Applying the Gender Lens to Emergency Care: From Bench to Bedside

This article outlines the history, need, and evolution of gender medicine in emergency care research. Clinical examples are used where sex and gender play a role in diagnosis, management, or prognosis of patients in the emergency department (ED). The ED serves as an ideal setting to advance sex‐ and gender‐specific research as the primary access point for health care for much of the U.S. population, with more than 136 million annual visits. Gender medicine provides the biologic and social framework to provide high‐quality, safe, equitable, and cost‐effective sex‐ and gender‐specific care in the ED. With a 24‐hour hospital presence, and with access to high‐acuity patients, emergency physicians are well positioned to lead sex‐ and gender‐specific clinical studies for time‐sensitive conditions and also to serve as vital partners in interdisciplinary research projects. The ED also provides the primary access point for less life‐threatening conditions such as substance abuse, mental health, and pain management (both acute and chronic). Because one‐fifth of the U.S. population is without health insurance, and many more lack a regular provider or rapid access to their providers, the ED is often the only point of contact for advancing gender medicine in this population.     

Why do women have back pain more than men? A representative prevalence study in the federal republic of Germany

OBJECTIVES: In comparison with men, women have a healthier lifestyle, are more rarely overweight, have less stressful occupations, or are not employed outside the home. The "gender pain bias" is the fact that women nevertheless have a higher prevalence of back pain. This paper looks at the possible underlying reasons for this as yet unexplained gender difference, using Stokols' socioecological health model as a basis. METHODS: The first National Health Survey for the Federal Republic of Germany was carried out from October 1997 to March 1999. It comprised a representative total sample of 5315 persons between the ages of 20 and 64. The participants took part in a medical examination and answered a self-report form. chi test and logistic regression analyses were used to investigate correlations between self-reported low back pain and gender-specific biopsychobehavioral and sociophysical environmental factors. RESULTS: Seven-day back pain prevalence in the Federal Republic of Germany is 32% for men and 40% for women. Prevalences are significantly higher for overweight subjects, persons with a marked somatization tendency or a low level of social support, physically inactive individuals, smokers, elderly subjects, the nonemployed, "blue collar workers" and lower socioeconomic groups. From a multivariate perspective, however, none of these factors reduces (and hence sufficiently explains) the gender difference. Factoring in the gender-specific somatization tendency reduces the odds ratios of women versus men from 1.42 to 1.23. DISCUSSION: In view of the gender difference in pain prevalence, which remains stable despite a multivariate perspective, there is clearly a need for more research into the reasons underlying the gender difference. We believe that future studies should look at rarely investigated constructs such as "sex role expectancies," "anxiety," "ethnicity," and "family history" and take anatomic differences in muscle strength into account.     

Women and the Experience of Pain and Opioid Use Disorder: A Literature-based Commentary

It is generally understood that pain experience and opioid abuse have relied on male-dominated models. However, sex and gender play a role in both pain experience and opioid use disorder.Using the previously validated Texas Tech University Health Sciences Center Sex and Gender Specific Health PubMed Advanced Search Tool, the authors used pertinent literature to develop this literature-based commentary on sex and gender differences in pain experience and opioid use disorder. Women report their experience of pain more frequently, have increased rates of diagnoses related to pain, have increased pain sensitivity, and have a variable response to pain and analgesia. This variable response is due to anatomic, physiologic, hormonal, psychological, and social factors that differ by sex and gender. Women have been found to be at greater risk for opioid abuse in all age groups. This may be due to the differences in pain experience, as well as sex and gender differences in prescribing patterns, cultural norms, and the increased likelihood to experience dependency and withdrawal. Approaches to the treatment of opioid use disorder are also subject to sex and gender differences—an area in need of further investigation.     

Women's sexual/reproductive health and access challenges amid COVID-19 pandemic

Challenges to women's health in the context of COVID-19 is based on their unique experience shaped by sex/gender. This paper provides clinical practice-, research-, and policy-related commentary on key COVID-19 pandemic factors impinging on women's sexual/reproductive health (SRH) and care access, particularly in the context of pregnancy, childbirth, sexual/gender variations, and concurrent chronic conditions.Women tend to have less severe outcomes from COVID-19 than men but certain sub-groups are more vulnerable than others. Yet few United States studies have disaggregated the data accordingly. Forming a basis for well-informed policy generation, needed is more research specific to COVID-19 vulnerability/risk factors and outcomes for groups of women by age, race and socioeconomic and cultural determinants. Access to SRH-related clinical services has been diminished during the pandemic, making a priority for restoring/preserving inclusive SRH care for women, for example, family planning, healthy pregnancies, age-related disease screening and treatment, and health/wellness promotion.Important concerns include severity of the disease, morbidity in pregnant and postpartum women, increased risk to the fetus, virus transmission to fetus or newborn, and impact of lack care access. Uncertainty in current knowledge is heavily related to lack of sex specific data.     

