Download Definitions for Gender and Sex-Based Analysis

Definitions for Gender and Sex-Based Analysis
As the definitions may vary across disciplines, we begin with an overview of the terms and
concepts most often used in the context of GSBA. For instance, the term 'gender' has been
used in social sciences for decades; however, its introduction into the medical lexicon is more
recent. As a result, gender is sometimes mistakenly employed as an updated version of the
term 'sex.'4 In this document, we employ definitions from Health Canada, similarly embraced
by international bodies such as the World Health Organization and the European Union, as a
shared language across all pillars of health research.2, 5, 6, 7 Importantly, we acknowledge the
rich debate regarding the stability and validity of the binaries of nature and culture that
underpin the concepts of sex and gender 8,9 and the difficulties in segregating sex and gender
influences on health given the interactions between genes and environment.10
"Sex refers to the biological characteristics such as anatomy (e.g., body size and shape) and
physiology (e.g., hormonal activity or functioning of organs) that distinguish males and
females" (p.8).6 Sex differences may occur at the genetic/molecular, cellular, organ or
organism level and result from complex interactions between genetic, hormonal and
environmental factors that commence in the genetic and intrauterine environment and
continue throughout the lifespan of an individual. 11, 12 Sex differences begin with the
observation that every animal-derived cell has a sex.13 Within the context of a continuum of
variation, males and females present disparate genetic profiles beyond those responsible for
gonadal formation. It has been noted that as most phenotypic females possess two Xchromosomes, they may potentially express twice the gene product as males although
doubles are generally suppressed through the process of X-chromosome inactivation also
known as lyonization. Importantly, these gene products may be responsible for cellular
function, metabolism and growth. Genes on X and Y-chromosomes can code for slightly
different variants that may in turn produce different biochemical effects that may contribute
to sex differences in physiological responses and function.13 These variations place all
humans and animals on a continuum, and may also account for the reactions of males and
females to certain pharmaceutical products, differing rates of autoimmune diseases and
dissimilar symptom patterns of presentation for heart disease.6, 14, 15 Attention to sex-in all of
its variation-is vital to understanding the bio-genetic underpinnings of health.
"Gender refers to the array of socially constructed roles and relationships, personality traits,
attitudes, behaviours, values, relative power and influence that society ascribes to two sexes
based on a differential basis. Gender is relational-gender roles and characteristics do not exist
in isolation, but are defined in relation to one another" (p.14).5 All societies are divided
between at minimum two categories of sex and gender that are often assigned unequal
statuses. Gender roles, constructs and identities exist not as stable entities, but as expressions
that are located along a continuum. Ethnicity, socioeconomic status, sexual orientation,
geography and other social identifiers situate women and men differently in the social
landscape necessarily complicating the relationships between gender, sex and health
disparities defined by unequal access to health determinants.16 Notably these dynamic
intersections do not produce uniform outcomes, but are constituted, performed and resisted in
various ways by individuals and groups throughout the life cycle. Furthermore, the
dichotomous pairings of male/female, masculine/feminine and heterosexual/homosexual do
not reflect the variations in sex (i.e., intersex), gender and sexuality that represent lived
experiences8, 9 which are seldom captured in health research especially in the context of other
determinants such as ethnicity and socioeconomic status.17
Gender roles and constructs may have a direct impact on health. For example, care work is
generally associated with the female gender role and may contribute to significant health
problems attributable to the caregiving burden.18, 19 Moreover, men in some societies,
including Canada, may be socialized to value risk-taking behaviours and to inhibit support
and help-seeking activities both of which may be detrimental to men's health, although
notably not all men embrace these roles throughout their lifetimes.20, 21 Taking gender in all
its manifestations into account is essential to the task of generating meaningful health
knowledge that can enhance the health of all.
