Canadian Institute of Wh

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A Gender, Sex And HeAltH

reSeArcH cASebook

Canadian Institutes

of Health Research

Instituts de recherche

en sant du Canada

Institute of Gender and Health

Institut de la sant des

femmes et des hommes


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titut o dr ad alth

titut d la at d mm t d homm

What a Dierencex and G

MakeA , S H R C


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CIHR Institute of Gender and Health

University of ritish Columbia

6190 gronomy oad

oom 305, TEF 3 uilding

ancouver, ritish Columbia

V6T 1Z3 Canada

www.cihr-irsc.gc.ca/e/8673.html

Canadian nstitutes of ealth esearch

160 lgin treet, 9th loor

ddress ocator 4809A

Ottawa, Ontario K1 0W9 Canada

www.cihr-irsc.gc.ca

vailable on the web in HT ML and PD F formats er ajesty the Queen in ight of Canada (2012)

Cat. o.: MR 21-164/2012E-PD F

IS BN : 978-1-100-19250-5

For distribution and permission requests, please contact the CIHR nstitute o Gender

and ealth at [email protected] or 604-827-4470.

This casebook was produced by the nstitute o Gender and ealth o the anadian n-

stitutes o ealth esearch. The views expressed herein do not necessarily refect those

of the Canadian nstitutes of ealth esearch or the nstitute of Gender and ealth.

100%


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CONTENTS

A Ci i H R i H IVAg VF VIIntroductIon W i g ? Ix

Siig

PART I

1 Se and gender dierences in mental health research 1

Adr ianna Mendrek

2 The inuence o Mars and enus on lung development: implications or biomedical

research and beyond 8

Marc Simard, Er ic Bouche r and Yves Tremblay

3 Se and gender in stress research: the metamorphosis o a feld 17

Robert-Paul Juster and Sonia J. Lupien

4 hallenging dis-ease: se, gender and systematic reviews in health 25

Sari Tudiver, Madeline Boscoe, Vivien E. Runnels and Marion Doull

Sgig i

PART II

5 My mum, my dad, and se dierences in cardiac care: how a se-based analysis

revealed the importance o age 35

Randall Fransoo

6 Work eposures and musculoskeletal disorders: how the treatment o gender and se

in population-based surveys can aect detection o eposure-eect relationships 42

Karen Messing, Susan Stock and France Tissot

7 The inuence o gender in the implementation o an integrated management system

in an industrial work environment 50

Sade Savary

8 Making sure everyone counts: considerations or inclusion, identifcation and analysis

o transgender and transseual participants in health surveys 59

Greta R. Bauer

Tig i i

PART III

9 Diusion o environmental health inormation: the role o se- and gender-

dierentiated pathways 69

Johanne Saint-Charles , Marie Eve Rioux-Pel le tier, Pier re Mongeau and Frdr ic Mertens

10 eections on gender relations in an ndigenous emale adolescents seual health

literacy program 77

Elizabeth M. Banister and Deborah L. Begoray

11 hanging health systems with a se and gender lens 85Natalia Diaz-Granados and Donna E. Stewart

12 Mobilizing masculinity to support athers who want to be smoke ree 94

John L. Oli e, Joan L. Bot tor and Gayl Sarbi t


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iv

bout the anadian nstitutes o

ealth esearch nstitute o ender

and ealth

The nstitute o ender and ealth (IGH) is one o the 13 institutes

that make up the anadian nstitutes o ealth esearch (CIHR),

the overnment o anadas health research investment agency.

is the only organization in the world with a mandate to und

research on gender, se and health.

The mission o IGH is to oster research ecellence regarding the

inluence o gender and sex on the health o women and men

throughout lie, and to apply these research indings to identiy

and address pressing health challenges.


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v

Ag

h productio oWhat a Diference Sex and Gender Make would ot havb poibl without th imm cotributio o may i all tag oth proc, icludig:

Xcabook ditor Stphai o (IGH owldg ralatio aagr)ad Elizabth aitr (IGH titut dviory oard mbr);

Xth cabook author;

Xmmbr o th abook Editorial ommitt: Elizabth aitr,uylai oioault, Joa ottor, ary arbr;

Xcabook projct aitat at ogly;

Xth 16 pr rviwr;

Xcollagu at th CIHR owldg ralatio rach, CIHR rativ

Srvic ad CIHR ralatio;Xth IGH titut dviory oard; ad

Xth IGH ta.


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vi CIHR InstItute of GendeR and HealtH What a Difference Sex and Gender Make

F

t i with grat prid that w prnt thi gndr, x and halth rarch ca-

book, What a Diference Sex and Gender Make. h CIHR titut o drad alth (IGH) i th world rt, ad to dat th oly, halth rarchunding intitut with a pcic ocu on gndr, x and halth. For ovr 10

yar w hav upportd rarch that ll critical knowldg gap rlatd to

th halth o womn, mn, girl, boy and that advanc th cinc o gndr,

x ad halthom o thi tllar work appar i th pag that ollow.W can no longr aum that drug, dvic, intrvntion and polici

ar qually appropriat or m ad wom. aada, m di yougrtha wom, whil wom xpric a havir burd o chroic ill.hr ar umrou dirc i how m ad wom bhav with r-gard to thir halth, thir u o th halth ytm ad thir rpo tothrapi. hr i alo grat divrity within population o womn and o

m, a wll a importat imilariti btw m ad wom that d

to b coidrd i prvtio ad tratmt.ur purpo i dvlopig thi cabook i to howca th dirc

that accounting or x and gndr mak in halth rarch. h cabook

i a rourc o cocrt xamplrom acro th gamut o halth dici-pli ad topico how gdr ad x coidratio ar big icor-poratd i halth rarch ad why thi i importat. hi advac ourwidr commitmt to otrig th itgratio o gdr ad x a rou-tin conidration in all domain o halth rarch, a ocal point oIGH

kowldg tralatio (KT) tratgy.


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viiForeword

t i th poitio oIGH that all halth rarch hould coidr th

iuc o gdr ad x i ay phoma o tudy. our rarch d-ig do ot tak x ad gdr ito accout, th vidc w grat

may b icomplt or imply icorrct; w rik ot oly doig harm (ucha xtrapolatig dig bad o mal ampl to mal), but alo mi-ing critical opportuniti to improv halth (or xampl, not dtcting th

bnt o an intrvntion in a ubgroup o mn). W rcogniz that thr ar

rarch qutio whr x ad gdr ar ot rlvatbut irrlvachould b dtrmid by citic ratioal, ot ovright. hi cabookwill rv a a guid or halth rarchr lookig to icorporat gdrad x ito thir work.

W hop that thi cabook will circulat ar ad wid i upport orarch to improv th halth o vrybody.

D r . J O y J O h N S O N

Scientiic DirectorC IH R titut o dr ad alth


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ix

IntroductIon W i g ?

n this collection, you will ind eamples rom a diversity o disciplines and

health oci where accounting or se and gender in health research has ad-

vanced what we know, improved how we do research and made the products

o health research more useul. hi i th dirc that x ad gdrmak. What thi cabook dmontrat i that thi dirnc i ignicant;

thr i much to b gaid rom th routi itgratio o gdr ad xacro th halth rarch pctrum.

Each o th 12 chaptr in thi volum illutrat how halth rarch pro-

c and outcom can look dirnt whn th inunc o x and gndr

ar conidrd. Writtn rom a critically rctiv vantag point, th chaptr

har rarchr xpric i how thy cam to udrtad ad gaggdr ad x i thir work. Questions to considerar icludd to cour-

ag radr to xplor way that x ad gdr ca bt thir ow work.What a Diference Sex and Gender Make will b o intrt to a rang o au-

dinc. For train and nwcomr to gndr, x and halth rarch, thi

cabook or a rrnc point to bgin a oray into th ld. For rarch-

r cotmplatig takig up x ad gdr i thir tudi, thi collctioor xampl o how thi can b don. For th widr gndr, x and halth

rarch community, thi cabook aim to park nw ida and approach

to driv th ld orward. W hop that thi rourc will b hard withcollagu ad th xt gratio o gdr, x ad halth rarchr.


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CIHR InstItute of GendeR and HealtH What a Difference Sex and Gender Make

W i g? W i ?Genderi grally viwd a a ocial cocpt. h Gender, Sex and HealthResearch Guide dcrib gndr a ocially contructd rol, rlationhip,

bhaviour, rlativ powr, ad othr trait that ociti acrib to womad m (CIHR , 2010, para. 2). Sex, o th othr had, i ot quatd

with th phyical body, tially th biological ad phyiological charac-tritic that ditiguih mal rom mal (CIHR , 2010, para. 2). hrar o uivrally accptd ditio or ay paratio o th trm. t

th titut o dr ad alth, w mak a ocial/biological ditictiobtwn gndr and x with th cavat that thy ar intrrlatd and potn-tially iparabl. ur approach i to courag rarchr to idtiy thdimnion o gndr and/or x that ar rlvant to thir rarch qution

and to b xplicit about how thy oprationaliz th. W acknowldg that

ditio o x ad gdr ar volvig a th cic chag. thi volum, th majority o th chaptr ubcrib to a ocial/bio-

logical diviion and u ithr gndr or x a rlvant in thir dicuion.

thr opt or th trmsex/gendera a xprio o th mhmt o

th ocial ad th biological ( chaptr 4, 6 ad 9).

C i

hi cabook i orgaizd ito thr part that ocu o th dirc

that x ad gdr mak i trm o: (1) hitig th halth rarch lad-cap, (2) trgthig cic, ad (3) tralatig rarch ito actio.Whil w hav ituatd chaptr withi thi thr-part thmatic, w ot

that may pak acro th ociad rightully o; kowldg cratio,rarch mthod ad kowldg tralatio ar all part o th itrativ

proc that w call rarch.W bgi i part with xampl o whr itgratig gdr ad x

ha cratd w kowldg about halth ad ill. W hav glad wiight about th mchaim udrlyig dia, hitd paradigm okowldg bad olly o vidc drivd rom a igl x ad im-

provd th applicability o dig. chaptr 1, drk chroicl hrpath to dvlopig a program o rarch o gdr ad x dirc


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iIntroduction

i chizophria. Sh plot hr ow practical ad political challg i

coidrig gdr ad x i mtal halth rarch a a tudt adwr rarchr agait a tur i om ara o th ld to rcogiz i-unc o x and gndr. ndrk

illutrat how a x-blind approach

rik gnrating rronou nding.

chaptr 2, Simard, Bouchr ad

rmblay dcrib how conidring

x i thir biomdical rarch o

lug dvlopmt ld to bttr u-drtadig o th halth rik aociatd with prmatur birth or bothboy ad girl. ad o rmblay log-tadig rarch program, thtrio xplain how thy hav built x into thir xprimntal dign and th

bt o doig o. akig a hitorical viw, i chaptr 3 Jutr ad u-pi documt how gdr ad x chagd th cour o tr rarch.hy dmotrat how tr i a ca i poit whr th itrctio ogdr (ocial tror) ad x (biological ractio) mattr i dtr-

miig th trajctori o tr-rlatd coditio. Edig thi ctio,

i chaptr 4, udivr ad collagu addr th qutio to whom dorarch vidc apply? i thir xamiatio o how x ad gdr arconidrd in ytmatic rviw. Sytmatic rviw ar ynth o mul-

tipl rarch tudi o a giv topic that ar rgardd a o o th motauthoritativ ourc o citic vidc. t i vidt i th chaptrthat icorporatig x ad gdr i halth rarch ca rcogur thkowldg tatu quo.

art brig togthr ca that xmpliy how takig x ad gdr

into account contribut to mor robut mthod and analytic ramwork.ur tudy dig ram th poibiliti or what w ca know ad whatw ca do with our rarch vidc; icludig gdr ad x xpadth cop o tho poibiliti and provid a rontir or innovation. n an

xampl rom halth car rvic in chaptr 5, Franoo dmontrat how

a x-bad aalyi ca b a tr ito udrtadig th igicaco othr xplaatory actor i rlatio to outcom o itrt. chap-tr 6, ig, Stock ad iot draw o thir rarch about th cto prologd workplac tadig to illutrat why tratiyig by gdr i

Gender and sex make

a differ ence

In health research.