Exploring Differences Between Community-Based Women and Men with a History of Mental Illness

Relatively little is understood concerning the role of gender in persons with a history of mental illness residing in the community. This paper aims to explore gender's effect using data from the Community Research University Alliance project entitled, Mental Health and Housing. The primary five-year longitudinal study examined housing situations for psychiatric consumer/survivors in a mid-size, central Canadian region in an effort to improve the number and quality of appropriate housing situations. Data from 887 subjects in the original research underwent secondary analysis with particular relevance to differences between gender and indicators of health status including psychiatric history, levels of functioning, personal strengths and resources, and illness severity. Results of the secondary analysis found male and female differences that corroborated previous research. More women are housed than men, more women with mental illness were coupled than men, men have fewer social supports, and men have more substance abuse issues than women. These findings suggest health services within the community must consider these sex differences if they wish to properly assist Canadian individuals diagnosed with mental illnesses.     

The Impact of Sexism and Gender Stereotypes on the Legitimization of Women's Low Back Pain

BackgroundLow back pain is the worldwide leading cause of disability and, even though women's pain experience is more severe, frequent, and enduring, female patients are often underdiagnosed and undertreated. Health professionals’ gender stereotypes and social norms may underlie the downgrading of pain.AimThis pilot study aimed to examine the legitimation of low back pain by health professionals in relation to the sex of the patient as well as their gender awareness and the relationship between them.MethodThis study had a cross-sectional design. Eighty health professionals and students selected by convenience answered a 4-part online questionnaire. The eligibility criteria for participants were: aged >18 years, students in the last course of nursing/medicine or a physician/nurse, and Spanish-speaking. The questionnaire comprises: (1) a between-subjects virtual clinical low back pain case with four random versions (female/male patient and evidence/non-evidence of pathology); (2) the Spanish version of Nijmegen Gender Awareness Scale (S-NGAMS); (3) Ambivalent Sexism Inventory (ASI); and (4) Ambivalence toward Men Inventory (AMI).ResultsThe total score of legitimation of low back pain correlated negatively with gender role ideology and sexism scales (when the virtual patient was female), as well as the subscales of willingness to offer support and credibility.ConclusionsBoth sexism and gender role ideology could undermine the legitimation of low back pain, the willingness to offer support, and credibility only in female patients. The results showed a possible gender bias in low back pain assessment in health professionals. Low gender sensitivity and high sexism must be treated as modifiable risk factors for health inequities in pain care.     

Foundations for a Novel Emergency Medicine Subspecialty: Sex,Gender, and Women's Health

Sex and gender affect all aspects of health and disease, including pathophysiology, epidemiology, presentation, treatment, and outcomes. Sex‐ and gender‐specific medicine (SGM) is a rapidly developing field rooted in women's health; however, inclusion of SGM in emergency medicine (EM) is currently lacking. Incorporating principles of sex, gender, and women's health into emergency care and training curricula is an important first step toward establishing a novel subspecialty. EM is an ideal specialty to cultivate this new field because of its broad interdisciplinary nature, increasing numbers of patient visits, and support from academic medical centers to promote expertise in women's health. This article describes methods used to establish a new multidisciplinary training program in sex, gender, and women's health based in a department of EM. Women's health and SGM program initiatives span clinical care, patient education, clinical research, resident and fellow training, and faculty development.     