Gender-Sensitive Research
"Doing real gender-sensitive research means systematically checking on the lack of attention
for gender aspects or on hidden imbalances in the attention paid to aspects relevant to men
and women . . . It also means analyzing in a way that tries to retrieve the complex
interdependence of biological, psychological, social and cultural factors-and not dealing with
sex as if it were a confounding variable" (p.49). 22
"Sex/Gender-Sensitive Health Research investigates how sex interacts with gender to
create health conditions, living conditions and problems that are unique, more prevalent,
more serious, or for which there are distinct risk factors for women or men" (p.9).6 As groups
of women and men tend to lead different lives that result in disparate environmental
exposures and social pressures, responses to these factors are the result of an interaction of
genetics, physiology, cultural, social and individual responses-in other words of the interplay
of sex and gender. Sex and gender-sensitive health research, therefore, produces knowledge
that reflects the complexity and diversity of human health.
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Gender & Sex-Based Analysis
"All societies are organized along what Hanna Papanek (1984) has called the 'fault lines' of
sex and gender which means that women and men are thought of, treated and go about their
lives as different kinds of people with different types of bodies and different roles,
responsibilities and opportunities. This can result in women and men having different access
to life choices and chances-including economic activity, educational attainment, health and
care. Women's and men's health and health needs are different both because of differences in
their bodies and also because of differences in how women and men live, work and play";
(p.2). 23
"GSBAF1 is an approach to research and evaluation which systematically inquires about
biological (sex-based) and sociocultural (gender-based) differences between women and men,
boys and girls, without presuming that any differences exist. The purpose of GSBA is to
promote rigorous sex/gender-sensitive health research which expands understanding of health
determinants in both sexes, in order to provide knowledge which can result in improvements
in health and health care."24 Gender-blind science fails to account for disparate life
trajectories that are influenced by interactions among genetic endowment, environmental
exposures and social and political environments.
GSBA is meant to be applied within the context of a diversity framework,6 that attends to the
ways in which determinants such as ethnicity, socioeconomic status, disability, sexual
orientation, migration status, age and geography interact with sex and gender to contribute to
exposures to various risk factors, disease courses and outcomes. These intersecting factors
have significant impact on health and wellbeing.16, 25 Without these considerations, we may
miss or misread the experiences of a significant portion of the population. Using a GSBA lens
brings these considerations into focus and can help to formulate research, policies and
programs that are relevant to the diversity of the Canadian populace.
Implementing GSBA
According to Health Canada, "the integrated use of GBA throughout the research, policy and
program development processes can improve our understanding of sex and gender as
determinants of health, of their interaction with other determinants, and the effectiveness of
how we design and implement sex- and gender-sensitive policies and programs" (p.1).6
GSBA is Good Science
The promulgation of GSBA is in part a response to research that either fails to account for
sex and gender differences or presumes they exist without evidence. Generalizing from one
sex or gender is highly problematic. Between 1977 and 1993, women of childbearing years
were banned from participating in clinical drug trials in the United States until the efficacy
and safety of the medications were established.26, 27 Fears regarding potential teratogenic
effects and concerns about the impact of hormonal fluctuations associated with the female
menstrual cycle were cited as reasons for the exclusionary practice.26, 27 GSBA advocates
among the scientific and health consumer communities succeeded in removing the
restrictions based on the need to test new substances on a diverse sample, especially as
women are the major consumers of pharmaceutical products.28 The inclusion of women in
clinical drug trials has allowed for the monitoring of adverse effects and for greater
consideration of dosage given sexual differences in relative body size, hepatic clearance and
metabolism of drugs.29 While women are still not equitably represented in clinical trials, an
increasing number of drugs have been withdrawn due to elevated rates of adverse effects
among women.14, 30, 31
By failing to capture the complexity and diversity of human health, serious omissions or
errors in understanding can lead to poor evidence and inappropriate-potentially injuriousoutcomes.32, 33
GBSA demands greater attention to the construction of measurements and variables in
research. "There is a risk of overemphasizing sex differences in relation to other anatomical
and physiological contributions to population variation . . . the relevant source of variation
may be size difference, not the sex difference, and may not apply to small men or large
women. It is undeniably easier to record sex rather than measure the relevant body
dimensions, but it may not be as good a predictor (Bylund & Burstom, 2003)" (p. 159). 10
GSBA is Ethical Research
GSBA with its attendant sensitivity to sex and gender is vital to the production of ethical
research. The Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans
clearly states that women may not be excluded from research solely on the basis of sex or
reproductive capacity.34 The document emphasizes that: "The inclusion of women in research
is essential if men and women are equally to benefit from research. It advances both the
commitment to justice and to rigorous scholarly or scientific analysis" (p.53).34 In addition,
researchers must not exclude research participants based on sex, culture, religion, disability,
sexual orientation or age unless there are valid and specified reasons to do so. More inclusive
research contributes to more meaningful and accurate research outcomes that ultimately
contribute to a healthier population.