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ii CIHR InstItute of GendeR and HealtH What a Difference Sex and Gender Make

multivariat tatitical aaly rval lik btw xpour ad ct

that may othrwi rmain hiddn. Savary, in chaptr 7, har analytic l-o lard about th importac o coidrig gdr i aig thimplmtatio o a aty protocol i a mal-domiatd idutry. Savarydmontrat how making gndr an xplicit actor in hr rarch nabld

hr to ucovr aw i th aty pla that could ot b xplaid by hriitial approach. loig thi ctio, aur illutrat how th tratmto x ad gdr i urvy dig ca lad to th xcluio o tragdrtudy participant. Baur how how x and gndr in urvy qution d-

ig ca b addrd to b mor icluiv o populatio. h chaptrprt om o th myriad way that gdr ad x coidratio co-tribut to mor citically oud rult.

h third and nal ction o thi cabook ocu on moving rarch

ito actio, alo kow a kowldg tralatio (KT). KT ivolv th

tralatio o rarch vidc ito domai uch a policy ad practicwhr it ca b applid to improv halth ad halth car. CIHR dKT a a dyamic ad itrativ proc that iclud ythi, dimia-tion, xchang and thically-ound application o knowldg to improv th

halth o anadian, provid mor ctiv halth rvic and product and

trngthn th halth car ytm (About Knowledge Translation, n.d., para. 1).

h chaptr i thi ctio dmotrat how itgratig x ad gdrito tratgi or KT ca lad to mor tramlid utilizatio o rarchvidc ad mor tailord itrvtio. chaptr 9, Sait-harl ad

co-author bring togthr two intr-

national xampl rom thir tam

work that dmontrat how x and

gndr hap conduit or th tran-miio o w kowldg about

viromtal rik ad hazard.

Banitr and Bgoray, in chaptr 10,

xplor how gdr iucd th

dvlopmnt and ucc o a xual halth litracy program or ndignou

mal adolcnt. hir contxt-pcic approach to ngaging with young

womn concption o gndr provid a clar xampl o how gndr can

acilitat idntiy ing knowldg ur nd and th appropriat tratgi

IncorporatInG Gender

and sex In he alth research

Is desirable and

doable .


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xiiiIntroduction

to mt thm. Diaz-aado ad Stwat, i hapt 11, pot how a x-

and gender-based analysis led to health-related policy changes at a nationallvl i multipl outi; thi wok udo th pottial o uig

a x ad gd l o gatig wid-agig impat. Fially, Oli,

Bottor and Sarbit recount their development o the frst-ever men-centred

resource or reducing and quitting smoking. Their work illustrates how

gd a b a atalyt to bidg th gap btw kowldg ad halth

bhaviou hag. By atig a itvtio that tappd ito mauli

ideals, the team efectively packaged health messaging to be meaningul

o m who mokd.The diversity o examples contained herein underscores the transversal

lva o gd ad x to th tudy o halth. A a olltio, th

cases paint a compelling picture o the dierence that sex and gender make

i halth ah.

Casebook editors

S t e p h a n i e Co e n, IGH Kowldg Talatio Maag

e l i z a b e t h b a n i S t e r, IGH titut Advioy Boad Mmb

references

Caadia titut o alth Rah (CR). (2010). Gender, sex and health research

guide: A tool for CIHR applicants. Rtivd om http://www.ih-i.g.a/

/32019.html

Caadia titut o alth Rah (CR). (.d.).About knowledge translation.

Rtivd om http://www.ih-i.g.a//29418.html


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PART I Shifting the healthreSearch landScape


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1

1 S g i

i

a Dr i a N N a m E N D r E k , Universit de Montral

Signiicant epidemiological and clinical data has amassed over the years

indicating important dierences between women and men in the preva-

lence, course and epression o various mental health problems. Yt, co-idrig gdr ad x i pychiatric rarch ad cliical practic i tillquit rar and mot thori (pcially nurobiological modl), a wll a

availabl tratmt (particularly pharmacothrapy), ar bad almot x-cluivly o dig i mal ubjct (aimal ad/or huma).

A a udrgraduat tudt i th ychology oour rogram at

oncordia nivrity bcam intrtd in gndr rarch. h rt major

projct that digd ad th rlatiohip btw maculiity admiiity (a maurd by th m Sx ol vtory) ad l-tm.oitt with xitig rport i thi ara, oud poitiv corrlatiobtw maculiity ad l-tm maur, ad gativ corrlatiobtw miiity ad l-tm. h ollowig yar, or my hoour

thi projct, akd my potntial uprvior, an xprt in th bhavioural

urobiology o drug addictio, i could ivtigat x dirc i thrwarding proprti o amphtamin in rat. mazingly h aid y, and

oud that mal rat likd amphtami mor tha mal. Still, durig


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2 CIHR InstItute of GendeR and HealtH What a Difference Sex and Gender Make

my graduat ad potdoctoral traiig, whil cotiuig rarch o thurobiology o motivatd bhaviour, ad latr whil tudyig brai uc-tio i chizophria patit, it wa difcult to covic my uprviorto invt in xamining x and gndr dirnc by tting ufcint num-

br o mal ad mal.hr wr numrou practical obtacl to doing thi typ o rarch

abov all th act that icludig both mal ad mal rat i tudi imor xpiv ad produc mor variabl rult. Fmal rat hav atrou cyclth quivalnt o human mntrual cyclthat contribut

to thi variability. bga to udrtad th challg a act o lithat ucarily complicatd cic ad wr bt avoidd. toppdiniting on tudying both mal and mal ubjct. wa not crtain any-

mor i tudyig x ad gdr dirc wa a worthwhil davour. covicd myl (partly bcau o my ocio-cultural backgroud adbia, ad partly bcau o th lack o vidc to covic m othrwi)

that th urobiological x dirc wr o gligibl that thy couldb igord i uroaatomical ad urouctioal rarch.

owvr, with tim, cic provd m wrog: w vidc tartd

mrgig that poitd to udiabl dirc btw mal ad malorganim that wr no longr rtrictd to rproductiv organ and bhav-

iour, but ncompad cognitiv tratgi, motion procing, rpon to

trul ituation, and o on. hu, whn nally tablihd myl a an

indpndnt rarchr, dcidd to r-viit my initial rarch paion and

xamin potntial x and gndr dirnc in vr pychiatric diordr. vturd ito th litratur ad wa urprid by what dicovrd:

pit a walth o rarch that tablihd that om o th mot prva-lt pychiatric problm, icludig dprio ad axity diordr, ardiagnod mor rquntly and otn hav a mor riou clinical cour in

wom tha i m, coidrig gdr ad x i mtal halth rarchad cliical practic wa till quit rar.

For xampl, th litim prvalnc o major dpriv diordr (MDD)

i wom i approximatly twic that o m. Etrog ha b propod

there are Important sex and Gender dIerences In the

prevalence and expressIon o numerous psychIatrIc

dIsorders that are oten overlooked in

rese arch and clinical pr actice.


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3Sex and gender differences in mental health research

pa

r

ti

to b an important playr in thi x dirnc bcau: (1) th rat oMDD

ar imilar in girl and boy bor pubrty and among ldrly popl; and (2)mood otn appar to uctuat with chang in hormon, uch a th low-

trogn prmntrual and potpartum priod whn womn ar at incrad

rik or mood diordr (Frma t al., 2004). dr-rlatd pychoo-cial actor hav b idtid a pottial cotributor to th dirtialprvalnc oMDD in mn and womn. For xampl, xprinc o ngativ

li vnt otn giv ri to pimitic attributional tyl (how popl at-

tribut th cau o thir li vt) i girl but ot i boy, makig thm

mor vulnrabl to utur dpriv piod in trul ituation (Noln-okma, irgu, & Sligman, 1992). h pictur i urthr complicatd by

a cliical bia to diago dprio i wom mor radily tha i m.Whn it com to addictiv, compuliv and obiv bhaviour, larg

dicrpaci btw th x hav alo b obrvd. For xampl,

whil atig diordr ar mor commo amog wom tha m (Stigr& ruc, 2007), ubtac u diordr ar mor commo i m (ckr& u, 2008). t i importat howvr to poit out that dpit lowr rato drug abu in womn than in mn, th numbr o womn uing and abu-

ing prcription and illgal drug i incraing. Following initiation, womn

tnd to incra thir rat o conumption and bcom addictd to alcohol,

marijuaa, opiat ad cocai mor rapidly tha do m. Furthrmor,oc addictd to a drug, wom ca d it mor difcult to quit tha mdo (ckr & u, 2008). h udrlyig mchaim o th x dir-c rmai uclar, but a w actor hav b tudid icludig th

hormo trog ad progtro.Whn rviitd th ld wa primarily intrtd in chizophrnia and

rlatd pycho ad ralizd that vry littl rarch had ocud o xad gdr dirc i thi complx ad dvatatig coditio. h riko dvlopig chizophria ovr o litim i approximatly 1%. t typi-cally bgin during lat adolcnc or arly adulthood, otn lad to a ocial

ad coomic impovrihmt ad to grat ditr or patit ad thiramili. Schizophria d i uicid i 1012% o ca (50% o patitwill attmpt uicid at om poit i thir ill). t i charactrizd by ahtrognou clinical prntation with ymptom ranging rom hallucina-

tio ad dluio (o-calld poitiv ymptom), through to diorgaizd


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bhaviour, to ocial withdrawal, povrty o pch and lack o motivation (r-

rrd to a gativ ymptom). pit dcad o citic ivtigatiow till do ot kow it caualthough w hav om vagu ida aboutvariou contributing actoror how to adquatly trat chizophrnia (about

30% o patit do ot rpod to availabl pharmacological tratmt).hr i till cotrovry a to whthr thr ar x dirc i th

litim rik o dvlopig chizophria, but rarchr ad cliicia

agr that i th yougr populatio th rik i highr i m, whil ovrth ag o 40 th rik i highr i wom. thr importat x dirc

i chizophria compa prmorbid uctio (poorr acadmic, occu-pational and intrpronal unctioning in mal than in mal bor thdiagoi), cliical xprio (mal td to prt with mor gativymptom, whil mal hav mor activ ymptom uch a irritabil-ity, aggrio ad mood drgulatio) ad rpo to tratmt (bttri mal tha i mal, but with mor id ct i mal) (ug &hu, 2000). lthough th dirc hav b wll documtd, wtill know vry littl about thir undrlying mchanim. onquntly mn

ad wom with chizophria td to rciv imilar pychopharmaco-logical (drug) and pychoocial intrvntion (group hom, occupational

thrapy), omtim with uboptimal rult. xampl i th prcrip-tio o imilar atipychotic doag rultig i mor riou id cti wom who typically rquir mallr do (Sma, 2009).

ll o thi ha motivatd m to tablih a rarch program dvotd to

xamining nurounctional, hormonal and pychoocial actor implicatd

i x ad gdr dirc i pycho. h work i my laboratory todat ha rvald an intriguing rvral o typical x dirnc in pror-

mac ad brai uctio durig th prormac o a viuo-patial tt

IncludInG both men and women In mental health research can

make a sIGnIIcant dIerence In obtaIned results. ocusInG on

a sInGle sex (where not scIentIIcally warranted) can lead

to erroneous genera lizations

and lImIt potentIal pathways to treatment.


