: Asking the right questions:Scoping studies in the commissioning of research on the organisationand delivery of health services. Health Res Policy Syst 2008, 6:7.17. Pharmaceutical Policy Research Collaboration: Pharma Policy 101.PharmaceuticalPolicy.ca Vancouver, BC: University of British Columbia; 2010[http://www.pharmaceuticalpolicy.ca/pharma-policy-101].18. Varcoe C, Hankivsky O, Morrow M: Introduction: Beyond gender matters.In Women’s health in Canada: critical perspectives on theory and policy.Edited by: Morrow M, Hankivsky O, Varcoe C. Toronto, ON: University ofToronto Press; 2007:3-30.19. Ferner RE, Beard K: Over the counter medicines: proceed with caution.BMJ 2008, 336(7646):694-696.Greyson et al. International Journal for Equity in Health 2010, 9:26http://www.equityhealthj.com/content/9/1/26Page 7 of 820. Furrow ME: Pharmaceutical patent life-cycle management after KSR v.Teleflex.x. Food Drug Law J 2008, 63(1):275-320.21. Marcee AK: Expanded access to Phase II clinical trials in oncology: a steptoward increasing scientific validity and compassion. Food Drug Law J2008, 63(2):439-457.22. Milewa T: Representation and legitimacy in health policy formulation ata national level: perspectives from a study of health technologyeligibility procedures in the United Kingdom. Health Policy 2008,85(3):356-362.23. Molyneux DH: Combating the “other diseases” of MDG 6: changing theparadigm to achieve equity and poverty reduction? Trans R Soc Trop MedHyg 2008, 102(6):509-519.24. Ashar BH, Miller RG, Pichard CP, Levine R, Wright SM: Patients’understanding of the regulation of dietary supplements. J CommunityHealth 2008, 33(1):22-30.25. Hartung DM, Carlson MJ, Kraemer DF, Haxby DG, Ketchum KL,Greenlick MR: Impact of a Medicaid copayment policy on prescriptiondrug and health services utilization in a fee-for-service Medicaidpopulation. Med Care 2008, 46(6):565-572.26. Kumar P, Walker JK, Hurt KM, Bennett KM, Grosshans N, Fotis MA:Medication use in the neonatal intensive care unit: current patterns andoff-label use of parenteral medications. J Pediatr 2008, 152(3):412-415.27. Vuorenkoski L, Valta M, Helve O: Effect of legislative changes in drugpromotion on medical students: questionnaire survey. Med Educ 2008,42(12):1172-1177.28. Cohen-Kettenis PT, Delemarre-van de Waal HA, Gooren LJ: The treatmentof adolescent transsexuals: changing insights. J Sex Med 2008,5(8):1892-1897.29. Erdman JN, Grenon A, Harrison-Wilson L: Medication abortion in Canada: aright-to-health perspective. Am J Public Health 2008, 98(10):1764-1769.30. Lexchin J: Clinical trials in Canada: whose interests are paramount? Int JHealth Serv 2008, 38(3):525-542.31. Hankivsky O: Gender-based analysis and health policy: the need torethink outdated strategies.Edited by: Morrow M, Hankivsky O, Varcoe C.Toronto, ON: University of Toronto Press; 2007:143-168.32. Hammarström A: A tool for developing gender research in medicine:Examples from the medical literature on work life. Gender Med 2007,4(Suppl B):S123-S132.33. Johnson SM, Karvonen CA, Phelps CL, Nader S, Sanborn BC: Assessment ofanalysis by gender in the Cochrane reviews as related to treatment ofcardiovascular disease. J Women’s Health 2003, 12(5):449-457.34. Doull MD, Runnels VE, Tudiver S, Boscoe M: Appraising the evidence:Applying sex- and gender-based analysis (SGBA) to Cochrane systematicreviews on cardiovascular disease. J Women’s Health 2010, 19(5):997-1003.35. Studdert DM, Brennan TA: No-fault compensation for medical injuries: theprospect for error prevention. JAMA 2001, 286(2):217.36. Valente TW, Rrogers EM: The Origins and development of the diffusion ofinnovations paradigm as an example of scientific growth. Sci Commun1995, 16(3):242-273.37. Zarin DA, Tse T, Ide NC: Trial Registration at ClinicalTrials.gov betweenMay and October 2005. N Engl J Med 2005, 353(26):2779-2787.38. Morgan S, Cunningham C: The effect of evidence-based drug coveragepolicies on pharmaceutical R&D: a case study from British Columbia.Healthcare Policy 2008, 3(3):1-25.39. Mintzes B, Morgan S, Bassett KL: Medicine by media: did a criticaltelevision documentary affect the prescribing of cyproterone-estradiol(Diane-35)? CMAJ 2005, 173(11):1313.40. Kennedy J, Morgan S: Cost-related prescription nonadherence in theUnited States and Canada: a system-level comparison using the 2007international health policy survey in seven countries. Clin Ther 2009,31(1):213-219.41. Briesacher BA, Gurwitz JH, Soumerai SB: Patients at-risk for cost-relatedmedication nonadherence: a review of the literature. J Gen Intern Med2007, 22(6):864-871.42. Hanley GE, Morgan S: Chronic catastrophes: exploring the concentrationand sustained nature of ambulatory prescription drug expenditures inthe population of British Columbia, Canada. Soc Sci Med 2009,68(5):919-924.doi:10.1186/1475-9276-9-26Cite this article as: Greyson et al.: Sex, drugs and gender roles: mappingthe use of sex and gender based analysis in pharmaceutical policyresearch. International Journal for Equity in Health 2010 9:26.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitGreyson et al. International Journal for Equity in Health 2010, 9:26http://www.equityhealthj.com/content/9/1/26Page 8 of 8


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