Gender Imbalances in Health Research
What are the mechanisms behind gender imbalances in the contents and processes of health research?
Gender discrimination and bias not only affects differentials in health needs, health seeking behaviour, treatment, and health outcomes but also influences the content and the process of health research.
Gender imbalances in the content of health research refer to disparities in what is studied:
- the slow recognition of health problems that affect women and men differently
- misdirected and incomplete approaches to women’s and men’s health needs
- lack of recognition of the interaction between gender and other social
Gender imbalances in the process of health research refer to how topics are studied: the lack of data disaggregation in projects; the lack of researcher sensitivity to the varied dimensions of disparity; the lack of a gender perspective and/or exclusion of female subjects from medical research and clinical trials; gender imbalance in the composition of ethical committees, research funding and advisory bodies; and differential treatment of female scientists (EU-‐adapted from WGEKN, 2007).
The need for gender equity in health research
Biomedical and health research initially focused on the biological differences between the sexes related to reproduction. It has become increasingly clear that meaningful sex differences exist in health conditions not associated with reproduction (i.e. osteoporosis, depression and others)(Editorial Nature, 2010). Moreover, social researchers have shown that including only biological sex differences in health research is insufficient for understanding the differences in health and illness between men and women. Thus health research has been expanded to include the impact of the socially constructed concept of gender.
Gender as a social construction determines health outcomes of men and women. In addition, various social inequalities (i.e. age, ethnicity, class, and others) intersect with gender to produce vulnerabilities in health. Health research has begun to acknowledge and explore this intersection (Payne, 2009; Kuhlmann and Annandale, 2010; Lin and L’Orange, 2010; Payne and Doyal, 2010). Recently researchers have provided guidelines and training to include gender and sex in research and education (Nieuwenhoven and Klinge, 2010; Schiebinger and Klinge, 2010).
Existing EU-Level Policy
Incorporation of Equal Opportunities into European Community Policies Act (1996) The first time Europe honored its gender-‐ mainstreaming commitments, set out in the Platform for Action of the 1995 Fourth World Conference on Women in Beijing and reflected and strengthened by the terms of the 1997 Treaty of Amsterdam, by mainstreaming gender into European science research policy was between 1998-‐ 2001 with the Fifth Framework Programme (FP5).
European Council Resolution on Science and Society and Women in Science (2001) The resolution asks the European Commission to “ensure effective mainstreaming of the gender dimensions when implementing the Sixth Framework Programme.” This resolution has materialized in the Gender Action Plans under FP6.
Council of Europe: Recommendation of the Committee of Ministers to member states on the inclusion of gender differences in health policy (2008) It recommends among other things, that it is necessary to develop and disseminate gender sensitive knowledge that allows evidence-‐based interventions through systematic collection of appropriated sex-‐ disaggregated data and the promotion of relevant research and gender analysis. Re-‐ iterated at the Competitiveness Council of May 26, 2010 emphasizing; “in particular the need to include gender issues in research as a way to create new knowledge and stimulate innovation”
Framework Programme 7, Directorate General Research & Innovation The €50 billion programme funds research grants on technological and demonstration projects from 2007-‐2013. The projects must have “European added value” One of the ten areas for research is health ( EC, 2007). In the Cooperation Work Programme Health “the differences of gender/sex in research ( risk factors, biological mechanisms, causes, clinical features, consequences and treatment of diseases and disorders) must be considered where appropriate” (EC, 2011).
“Medicine as it is currently applied to women is less evidence-‐based than that being applied to men” Nature editorial, 10 June 2010.
The Multiple Levels of Gender Relations
Gender relations operate at various levels to shape men and women’s health behaviours as well as their exposures to illness.
At the individual level, gender explains individual behaviours, including health-‐ related behaviours, which often reflect or reproduce gender norms.
At the institutional level—in medical institutions, workplaces, and neighbourhoods—gender relations explain how institutional policies and practices shape ideas of gender and consequently constrain health and health choices of men and women.
At the policy level, public policies that determine labour standards, pension access, and paternity/maternity leave consequently shape gender relations in men and women’s daily lives. Patterns of health, illness and diseases among men and women vary cross-‐nationally, which indicates that varied policy regimes have gendered effects on health.
Gender Relations & Social Inequalities
Other social categories, such as age, ethnicity, social class, sexual orientation have been proven to intersect with gender imbalances thereby increasing the vulnerability and inequity in health. Health researchers have adopted a new framework using both qualitative and quantitative approaches to illustrate the complex intersection of social inequalities and gender imbalances and its impact on health.
Example of Gender & Socioeconomic Status
Women work more often in lower paid jobs than men and compared to men they have less control over their work and face more violence and harassment at work. Both men and women face health consequences of vertical and horizontal sex segregated labour markets, e.g. work-‐related fatigue occurs more often in women, whereas men have more often work-‐ related injuries and accidents.