社区失能老人家庭照顾者主观幸福感现状及影响因素分析

目的 调查广州市社区失能老人家庭照顾者主观幸福感水平,分析其影响因素。方法 采用便利抽样法,于2019年8月—2020年8月选取广州市13个社区526名失能老人家庭照顾者为研究对象,采用一般资料调查表、总体幸福感量表、身体健康感知量表、家庭关怀度指数问卷和中文人生意义问卷对其进行调查,运用分层多元回归分析主观幸福感的影响因素。结果 失能老人家庭照顾者主观幸福感总分为（69.41±19.17）分;分层多元回归结果显示,照顾者的社会人口学因素（性别、宗教信仰、婚姻状况和目前工作状态）、身体健康状况（患有慢性病数和身体健康感知）、照顾因素（是否与老人同住、与老人的关系和照顾意愿）、家庭支持（协助照顾工作的家庭成员人数和家庭关怀度）以及生命意义感是失能老人家庭照顾者主观幸福感的影响因素,共解释41.3%的变异量,其中身体健康状况贡献最大,解释14.4%的变异量。结论 失能老人家庭照顾者主观幸福感处于中等水平,受到性别、宗教、婚姻和工作状态等社会人口学特征、照顾情况、身体状况、家庭支持和生命意义感等因素的影响。社区工作者应加强照顾者生命意义教育,调动家庭支持作用,改善身体素质,增强幸福感体验,从而提高失能老人的照顾质量。     

护士心理健康及工作压力的相关性

目的 观察某综合性医院护士的心理健康水平,探讨工作压力与心理健康的相关性及其影响因素.方法 采用横断面调查设计,以某三级甲等综合性医院270名护士为研究对象,用一般健康状况量表（GHQ-12）和压力反应量表来评价护士的心理健康水平、工作压力,并对两者的影响因素和相互关系进行统计分析.结果 在270名调查对象中有69名健康状况不良,健康状况不良检出率为25.50％.GHQ-12得分在不同的年龄、性别、科室、职称、学历和婚姻状况之间差异有统计学意义（P＜0.05）.工作压力与心理健康呈正相关,医务人员工作压力越大,心理健康不良的检出率越高.结论 护士的心理健康状况不良检出率较高,高于一般人群的心理健康不良水平.其中专业技术初级职称、大专、年龄＜ 30岁、已婚的护士较为严重.护士的工作压力状况与心理健康高度相关.     

Systematic review of cardiovascular disease in women: assessing the risk

Cardiovascular disease is the number one cause of death for women. In an effort to reduce cardiovascular burden for women, identifying risk factors and increasing awareness of sex differences are fundamental. This systematic review examines cardiovascular disease risk for women. A search of the literature was undertaken using key health databases. Search terms used were cardiovascular disease AND women OR gender. Additional references were manually identified from this literature; 58 articles were reviewed in total. On average, cardiovascular disease presents 10 years later in women compared to men. By this time, they are more likely to suffer from more comorbidities, placing them at higher risk. The complexity of cardiovascular disease identification in women is accentuated through atypical symptoms, and has the potential to lead to delayed and/or misdiagnosis. It is clear through identifying sex differentiation in cardiovascular risk factors that there has been an increased awareness of symptom presentation for women. In light of the sex differences in risk factors, sex‐specific aspects should be more intensively considered in research/practice to improve clinical outcomes for female cardiovascular disease patients.     

SF-36 Health Survey in Rehabilitation Research. Findings from the North German Network for Rehabilitation Research,NVRF, within the rehabilitation research funding program

The SF-36 Health Survey and its 12-item abridged form is an instrument for the assessment of health related quality of life that can be used with healthy persons and patient populations. Its use has been recommended within a large German multicentre rehabilitation research programme. The paper examines missing data across all five study projects of the North German Network for Rehabilitation Research (NVRF) as well as psychometric properties of the instrument. In addition, data were compared to representative norm data using the SF-36 (SF-12) in the German National Health Survey. Results showed that there were few missing data in the SF-36. Examining the impact of age, gender and health status yielded effects of higher age and female gender on missing data. Psychometric analyses showed good to excellent results of the instrument in terms of scale fit and reliability. In terms of convergent validity, medium to high correlation of the SF-36 subscales with comparable instruments (e. g. SCL-90-R) could be found. Summarizing, the SF-36/SF-12 can be recommended for use in rehabilitation research. Analyses regarding sensitivity should be conducted in future studies.     