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5Sex and gender differences in mental health research

pa

r

ti

(mtal rotatio o thr-dimioal gur) (Jimz, acii-ari,

aki, & ndrk, 2010), a wll a during xpour to motionally ngativpictur (.g., c dpictig violc, war, ad ac), i chizophriapatit (drk, acii-ari, Fahim, & Stip, 2007). Spcically, i

o tudy w akd participat to prorm a claic mtal rotatio takwhr participat ar prtd with pair o rotatd or urotatd gurad hav to dtrmi i th gur ar idtical or i thy ar mirror im-ag. urig thi tak, participat ar cad with uctioal magticronanc imaging (MRI) (imaging that how how th brain work). hi

tak ormally licit bttr prormac ad gratr brai activatio im tha i wom i th gral populatio. our tudy w hav rpli-catd th dig o uprior prormac ad brai activatio i cotrolmal rlativ to mal, but th oppoit pattr wa prt i patitwith chizophria (Jimz t al., 2010): mal with chizophria x-hibitd a pattr o brai activatio imilar to o-chizophric mal,ad mal with chizophria wr mor lik o-chizophric mal,a dpictd i Figur 1-1. What i critical to ot i that w would ot havb abl to dtct thi ct i w had icludd oly o x i our tudy.

figure 1-1 Brain activations during mental rotation in schizophrenia patients and in healthy compari-

son patients.

patient women

control men control women

patient men


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ortuatly, a ovrwhlmig majority o uctioal uroimagig

tudi in chizophrnia conit o xcluivly or prdominantly mal am-pl. Ev i th ampl ar mixd, thr i uually a iufcit um-br o wom to allow or compario btw th x. act, had woly icludd m i our tudy, our cocluio would b oly partly tru. mal-oly ampl would hav ld u to argu that patit with chizo-phria wr charactrizd by dcit i viuo-patial procig at th

bhavioural ad urouctioal lvl wh, i act, it wa oly mal pa-tit who prtd with a dramatic dcit; thi dcit wa ot prtd

by mal patit.ur rult uggt that wom ad m with chizophria may bcharactrizd by dirnt cognitiv and nural anomali. hi i important

bcau urocogitiv dcit rprt a hallmark problm i chizo-

phria ad om cogitiv rmdiatio tchiqu hav b dvlopdrctly to hlp patit i thir daily activiti. haractrizatio o di-rc i cogitiv uctio ad udrlyig brai circuitry could hlp

i applyig uiqu approach appropriat or ach x. or grally,

thi rarch may cotribut to dvlopig bttr modl ad thori o

chizophria, which would tak x ad gdr ito coidratio. t ipoibl that th actor cotributig to th dvlopmt o pycho ardirt i m ad wom.

arry ahill ha bn xploring x and gndr dirnc in motional

mmory ovr th pat 10 yar with om trikig rult. cloig, thollowig by ahill i a importat mthodological poit:

h trikig quatity ad divrity o x-rlatd iuc o rvou

ytm uctio argu that th burd o proo rgardig th iu ha

hitd rom tho xamiig th iu i thir ivtigatio grally

havig to jutiy why, to tho ot doig o havig to jutiy why ot.

(ahill, 2010, pp. 29)


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tiQUE STIONS TO CONSIDER

1Given that there are signicant dierences between women and

men in the brain, behaviour and mental health, how can you design

studies to account or these diferences and apply some o this know-

ledge in clinical practice?

2Are there any gender biases that could infuence the way you view

and interpret scientic results and transmit them?

reerences

Bk, J. B., & Hu, M. (2008). Sx di i dug abu. Frontiers in Neuroendo-

crinology, 29, 3647.

Cahil l, L. (2010). Sx ifu o bai ad motioal mmoy: Th bud o poo

ha hitd. Progress in Brain Research, 186, 2940.

Fma, E . W., Samml, M. D., Liu, L., Gaia, C. R., Nlo, D. B., & Hollad, L. (2004).

Homo ad mopaual tatu a pdito o dpio i wom i taitio

to mopau.Archives of General Psychiatry, 61, 6270.

Jimz, J., Maii-Mai, A., Laki, N., & Mdk, A. (2010). Ditubd omalxual dimophim o bai ativatio duig mtal otatio i hizophia.

Schizophrenia Research, 122, 5362.

Lug, A., & Chu, P. (2000). Sx di i hizophia, a viw o th litatu.

Acta Psychi atri ca Scandinavica , 401, 338.

Mdk, A. (2007). Rval o omal bal xual dimophim i hizophia:

Evid ad pulatio.Medical Hy pothes is , 69, 896902.

Mdk, A., Maii-Mai, A., Fahim, C., & Stip, E. (2007). Sx di i th

bal utio aoiatd with poig o aviv timuli by hizophia

patit.Austral ian and New Zealand Jour nal of Psychiatry, 41, 136141.

Nol-Hokma, S., Gigu, J. S., & Sligma, M. E. (1992). Pdito ad oqu

o hildhood dpiv ymptom: A 5-ya logitudial tudy.Jour nal of Abnormal

Psychology,101, 405422.

Sma, M. V. (2009). Soday t o atipyhoti: Wom at gat ik tha

m. Schizophrenia Bulletin, 35, 937948.

Stig, H., & Bu, K. R. (2007). Photyp, dophotyp, ad gotyp i bulimia

ptum atig diod. Canadian Journal of Ps ychiatry,52 , 220227.

Research described in this chapter was supported by unding rom the CIHR Institute o Gender and Health

[MOP 81140], the Fonds de recherche en sant Qubec (FRSQ) and the Louis-H. Lafontaine Hospital

Research Foundation.


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8

2 T i M V

g : iii

ii

m a r C S i m a r D, E r i C b O u C h E r a N D

y v E S T r E m b l ay, Universit Laval

i

Our laboratory team investigates the expression and activity o enzymesinvolved in the metabolism o steroidal hormones (primarily andro-gens and glucocorticoids) in lung development and maturation (Seaborn,

Simard, Provost, Piedboeu, & Tremblay, 2010). ur baic cic rarch

tak plac in a clinical tting daling with pulmonary dia aociatdwith prmatur birth, uch a rpiratory ditr ydrom ad brocho-pulmoary dyplaia. ca o xtrm prmaturity, boy ar at gratrrik o dvlopig th dia tha girl o comparabl gtatioal ag.owvr, th impact o x on lung dvlopmnt mut b placd in contxt.

lthough may x dirc, uch a th highr icidc o rpiratoryditr ydrom i boy, ar wll tablihd, othr, uch a tim lagin th xprion o crtain gn, ar not wll undrtood. Sx dirnc

ar not limitd to dirct or indirct ct o th troid hormon crtd


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The influence of Mars and Venus on lung development

by th goad (tt, ovari); thy ca alo appar a tmporal ad pa-

tial dirc i th pulmoary iactivatio or activatio o tho amhormo ad thir prcuror.

thi chaptr, w rai thr rlvat qutio bad o our xp-ric o icludig x a a biological variabl i biomdical tudi, ad-

drd in turn blow.W provid om poibl anwr that dmontrat

why x i a critical compot i th dvlopmt o olutio to improvth halth o prmatur babi. For dnition o trm w u throughout

thi chaptr, pla coult abl 2-1.

table 2-1 Glossary of Terms

ndrogenFamily o steroid hormones responsible ormale se characteristics, normally produced by

the gonads (e.g., testosterone).

lucocorticoid

Family o steroid hormones known or their

role in immunity, glucose metabolism and stressresponse, normally produced by the adrenals(e.g., cortisol).

Local androgen metabolism Local inactivation and/or activation oandrogens outside o the gonads.

espiratory distress syndromeand bronchopulmonary dysplasia

Functional and structural pulmonary anomaliesrequently observed among children born

prematurely.

Pulmonary suractant

comple miture o lipids and proteins that is

necessary or normal pulmonary unction andprevents the lungs rom collapsing.

Meta-analysis

Statistical method combining the results o

several studies to more adequately address oneor more research hypotheses raised individually

in each o the studies.

Statistical variance

Measure used to evaluate the dispersion o

samples or measures as compared to theiraverage value.

onounding actorFactor that can introduce a bias becauseit is simultaneously linked to what is beingmeasured and to another actor.


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W i i i ii g ?

Sx i a crucially important actor in rarch on lung dvlopmnt bcau

mal and mal how hormonal, phyiological, gntic and morphological

pciciti both i ormal lug dvlopmt ad i th cau o crtaipulmoary dia. For xampl, mal lug ar xpod to highr lvlo adrog tha mal lug at vral tag o lug dvlopmt a arult o thir production in th tt. Bcau th ovari ar not producing

quivalnt lvl o androgn at that am dvlopmntal tag, xpour toadrog i mal ad mal durig dvlopmt i aymmtrical. hiaymmtrical xpour to androgn ha many conqunc; in particular

it crat a ormal dlay i th ot o th ythi o pulmoary ur-actat (a complx mixtur o lipid ad proti that prvt pulmoarycollap) or mal tu. hi dlayand hnc, lowr lvl o uractant

until latr in dvlopmntmak mal born prmaturly mor ucptibl

tha mal to rpiratory ditr ydrom. owvr, hormoal dir-c btw mal ad mal prcd obrvd x dirc i lug

dvlopmnt by vral wk in trm o th ont o pulmonary uractant

ythi ad othr pulmoary dimorphim. h iuc o x o lugdvlopmt i thror ot limitd to a dirc i hormo lvl at agiv poit i tim, but cotiu ad i maitd i may or v all oth vt govrig lug dvlopmt ad dia.

the study o the hormonal, physiological,

genetic and morphological specificitieso males and emales In lunG development and

certaIn pulmonary dIseases Is necessary to hIGhlIGht the

ull complexIty o the Inluence o sex as a

actor In lunG development.


