Gender
"Gender consists of socially-constructed roles, behaviours, expressions and identities of girls, women, boys, men, and gender diverse people. It influences how people perceive themselves and each other, how they act and interact, and the distribution of power and resources in society. Gender identity is not confined to a binary (girl/woman, boy/man) nor is it static; it exists along a continuum and can change over time. There is considerable diversity in how individuals and groups understand, experience and express gender through the roles they take on, the expectations placed on them, relations with others and the complex ways that gender is institutionalized in society. "
Canadian Institutes of Health Research. (2023). "What is Gender? What is Sex? Retrieved from https://cihr-irsc.gc.ca/e/48642.html
Gender in health research practice
Systemic barriers in health research: Why is EDI needed?
Gender discrimination in medicine
Women are increasingly represented in the medical field across Canada. A survey conducted by the Canadian Medical Association found that over half (54%) of physicians under the age of 40 are women. Despite the numerical parity, the same report found that over three quarters of women physicians and medical students (77%) had experienced gender inequity in their training or practice6. Women also report high levels of sexual harassment in training10, and lower pay9 throughout their careers across Canada. Much more work is needed to combat gender discrimination within medical organizations. Eighty-three percent of women respondents in the CMA survey reported that there were no practices, programs, policies or resources in place to support women in their workplace6.
Beyond the binary: gender discrimination in medicine
It is important to note that although research is only beginning to emerge, these experiences are magnified for transgender, and gender diverse people.
Under representation in academic medicine
Women continue to be underrepresented in the highest levels of medical school faculty within various medical departments and specialties in Canada. In the fields of Diagnostic Radiology7 and Orthopedics8, women are underrepresented in their departments and they are less likely to obtain the rank of full faculty. Within Obstetrics and Gynecology, women are underrepresented in the rank of full professor despite composing the majority of faculty4. Evidence from the United States, where more research has been established, shows these patterns are widespread across many departments and specialties.
Gender inequity in health research
Women's research is less likely than men's to be funded. A natural experiment conducted at CIHR provides evidence that implicit bias disadvantages women in funding. When instructed to focus on PI qualifications, reviewers at CIHR were are more critical in their evaluations when the principal investigator is a woman than when they were not instructed to focus on the PI2.
Addressing Systemic barriers in health research:
In order to address ongoing gender inequity and to achieve inclusiveness in the research team and research environment, research team leaders should identify the most pressing systemic barriers faced by women, transgender, and gender diverse people in your field of research (i.e. obstacles to publishing, funding, promotion), and within your own research environment (i.e. hiring practices, EDI training, implicit bias awareness) and then develop a plan to implement concrete best practices (i.e. mentoring and training) that will reduce those barriers.
CIHR instructs researchers applying for funding to provide an EDI plan with evidence of best practices in three areas of EDI in research practice: team composition and recruitment processes; training and development opportunities; inclusion in the research environment. In building their EDI plan, researchers should also consider how barriers are magnified by important intersections of gender with other identities and access to resources, such as sexuality, race, poverty, disability and parenthood.
Below is a compilation of concrete practices and resources to assist in building an EDI plan. They follow the structure of the CIHR 'Best practices in equity, diversity and inclusion in research practice and design' and include many of their recommendations, along with recommendations from the Canadian Medical Association's Equity and diversity in medicine6. Many practices are intended to make a more inclusive environment for the whole team, and others target gender inequities. For a comprehensive list of best practices in recruitment, hiring and retention, please see the Government of Canada guidance for Canada Research Chairs, available online at https://www.chairs-chaires.gc.ca/program-programme/equity-equite/best_practices-pratiques_examplaires-eng.aspx.