Responsible Knowledge Making
The genSET Consensus Seminar Report (2010) formulated recommendations aimed to change research processes and methods to impact scientific knowledge production:
“Leaders must be convinced that there is a need to incorporate methods of sex and gender analysis into basic and applied research; they must “buy into” the importance of the gender-‐dimension within knowledge making. The most effective way of doing this will be to illustrate how continually incorporating sex and gender analysis promotes research excellence. Such examples should be inventoried by European institutions (e.g. DG Research, ESF) and made available to institutional “change agents” (e.g. deans, provosts, opinion makers, department heads).”
And also: “ In all assessments – paper selection for journals, appointments and promotions of individuals, grant reviews, etc. – the use and knowledge of methods for sex and gender analysis in research must be an explicit topic for consideration. Granting agencies, journal editors, policy makers at all levels, leaders of scientific institutions, and agencies responsible for curricula accreditation, should be among those responsible for incorporating these methods into their assessment procedures.”
Conclusions from Analysis of Existing Practice
A good practice for promoting gender equity in health research means that attention is paid to the topic as well as the research methodology. For instance, a request that women are included in pharmaceutical drug trials, and data are separately analyzed for women and men.
The majority of good practices (GPs) in the database on the topic of health research include socially constructed gender as a determinant in health research thus challenging the content of existing health research.
About a quarter of the GPs make efforts to address gender imbalances by changing not only the content but also the process of health research. This trend signals that research strives to educate and guide health researchers in the avoidance of sex and/or gender bias in their research.
In addition, some GPs challenged the process of health research through mainstreaming gender equality addressing participation of women in research and through the production of practical research guidelines for analysing gender and other inequalities. These efforts illustrate the innovation potential of new in methodologies in health research.
The most important existing challenge is to study and address the interactions between sex and gender, and other sources of social inequalities that impact on health. Recently, health researchers increasingly adopt an intersectional framework to address this challenge.
Rather than simply describing health disparities, researchers need to consider how various inequalities operate, intersect, overlap, and reinforce to produce health disparities, Since few GPs address other social inequalities—such as ethnicity, age, social class and sexual orientation—future research needs to consider the complexity of the intersection of diverse social inequalities and health vulnerabilities. Health researchers need to collaborate with other disciplines, including social psychology, sociology, anthropology, and history to accomplish this aim.
Good Practice Example 1:
Sex and gender in biomedicine: promises for women and men, the Netherlands
This good practice presents an overview of Gender Medicine as a research domain and provides evidence on how incorporation of sex and gender analysis in research will lead to a better health care for women and men. Next to describing innovative developments in the field of cardiovascular research, it illustrates ways to create new knowledge in research fields on i.e. asthma, depression and osteoporosis.
Good Practice Example 2:
Guidelines for gender equality programs in science, EU
In order to promote equality between male and female researchers, this good practice provides useful guidelines for universities, research centres and other stakeholders to implement a new institutional cultural change for a greater inclusiveness of women scientists, and the improvement of the working conditions of women and men.
Good Practice Example 3:
Untold Problems: a review of the essential issues in the mental health of men and boys, United Kingdom
The Men’s Health Forum and the Mental Health Charity Mind have come together to produce a review of the most important mental health issues affecting men and boys. Guidance on effective mental health practice with men and boys has been developed. This guidance is relevant to policy makers and all practitioners who work with men and boys in the area of mental health.
Good Practice Example 4:
Assessment of the health situation of people with various disabilities, Sweden
The Swedish National Institute of Public Health has assessed the health of people with various disabilities. The gender perspective was taken into account in the results. The institute monitors the health of people with various disabilities as they constitute an important vulnerable group whose health ought to be enhanced according to the Governments directives. This assessment has shown that people with various disabilities have poor health compared to the majority of the population. This poor health is avoidable. There is a correlation between risky lifestyles and poor health among people with various disabilities. The institute has outlined recommendations and actions to enhance the health of people with various disabilities.
Steps for Policy Action
1)Continue and increase of financial support for research that challenges both the content and the process of existing health research
Stimulate cooperative exchange among national grant councils, affiliates, research institutions and individuals concerning criteria for funding. National and international networks of organizations and individuals should be expanded. Recent insights in the process of engendering health research, policy and action initiatives, funding opportunities, and other resources should be disseminated.
2)Continue and increase the encouragement of research that focuses on the development of methods of sex and gender analysis in health research
Strong support for health researchers to further develop theoretical frameworks and practical applications for integrating sex and gender in research, clinical and public health practices. Incorporating sex and gender analyses act as controls providing critical rigor in research, policy, and practice. It will ensure excellence and quality in outcomes and enhance sustainability.
3)In particular, encourage the development of research methods to study health from an intersectional perspective
Support for research from an intersectional perspective that engages with current trends and debates in health studies. Encouragement of new ways to theorize and empirically research the multiple factors and processes that determine people’s health. Collaboration with other disciplines such as social psychology, sociology, anthropology and history is essential.