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any mchanim ncary or lung dvlopmnt hav bn idntid,

uch a th dlayig ad acclratig ct o adrog ad glucocorti-coid (anothr amily o troid hormon), rpctivly, on th production

o pulmoary uractat. th ca o prgaci at rik o prmaturdlivry, antnatal adminitration o glucocorticoid rduc th incidnc

o rpiratory ditr ydrom ad it coquc.

Horizon(s) by Stphanie loutier and Tommy Seaborn.


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Whil w obrv a lik btw th actio ad rgulatory mcha-

nim o androgn and glucocorticoid and x dirnc in th proc olung maturation, cau and ct rlationhip ar till poorly undrtood,

pcially i rlatio to latr tag o dvlopmt. For xampl, a mta-aalyi rctly publihd by our rarch tam that addrd th iu-c o x o th ctiv o atatal glucocorticoid admiitratiocormd that thi tratmt i ctiv i th prvtio o rpiratoryditr ydrom ad ultimatly i th rductio o mortality amog x-trmly prmatur mal ad mal wbor (obrg t al., 2011). h

am aalyi, howvr, alo poitd to dirc i th ctiv odirt typ o glucocorticoid by x, uggtig that utur tudihould ivtigat what typ o glucocorticoid i mot ctiv bad oth iat x. ay othr qutio prit about th u o glucocorti-coid. particular, why do may tu, rgardl o x, ot rpod toatatal tratmt (Job & kgami, 2000)? additio, ulik th cao rpiratory ditr yndrom, a connction btwn androgn and th

highr icidc i mal oatal brochopulmoary dyplaia ha yt tob dmotratd.

For th rao a wll a tho uggtd by our work, tudi olug dvlopmt caot igor th iuc o x ad hould coidrall o th commo ad ditiguihig actor charactrizig lug dvlop-mt i both x. thi cotxt, our tam ha dcidd ot to limit ittudi to th iuc o x ad x hormo i proc ad patholo-gi or which a x dirc ha prviouly b idtid, but to co-idr th iuc o x a a actor, i all it complxity, i all apct olug dvlopmt.

H i i i ii ?

bviouly, our tam i ot th oly group to poit out th importac ocoidrig x wh aalyzig data o lug dvlopmt. hi poit waraid i a rct lttr publihd i th American Journal o Respiratory

and Critical Care Medicine (auma, 2010). Still, icorporatig x itoour rarch ort wa o ay at. t rquird xtiv chag to ourapproach. W had to ocu mor on x in our litratur rviw; ormulat


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hypoth that lt u includ x a a actor; plan our xprimnt and col-

lct our ampl accordigly; ad pay pcial atttio to x i our dataaalyi, icludig our tatitical aaly. o ivtigat th iuc ox on lung dvlopmnt, on mut thror not only includ ampl rom

mal ad mal, but alo dig a mthodological ramwork by whichthi inunc can b analyzd. o nur th gratr tatitical rigour that

icludig x a a actor impli, it i cary to gathr a largr umbro ampl, ad th ampl mut b o uprior quality. For xampl, toavoid havig ithr x b ovrrprtd ad itroducig a bia i th

aalyi o rult, imilar umbr o mal ad mal ubjct mut bicludd or vry coditio ad dvlopmtal tag to b tudid.Studi o lug dvlopmt ot attmpt to compar ampl rom

vral dirnt dvlopmntal tag. h addition o x a a actor con-

tribut additional tatitical varianc and dmand that th variability du

to th othr actor b miimizd. For xampl, i our mou modl, wnow u mating protocol that minimiz uncrtainty rgarding gtational

ag. Evn in th abnc o idntiabl x dirnc, thi approach i till

dirabl, bcau it ur mor rprtativ rult or a populatio

that i htrogou with rgard ot oly to x, but to umrou othractor a wll.

corporatig th iuc o

x ito all apct o our rarchha nabld u to dicovr a local an-

drog mtabolim (local iactiva-tio ad/or activatio o adrog)that i commo to both x. hi

uggt that thr i alo a b-cial rol or adrog i ormal

lug dvlopmt i both x.

ikwi, w hav alo idtid

vral gn that ar xprd di-

rtially or ot accordig to x

or a a uctio o lug dvlop-

mt. Bcau w hav mad x

uch a ctral coidratio i our

IncorporatInG sex as a actor

In our research requIred

extensive changes

to our a pproach to

all o the staGes o our research

and enabled us to IdentIy

mechanIsms specIIc to one sex

and others common to both sexes.


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rarch, x ha bcom ar mor than imply a conounding actor. On th

cotrary, it ha abld u to dcrib importat dvlopmtal dircbtw mal ad mal likd to g xprio ad hormo lvl.ndrtanding th dirnc ha, in turn, ld u to mor ctivly ana-

lyz thir impact and to intgrat thm into a lung dvlopmnt modl that

iclud both x.

H ii igi ?

Our rarch xpric ha taught u that both rarch qutio ad

rarch dig ca ivolv apct that go ar byod th phyiologi-

cal dirc btw x. cau o th particular cliical ttig iwhich w do our rarch, iu o critical cocr i othr ld uch apidmiology, pychology, thic and law hav arin. wll, it i clar that

thr i a icrad d or ctiv kowldg tralatio. h hav

all mrgd rom our iitial biomdical cocr.haractrizig th rik actor aociatd with prmaturity ad th

iluc o x o variou coditio that ca act prmatur w-

bor ar importat oci or biomdical rarch. t th am tim, it ialo vry importat to ivtigat th impact o x ad it phyiologi-

cal ct o th log-trm propct or childr bor prmaturly, itrm o thir itgratio ito ocity, thir acadmic ad proioal

prormac ad thir ocial kill. h thical ad lgal implicatio

ar alo quit igiicat, bcau ituatio whr childr ar bor at

the InteGratIon o sex In our bIomedIcal studIes enabled

us to push the en velope within thepar adigm of extreme prematurit y

by requIrInG us to also consIder complementary InsIGhts

rom other dIscIplInes, IncludInG socIal scIences.


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th thrhold o viability rai iu o thic ad valuad th lgal

ramwork, in anada at lat, lav much room or intrprtation. albor at th thrhold o viability hav highr mortality rat, xhibit a

highr icidc o oatal pulmoary pathologi ad ar thought toalo hav highr rat o pychoocial dvlopmntal problm. hi rai

may thical qutio or part ad th cargivig tam cocrighow thi kowldg hould b itgratd i th dciio proc rlatdto oatal car ad guidli. Should thi iormatio b giv to thprmatur boy part ad, i o, how? Should tho pidmiological

act b rlctd i mdical dciio or guidli o rucitatio oxtrmly prmatur oat?o that d, w ra a oli multidicipliary dicuio orum that

addrd variou qutio likig x ad xtrm prmaturity. ar-

ticipat rom vral dirt dicipli combid thir kowldg adtogthr dvlopd a tradicipliary ythi o th ky iu. hi

tradicipliary groudwork bcam th bai o a book o x, xtrmprmaturity and th improvmnt o practic, polici and dciion-making

proc likd to th mal diadvatag rom birth at th thrhold o

viability ad or babi bor at th thrhold o viability i gral (Simard& ag, 2010).

Ci

h itgratio o x ha ot oly addd valu to our work, but it ha alotaught u a grat umbr o thig. o th lo w lard i thatto b uccul, th itgratio o x a a actor ad th valuatio o it

impact o variou biological proc mut b carrid out at all tag obaic biomdical rarch. W alo dicovrd that tudi icludig x

a a actor ar ot limitd to th obviou dirc ad that th rultobtaind rom th approach may b unxpctd; nvrthl th di-

rc ar crucial ad may poit i w dirctio that would othrwihav rmaid uxplord. h itgratio o x i th qutio, xpri-mntal approach and dirction o biomdical rarch contitut a nw

paradigm or biomdical rarch rquirig multidicipliary xchag

ad tradicipliary thikig.


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Marc Simard and Eric Boucher contributed equally to this chapter and are co-frst authors. Research

described in this chapter was supported by unding rom the CIHR Institute o Gender and Health

[BM 86007 and T 92185] and the anadian nstitutes o ealth esearch [MOP 84221].

QUE STI ONS TO CONSIDER1Why should se be considered a actor in biomedical researchon lung development?

2ow can the concept o se be successully incorporated intobiomedical research, and what are its benefts?

3ow can biomedical research etend beyond the physiologicalaspects o se?

Re eRen C es

Job, . ., & kgami, . (2000). ug dvlopmt ad uctio i prtrm iati th uractat tratmt ra.Annual Rev iew o Physiology, 62 , 825846.

auma, F. (2010). Sx dirc i huma lug dvlopmt. American Journalo Respiratory and Critical Care Medicine, 181(5), 523.

obrg, S., aca, Y., app, S., rmblay, Y., ari, ., iu, J., t al. (2011). ol o talx i th outcom o atatal glucocorticoid tratmt to prvt rpiratoryditr ydrom: Sytmatic rviw ad mta-aalyi.Journal o Obstet ri cs

and Gynaecology Canada, 33(3), 216226.Sabor, ., Simard, ., rovot, . ., idbou, ., & rmblay, Y. (2010). Sx hormo

mtabolim i lug dvlopmt ad maturatio. Trends in Endocrinology andMetaboli sm, 21(12), 729738.

Simard, ., & ag, . . (Ed.). (2010). Limpact de la prmaturit et du sexe sur lasant de lenantUne approche t ransdi sciplinaire (1t d.). Saarbrck, rmay:ditio uivritair urop. tr ivd rom http://www.md.ulaval.ca/prma/


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17

3 S g i : i i

r O b E r T - p a u l J u S T E r , McGill University

S O N i a J. l u p i E N, Universit de Montral

Every cell is sexed, every person isgenderedand every organism is stressed.

Str i, or good or or ill, a atural part o li util dath (upi,2010). vr th lat dcad, tr rarchr hav bgu icorporatigx ad gdr ito vr volvig prpctiv that hav crytallizd itobttr undrtanding o tr and coping. hi chaptr will documnt thi

mtamorphoi to guid utur rarch. Firt, w d tr. Scod,w dcrib paradigm hit that brought x dirc to th or i

thortical ad mpirical tr litratur. hird, w xplor how x ad

gdr prpctiv o workplac tr itract to hac udrtad-ig o chroic tr.

