Lessons learned from the Gender in Research workshop

Sex and gender in health and research
Integrating sex and gender in health and health care research is not always a piece of cake for researchers. How do you account for sex and gender in design, execution and reporting of your research? Which resources are available to help with this task? And how about the patient perspective or other diversity dimensions?

During the Erasmus Summer Programme in August 2022, ZonMw and ErasmusMC organized an intensive course program on sex and gender in health and research for a third edition. For five days, (inter)national experts and guest speakers shared their knowledge and expertise with early career researchers from all around the world. Which lessons did they learn about integrating sex and gender in research?

To realize quality health care for all, the sex and gender dimension needs to be integrated in all aspects of research and clinical practice. In the week of 22-26 August 2022, ErasmusMC and ZonMw jointly offered a 5-day course program within the Erasmus Summer Programme to (inter)national PhD candidates and early postdoc researchers to gain knowledge and skills in sex and gender in health and health research. The program consisted of the Gender and Health course by ErasmusMC and the Gender in Research workshops coordinated by ZonMw.

About the program

The Gender and Health course brought together experts form a multitude of disciplines including clinical, basic science, public health and policy, to provide participants an understanding of the critical issues in women’s and men’s health throughout the life cycle and the influence of sex and gender on health and health care. The Gender in Research workshops were focused on improving the skills of early career researchers in doing sex and gendersensitive research. Through pre-recorded lectures and reflections on the lecture content by a select number of participants, the participants worked on how to integrate sex and gender in different phases of research. Each workshop session included an (inter)national guest speaker to offer a certain perspective on sex and gendersensitive health research, such as the patient perspective, an intersectional perspective, an early career perspective and a research funder’s perspective.

During the course week, a competition was set for the workshop participants, challenging them in teams to come up with a creative and innovative way to share the knowledge and skills gained during the course with peers, colleagues and other stakeholders.

'Having a sex and gender informed perspective increases the robustness of our research. It expands the relevance of our research. And it makes our results, the results of our research and inferences, more valid.'
Dr. Maryam Kavousi

Implications of sex and gender in research design

The first 2 days of the course are centred around sex and gender in research design. In 4 pre-recorded lectures by Dr. Maryam Kavousi and panel discussions with Maria Henneman, Dr. Jeanine Roeters van Lennep and Dr. Lieza Exalto, the participants are introduced to the basic principles of integrating a sex and gender dimension in their research design. An important lesson? It always starts with the research question and a good understanding of the research topic. What do you want to know? And what is already known about the influence of sex and gender in that area? What effect does that have on issues such as sample size, preventing bias in your data collection and interpretation, or the type of analyses you do?

Interested in the lectures? Watch them yourself!

The participants try to formulate answers together. Reflections on the lecture contents by 4 participants help with that. Struggles with for example measuring sex and gender separately, or with the fact that in existing databases often only sex is recorded which makes measuring the influence of gender much harder are shared. Luckily the discussions also elucidate solutions how to deal with these issues and several participants offer tips and resources that helped them.

Stratification offers new insights

The reflections by participants on the lecture contents offers valuable insights. 1 of the participants shares the importance of performing stratified analyses: where analysis of the group as a whole did not show significant improvement of schizophrenia symptoms in people using a certain drug, a stratified analysis by sex illuminated that women actually did significantly benefit from the drug. Another participant underlined the importance of being mindful of different life phases: due to differing hormone levels, pre-menopausal women can react differently to cancer treatment than post-menopausal women. Not taking that into account can skew your results.

What if someone identifies as a beaver rat?

What many participants find complicated, is that they often don’t know how to best record or measure sex and gender separately. Someone shows how biological sex and gender identity are asked about separately in her questionnaire: not only does she ask about the sex recorded at birth, she also inquires if someone identifies as male/masculine, female/feminine, non-binary or by another term. That it matters how the question about gender identity is asked is illustrated by an anecdote of another participant. He all of a sudden had to deal with beaver rats in his sample due to a creative bunch of respondents and a clumsily phrased multiple choice question that included the option ‘Other, please specify…’

Indirect measurement of gender through a composite gender score

Another much encountered stumbling block is that when using existing datasets, usually only sex is recorded. This makes studying the influence of gender complex. Using a so-called composite gender score can help, as transpires from the experience of several participants. Such a score makes use of information that is available - such as who is the primary care taker in the family or who is the primary breadwinner – to indirectly measure the influence of gender after all.

Top 3 lessons learned

  1. How to integrate sex and/or gender in your research always starts with your research question and a good understanding of the available literature on your topic. Biological and/or sociocultural differences between men and women affect among other things your data collection and data analyses, even when researching sex and gender differences is not the primary objective of your research. Besides the pre-recorded summer school lectures, much can be learned from the online training modules of CIHR-IGH.
  2. Performing stratified analyses by sex and/or gender can reveal relevant differences between women and men that otherwise remain hidden. There can also be relevant within group differences by sex and/or gender, for example in pre- and post-menopausal women due to hormone levels.
  3. Even when sex and gender are not recorded separately in existing databases, it is possible to include gender as a variable. Different resources are available to help with this, such as this issue of the Canadian Meet the Methods series or this guide.