Funds should be made available to explicitly encourage collaborative research, communication, and cooperative exchange among different disciplines at different levels. Support for networks of organizations and individuals from the different disciplines that actively disseminate research findings.
4)Prioritize major public health problems with relations to other domains, such as violence against women, occupational health issues, (mental) health needs and care options
Encourage research capacity-‐building action to help forge multidisciplinary teams around strategic research themes that aim at optimization of health for all. Encourage researchers from relevant disciplines including those who have not been primarily or previously involved in health research. One example is research on the dynamics in the relationship between unequal opportunities in the workplace and gender equity in health. A focus on gender relations, or how men and women’s health relate to each other, need to be addressed. Encouraging this type of research will help to understand how daily interactions, embedded in larger gendered structures, between and among a diversity of men and women structurally contribute to differences health and illness.
Ineke Klinge PhD, Maastricht University, the Netherlands
Carina A. Furnée PhD, Maastricht University, the Netherlands
María Cristina Quevedo-Gómez MD, MPH, Maastricht University, the Netherlands
Petra Verdonk PhD, Maastricht University, the Netherlands
Karolinska Institute, Sweden
Peggy Maguire, European Institute of Women’s Health (EIWH), Ireland
Kristin Semancik, European Institute of Women’s Health (EIWH), Ireland
Special thanks to Expert-reviewers
Dr. Elizabeth Mestheneos
1)Editorial: Putting Gender on the Agenda (2010). Nature, 465(7299), p.665 http://www.nature.com/nature/journal/v465/n7299/full/465665a.html
2)European Commission (2007) FP7 in Brief. http://ec.europa.eu/research/fp7/pdf/fp7-‐inbrief_en.pdf
3)European Commission (2011) FP7 Cooperation Work Programme: Health 2012. ftp://ftp.cordis.europa.eu/pub/fp7/docs/wp/cooperation/health/a-‐wp-‐201201_en.pdf
4)genSET Consensus Seminar Report (2010) http://www.genderinscience.org/consensus_report.html
5)Klinge I (2010). Gender assessment: European health research policies, in: Kuhlmann E and Annandale E (eds.) The Palgrave Handbook of Gender and Healthcare, Basingstoke: Palgrave, 91-‐106.
6)Kuhlmann E, Annandale E (2010). Bringing gender to the heart of health policy, practice and research, in: Kuhlmann E and Annandale E (eds.) The Palgrave Handbook of Gender and Healthcare, Basingstoke: Palgrave, 72-‐90.The Palgrave Handbook of Gender and Healthcare, Basingstoke: Palgrave, 1-‐17
7)Lin V, L’Orange H (2010). Gender-‐sensitive indicators for health, in: Kuhlmann E and Annandale E (eds.) The Palgrave Handbook of Gender and Healthcare, Basingstoke: Palgrave, 72-‐90.
8)Klinge I, Newman S ( 2010). Gender and sex in biomedical and health research in Europe 1980-‐2010, in: Schiebinger L and Klinge I (eds.) Meta-‐analysis of gender and science research – Topic report. Mainstreaming sex and gender analysis into research.
9)Luxembourg: Publications Office of the European Union
10)Nieuwenhoven L, Klinge I (2010). Scientific Excellence in Applying Sex-‐ and Gender-‐Sensitive Methods in Biomedical and Health Research. Journal of Women’s Health. February 2010, 19(2): 313-‐321. doi:10.1089/jwh.2008.1156.
11)Payne S, Doyal L (2010). Re-‐visiting gender justice in health and health care, in: Kuhlmann E and Annandale E (eds.) The Palgrave Handbook of Gender and Healthcare, Basingstoke: Palgrave, 21-‐35.
12)Payne S (2009). How can Gender Equity be Addressed through Health Systems?, Joint Policy Brief 12, World Health Organization, on behalf of the European Observatory on Health Systems and Policies, http://www.euro.who.int/document/E92846.pdf .
13)Schiebinger L, Klinge I (eds.) (2010). Meta-‐analysis of gender and science research – Topic report. Mainstreaming sex and gender analysis into research. Luxembourg: Publications Office of the European Union Available at http://www.genderandscience.org/web/index.php
14)Verdonk P, Hooftman WE, Van Veldhoven MJPM, Boelens LRM, Koppes LJ (2010). Work-‐related fatigue: the specific case of highly educated women in the Netherlands. International Archives of Occupational and Environmental Health, 83, 309-‐321.
15)WGEKN (Women and Gender Equity Knowledge Network) (2007). Unequal, Unfair, Ineffective and Inefficient Gender Inequity in Health: Why it exists and how we can change it. Final Report to the WHO Commission on Social Determinants of Health work, http://www.who.int/social_determinants/resources/csdh_media/wgekn_final_report_07.pdf.