GSBA is Essential to Equity
The Federal Plan for Gender Equality (1995) recognizes the need to address sex/gender
disparities in health that arise from the diverse and multiple realities of men and women, girls
and boys.3 It called for more research on both sex differences in disease and the identification
of the health needs of marginalized women. The Plan commits to the development and
implementation of gender-based analysis within all government departments. CIHR's
application of GSBA is, therefore, in harmony with the government's commitment to ethical
and scientifically sound enquiries.
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Examples
The following examples highlight the significance of attending to sex, gender and their
interactions in health research. Neither the examples nor the accompanying questions are
exhaustive; they should, however, stimulate reflection as to the salience of sex and gender
across the four pillars of health research.
Sex, Genes & Lung Cancer in Women
Why are women two to three times more likely to develop lung cancer than men? Why are
non-smokers who develop the disease three times more likely to be female?35 One major clue
to these findings may lie in the sex differences of gene expression. Female somatic cells have
one randomly inactivated chromosome; however, between 10% and 15% of the genes on this
chromosome can be expressed.36 The gene, gastrin-releasing peptide receptor (GRPR)
appears to be linked with lung cancer. GRPR is activated during fetal development, but is
turned-off once the organs are fully developed.35 In a recent study, 55% of non-smoking
women expressed the gene, while none of the males did; among light smokers, 75% of the
women as compared to 20% of the men showed this gene expression. As women have the
potential to express higher amounts of the gene because they possess two copies, one from
the inactive chromosome, this may put them at increased risk of lung cancer.35
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How is our understanding of lung cancer altered by the consideration of sex
differences in gene expression?
How might this knowledge alter health promotion programs or the development of
new therapies?
What else might we want to know about how expression of GRPR, gender and
environmental influences interact?
Sex, Hormones & Aging Men
Male life expectancy is generally lower than that of females due in large part to higher levels
of risk taking particularly among younger men, negative health behaviours, and lower
participation in preventative health measures.20 Men who embrace the dominant view of
masculinity in our society are more vulnerable to health risks; however, this perspective is
neither universal nor uniform throughout the lifecycle and is influenced by ethnicity, sexual
orientation, socioeconomic status, geography, and age among other factors.20 As men age,
over 80% in their 60s will suffer from at least one of the following conditions: cardiovascular
diseases cancers, chronic obstructive pulmonary diseases, degenerative and metabolic
diseases, visual and hearing loss, mental health problems, sexual dysfunction, dementia or
endocrine disorders.37 Moreover, mortality rates-generally associated with low bone mineral
density (BMD)-are higher in men for most osteoporotic fractures.38 Exercise, body size and
alcohol consumption all have an impact on BMD as do the changing hormone profiles of
individuals as they age.38, 39 Estradiol is vital to bone formation 40 and testosterone plays a
role in BMD as well as liver function, muscle mass, immune function, erythropoiesis, and
libido.39 Sex-hormone binding globulin (SHBG), however, increases with age, reducing the
levels of bioavailable testosterone and estradiol.39 While the rate of decline of testosterone is
similar in healthy men as in men with chronic illness, healthier men have androgen levels 1015% higher than their counterparts.39
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How might health promotion activities and medical screening promote better bone
health for aging men?
How might health researchers examine factors including ethnicity, socioeconomic
status, gender roles, sexual orientation, and geography as they intersect with genetic
and endocrine systems in influencing health behaviours and the use of health services
among aging men?
