Gender as a Social and Cultural Variable and Health

Guest Blog By Drs. Elizabeth Barr and Sarah Temkin

Drs. Elizabeth Barr and Sarah Temkin (vertical)

Consideration of sex and gender in research is critical to advancing the NIH mission of seeking knowledge to enhance health, lengthen life, and reduce illness and disability.n recognition of the importance of the influence of sex and gender on human health, the 2019–2023 Trans-NIH Strategic Plan for Women’s Health Research charges the NIH community with developing methods and leveraging data sources to consider sex and gender influences that enhance research for the health of women (Goal 2 of the strategic plan). Although “sex” is often conflated with “gender,” the terms describe different but interconnected constructs. 

Domains of Sex and Gender; 4 domains of sex include anatomy, physiology, genetics and hormones; domains of gender include identity/expression, roles/norms, power relations, equality/equity

Sex is a multidimensional construct based on a cluster of anatomical and physiological traits, that include external genitalia, secondary sex characteristics, gonads, chromosomes, and hormones.1 The landmark 2016 Sex as a Biological Variable (SABV) policy articulates NIH’s expectation that sex, as a biological variable, be factored into research design, analyses, and reporting in human and vertebrate animal studies. 

Gender is a social and cultural variable that encompasses several domains, each of which influences health: gender identity and expression, gender roles and norms, gender relations, structural sexism, power, and equality and equity. Gender socialization and norms of masculinity influence boys’ and men’s health-seeking behaviors. Structural gender inequalities limit girls’ and women’s access to health services and contribute to health inequities. Other social variables—including race, ethnicity, socioeconomic status, and State and Federal policies—may additionally interact with gender to influence health, highlighting the importance of an intersectional approach to health research.

Women’s symptoms can lead to diagnostic delays for diseases such as cancer and cardiovascular disease, most likely related to expected gender norms and power relations within patient–provider interactions.2, 3 Clinical presentation of back pain, dizziness, or nausea during a heart attack—symptoms that are typical for women—has historically been labeled atypical; while chest pain and diaphoresis, which are more common for men, have been considered “typical.”4 

Following a diagnosis, women may face delays in referral for care or not be offered care at the same rate as men. For example, late referral for osteoarthritis in women results in worse function at the time of joint replacement surgery, affecting the level of function that women achieve after surgery.5 Social stigma around menstrual disorders and other female-specific conditions, such as menopause, contributes to societal tolerance of inadequate treatments and limited research investment.6 For diseases that afflict primarily one sex, NIH funding patterns demonstrate greater fiscal investment for conditions that predominantly affect males when compared to burden of the disease within the population. Relative to disease burdens in the population, NIH funding exceeds what would be expected for conditions that occur predominantly in men.7

Disentangling the influence of either sex, gender, or both on health is a complex undertaking that has been limited to date. The current NIH requirement for research on human subjects is for collection of only one variable (sex or gender). Sex, whether self-reported by participants or extracted from medical records, has most frequently been the variable that is collected. Both sex and gender affect health, and should be collected and studied appropriately. Yet few best practices exist to measure gendered phenomena in health research, and additional research to validate instruments in the collection of information about gender is needed. Evolving social norms have shifted definitions and understandings of sex and gender, and few tools to measure sex and gender have been available and validated.1

In recognition of the significant health effects of gender as a social and cultural variable, ORWH and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) convened a series of roundtable discussions for NIH staff members in the fall of 2021 These roundtables brought together scientific and program staff members from NICHD, ORWH, the National Cancer Institute (NCI), the National Institute on Aging (NIA), the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute of Mental Health (NIMH), the Fogarty International Center, the Office of Behavioral and Social Sciences Research (OBSSR), the Office of Disease Prevention, and the Sexual and Gender Minority Research Office and provided an opportunity to explore the current landscape of NIH research on gender as a social and cultural variable. Participants discussed the landscape of NIH-supported research on gender roles, gender norms, and gender inequity and identified opportunities in this space.  