Dfig , i

t th ntr or Studi on uman Str (www.humantr.ca), w ur-

vyd th gral public ad oud that popular ditio o tr do

ot match citic o. For th public tr i yoymou with timprur, whra cholarly dnition divid tr among contruct lik


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stressorinput, distressingproc andstress response output. ccording to

r. Shldon ohn, thr broad intrconnctd tradition xit or maur-ing tr: (1) environmental perspectives (.g., objctiv tror rqunci

and xpour to avriv circumtanc); (2)psychological perspectives (.g.,

ubjctiv ditr o tror quantid uing qutionnair, intrviw);

and (3) biological perspectives (.g., phyiological markr lik tr hormon

or cardiovacular uctioig). Each o th traditio i complmtaryad i our tm bt udrtood i combiatio.

cad o rarch hav how u that th pychological igrdit

involvd in trul rcip o li includ Novlty, nprdictability, hratto th go/l and/or diminihd Sn o control (jut rmmbr th acro-

ym nUTs). h igrdit ar additiv ad uiquly alit: w all

hav dirtial itiviti to nUTs (upi, 2010). dd, pychologi-cal tr rarch tartd with r. Joh ao work i th 1960 uigparachutit ad othr group o popl volutarily udrgoig trulituation. comprhniv dnition o tr, which tak th inhrnt

idividual dirc ito accout, wa ormulatd by r. ruc cEw:tr i ay ral or itrprtd thrat to a idividual wll-big that

rult i biological ad bhavioural rpo.Wh acig trul ituatio

ivolvig nUTs lmt, w activat

stress responses. Sufc it to ay that thi

involv two complx biological ytm

that ultimatly call ito actio our littr hormo ( Figur 3-1). h

rt wav ivolv th wit rla o

moami kow a adrenalin withicod, ollowd by th productio o th troid cortisol withi miut.Surg i th tr hormo mobiliz rgy tor by turig at itougar and allocating it throughout our bodi. hi maximally acilitat th

otoriou ght-or-ight rpo rt dcribd by r. Waltr ao.h mot importat poit to rmmbr i that without tr rpo,our actor would ot hav b abl to ght, or rz wh acigmammoth ad othr prdator o ago.

Str i thror a ihrtly adaptiv phomo that kp u

our understandInG o the

stress-dIsease lInk was

until r ecently

limited to ma les.


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Sex and gender in stress research

brathig ad brdig. Nvrthl, whil acut tr rpo ar

halthy, chroic tr ca lad to pottial maluctio i tiallyvry biological ytm. hi i bcau vry cll ca rciv biochmicalmag rom tr hormon that will conquntly altr thir unction.

Wh tr hormo coctratio all ito rag that ar too high ortoo low, ormal adaptatio traorm ito maladaptatio. hi biologicaldtrioratio wa rt ivtigatd by r. a Sly i otral durigth 1930, o it i with prid ad pac that w ca ay that th ida thatchroic tr ca gt udr our ki i a aadia cocpt.

figure 3-1 Schematic o stress responses. Stressors (absolute or relative) in the environment must frst

be detected to trigger two systems. Within seconds, catecholamines like adrenalin are released into circula-

tion as part o the s ympathetic-adrenal-medullary axis. Followed next within minutes is the production o

glucocorticoids like cortisol as part o the hypothalamic-pituitary-adrenal axis. Note: CRF = corticotrophin-

releasing actor; ACT = adrenocorticotropic hormone. (Artist : Jason Blaichman.) mage reproduced rom

The eects o stress and stress hormones on human cognition: mplications or the feld o brain and

cognition, by S. Lupien, F. Maheu, M. Tu, A. Fiocco, and T. E. Schramek, 2007, Brain and Cognition, 65, p. 211.

opyright 2007 by lsevier. eproduced with permission.

Stress(absoluteor relative)

Hypothalamus

Pituitary gland

Adrenal gland

GlucocorticoidsCatecholamines

CRFACTH


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So ar, w hav giv a bri hitory o th tr ld ad it di-

tio with o major cavat: th tr rpo ha primarily b ttdi mal. p util a rctly a 1995, mal rprtd a mr 17% ohuma participat or aimal ubjct i biological tr tudi (aylort al., 2000). Fmal wr xcludd bcau rproductiv vnt lik mn-

truatio, mopau ad prgacy lad to uctuatio i x hormo(.g., trog) that modulat tr hormo lvl ad pottially co-oud data. Wh th ior author o thi chaptr tartd i thi ld, itwa tak or gratd that you rcruitd mal, trd thm, mad thm

pit (w maur cortiol aily i aliva) ad wrot up dig that wruppodly gralizabl acro x. oday, it i much hardr to publihi trog joural i mal ad mal ar ot icludd, rprtig aimportat paradigm hit that w ow addr.

A i E: gi ig

th bgiig, th brai o livig cratur ad vtual cav(wo)mlowly dvlopd vr bttr mchaim or dtctig thrat, mobiliz-

ig tr rpo ad urvivig. r w d to mak th ditictiobtw absolute stressors (.g., prdator, atural diatr) that thratour urvival ad ivariably lad to tr rpo i compario to rela-tive stressors (.g., trafc, public pakig) that thrat wll-big oly

i th pro dm thm trul bad o nUTs lmt (upi t

al., 2006). hroughout volutio, w hav acd ancient stressors that havdiappard (.g., mammoth) ad modern stressors (.g., bo), but ourbrai till ract a though w wr hutr-gathrr.

n part, bcau o morphological dirnc, cavmn wr mor liklyto b th hutr tha cavwom, which might xplai why modr mconitntly mobiliz mor intn tr rpon. hi mak n, inc

volutionary prur will b appropriatd by on x that thn lctivly

contribut, ovr countl gnration, to phyiological x dirnc and

gndr-rlatd bhaviour. For cavwomn, thi prhap mant mor gath-

rig ad urturig bhaviour. Now lt at-orward to 2000AD whr. Shlly aylor potulatd that mal might hav volvd a uniqu tr

rpo uaddrd i hithrto mal domiatd tudi.


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r. aylor ad othr mit tr rarchr propod th mal-typical td-ad-brid rpo a a altrativ to th mal-typicalght-or-ight rpo. h ctral tt hr i that itad o utilizig

phyical rtaliation whn acd with thrat, womn ocu on bhaviour thatprotct vulnrabl opring and maintain ocial bond (aylor t al., 2000).

hi thory ha rcivd complling upport; till, it i unclar whthr th

rpon ar du to x, gndr or bothor whthr th ar obrvd b-

cau o how our own gndrd aumption actor into our rarch dign.

Wh acig acut tror m td to bt rom thir mal

partnr ocial upport by crting l tr hormon, whra womn

produc mor tr hormo i th prc o thir mal partr thai th prc o a tragr (irchbaum, laur, Filipp, & llhammr,1995). ntrtingly, rarch ubqunt to thi pionring tudy ound that

wom btd rom am-x rid prc wh ditrd. aytudi lik th coductd by our rma collagu hav b itru-mntal in bringing conidration o x dirnc into tr laboratori.

Sinc thn, othr invtigation hav turnd thir attntion to how x and

gdr itract. our xt ctio, w xami how th itractio

ca hlp xplai dirc i tr-rlatd dia vi--vi workplacditr ad byod.

S g ii i

rcivig tror, itrprtig thrat ad gratig tr rpoudamtally dir btw x ad a a uctio o gdr. Woml-rport mor tror ad ditr tha m ad coittly rportmor phyical halth ymptom, but m ar mor tr rpoiv addi yougr. h typ o x dirc ar ctral to tudyig tr,but can b limitd by ocuing olly on dichotomou x dirnc in th

due to evolutionary a nd

socio-cultur al pressures,

sex and Gender dIerences exIst In sensItIvItIes

to envIronmental stressors, psycholoGIcal

dIstress and bIoloGIcal stress responses.


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abc o gdr prpctiv. dd, wom diplay icrad tr

hormo lvl wh corotd by ocial rjctio challg (Stroud,Salovy, & Epl, 2002), whra m td to b mor ractiv to achiv-mt-bad tror (ickro & my, 2004). hi uggt that

dirtial gdr-bad attributio might b ivolvd. A importat

challg ha b to udrtad how to tudy th dyamic atur o xad gdr throughout lipa dvlopmt i rlatio to tr-rlatddia trajctori that actually chag throughout hitory.

a point in ca, conidr cardiovacular dia: onc a prdominantly

mal pathology, it now claim at lat 41% o all dath o anadian womni compario to 37% or m. hi rvral might b bttr xplaid bygndr rol than by x i w conidr ocio-cultural chang ovr th lat

dcad. For intanc, th World Bank, ntrnational abour Organization,

ad World alth Orgaizatio rport that wom hav icrad thir

participatio i th workorc by 126% ovr thlat 30 yar and now rprnt 42% o th ntir

global labour orc. grttably, highr lvl otr or working womn who mut otn balanc

multipl work-amily rol ad rpoibiliti

ca trai thir halth ad wll-big. roud-brakig work by r. aria Frakhaurand collagu rom Scandinavia ha conitntly

hown that womn in non-traditional occupation

(.g., managr, nginr) l-rport mor ma-

culi or artiv gdr rol that put thm atgratr rik o tr-rlatd dia. h gndr

inunc rprnt an important orm o trainthat can advrly trickl into othr li domain.

dd, workplac ovrload ad ocial ijutic ca lad to spill-overefects (work tr to hom ditr) ad over-spill efects (hom tr towork ditr). r too th x dir: Fmal managr do not dingag

a much atr work a mal maagr (udbrg & Frakhaur, 1999;upin, King, any, & cEwn, 2000). hi ha conqunc or vry-

o, a lvatd lvl o tr hormo atr work mdiat th ct ojob dmand and job control lmnt in prdicting halth car cot. Not

the InteractIon

between sex and Gender

best explaIns how

chronic str ess

lead s to w ear

a nd te a r that

ultImately contrIbutes to

stress-related dIseases.


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23

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that on third o anadian rport chronic tr at work that put thm at

incrad rik o dprion, burnout and anxity diordr, to nam a w.h tatitic ar ditributd dirtly amog m ad wom ad aa uctio o maculi or mii gdr-rol. ak togthr, x adgdr itract to xacrbat our vulrabiliti to chroic tr that cahav dir coquc o halth ad wll-big.

tr dcad o advanc nationally and intrnationally, tr rarch-

r now can objctivly maur chronic tr by aing biological rca-

libration o what w call allostatic load (cEwn & Stllar, 1993). hi war

and tar i blivd to occur whn tr hormon go o-kiltr and topplovr oto othr biological ytm lik a domio ct trailig towarddia (or a rviw, Jutr, cEw, & upi, 2010). For xampl,nurondocrin, mtabolic, immun and cardiovacular malunctioning will

occur wh tr hormo uctioig collap. ur ow rarch haocud o th biopychoocial igatur aociatd with allotatic loadad divr tr-rlatd coditio (.g., burout, griatric dprio)that ditictly act vulrabl populatio (.g., ldr, workr, xualmioriti). W hav obrvd that thi approach to quatiyig chroictr i likd to o x, gdr, xual oritatio, ag ad occupa-

tioal charactritic. dd, dirt biomarkr clutr (.g., cortiol,blood prur, choltrol) ar ot mor likly to b xacrbatd i ox or aothr throughout th li cycl, but i way that dpd o co-titutioal (gtic, dvlopmt, xpric), bhavioural (copig ad

halth habit) ad hitorical (trauma/abu, major li vt, trul

viromt) actor that ar ot gdr pcic (Jutr, cEw, &upin, 2010). dmontratd by incraing prvalnc o cardiovacular

dia i wom, thi array o actor i dyamic.o coclud, it i ow bcomig clar that th biopychoocial at-

cdnt and unctional conqunc o high allotatic load ar bt undr-

tood by takig ito accout x ad gdr togthr. h paradigm hitthat hav otrd icluio o x ad gdr hav rvd a th imp-

tu or acclratd advac i our udrtadig o who dvlop whichtr-rlatd dia. w mov toward pro-ctrd paradigm, wackowldg that progr i tr rarch ha btd mot by iv-tigatig x ad gdr i yrgy ad ot paratly.