How might an interdisciplinary approach to sex, gender and health alter health
research, programs and practice for Canada's aging population?
Sex and Multiple Sclerosis: Estrogens Reduce Symptoms in Both Female and
Male Animal ModelsF2
Women are two to three times more likely to be affected by multiple sclerosis (MS) than
men. In addition, women acquire MS younger than men-most often the relapsing-remitting
pattern-in contrast to men who generally develop the unremitting and progressive disease
variety. While little is known about why the incidence of MS is higher in women than men,
MS in women is often remitting during pregnancy.41, 42, 43 Estrogens have been implicated in
lessening the severity of the T-cell autoimmune conditions during pregnancy and indeed, a
Phase I clinical trial treating women with MS with oral estriol has demonstrated a significant
decrease in the lesions in relapsing-remitting MS patients as compared to baseline.44 Might
treatment with estrogens be helpful in lessening the severity of the condition for men?
Palaszynski et al45 used the mouse model of experimental autoimmune encephalomyelitis
(EAE) to compare the response of female and male rodents to treatment with estriol. They
found that estriol decreased the mean clinical disease scores in females and males as well as
the load of pro-inflammatory cytokines.45 The one sex difference observed was that males but
not females had an increase in one of the cytokines, IL-5. The authors point out that
Glatiramer acetate, an approved therapy for MS, also increases levels of IL-5. Not only is
estriol as good for males as for females, but the added induction of IL-5 in males might
provide further protection from MS.
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How might future research examine the relative contributions of sex chromosomes
and steroid hormones to the etiology and course of multiple sclerosis?
Would it be useful to test other steroid hormones in females and males? Which ones?
How might women's menstrual cycles and the stages of their reproductive lives affect
the efficacy of Glatiramer acetate?
Aspirin and Primary Prevention: Learning from Sex Disaggregated Data
Aspirin reduces the risk of cardiovascular events in both men and women at similar rates;
however, sex-specific analysis shows that there are differences in the advantages that women
and men receive from the medication. Men benefit from a reduced risk of myocardial
infarction yet may experience increased odds of succumbing to hemorrhagic stroke. Women
taking aspirin for preventative therapy reduce their chances of experiencing ischemic strokes;
however, the therapy appears to have no impact on rates of myocardial infarction or
hemorrhagic strokes. Analyzing this data according to sex may have implications for clinical
practice.46
Sex, Gender & the Workplace
How are sex and gender implicated in workplace health? Inverse associations between status
and health have been reported in occupational hierarchies.47 High demand/low control jobs
accompanied by frustrated ambitions and the erosion in self-esteem can induce autonomic
and neuro-endocrine stress responses.48 In Canada, women, especially from ethnic minority
communities, are disproportionately likely to occupy low wage, high demand, low control
positions and may, therefore, be more vulnerable to these effects.49, 50 Men from ethnic
minority communities are also over represented in similar positions; furthermore, they are
also less likely to ask for, or receive, social support-a factor that can mitigate the effects of
these stressors.51, 52 Research on workplace configurations and occupational exposures have
often focused on men's experiences and are based on men's general size and ergonomic
needs. Messing53 demonstrated that the pace and requirements of work for female and male
workers may be disparate resulting in differing, but equally serious, patterns of injury.
Ethnicity and socioeconomic status are also implicated in these issues. McDuffie54 has drawn
attention to pesticide exposure among farmwomen, a hazard that was presumed to be
primarily a male problem. Moreover, as women tend to possess greater adiposity and
chlorinated hydrocarbons are fat soluble, total body pesticide concentrations may often be
higher among women than men. Caution must be used however as sex should not be
deployed as a proxy for weight, height or body fat estimations.10
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How might gender influence the expression and interpretation of sex-linked biological
traits and how might these sex-linked traits contribute to, or amplify, gender
differences in occupational health?F3
"Employment" cannot be regarded as a simple variable given the complex
associations between gender, ethnicity and variable control/demand issues. How can
health researchers best take these factors into account?
How might research on health and work become more sensitive to the intersections of
sex, gender, ethnicity and immigration status?