Team composition and recruitment processes
Removing barriers to candidate diversity
Identify barriers to equitable representation in your field of research
Conduct a brief review of published articles and unpublished pieces [blog posts, news articles, social media posts]
Identify resources that are currently available at IWK Health
Read Pillar 2. Diverse Workforce in the Provincial Diversity and Inclusion Framework 11 and the IWK People Strategy
Re-familiarize yourself and your team with the Respectful Workplace training module
Engage in inclusive hiring practices within your team
Communicate employment opportunities to a diverse audience by circulating posts in public, widely circulated venues; to special interest groups
Use nongendered, inclusive, unbiased language in postings
Include an equity statement in postings that describes your commitment to EDI and how you will create an equitable team environment
Removing barriers to an equitable recruitment process
Ensure the selection process is based in best practices
Familiarize yourself with IWK Health selection processes and align best practices
Mitigate unconscious bias in each stage of the selection process, CIHR has provided an online training module for mitigating bias in the peer review process. Many of the principles discussed are also applicable to the hiring process.
Use a standardized assessment process
Provide an accessible assessment (i.e. provide questions prior to an interview)
Do not penalize candidates whose careers have been impacted by life circumstances (parental leave, sick leave disability).
Training and development opportunities
Establish equitable training and development procedures
Communicate opportunities to everyone
Ensure that individuals are not disadvantaged by life circumstances (e.g. family responsibilities, sickness, disability)
Provide support for professional development (conference attendance, skill development)
Ensure that developmental opportunities for trainees to network and work with established researchers are available
Provide mentorship to trainees
Create an environment of mentorship
Ensure that mentoring activities are valued and recognized as an important research activity
Ensure safe and equal mentorship
Ensure equal access to mentoring opportunities for trainees
Ensure that mentoring responsibilities are equitably distributed within the established members of the team
Ensure that mentors have received EDI training
Inclusion in the research environment
Achieve inclusion in the research environment
Provide educational opportunities for your team
Provide training on intersectionality so that team members can consider their own social location
Provide resources to foster a safe, respectful environment through using inclusive, gender neutral language in both spoken12 and written13 communications.
Ensure a culturally safe environment by providing education on microaggressions14
Implement inclusive policies
Implement a conflict management process that protects less established team members
Ensure reporting policies are safe and effective for women, transgender and gender diverse people who experience discrimination, harassment or abuse
Schedule team meetings and social events during accessible times, (taking into account the needs of team members with family responsibilities or disabilities) and in inclusive places.
Promote groups that support underrepresented faculty and trainees
Identify easily accessible and appropriate resources that are currently available at IWK Health
Gender in Research Design
Background
Healthcare access:
Transgender and gender-diverse individuals face barriers to healthcare access25, and they are under-served populations in Canada.
Healthcare outcomes
Disparities are evident across the spectrum of healthcare services, including mental health services, and reproductive care. Transgender and gender diverse youth report worse mental health status, inducing depression, anxiety and suicide24.
Intersections
Gender and sexuality intersect with race, indigeneity, disability21, region23 and class22 to produce unequal health outcomes.
Considerations to determine the applicability of gender in research
Consider how gendered roles, expectations, discrimination, and unequal access to resources contribute to differences in the subject of study's:
incidence and/or prevalence
severity
response to treatment
timely diagnoses
burden of disease
What are reviewers looking for?
Submissions to CIHR will be evaluated based on whether or not the submission:
includes what is known about gender in the subject of study
describes how gender will be measured, or investigated
describes how recruitment methods will address and mitigate bias
will disaggregate and analyze results by gender
includes a knowledge translation plan that considers gender
How can I incorporate sex into my health research?
A successful consideration of sex will be integrated throughout the research design. CIHR provides practical suggestions for integrating sex and gender into the research design in a series of training modules that can be found here.
Language
The use of precise, accurate terminology is fundamental to integrating sex and gender into research15. It is also imperative to note that culturally sensitive language is always changing, and that the current usage may not be preferred in the future2.
Sex is a biological construct referring to a set attributes including chromosomes, genetic expression, hormones, and anatomy.
Intersex describes a set of sexual attributes including chromosomes, hormones and anatomy that do not fit into exclusive binary categories of male or female.
Gender is a social construct referring to roles, behaviours, expressions and identities of girls, women, boys, men, and gender diverse people.