Health status, sociodemographic factors, and the use of prescribed psychotropic drugs

The relations among sociodemographic factors, health status, and use of prescribed sleeping pills and tranquilizers are examined. The data are from the Rand Health Insurance Experiment, which has a random sample of the nonaged, noninstitutionalized, civilian population in six U.S. sites. Information on sociodemographic factors, health status, and the use of prescribed psychotropic drugs during the previous 3 months was obtained from self-report questionnaires collected at enrollment. Mental and physical health status have large independent and significant effects on the probability of use of both prescribed tranquilizers (P less than 0.0001) and sleeping pills (P less than 0.0001), whether or not we remove the effects of sociodemographic factors. For the probability of tranquilizer use, there is no significant interaction between gender and mental health or between mental health and physical health. Age and gender have large and significant effects on the use of prescribed psychotropic drugs even after controlling for differences in health status and other demographic factors. The effects of site and socioeconomic status are modest compared with the effects of health, age, and gender.     

Sexuality in persons with lower extremity amputations

Purpose: There is a paucity of information regarding sexual functioning in persons with lower extremity amputations. The purpose of this study was to describe sexual and psychological functioning and health status in persons with lower extremity amputation. Methods: Self-report surveys assessed sexual functioning (Derogatis Inventory), depression (Beck Depression Inventory, anxiety (State-Trait Anxiety Inventory), and health status (Health Status Questionnaire) in a convenience sample of 30 men with lower extremity amputations. Mean age of the participants was 57 years (range 32-79). Mean duration since amputation was 23 months (range 3-634 months). Twenty one subjects (70%) had trans-tibial and seven subjects (23%) had trans-femoral amputations. Results: A majority of subjects were experiencing problems in several domains of sexual functioning. Fifty three percent (n = 16) of the subjects were engaged in sexual intercourse or oral sex at least once a month. Twenty seven percent (n = 8) were masturbating at least once a month. Nineteen subjects (63%) reported orgasmic problems and 67% were experiencing erectile difficulties. Despite these problems, interest in sex was high in over 90% of the subjects. There was no evidence of increased prevalence of depression or anxiety in these subjects when compared to other outpatient adult populations. Conclusions: Sexual problems were common in the subjects studied. Despite these problems, interest in sex remained high. Few investigations have been directed toward identifying the psychological and social factors that may contribute to these problems and more research with a larger population is needed in this area.     

Socioeconomic status and dissatisfaction among HMO enrollees

OBJECTIVES: Member satisfaction is commonly used as an indicator of the quality of care delivered by health plans. Yet few contemporary studies have explored the extent to which individual patient characteristics influence dissatisfaction in HMOs. We sought to determine whether socioeconomic status is associated with enrollee dissatisfaction. METHODS: Data are from a cross-sectional, telephone survey of a probability sample of adults enrolled in New Jersey HMOs in 1998 (n = 7,983). Health plan ratings were elicited as part of the Consumer Assessment of Health Plans Study (CAHPS) survey, along with income, education, and race/ethnicity. Other factors known to influence satisfaction (age, gender, health status, extent of plan choice, and payment for plan) were also ascertained. RESULTS: Socioeconomically advantaged enrollees were more likely to give low ratings to their health plans. In a multivariate logistic regression model, those with incomes exceeding $100,000 had 1.65 times the odds of being dissatisfied compared with those with family incomes less than $25,000 (P <0.001); those with a college education had 2.53 times the odds of being dissatisfied than those who had not completed high school (P <0.001). However, among enrollees in their plans for > or =5 years, those in the lowest income group were significantly more dissatisfied than higher-income enrollees. CONCLUSIONS: Among New Jersey HMO enrollees, higher socioeconomic status (SES) is associated with greater dissatisfaction. Although based on cross-sectional data and thus preliminary, the evidence presented here also suggests that the SES-dissatisfaction relationship varies as a function of duration of enrollment. Further research using longitudinal data could shed additional light on the SES-dissatisfaction link.     

Sexuality in persons with lower extremity amputations

Purpose : There is a paucity of information regarding sexual functioning in persons with lower extremity amputations. The purpose of this study was to describe sexual and psychological functioning and health status in persons with lower extremity amputation. Methods : Self-report surveys assessed sexual functioning (Derogatis Inventory), depression (Beck Depression Inventory, anxiety (State-Trait Anxiety Inventory), and health status (Health Status Questionnaire) in a convenience sample of 30 men with lower extremity amputations. Mean age of the participants was 57 years (range 32-79). Mean duration since amputation was 23 months (range 3-634 months). Twenty one subjects (70%) had trans-tibial and seven subjects (23%) had trans-femoral amputations. Results : A majority of subjects were experiencing problems in several domains of sexual functioning. Fifty three percent ( n = 16) of the subjects were engaged in sexual intercourse or oral sex at least once a month. Twenty seven percent ( n = 8) were masturbating at least once a month. Nineteen subjects (63%) reported orgasmic problems and 67% were experiencing erectile difficulties. Despite these problems, interest in sex was high in over 90% of the subjects. There was no evidence of increased prevalence of depression or anxiety in these subjects when compared to other outpatient adult populations. Conclusions : Sexual problems were common in the subjects studied. Despite these problems, interest in sex remained high. Few investigations have been directed toward identifying the psychological and social factors that may contribute to these problems and more research with a larger population is needed in this area.     