Looking through the lens of patients and intersectionality

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Looking through the lens of patients and intersectionality

‘My doctor said: it’s stress, take it easy for a bit. But the tiredness did not go away. A journey past different doctors began. In the end it became clear I had heart problems. Only after 2 years I received the right diagnosis. Apparently this happens to women more often.’ Caroline Verhage and Annemiek Hutten of Stichting VrouwenHart, movingly describe how a lack of knowledge about how heart disease can present itself differently in women has affected their personal life and health. With their foundation they therefore work towards more connections between patients, health professionals and researchers to increase attention to differences between men and women in heart disease. Their story makes clear that the patient perspective is indispensable in research.

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Give patients a full role

Verhage and Hutten provide participants with valuable tips to involve patients in different phases of research. It is important to give patients a full role that goes beyond them being merely a research subject. The experiences of patients can for example provide input on new research questions. Or they can help in coming up with or creating fitting solutions for problems they face as a patient. After all, they know like no other what it is like to be in a certain health situation. It is therefore important to make patients an integral part of the research team and involve them from the very start.

Tip! Look for patient organizations in your area or network that can help you find patients interested in providing input in different phases of research.

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There’s more than just sex and gender

Everyone has a unique social position, states Maaike Muntinga. This social position is determined by the advantages and disadvantages that someone experiences in their daily life under the influence of different social identities, such as gender, ethnicity or socioeconomic status. An intersectional perspective helps researchers explore this complexity. The assistant professor and researcher at Amsterdam UMC takes the participants on a quick journey of the theory and practice of this perspective in health research.

‘Intersectionality refers to the way in which aspects of social identity (such as gender, ethnicity etc.) interact to shape people’s everyday experiences. And also critically examines the influence of the social context in which people live, especially where there are differences in power and privileges. It is therefore not only about differences, but also about inequalities between (groups of) people.’

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Putting it in practice

After explaining the theory, Muntinga puts the participants to work. In small groups they discuss their own social position and how that influences their work. She also gives the groups 5 questions to help them discover and discuss how an intersectional perspective might benefit their own research.

  • What is the role of (intersections of) social identity in the health problem?
  • Do biological factors play a role in the research?
  • Which social groups might be missed in the research (intersectional invisibility), or how can you find out?
  • What is the role of the social context (power, privilege, disadvantage) for the health problem?
  • Which groups are most and least vulnerable (between ánd within groups) and why?
If you don’t acknowledge the fact that gender, sex and for example skin colour can have a huge influence on your models, then you’re narrowing your vision. And the answers you’re going to get are most definitely wrong. So ignoring that is not an option.’
Dr. Marijn van Wingerden

Reading, writing, implementing and reporting on sex and gender in research

On day 3 and 4 of the workshop, the pre-recorded lectures of Prof. dr. Sabine Oertelt-Prigione are the focus, including the panel discussions with Maria Henneman, dr. Petra Verdonk and dr. Marijn van Wingerden. 4 different topics around sex and gender in health research are discussed. Conceptualizations of sex and gender in biomedical literature and different options for operationalizing sex and gender are discussed. The lectures also cover (gender) diversity in the research team and academic leadership, as well as gender sensitive implementation. Lastly, practical examples of what to pay attention to when writing grant proposals and scientific publications are given. A common thread in all of it is the importance of transparency and explicitness in the choices you make around sex and gender in all phases and aspects of research.

Interested in the lectures? Watch them yourself!

The third and fourth day of the workshop again contain critical reflections on the lecture content. Many of the topics discussed on previous days prove to be relevant again when discussing operationalizations and conceptualizations of sex and gender. But there is also the recognition that sex and gender are often not the only relevant diversity aspects. Useful tips are being exchanged on librarians as best friends and how to be as transparent as possible in reporting on the choices you made as a researcher with regards to sex and gender.

The librarian as your best friend

When it comes to finding useful literature on sex and gender aspects in your research topic, 1 of the participants is convinced: librarians of the university library are your best friends. They can often help you with new search terms and with structuring your search for useful literature. This subsequently helps you in operationalizing sex and gender for your research. Another participant offers a great tip for writing of scientific publications once the research is done: the SAGER-guidelines. This comprehensive guideline outlines how to report on sex and gender in each step of the research process.

Diversity is more

An important topic of discussion is that sex and gender are often not the only relevant aspects of diversity. This influences research, but definitely also influences implementation. 1 of the participants illustrates this with her work in e-health, where women of colour are often hard to reach with health apps. Another participants adds to the discussion that patient participation can help in this. Consulting and actively involving patients with different backgrounds helps to make your results and end products better aligned with the needs of different groups within your target audience. Useful resources around intersectionality are also shared amongst each other.