Gender identity is a person's sense of themselves as being a 'man', 'woman', or other gender15.
Gender expressions are characteristics and behaviours of a person that are viewed as masculine or feminine within their culture.
Sex at birth refers to sex assigned at birth - typically assigned based on a visual inspection before or just after birth17.
Legal sex refers to the a person's sex that is recognized by law16.
Gender modality refers to the relationship between a person's gender identity and their sex at birth16.
Transgender refers to a state of being where a person's gender identity or gender expressions are not consistent with their assigned sex at birth15.
Cisgender refers to a state of being where a person's gender identity or gender expressions are consistent with their assigned sex at birth15.
Gender diverse refers to people who diverge from cultural gender norms in their gender expressions and/or gender identity15.
Sexual orientation refers to romantic and sexual attraction for people of the same or another sex or gender18
Beyond binary language
There is increasing recognition that binary language (male/female, boy/girl, man/woman) perpetuates stigma and negative perceptions of sexually diverse, and gender diverse people.
Two-Spirit is an English term used to describe a culturally-specific identity used by some Indigenous people to indicate a person whose gender identity, spiritual identity and/ or sexual orientation comprises both male and female spirits18.
Gender nonconforming, nonbinary, genderqueer, genderfluid, agender, third gender refer to identities that are not represented by the gender binary
Best practices for incorporating gender into health research design
Use precise and accurate language. Do not rely on language that assumes concordance between sex and gender in your research. When addressing participants, use the gender terms they prefer, and use inclusive language20.
Confront implicit bias
Understand the distinction between sex and gender and describe the significance of the distinction in your research. The assumption of a concordance between sex and gender is an implicit bias that normalizes the experiences of cisgender people and contributes to the erasure and marginalization of transgender and gender diverse people.
Sample selection
Recruitment methods that mitigate bias:
-be precise what do you really care about in your study - do not conflate gender, gender identity, gender expression, gender modality, femininity/masculinity, sex and sexuality, and anatomy
-be inclusive - don't exclude historically underrepresented identities through imprecision
Measurement
Gender identity
Gender is a multifaceted construct. When measuring gender, be precise. Do not conflate gender expression with gender identity.
Gender identity has many expressions. UBC suggests that if it is important to have a rich description of your sample, it is important to provide as many response options as possible (they list a number of options including: Man, woman, nonbinary, agender, gender neutral, genderqueer, pangender, bigender, demigirl, demiboy, neutrois, genderfluid, and genderflux) however, this list is not an exhaustive list of gender identities and the terms change through time. They also suggest researchers consider adding an 'something else/prefer to self-describe (write in box)' option. If group comparisons are the primary goal, 'man, woman, nonbinary, prefer not to say' is suggested.
Gender identity is not static, specify that you are interested in current gender identity and consider allowing participants to select 'all that apply'.
If you are using secondary data that did not collect gender identity, it is preferred to use a gender index than to exclude gender entirely: https://pubmed.ncbi.nlm.nih.gov/27233478/
Gender modality
There are several ways to measure how gender corresponds to assigned sex at birth.
The two-step method involves asking one question about gender identity, and another about sex assigned at birth and cross-referencing the responses. If you measure sex at birth, to ascertain gender modality, the question should be placed after questions about gender identity in the questionnaire. Importantly, this method does not measure gender identity. A person who's sex assigned at birth does not correspond to their current gender may or may not currently identify as transgender.
Measuring Two-Spirit Identity
The Two-Spirit identity is not directly analogous with sex or gender. UBC suggests placing the question with others about race and Indigeneity, allowing only those who identify as Indigenous to complete provide a response.
Data analysis
conduct subgroup analyses by gender, using as precise a measurement of gender as possible
Reporting
Do not centre cisgender, or male persons in your reporting. Encourage inclusive research by using accurate and precise language to describe biological phenomena associated with sex, and distinguish sex from the social construction of gender.
