Sex and gender influence the development of health conditions, the manifestation of symptoms, the effectiveness of treatments and overall clinical outcomes, yet remain overlooked by researchers and clinicians alike.
The medical evidence base relies on studies which are predominantly based on males – including cell lines, animals and people who participate in clinical trials – while females are under-represented.
The “male default”, where research is conducted primarily on one sex but generalised to the wider population, perpetuates subpar care and outcomes for all.
Throughout the life course, from girls less likely than their male peers to be diagnosed with autism, to the teenager who waits eight years for an endometriosis diagnosis, to the woman whose heart attack presentation is more likely to be misdiagnosed, to the elderly man living with frailty and osteoporosis, poor accounting of sex and gender impacts us all.
A first-of-its-kind sex and gender policy
Back in December, 29 leading organisations within the UK medical research community issued statements of intent to signal support for improved reporting of sex and gender in research. This marks an important stride forward for UK research.
The statement’s signatories contribute an estimated £4.1 billion annually to UK medical research and include the National Institute for Health and Care Research (NIHR), the Medical Research Council (MRC), and the Association of Medical Research Charities (AMRC). The unified statement is also backed by medical publishers including The BMJ and Elsevier, which encompasses The Lancet Group and Cell Press.
These signatories have been brought together by the Medical Science Sex and Gender Equity (MESSAGE) project, hosted at The George Institute for Global Health. MESSAGE is leading co-design by stakeholders from across the UK research sector of a sex and gender policy framework to be adopted by medical research funders. The MESSAGE policy framework, which will launch in early 2024, will drive forward sector-wide change to address these gaps and biases.
The educational imperative
Closing the gender health gap requires more than policy change. Both the researchers who generate our evidence base and the clinicians who deliver clinical care must be equipped to think about the implications of sex and gender, search for sex and gender-based differences and similarities, and then translate these findings into change practice.
Training within higher education must integrate sex and gender considerations throughout curricula to ensure that students – future scientists and clinicians – have a robust skillset to meet the needs of all members of society.
Women’s health has been viewed as synonymous with reproductive health and sex and gender have been seen as a research niche reserved for a single lecture in a curriculum – education must shift to integrate these considerations throughout all aspects of clinical and research training and change the narrative of what – and who – is studied.
Upskilling researchers
The lack of a sex and gender lens in biomedical, health and care research leads to poor inclusion of non-male participants, limited sex- and gender-based analyses, and poor reporting of sex- and gender-disaggregated data.
Training is needed to help researchers to understand why these gaps pose a problem, and how they can be addressed. For example, fostering awareness and developing strategies to promote inclusion of female participants (who are known to be more difficult to recruit) to clinical trials would enable researchers to build more equitable study samples.
Similarly, guidance on statistical methodologies for sex- and gender-based analysis will support researchers to integrate these techniques to the core of their analysis plan.
Training to upskill the existing research workforce will be essential to moving this change forwards in the short term – in the longer term, sex and gender considerations must be threaded through curricula to ensure all researchers account for these dimensions as a default.
Addressing misconceptions
Building the workforce’s capacity to account for sex and gender will also require addressing known misconceptions about this work.
One such misconception is the belief that the hormonal variability of the oestrous cycle means that female participants are too complex to study and will “muddy” research data. This long standing myth has been disproven by studies that show both males and females have hormonal variability and female variability does not affect study outcomes to a greater extent than male variability.
Similarly, although some researchers are hesitant about including women in clinical research in the wake of instances such as the thalidomide scandal of the 1960s, it is clear that excluding women from research only to expose them to the same risks outside of the controlled laboratory environment undermines key principles of patient safety.
Courses should show researchers that accounting for sex and gender does not mean doubling sample sizes in every instance – many studies can use multifactorial analysis to conduct their experiments without increasing sample sizes, and researchers can account for sex and gender dimensions without needing to produce statistically significant results for each sex and/or gender group.
Medical education and improving clinical care
Health professions education perpetuates gaps in clinical knowledge by omitting to train clinicians about known sex and gender differences in disease presentation and treatment responses. Practical training and clinical examinations are typically based on the bodies of thin, young, white men. For example, CPR mannequins do not typically have breasts and training rarely covers how to negotiate underwired bras. Trainees’ poor confidence translates to women being less likely to receive bystander CPR. The vast majority of textbooks and online resource perpetuates the same norm, with women underrepresented in medical illustrations, which leads to gaps in clinical knowledge.
Androcentric teaching materials see medical students feeling less confident in treating non-male patients. For example, students remain less confident listening to a woman’s heart and placing ECG leads across a woman’s torso, with studies in the US showing doctors to be less competent at listening to the apex beat – the heart sound found furthest down the chest wall – on women given its proximity to the left breast.
Furthermore, there is an over-representation of male-specific conditions in medical curricula, which lead to disparities in these conditions being treated over female-specific counterparts. For example, testicular torsion (twisting of the spermatic cord which supplies blood to the male testicles) is treated with considerably more urgency than ovarian torsion, despite both being of comparable risk to patients – delays in treatment of either will result in the loss of gonadal function and fertility.
Similarly, while erectile dysfunction and its treatment feature commonly in multiple choice exams, female anorgasmia is seldom mentioned in training and poorly treated in practice. Moreover, medical education rarely covers specific trans healthcare or appropriate means of delivering care for trans, non-binary and intersex groups.
Change is clearly needed in how we train the doctors of tomorrow and upskill the doctors of today to account for sex and gender dimensions. This is set out as a priority in the Women’s Health Strategy for England and Women’s Health Plan for Scotland, leading NHS England to make teaching and assessments on women mandatory for graduating medical students from 2024.
This is laudable progress that has the potential to make real difference, but for meaningful change across all areas of medical care, sex and gender considerations must be embedded in all curricula – from primary school biology classes up to postgraduate specialist training.
Beyond the statement of intent
The publication of the MESSAGE statement of intent is not the end of a process but the beginning of a journey to make considerations of sex and gender a priority for everyone in the biomedical, health and care sectors.
Higher education will play a pivotal role in upskilling researchers and clinicians alike, and generating interest and enthusiasm among the academic and clinical workforce, to ensure policies achieve real-world impact to improve outcomes for all patients.