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24

obert-Paul Juster holds a doctoral scholarship rom the nstitute o ging [S 95402]. Sonia J.

Lupien holds a Senior esearch hair in ender, Se and ealth rom the nstitute o ender and

ealth [S 91039].

QUE STI ONS TO CONSIDER

1ow might risk or protective actors aect the impact o sex on

what you are studying?

2ven i the body o evidence related to what you are studying isbased on single-se data, how can you probe urther or the pos-

sible inuences o se and gender?

Re eRen C es

ickro, S., & my, . (2004). cut tror ad cortiol rpo: thorticalitgratio ad ythi o laboratory rarch. Psychological Bulletin, 130, 355391.

Jutr, .-., cEw, ., & upi, S. (2010). llotatic load biomarkr o chroic trad impact o halth ad cogitio. Neuroscience & Biobehavioral Reviews, 35, 216.

irchbaum, ., laur, ., Filipp, S., & llhammr, . (1995). Sx-pcic ct oocial upport o cortiol ad ubjctiv rpo to acut pychological tr.Psychosomatic Medicine, 57, 2331.

udbrg, ., & Frakhaur, . (1999). Str ad workload o m ad wom ihigh-rakig poitio.Jour nal o Occupational Health Psychology, 4 , 142151.

upi, S. (2010). Par amour du stress. roibriad (ubc): ditio au arr.

upi, S., ig, S., ay, ., & cEw, . (2000). hild tr hormo lvlcorrlat with mothr ociocoomic tatu ad dpriv tat. BiologicalPsychiatry, 48, 976980.

upi, S., ahu, F., u, ., Fiocco, ., & Schramk, . E. (2007). h ct o trad tr hormo o huma cogitio: mplicatio or th ld o brai adcogitio. Brain and Cognition, 65, 209237.

upi, S., ullt-ori, ., upbach, ., Walkr, ., u, . ., u, ., rur, J., &cEw, . (2006). yod th tr cocpt: llotatic loada dvlopmtal

biological ad cogitiv prpctiv. . icchtti & . J. oh (Sri Ed.),Developmental psychopathology: Vol. 2. Developmental neuroscience (2d d., pp.784809). obok, NJ: Joh Wily & So.

cEw, ., & Stllar, E. (1993). Str ad th idividual: chaim ladig todia. Archives o Inte rnal Medicine , 153, 20932101.

Stroud, ., Salovy, ., & Epl, E. (2002). Sx dirc i tr rpo: Socialrjctio vru achivmt tr. Biological Psychiatry, 53, 318327.

aylor, S., li, ., wi, ., ruwald, ., urug, ., & pdgra, J. (2000).iobhavioral rpo to tr i mal: d-ad-brid, ot ght-or-ight. Psychological Reviews, 107, 411429.


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25

4 Cgig i-: , g i i i

S a r i T u D i v E r,Independent researcher/writer, Ot tawa, Ontario

m a D E l i N E b O S C O E ,REACH Community Health Centre

v i v i E N E. ru N N E l S,University o Ottawa

m a r i O N D Ou l l , University o British Columbia

Systematic reviews in health provide evidence to guide clinical decisions,technology assessments, health policies and urther research. Sinc 2005,our Sx and ndr Working roup on Sytmatic viw ha bn ngagd

i a projct to ur that ytmatic rviw i halth ar atttiv to xad gdr dirc ad imilariti, with th goal o improvig halthoutcom or wom ad m. hi iitiativ aro rom a log-tadig

o di-a about what w kow ad do ot kow about halth vi-dc, tmprd with om optimim or chag.

B

For two o u (adlin, Sari) thi di-a bgan with work in th womn

halth movmt i th 1970. W dvlopd coumr halth iorma-

tion, wrot policy bri and wr part o coalition promoting quality car,

icludig a, ctiv ad ratioal u o pharmacutical or wom.


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ollaboratig with othr rarchr, halth practitior ad coumr,

w rviwd th citic vidc or cotracptiv (.g., alko ShildIUD, po-rovra), itrvtio i childbirth (.g., tal moitorig),

mopau (.g., hormo thrapy) ad mdical dvic (.g., brat im-

plat) ad gaid iight ito th mdicalizatio o wom liv.W lard rom two ca i particular that cliical dciio ot

rootd in ound vidnc could lad to riou harm. Firt, dpit vidnc

i th 1950 about lack o fcacy o dithyltilbtrol (Des) to prvt

micarriag (ickma, avi, ykiwicz, & ottigr, 1953), th drug

wa promotd i advrtimt i major mdical joural ad prcribdutil th 1970, with ubqutdir conqunc or th opring

o wom to whom it wa giv.

Scond, hormon thrapy (HT) wa

prcribd a a tadard o car tohalthy pot-mopaual wom

bad o limitd rult rom ob-rvatioal tudi ad aump-

tion about th bnt o trogn

rplacmnt. n 2002, rult rom

radomizd cotrolld trial dmotratd mor harm tha bt romHT but by that tim thouad o wom prcribd HT had xpricdbrat cacr, hart dia, trok ad dmtia (Natioal art, ug &lood titut, .d.). ocumt ow rval th may way mauactur-r promotd th bnt and downplayd harmul ct oHT to doctor

ad wom (Fugh-rma, 2010).

W wr alo concrnd about womn xcluion rom clinical trial. twa widly aumd that mot cocluio drivd rom rarch o malubjctaimal ad humacould b xtrapolatd to mal. h

ca ad othr mad u cautiou about halth vidc.W larnd to carully rviw th dign and quality o tudi in ordr

to valuat th rliability, validity ad applicability o th rult. W akd:Who wa includd and xcludd in trm o x, ag, thnicity, ocio-conomic

background and othr charactritic? Whil polici upportd gratr inclu-

ion o womn in clinical trial inc th arly 1990, gap rmaind. Womn

IdentIy who may or may

not beneIt rom partIcular

InterventIons by knowInG to

whom the evidence

does or does not apply.


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27

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Challenging dis-ease

continud to b undr-rprntd in particular tudy ara (.g., cardiova-

cular trial), whil m wr udr-rprtd i othr (.g., rhumatoidarthriti). hildr ad th ldrly wr commoly xcludd. W ought toudrtad th implicatio o th rarch practic or halth quity.

W trid to ditagl ad wigh dirt orm o pottial biai publihd tudi, uch a pharmacutical idutry udig o authorad rarch; rportig hort-trm (uually poitiv) rult rom a tudy;citig rlativ vru abolut rik; ailig to rport or adquatly aadvr vt; ad xtrapolatig rom limitd obrvatioal tudi or

mall trial to broad cliical u amog divr populatio.y th bgiig o th 21t ctury, progr had occurrd i udr-tadig th complx dyamic o x ad gdr a ocial cotruct addtrmiat o halth. hr wa trog vidc about x ad gdrdirc i pharmacokitic ad pharmacodyamic, gtic xpr-io, prvalc, ot ad vrity o dia, ubjctiv xpric ocoditio uch a dprio ad chroic pai, rpo to halth itr-vtio, th utilizatio o halth car ytm ad may othr procthat iuc halth. W hopd wly publihd rarch would clarly

idtiy to whom th rult applid, icludig whthr x ad/or gdrdirc wr rlvat or ot to th dig.

owvr, dpit aadia ad itratioal polici upportig adv madatig x ad gdr aalyi (alth aada, 2009), primarytudi ad ytmatic rviw did ot coittly rport x-diaggr-

gatd data nor analyz th implication o x and/or gndr or th nding

(lauwt, ay, cau, dbrg, & Walh, 2007). ur di-a aboutth quality o halth vidc ad pottial or harm rmaid.

T S Wig Si Ri:

Early i 2005, adli uggtd w gag th ochra ollaboratio,a itratioal twork o rarchr who carry out ytmatic rviwi halth, i a dialogu to courag x/gdr aalyi i ochra r-viw. (Not that w u th trm x/gdr i rlatio to aalyi to ac-knowldg th intrrlationhip among th concpt.) W wr amiliar


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with ochra origi idtiyig oud practic i matrity car adit rputatio a th gold tadard o rviw. W aw a opportuity

to apply th aalytic tool o x/gdr aalyi to a rviw o a clarlyormulatd qutio that u ytmatic ad xplicit mthod to idtiy,lct, ad critically apprai rlvat rarch, ad to collct ad aalyz

data rom th tudi that ar icludd i th rviw (ochra ollabo-ration, 2005). h rviw proc ncouragd prntation o dmographicdata and ubgroup analy to hlp anwr th qution: o whom do th

vidc apply? wll, om ochra rarchr wr bgiig to ad-dr quity-rlatd iu, icludig gdr, i rviw.

ur rt prtatio wa at th 4th aadia ochra Sympoium,cmbr 2005 (Boco & udivr, 2005). With trpidation w tood bor a

izabl audinc to prnt ky concpt o x/gndr analyi, th mandat

or thi work i aada ad itratioally ad om challg to impl-

mtatio. rawig xampl rom cardiovacular dia ad total joitarthroplaty, w mad th ca that rigorou x/gndr analyi contribut

to bttr cic. Notig that rct rviw rvald almot o aalyi ox or gdr, w propod ytmatically icludig x/gdr aalyi iytmatic rviw. W ound nthuiam or thi initiativ and agrd to col-

laborat with mmbr o th ampbll and ochran Equity thod roup.

By 2007 our duo had amlly xpandd to includ arion and Vivin,

doctoral tudt i opulatio alth at th ivrity o ttawa. W

digd a rarch projct to dtrmi whthr ad how a ampl oochra ytmatic rviw o cardiovacular dia addrd x

ad/or gdr (thy did ot!), th ampld th primary tudi o whichth rviw wr bad to i th ytmatic rviw rplicatd gap

i th primary tudi (thy did!). W dvlopd ad ttd a x/gdrappraial tool or ytmatic rviw ad adaptd it to apprai primarytudi and protocol or nw rarch (Boco, oull, unnl, & udivr,

2009; oull, ul, udivr, & oco, 2010) ad or plaig ytm-atic rviw ( Figur 4-1).

researchers and systematIc revIewers need practical

tools to operationalize and measure

sex/gender In relatIon to other health determInants and

to elucIdate the contexts wIthIn whIch health InterventIons occur.


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29Challenging dis-ease

Methods

If possible, extract data

or men and women

separately.

If data extraction by

se/gender cannot be

done, provide a rationale

and/or contact primary

study authors or more

inormation.

Results andAnalysis

If possible, distinguish

between fndings or men/

women/subgroups in your

results.

Analyze the ndings

taking se/gender into

account.

If subgroup analysis by

se/gender could not be

completed, eplain why.

Table of IncludedStudies

Is there sucient

inormation on primary

study samples to include

se/gender, age and

ethnicity in your table o

included studies?