Sex and Gender champions
Consider including a sex and gender champion on the research team to consider sex and gender throughout the process. The champion will integrate sex and gender concerns from proposal writing, community engagement, data collection, and data analysis, to dissemination of results.
https://cihr-irsc.gc.ca/e/50652.html
References
1 Toor, A. Edmiston, E. K., Donald, C. A., Sattler, A. R., Peebles, J. K., Ehrenfeld, J. M., & Eckstrand, K. L. (2016). Opportunities and Gaps in Primary Care Preventative Health Services for Transgender Patients: A Systematic Review. Transgender Health, 1(1), 216–230. https://doi.org/10.1089/TRGH.2016.0019
., Wooding, D. J., Masud, S., & Khosa, F. (2021). Gender distribution in awarded Canadian Institutes of Health Research grants among anesthesiologists: a retrospective analysis between 2008 and 2020. Canadian Journal of Anesthesia, 68(10), 1580–1581. https://doi.org/10.1007/S12630-021-02043-W/FIGURES/1
2 Witteman, H. O., Hendricks, M., Straus, S., & Tannenbaum, C. (2019). Are gender gaps due to evaluations of the applicant or the science? A natural experiment at a national funding agency. The Lancet, 393(10171), 531–540. https://doi.org/10.1016/S0140-6736(18)32611-4
3 Girod, S., Fassiotto, M., Grewal, D., Ku, M. C., Sriram, N., Nosek, B. A., & Valantine, H. (2016). Reducing implicit gender leadership bias in academic medicine with an educational intervention. Academic Medicine, 91(8), 1143–1150. https://doi.org/10.1097/ACM.0000000000001099
4. Kim, K. Y., Kearsley, E. L., Yang, Y., Walsh, J. P., Jain, M., Hopkins, L., Wazzan, A. B., & Khosa, F. (2022). Vancouver General Hospital, Vancouver, CAN 4. Obstetrics and Gynecology. https://doi.org/10.7759/cureus.22535
5. Salles, A., Awad, M., Goldin, L., Krus, K., Lee, J. V., Schwabe, M. T., & Lai, C. K. (2019). Estimating Implicit and Explicit Gender Bias Among Health Care Professionals and Surgeons. JAMA Network Open, 2(7), e196545–e196545. https://doi.org/10.1001/JAMANETWORKOPEN.2019.6545
6. https://www.cma.ca/physician-wellness-hub/content/equity-and-diversity-medicine
7 Moghimi, S., Khurshid, K., Jalal, S., Qamar, S. R., Nicolaou, S., Fatima, K., & Khosa, F. (2019). Gender differences in leadership positions among academic nuclear medicine specialists in Canada and the United States. American Journal of Roentgenology, 212(1), 146–150. https://doi.org/10.2214/AJR.18.20062/ASSET/IMAGES/MEDIUM/01_18_20062_EQ01.GIF
8 Hunter, J., Grewal, R., Nam, D., & Lefaivre, K. A. (2022). Gender disparity in academic orthopedic programs in Canada: a cross-sectional study. Canadian Journal of Surgery, 65(2), E159. https://doi.org/10.1503/CJS.008920
9 Cohen, M., & Kiran, T. (2020). Closing the gender pay gap in Canadian medicine. CMAJ, 192(35), E1011–E1017. https://doi.org/10.1503/CMAJ.200375/TAB-RELATED-CONTENT
10 Phillips, S. P., Webber, J., Imbeau, S., Quaife, T., Hagan, D., Maar, M., & Abourbih, J. (2019). Sexual Harassment of Canadian Medical Students: A National Survey. EClinicalMedicine, 7, 15–20. https://doi.org/10.1016/j.eclinm.2019.01.008
11 PROVINCIAL DIVERSITY AND INCLUSION FRAMEWORK 2017-20PROVINCIAL DIVERSITY AND INCLUSION FRAMEWORK STEERING COMMITTEE (A joint Nova Scotia Health Authority and IWK Health Centre committee). (2017).