Home as Haven: A Sex and Gender Perspective
In the traditional model of sickness, an individual who becomes ill is able to relinquish
responsibilities and rest at home. Home is often regarded as a refuge from the pressures of
work and the outside world, but is home a haven for everyone?56 For far too many women in
Canada and around the world, home is a site of family violence.57, 58 Furthermore as women
are still primarily responsible for home and child care, home often means unceasing demands
from children and other family members and the increased burden of household tasks.18, 59
The intersections between paid and unpaid work have repercussions for health. Studies show
that while men's blood pressure declines when coming home, women's often rises.60 Married
men in Canada live an average of eight years more than never married men; married women
survive an estimated three years longer than single women.61 The Framingham Heart Study
has found that women with three or more children are twice as likely to develop heart disease
than counterparts with fewer or no children. Moreover, having more family members62 has a
negative impact on the mental health of female manual workers.63
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What are the implications of these findings for measurements of stress hormones, and
other physiological markers?
How might health surveys heighten the analytical complexity of terms such as
"housewife" or "unemployment"?
Given the frequent associations between poverty, gender, lone-parent households, and
ethnicity, how might health research be enriched by taking these factors into
consideration?
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Guiding Questions
The following questions are provided as a general checklist for applicants and reviewers.
Given the breadth and depth of CIHR funded research-biomedical, clinical, health services
and population health-, the questions are general, and may not be equally relevant to all
disciplines or methodologies. Applicants should give careful consideration as to how their
research addresses these queries and should, where applicable, provide detailed response to
these questions in their proposals. See "Further Readings" for additional information.
Applying Gender- and Sex-Based Analysis
Research Question
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Are sex and/or gender identified and defined? Are the definitions supported by recent
academic literature?
Does the proposal demonstrate awareness of what is known about sex, gender and
diversity (ethnicity, socioeconomic status, sexual orientation, migration status, etc.) in
this area of research?F4
Are the concepts of sex, gender and diversity taken into account in the development
of the research question(s)?
Are the concepts of sex, gender and diversity applied clearly and appropriately?
If used in the study, does the researcher identify and justify the choice of the sex of
cells, cell lines, and/or animals?
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If the applicant asserts that sex and/or gender and diversity are not relevant to the
proposed research, what evidence is presented?
Does the research question reflect the diversity in and among females and males ?
Data Collection
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Does the sex/gender/diversity composition of the sample reflect the research
question?
Does the sample match the researchers' plans for generalizing from the data?
Have research instruments (i.e., surveys, measurements) been validated to reflect
gender/sex and diversity?
If sex is used as a proxy for weight, height and body fat/muscle ratios, is there an
explicit explanation and analytical strategy provided for employing this approach?
In the case of clinical trials: Does the sample reflect the distribution of the condition
in the general population? For proposed clinical trials, are sufficient numbers of
women and men included in the sample to enable safety as well as efficacy analysis?
Where appropriate, how will the clinical trial track and account for female menstrual
cycles? Does the applicant plan to analyze results in the context of known sex-specific
adverse effects, height-weight-sex relationships, and interactions with commonly used
drugs?
Data Analysis and Interpretation
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Will the researchers disaggregate and analyze data by sex/gender?
Does the use of gender as a variable mask or intersect with other potential explanatory
factors such as socioeconomic status, physical attributes and/or ethnicity?
What assumptions are being made about gender and/or sex-especially as they intersect
with other diversity indicators such as ethnicity, sexual orientation, socioeconomic
class, etc.-while formulating the research problem, sampling, data collection, analysis
and interpretation?
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A Work in Progress
This draft resource guide will be enriched and refined with your input and feedback. Please
give consideration to the following questions:
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Are the guiding questions relevant to your area of research?
Are there other questions we should be asking?
Can you recommend other examples of good gender and sex-based analysis?
Do you have additional suggestions for improvement?
We are counting on your feedback to ensure that this resource guide is both meaningful to
you as researchers and peer reviewers, and is true to CIHR's commitment to gender and sexbased analysis in health research