We are excited to share an opportunity for additional dialogue and support on Wednesday, October 26, 2022: a scientific workshop titled Gender and Health: Impacts of Structural Sexism, Gender Norms, Relational Power Dynamics, and Gender Inequities. This virtual workshop is being convened in partnership with NICHD, NIA, NIAID, NCI, National Heart Lung and Blood Institute, the National Institute on Diabetes and Digestive and Kidney Diseases, the National Institute of Neurological Disorders and Stroke, the NIMH, National Institute on Drug Abuse, and OBSSR. 

In line with the ORWH mission of putting science to work for the health of women, this workshop will convene members of the scientific community to discuss methods and best practices in health research on gender roles, gender norms, gender inequity, and structural sexism. Opening plenaries from Drs. Nancy Krieger, Patricia Homan, and Typhanye Dyer will set the stage for an afternoon of concurrent sessions. We invite you to learn more and register for this event.

Another opportunity to advance research on gender and health is a recently launched ORWH signature program: the Galvanizing Health Equity Through Novel and Diverse Educational Resources (GENDER) research education program (R25). The GENDER R25 will help meet the need for sex- and gender-specific training in science, medicine, and allied health professions by supporting the development of sex- and gender-focused courses, curricula, and methods. Courses and curricula can be targeted to audiences at any career stage, including researchers, health care providers, students (undergraduate, graduate, medical, dental, veterinary, nursing, public health, and other allied health professions), postdoctoral researchers, community advocates, the public health workforce, and more. Funded projects will result in curricula, courses, and methods that can be utilized across disciplines and will be made available through the ORWH Interprofessional Education Portal to ensure wide dissemination. The first due date is October 27, 2022, for non-AIDS-related applications, and the due date for AIDS-related applications is January 7, 2023. We invite you to register for the 1-hour technical assistance webinar for the GENDER R25 on September 21, 2022, at 4:00 p.m. EDT.  

We are enthusiastic about these new programs and activities, which we see as important steps in building momentum, support, and capacity for the incorporation of Gender as a Social and Cultural Variable into the NIH research agenda. ORWH welcomes these and other opportunities to partner with our NIH colleagues and the extramural community to advance health-related research that rigorously considers the effects of gender roles, norms, power relations, and inequalities. Approaching gender’s influences on health with scientific rigor is critical to advancing health-related research for the health of women.

Authors

Elizabeth Barr, Ph.D.
Social and Behavioral Scientist Administrator
Office of Research on Women's Health
National Institutes of Health

Sarah Temkin, M.D.
Associate Director for Clinical Research
Office of Research on Women's Health
National Institutes of Health

References
  1. National Academies of Sciences E, and Medicine,. Measuring Sex, Gender Identity, and Sexual Orientation. Measuring Sex, Gender Identity, and Sexual Orientation. 2022.
  2. Din NU, Ukoumunne OC, Rubin G, et al. Age and Gender Variations in Cancer Diagnostic Intervals in 15 Cancers: Analysis of Data from the UK Clinical Practice Research Datalink. PLoS One. 2015;10(5):e0127717. doi:10.1371/journal.pone.0127717
  3. Maas AHEM, Appelman YEA. Gender differences in coronary heart disease. Netherlands Heart Journal. 2010/11/01 2010;18(12):598-603. doi:10.1007/s12471-010-0841-y
  4. Heart Attack Symptoms in Women. American Heart Association. Accessed October 7, 2021, https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack/heart-attack-symptoms-in-women 
  5. Templeton K. Musculoskeletal disorders: Sex and gender evidence in anterior cruciate ligament injuries, osteoarthritis, and osteoporosis. How Sex and Gender Impact Clinical Practice. Elsevier; 2021:207-227.
  6. As-Sanie S, Black R, Giudice LC, et al. Assessing research gaps and unmet needs in endometriosis. American journal of obstetrics and gynecology. 2019 Aug 2019;221(2):86–94. doi:https://doi.org/10.1016/j.ajog.2019.02.033
  7. Mirin AA. Gender Disparity in the Funding of Diseases by the US National Institutes of Health. Journal of Women's Health. 2020;doi:10.1089/jwh.2020.8682