Gender Differences in Acute and Chronic Pain in the Emergency Department: Results of the 2014 Academic Emergency Medicine Consensus Conference Pain Section

Pain is a leading public health problem in the United States, with an annual economic burden of more than $630 billion, and is one of the most common reasons that individuals seek emergency department (ED) care. There is a paucity of data regarding sex differences in the assessment and treatment of acute and chronic pain conditions in the ED. The Academic Emergency Medicine consensus conference convened in Dallas, Texas, in May 2014 to develop a research agenda to address this issue among others related to sex differences in the ED. Prior to the conference, experts and stakeholders from emergency medicine and the pain research field reviewed the current literature and identified eight candidate priority areas. At the conference, these eight areas were reviewed and all eight were ratified using a nominal group technique to build consensus. These priority areas were: 1) gender differences in the pharmacological and nonpharmacological interventions for pain, including differences in opioid tolerance, side effects, or misuse; 2) gender differences in pain severity perceptions, clinically meaningful differences in acute pain, and pain treatment preferences; 3) gender differences in pain outcomes of ED patients across the life span; 4) gender differences in the relationship between acute pain and acute psychological responses; 5) the influence of physician–patient gender differences and characteristics on the assessment and treatment of pain; 6) gender differences in the influence of acute stress and chronic stress on acute pain responses; 7) gender differences in biological mechanisms and molecular pathways mediating acute pain in ED populations; and 8) gender differences in biological mechanisms and molecular pathways mediating chronic pain development after trauma, stress, or acute illness exposure. These areas represent priority areas for future scientific inquiry, and gaining understanding in these will be essential to improving our understanding of sex and gender differences in the assessment and treatment of pain conditions in emergency care settings.     

Men and cancer: the gender dimension

Cancer affects more men than women; evidence shows that men are almost 40%more likely than women to die from cancer (Men's Health Forum, 2009). The three cancers that only affect men are penile, prostate and testicular cancers, with prostate cancer being the most common of all cancers in men. This article provides an overview of the health of men in the UK from a male cancer perspective. It suggests that gender is a significant determinant of health status, and that the nurse must take this into account when providing health services and when planning and devising strategy and policy. There are complexities and inter-relationships between gender and social class, ethnicity, disability, sexuality and age that are associated with male health. Ways in which the challenges faced by men and ways in which men access health services are discussed. Further research is needed to address this important healthcare issue.     

Schmerzmedizin aus einer interkulturellen und geschlechterspezifischen Perspektive

Cultural setting and sex and gender of the patient are important factors affecting the occurrence, severity, clinical course and prognosis of pain and pain-related diseases. Intercultural differences in the perception and verbal expression of symptoms and emotional function are fundamental and it is important to realize these differences in order to understand patients with a migration background. A trusting doctor-patient relationship is generally very sensitive and it is even more difficult to establish when differences in the cultural background impair mutual understanding. Regarding sex and gender there is evidence that females are more susceptible to developing chronic pain conditions, experience more severe pain and respond differently to pain therapy; however, results of recent studies indicate that females are not that different to males when comparing several modalities of experimental pain (although some differences exist). Similarly, sex and gender differences in postoperative pain seem to exist but the differences are relatively small when pain scores are compared. Other aspects, such as the response to analgesics and role of psychosocial factors should be addressed when sex and gender aspects are studied. Similarly, sex and gender differences in the prevalence of chronic pain exist but the results of some studies, e.g. those controlling for confounders, are not very clear. Research is needed to delineate the role of specific aspects affecting sex and gender differences and the underlying mechanisms (e.g. reduced inhibitory control, hormones, psychological aspects and social factors). Altogether, we need to open our minds to some intercultural and sex and gender aspects in the clinical setting. For sex and gender differences we may need a more biopsychosocial approach to understand the underlying differences and differentiate between sex and gender and sex and gender-associated aspects for acute and chronic pain.