The idea you don’t have, is the voice you haven’t heard

The discussions also bring up experiences of diversity in research teams. Especially participants with backgrounds of less privilege or minority groups speak from personal experience that they feel they have to work harder to have their voice heard or appreciated. The discussion can be summarized by a quote that one of the participants shares: ‘the idea you don’t have, is the voice you haven’t heard’. The participants agree that much can be won already if everyone’s experience is listened to and matters of diversity are openly and safely discussed in the research team.

Top 3 lessons learned

  1. Be transparent and explicit in each phase of the research process about the choices you make with regards to sex and gender and their conceptualization and operationalization. A useful resource that can help you with your choices is Gendered Innovations, where key terms and concepts are described and several case studies are highlighted.
  2. Sex and gender are not the only important aspects of diversity in health research. A handy reading list for health researchers wanting to know more about applying an intersectional perspective in health research is on the website of the Intersectionality Training Institute.
  3. The SAGER-guidelines offer a guideline for reporting on sex and gender in all steps of the research process: from design and data analysis to results and its interpretation.

Looking through the lens of a funder and a researcher journey

Gender in Research
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‘You are all future leaders’

With that message Cara Tannenbaum, scientific director of the Canadian Institute of Gender and Health (CIHR-IGH) kicks off her talk. In an inspiring way, she demonstrates that CIHR-IGH is more than a funding organization for health research focused on the influence of sex and gender on health.

‘Don’t let up’

At rapid speed, Tannenbaum shows what the institute has done through the years to make the integration of sex and gender in health research commonplace. Mandating, enticing as well as training and coaching researchers and reviewers in integrating the sex and gender dimension in their work have proven to be important strategies. And also: don’t let up, or in other words, keep communicating the message. Where previously this message focused mainly on the importance of sex and gender in health research, CIHR-IGH now also underlines the significance of a broader, intersectional perspective.

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What can you do?

Tannenbaum concludes her talk by inviting the participants to be bold, to push the boundaries and to show leadership. Her call to action for early career researchers:

  1. Pay attention and point out if sex and gender are not mentioned in lectures or journal articles.
  2. Be a role model for appropriate integration of sex and gender in your research, and invite colleagues to use resources such as the CIHR-IGH Meet the Methods series.
  3. Use the momentum of policy changes at research funding organizations as an opportunity to bring about organizational change for sex and gender science at your own institution.
  4. Start pushing the limits beyond sex and gender science, to embrace intersectionality and anti-racist science approaches in the spirit of social justice.
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‘Perseverance is key to a career in academia’

Through her own journey as a researcher, Dr Sanne Peters – by now associate professor at UMC Utrecht and senior lecturer at the George Institute for Global Health and Imperial College London – tells more about building a career as a researcher interested in sex and gender in health.

Her career led her from Utrecht to Australia, England and back to Utrecht. Every step brought her further in the kind of research she wanted to do. Peters not only shares her successes with the participants, she also highlights some of the missed research positions and rejected grant applications she encountered along the way. After all, building a career in academic research is not always a bed of roses. Perseverance and a bit of luck are absolutely necessary.

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10 lessons learned

All in all, Peters has gleaned 10 lessons from her own path that could help early career researchers as they set out on their journey.

  1. Choose the right mentors
  2. Be involved
  3. Work on your network: talk to people
  4. Work hard and have fun
  5. If possible, go abroad
  6. Focus on something
  7. Take opportunities and go for it
  8. Give up on things that don’t work out
  9. Be persistent
  10. Have some luck

And the winner is…

The final day of the workshop is all about the Gender in Research competition. Throughout the entire week, the participants have worked in teams to come up with a creative and innovative way to share their newly gained knowledge and skills with others. An international jury consisting of Daphne Bloemkolk (Dutch Heart Foundation), Ines Medved (DFG), Bryn Hummer & Margot Morssinkhof (Start NVG&G) en Cule Cucic (ZonMw) assessed the ideas. Each team had a chance of winning the Gender in Research Award, a prize of € 8,000 to bring their idea to fruition.

Firstly all jury members introduce themselves and their organization. Then it is the turn of the 4 teams to creatively pitch their ideas and convince the international jury in less than 4 minutes of their ideas. The jury is invited into podcast recording studios and film studios, hear about social media campaigns and about joining forces by Canadian and Dutch patient organizations. Each group is critically questioned by the jury before they retired to deliberate. It was a tight race, but eventually Cule Cucic had the honour of presenting the award to the happy team Portraits of Psychiatry. They can now start working on their video trilogy in which patients, health care professionals and researchers give a face to sex and gender difference in psychiatry.

New edition in 2023

In 2023 ZonMw again offers the opportunity for 20 early career researchers from around the world to participate in the joint summer course program by ErasmusMC and ZonMw. The fourth edition will take place in Rotterdam from 14-18 August 2023.