Are answers to other

tool questions consistent

with inormation provided

in the table?

If basic demographicinormation has not been

reported in primary studies,

discuss the implications or

the systematic review.

Discussion andConclusions

Discuss whether the

primary studies analyzed

or ailed to analyze

results by se/gender and

addressed any implications

o se/gender.

Discuss to whom this evi-

dence does or does not

apply.

Discuss any implications

o se/gender or clinicalpractice, policy and regu-

lation and or urther

research in the subject

area.

Background

Provide a clear rationale

or why se and/or gender

are or are not relevant to

the systematic review (S)

question (e.g., evidence in

the literature o se/gender

dierences in prevalence

o condition, health

outcomes, etc.).

What is known about sex/gender in relation to other

health determinants in the

subject area?

Inclusion/ExclusionCriteria

Do the criteria for

including/ecluding studies

in the S consider se/

gender dierences? (e.g.,

could outcome measures

dier between men and

women?)

If relevant, provide a

rationale or why somepopulation groups are

ecluded rom the review

(e.g., women, men, or

particular subgroups).

figure 4-1 ntegrating se and gender in systematic reviews: a planning tool. dapted rom Se and

gender in systematic reviews: planning tool, M. Doull, . . unnels, S. Tudiver, and M. Boscoe, 2011,

May, Presentation at ombining orces to improve systematic reviews: ender, equity and bias. Ottawa,

Ontario. dapted by original authors.

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W hav bntd rom numrou collaboration and dicuion with

rarchr, policy aalyt, halth practitior, rviwr, libraria,tudt ad wom group i aada ad itratioally. o acilitatdialogu amog ytmatic rviwr ad ur o halth vidc, i ay2011 w hotd a two-day mtig, Combining orces to improve systematicreviews: Gender, equity and bias (Ottawa, Ontario). hirty participant hard

approach ad mthodological challg i idtiyig: o whom doth vidc apply? ll agrd to combi orc ad dvlopd a actioplan to improv th applicability o ytmatic rviw. Our Working roup

rv a a hub or thi mrgig commuity o practic ad pla to pro-vid mthodological and concptual guidanc or ytmatic rviw rlat-ig to x/gdr aalyi.

W

Our work ha providd u with inight into how knowldg i contructd,

orgaizd ad tralatd. our collaboratio progrd, th iightmrgd a momt o ralizatio about x, gdr ad vidc (

ha! momt). h qutio that d to b akd bor mbarkigo a joury through th kowldg ytm ar: Who dcid what will btudid ad, how will it b tudid?

A! Prior to this project, I was working on a systematic review about HIV-

positive women. Finding studies that included only women or reported

outcomes or women was challenging. This rustrated and surprised me.

The questions posed by researchers oten refected assumptions about

sex and gender; young men are mostly asked about violence and aggression

but rarely about love and young women about their powerlessness but

not about their power. Through our collaboration, I see more clearly

how understanding the eectiveness o interventions or men, women

and children remains elusive when dierences are not parsed out and

assumptions are unchallenged.

~ Marion


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Challenging dis-ease

As summaries o evidence distilled rom primary studies, systematic re-

views are an end point o knowledge production. Even in the area o cardio-

vascular diseases where sex and gender diferences are known and ignoring

them may result in harm, our research determined that reviews replicateomissions rom primary studies. These results helped us recognize the added

value i sex/gender analysis had been applied throughout the knowledge pro-

duction process rom primary studies to systematic reviewsin ormulating

the research question, developing a protocol, choosing methods, collecting

data, reporting, analyzing and discussing results and their implications, in-

cluding who benefts and who does not rom an intervention. Asking about

sex and gender at each stage to identiy or rule out potentially signifcant

dierences contributes to quality assurance o evidence.

I was surprised when I had an aha momentan authentic intellectual

realization that the majority o studies (evidence) on which we base all

aspects o medical and clinical practice, diagnosis and prognosis, choice o

treatments, prescriptions and care, understanding o adverse events, etc.

were deeply i not primarily inuenced by sex and gender, and that such in-

uences were rarely considered. This realization was not only shocking but

it shook me up. It seemed particularly unair and unscientic, not just to

women and girls but also to boys and men. This aha moment eventually

was converted rom a single event into an ongoing, diferent and criticalapproach that has orced me to ask questions not just directed towards

womens health, but to the raming o many issues.

~ Vivien

Despite many policy statements anD robust research about sex

anD genDer Differences, little progress has been

made in addressing the applicability of

research findings. incentives anD accountability

mechanisms are neeDeD to ensure positive change.


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W hav alo gaid iight ito how x ad gdr ar complx

cotruct rvalig th itrrlatiohip amog biological ad ocialproc acro th li cour. Whil thr i a rich tradicipliary lit-ratur addrig th dyamic, w ar till i th arly tag o d-vlopig cocptual approach ad mthodological tool to xplai admaur th proc ad itractio with othr halth dtrmiatad idtiti. Fw primary tudi or ytmatic rviw i our rarchicludd v baic cotxtual iormatio about x ad gdr dir-

c i prvalc ad vrity o a coditio or addrd th dirt

challng which mn and womn o dirnt ag and background mightac xpricig dia ad accig car.W a d or practical tool that rarchr ad ytmatic r-

viwr can u to oprationaliz and maur x and gndr in rlation to

othr halth dtrmiat ad th cotxt withi which halth itrv-tio occur. h challg i to d ctiv, ytmatic way appropriatto a particular rarch qutio that ca ctivly combi cocptualapproach ad mthod, icludig thographic ad othr qualitativ

mthod in ordr to trngthn th vidnc or improvd halth outcom.


1 ow will you identiy to whom the evidence applies or does not

apply?

2 ow will you identiy who may or may not beneft rom an inter-

vention?

Re eRen C es

lauwt, . ., ay, S. N., cau, ., dbrg, . F., & Walh, . N. (2007).ow rat o x-pcic rult rportig i cardiovacular trial. Mayo ClinicProceedings, 82, 166170.

oco, ., oull, ., ul, ., & udivr, S. (2009, arch). dr-bad aalyi:lvac to ochra ytmatic rviw: dicuio workhop o a x &gdr appraial tool. rtatio at th 7th aadia ochra Sympoium,aliax, NS.


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33

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Marion Doull holds a CR postdoctoral ellowship [MFE 101128]. Combining forces to improve systematic

reviews: Gender, equity and bias was supported by unding rom the nstitute o ender and ealth

[M 228304].

oco, ., & udivr, S. (2005, cmbr). pplyig gdr-bad aalyi to vidc

ad policy. rtatio at th 4th aadia ochra Sympoium, otral, .ochra ollaboratio. (2005, ay). loary o trm i th ochra ollaboratio.

rio 4.2 .5. trivd rom http://www.cochra.org/gloary

ickma, W. J., avi, . E., ykiwicz, . ., & ottigr, . E . (1953). o thadmiitratio o dithyltilbtrol durig prgacy hav thraputic valu?American Journal o Obstet rics and Gynecolog y, 66(5), 10621081.

oull, ., ul, . E., udivr, S., & oco, . (2010). ppraiig th vidc:pply ig x- ad gdr-bad aalyi (sGBA) to ochra ytmatic rviwo cardiovacular dia.Journal o Womens Health, 19(5), 9971003.

oull, ., ul, . E., udivr, S., & oco, . (2011, ay). Sx ad gdr iytmatic rviw: plaig tool. rtatio at ombiig orc to improvytmatic rviw: dr, quity ad bia, ttawa, N.

Fugh-rma, . J. (2010). h hautig o mdical joural: ow ghotwritig old. PLoS Med, 7, 1000335.

alth aada. (2009). Federal health portolio sex and gender-based analysis policy.trivd rom http://www.hc-c.gc.ca/hl-v/pub/wom-mm/gba-policy-politiqu-ag-g.php

Natioal art, ug & lood titut. (.d.). Findings rom the womens health initiativepostmenopausal hormone therapy trials. trivd rom http://www.hlbi.ih.gov/whi


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PART IIStrengthening

Science


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35

5 M , , ii i : - i

i g

r a N D a l l F r a N S O O, University o Manitoba

t was the younger o my two older sisters who called to tell me our dad hadjust suered another major hear t attack. t wa th prig o 1988 ad myparnt wr viiting with rind during a topovr on th driv hom rom

thir witr gtaway i rizoa. hir hot wa i th midt o roog higarag, o aturally my dad got right to work carryig bal o higl upa laddr oto th roo. y th 68-yar-old dad alrady had a igicatcardiac hitory, bgiig with th hart attack that prcipitatd hi u-

wlcom arly rtirmt om 13 yar arlir.d b ruhd by ambulac to th art hopital ad wa told h

ndd mrgncy bypa urgry on thr or poibly our artri. h big

qutio or m ad my v iblig wa: who wa goig to go? much aw all wantd to go, that wa nithr practical nor in anybody bt intrt.

With jut a w momnt dicuion it bcam clar that th bt option wa

or th two girl to go; th oldr bing our mothr bt rind and upport,

th youngr with ignicant mdical training and vocabulary. h our boy,

o which am youngt, had no rol but to it by our phon to wait and hop.


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riv by curioity ad my

inability to rmain idl, dciddto do om radig about bypaurgry. t wa all rk to mlitrally, a at that tim had ab-olutly o mdical or rarch

training; wa a junior indutrial

nginr at Nortl. So imagin my

urpri whn th rt w articl

ound about bypa urgry wrplit almot 50-50 rgardig thctiv o th procdura thy calld it. ow could thi

b? Surly uch a ivaiv, x-

pniv and riky procdur would not b undrtakn i it wrnt clarly th

bt thig to do? didt rad ar ito thi litratur bcau it wa riddldwith trm didnt undrtand, and what did undrtand wa too dpr-

ing. hankully my dad urgry wnt wll and h njoyd a good rcovry.

Fat-orward to 2004, by which tim d changd carr path rom ngi-

nring, through biomchanic and phyiology, into halth rvic rarch.

wa a w rarch citit at th aitoba tr or alth olicy

(MCHP) ad wa jut giv my rt lad rol o a major rarch projct.h rport wa o x dirc i halth tatu ad halth car u i

aitoba. h objctiv wa to crat a atla-tyl rport, with all idica-tor calculatd paratly or mal and mal (Franoo t al., 2005). had

a trog itrt i rarchig cardiac car giv my dad hitory o hart

dia, ad with th w thig d hard about a x bia i thi ara, dcidd arly on to ddicat on o th chaptr o that MCHP rport to car-

diac car. h ky nding wr ubquntly publihd in Healthcare Policy,

including a complt litratur rviw and dicuion (Franoo t al., 2010).

hat cardiac car chaptr (and or that mattr, th ntir MCHP rport)

would hav b much l itrtig had it ot b or th rmarkablgroup o collaborator wa workig with: th Nd o ow am, plua umbr o local xprt o m halth ad wom halth. h Ndo Know am i an award-winning collaborativ rarch group ld by my

throuGh thIs collaboratIve

research project, I learned the

Importance o careul attentIon

to sex and aGe In health servIces

research. and the Government,

the reGIonal health authorItIes

and the people o manItoba

(and beyond) learned that

cardiac care after

a mi is blind to

sex. as It should be.