12 Inclusive Language - Canada.ca. (n.d.). Retrieved August 22, 2023, from https://www.canada.ca/en/department-national-defence/services/conduct-and-culture/diversity-inclusion/positive-space/inclusive-language.html
13 Inclusive writing – Guidelines and resources – Writing Tips Plus – Writing Tools – Resources of the Language Portal of Canada – Canada.ca. (n.d.). Retrieved August 22, 2023, from https://www.noslangues-ourlanguages.gc.ca/en/writing-tips-plus/inclusive-writing-guidelines-resources
14 Findings from CIHR Environmental Scan on Systemic Racism in Health Research and Funding Systems (2021-22) - CIHR. (n.d.). Retrieved August 22, 2023, from https://cihr-irsc.gc.ca/e/52899.html
15 Madsen, T. E., Bourjeily, G., Hasnain, M., Jenkins, M., Morrison, M. F., Sandberg, K., Tong, I. L., Trott, J., Werbinski, J. L., & Mcgregor, A. J. (n.d.). Sex-and Gender-Based Medicine: The Need for Precise Terminology. https://doi.org/10.1089/gg.2017.0005
16 Gender & Sex in Methods & Measurement. (n.d.). The University of British Columbia Centre for Gender & Sexual Health Equity.
17 Statistics Canada https://www23.statcan.gc.ca/imdb/p3Var.pl?Function=DEC&Id=24101
18 https://femmes-egalite-genres.canada.ca/en/free-to-be-me/2slgbtqi-plus-glossary.html
19 https://www.chairs-chaires.gc.ca/program-programme/equity-equite/best_practices-pratiques_examplaires-eng.aspx
20 Lady, S. D., & Burnham, K. D. (2019). Sexual Orientation and Gender Identity in Patients: How to Navigate Terminology in Patient Care. Journal of Chiropractic Humanities, 26, 53–59. https://doi.org/10.1016/j.echu.2019.08.005
21 Strang, J. F., McClellan, L. S., Raaijmakers, D., Caplan, R., Klomp, S. E., Reutter, M., Lai, M.-C., Song, M., Gratton, F. v., Dale, L. K., Schutte, A., Vries, A. L. C. de, Gardiner, F., Edwards-Leeper, L., Minnaard, A. L., Eleveld, N. lou, Corbin, endever*, Purkis, Y., Lawson, W., … Miesen, A. I. R. van der. (2023). The Gender-Diversity and Autism Questionnaire: A Community-Developed Clinical, Research, and Self-Advocacy Tool for Autistic Transgender and Gender-Diverse Young Adults. Https://Home.Liebertpub.Com/Aut, 5(2), 175–190. https://doi.org/10.1089/AUT.2023.0002
22 Renner, J., Blaszcyk, W., Täuber, L., Dekker, A., Briken, P., & Nieder, T. O. (2021). Barriers to Accessing Health Care in Rural Regions by Transgender, Non-Binary, and Gender Diverse People: A Case-Based Scoping Review. Frontiers in Endocrinology, 12, 717821. https://doi.org/10.3389/FENDO.2021.717821/BIBTEX
23 Logie, C. H., Lys, C. L., Dias, L., Schott, N., Zouboules, M. R., MacNeill, N., & Mackay, K. (2019). “Automatic assumption of your gender, sexuality and sexual practices is also discrimination”: Exploring sexual healthcare experiences and recommendations among sexually and gender diverse persons in Arctic Canada. Health and Social Care in the Community, 27(5), 1204–1213. https://doi.org/10.1111/HSC.12757
24 Clark, B. A., Veale, J. F., Greyson, D., & Saewyc, E. (2018). Primary care access and foregone care: A survey of transgender adolescents and young adults. Family Practice, 35(3), 302–306. https://doi.org/10.1093/FAMPRA/CMX112
25 Edmiston, E. K., Donald, C. A., Sattler, A. R., Peebles, J. K., Ehrenfeld, J. M., & Eckstrand, K. L. (2016). Opportunities and Gaps in Primary Care Preventative Health Services for Transgender Patients: A Systematic Review. Transgender Health, 1(1), 216–230. https://doi.org/10.1089/TRGH.2016.0019