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37

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My mum, my dad, and sex differences in cardiac care

mtor r. atricia art, with rprtativ rom ach o th 11 -

gional alth uthoriti in anitoba and ky ta rom anitoba alth.t wa thi group iitc that all aaly b tratid by ag i addi-tio to x that ld to th mot importat iight.

W tartd by aalyzig th populatio-bad rat o th our chi

cardiac procdur: cardiac cathtrization, angioplaty, tnt inrtion, and

bypa urgry. ardiac cathtrizatio, alo kow a a agiogram, i adiagotic procdur ud to idtiy th xtt ad locatio o blockagi th coroary artri. t i th gatway to th othr procdur, a th

knowldg gaind rom thi procdur i ud to dtrmin what hould bdo xt i a patit cardiac car. gioplaty i wh a tiy balloo iinatd inid a narrowd artry to nlarg it and incra blood ow. ot

angioplati ar now ollowd by a tnt inrtion: a hollow mtal cylindr

i irtd i th artry ollowig th agioplaty to hold th artry op.ypa urgry i wh vrly blockd gmt o coroary artri arrmovd ad rplacd by grat rom lwhr i th body.

ur populatio-bad rult mirrord prviou dig that cardiacprocdur rat wr twic a high among mal a mal (yanian & Ep-

ti, 1991; hadra t al., 1998; Jaglal, ol, & Naylor, 1994; ilot t al.,2004). hi md to rct what wa commoly rrrd to a th x

bia i cardiac car: that mal rciv mor aggriv tratmt tha

mal. r whr th tory gt itrtig.ik may thig i halth car, thr i o ditiv way to idtiy

all th popl who hould hav a agiogram. owvr, thr i littl

diagrmt that mot patit diagod with a cut yocardial -arctio (A MI or hart attack) hould (ra t al., 2003). So our xt tp

up with colla bor ation! many o the key

IndInGs that came out o thIs research were the result o

Ideas and Input that came rom our partners rather than

the researchers themselves (most notably, the desIre to do

all analyses by aGe In addItIon to sex).


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wa to crat a cohort o popl xpricig aA MI . aitoba uiquly

rich data ytm (oo, upta, Sood, & Jbamai, 2005) allow a morcomplt cohort to b cratd tha lwhr i aada bcau, i ad-

ditio to hopital data, idividual-lvl vital tatitic ar availabl. hi

ma w could iclud both tho hopitalizd or thir A MI (th uualca-nding mthod) and tho who did bcau o thirAMI but without

big admittd to a hopital (.g., did o th way).h rt importat dig wa i th raw umbr: Whil hart di-

a combind with trok now claim a many liv among womn a mn

(ublic alth gncy o anada, 2009), th incidnc oAMI rmain ub-tatially highr amog m. th 6,844A MI ca, 4,199 (61.3%) wramong mal with 2,645 (38.7%) among mal. h numbr promptd

an immdiat r-intrprtation o th procdur rat: givn that morA MI

occurrd amog mal, w hould hav xpctd to mor procduramog mal. hi impl x dirc i raw umbr xplai a igi-cat portio o th dirc i procdur rat, but i ot th d o thtory. owvr, it do dmontrat that comparing population-bad rat

o procdur i not particularly inightul or nding ral x dirnc

or bia i tratmt rat. t hould b otd hr that our data oly al-low idticatio o x, ot gdr, o th dirc i th rultmay rct x (biological) dirc, or gdr (ocial) dirc, or acombiatio o both.

h w procdd to ollow th cohort or o yar. W oud that

among allA MI patint who urvivd and wr hopitalizd, a ignicantly

highr proportio o mal tha mal rcivd a cardiac cathtriza-

tio durig thir A MI hopitalizatio (36.8% v. 26.9%). with th ii-

tial populatio-bad rat, thi dig appard to b coitt with aigicat x ad/or gdr bia i cardiac car. owvr, thi too i otth d o th tory.

h xt actor to accout or wa ag, a prviou tudi hav howthat on avrag, mal xprincAMI 810 yar youngr than mal (68

v. 76 yar in our cohort). On it own thi may not m lik a particularly

tartlig dirc, but it tur out to b critical bcau it itract withth al actor: th tp dcli i procdur rat with ag. A how

i Figur 5-1, th proportio o mal ad malA MI patit who rciv


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39

pa

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My mum, my dad, and sex differences in cardiac care

cardiac cathtrizatio durig thir AMI hopitalizatio drop rom ovr

50% amog m ad wom agd 4044 yar, to udr 10% or tho 85yar or oldr. h ovrlappig codc itrval idicat that i vry5-yar ag group, thr wa o igicat dirc btw th rat ormal vru mal. hi combiatio o actor compltly coouddth iitial dig.

So w oud thr wa actually o x ad/or gdr bia i cardiac

car, though patit ag atAMI wa critical. ar ot tratd mor ag-grivly tha wom, but yougrA MI patit ar tratd mor aggr-

ivly tha oldr A MI patit. d bcau wom ar oldr wh thyxpric A MI, thy ar l likly to rciv th ivaiv tratmt.Withi vry ag group, m ad wom wr tratd quallya digwhich i rctd i virtually all tudi o thi topic do ic 1995 (orcomplt litratur rviw Fraoo t al., 2010).

Male Female

%

90

80

70

60

50

40

30

20

10

0

4044 4549 5054 5559 6064 6569 7074 7579 8084 85+

AGE

figure 5-1 Percent o M patients receiving cardiac catheterization, by se and age group. eproduced

rom ge dierence eplains gender dierence in cardiac intervention rates ater acute myocardial in -

arction, by . . Fransoo, P. J. Martens, The Need To Know Team, . J. Prior, . Burland, D. hateau, and

. Katz, 2010, Healthcare Policy, 6, p. 95. opyright 2010 by Longwoods Publishing orporation. epro-

duced with permission.


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beore concludInG that a sex or Gender dIerence

represents a sex or Gender bIas In treatment

patterns, we have to do what we can as researchers

to ensureall other things are equal.

Ci

t wa via our x-bad aalyi that w wr abl to ucovr th impor-

tat ct o ag o rat o tratmt atr A MI . alyzig by x pro-vidd a window to bttr undrtand th mchanim undrlying apparntinqualiti. hat aid, dmontrating quality among mal and mal in

rat o tratmt atrA MI do ot gat gdrad x-rlatd di-rc or iu i cardiac rik actor, diagoi, patit prrc ortratmt ctiv.

All o thi i raurig wor my itr, ad pcially or my

mum ow approachig hr 85th birthday without hart problm, but gladto kow that hould hr luck chag, hr tratmt will b a good a hr

hubad wa.

Eig

bout 14 yar atr th bypa urgry (thr yar bor thi rarchprojct bga), my athr ll ad urd a maiv trok rom which hvr rcovrd. livd aothr (difcult) yar ad a hal i a urig

hom bor dyig a digid dath rom pumoia, th diagoi Sir

William lr amouly rrrd to a th rid o th agd.


1 Do your usual research methods need a reresh? Perhaps a se-

specifc analysis is required to provide the answers needed. Many

health phenomena are distributed unevenly within age and sex

groupsso adjustingor these variables can actually hide impor-tant trends in the data.


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41

pa

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esearch described in this chapter was supported by unding rom the anadian nstitutes o ealth e-

search through the ommunity lliances or ealth esearch program [PP 85662] and Manitoba ealth.

2 an we know when the fnal truth has been established? Be

cognizant o the prospect that things may change. Just because a

se and/or gender dierence (or a lack thereo) was documented

at one time does not mean it will remain so indefnitely.

Re eRen C es

yaia, J. Z. , & Epti, . . (1991). irc i th u o procdur btwwom ad m hopitalizd or coroary hart dia. The New England Journalo Medicine, 325, 221225.

hadra, N. ., Ziglti, . ., ogr, W. J., ibru, . J., or, J. ., Frch,W. J., & ubio, . (1998). brvatio o th tratmt o wom i thitd Stat with myocardial iarctio: rport rom th Natioal gitry oyocardial arctio-.Archives o Internal Medicine, 158, 981988.

Fraoo, . ., art, . J., h Nd o ow am, urlad, E., rior, ., urchil l, .,. . . aitoba tr or alth olicy. (2005). Sex dierences in health status,

health care use, and quality o care. Wiipg, aitoba: aitoba tr oralth olicy.

Fraoo, . ., art, . J., h Nd o ow am, rior, . J., urlad, E., hatau,., & atz, . (2010). g dirc xplai gdr dirc i cardiacitrvtio rat atr acut myocardial iarctio. Healthcare Policy, 6, 88103.

Jaglal, S. ., ol, ., & Naylor, . . (1994). Sx dirc i th u o ivaivcoroary procdur i tario. Canadian Journal o Cardiology, 10, 239244.

ilot, ., rrtt, ., arp, ., ltr, ., uti, . ., ox, J., . . . u, J. . (2004). ardiacprocdur atr a acut myocardial iarctio acro i aadia provic.Canadian Journal o Cardiology, 20, 491500.

ublic alth gcy o aada. (2009). Tracking heart disease and stroke in Canada2009 (p. No. 32-3/2009E). ttawa, N: uthor.

oo, . ., upta, S., Sood, . ., & Jbamai, . (2005). ata quality i a

iormatio-rich viromt: aada a a xampl. Canadian Journal o Aging,24(Suppl 1), 153170.

ra, . . ., , . S., Flitot, . F., iggio, ., rat, F. ., u, J. ., . . . Wilgoz,.(2003). /S quality idicator or acut myocardial iarctio car.Canadian Journal o Cardiology, 19, 3845.


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6 W i: g

i i-

i -

iik a r E N m E S S i N g, Universit du Qubec Montral

S u S a N S T O C k a N D F r a N C E T i S S O T,

Institut national de sant publique du Qubec

One Quebec worker in ive suers rom work-related musculoskeletaldisorders (MSD) (Arcand, Labrche, Stock, Messing, & Tissot, 2001).Our rarch tam ha b xplorig workplac xpour aociatd

with th diordr. hi chaptr prt why w coidrd m ad

wom paratly i our rarch, ad i doig o, what w lard aboutth halth ct o work.

not on trminologyconcptually, x rr to th biological pci-

city o wom ad m, ad gdr rr to ocial actor. mpiricalrarch with workplac populatio w ot d it hard to ditiguihwhthr obrvd mal-mal dirc ar du to biological or ocialactor. W thror u th trm x/gdr whr appropriat.


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43Work exposures and musculoskeletal disorders

pa

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h 1998 ubc alth and Social Survy (QHss-98) akd 11,735 work-

r about igicat muculokltal pai at variou body it that itr-rd with thir uual activiti otn or all th tim ovr th prviou 12

moth. Wh w lookd at th data, w oud that th prvalc o paiat om body it wa highr or wom, whil at othr it it wa highror mn or thr wa no ignicant x/gndr dirnc. tr accounting

or all igicat workplac xpour

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