Does gender bias exist in the use of specialist health care?

OBJECTIVES: To investigate the evidence for the existence of gender bias (defined as care provided independently of clinical need) in the use of specialist services by critically appraising the literature. METHODS: A computer-assisted search of the bibliographic databases PubMed, Medline, EMBASE, Healthstar and Social Science Citation Index for English language papers published from 1966 until May 1999. In addition, four journals were handsearched and the reference lists of identified papers were explored. Retrospective studies were only used when there were insufficient prospective studies. RESULTS: One hundred and thirty-eight studies were identified covering five major topics: coronary artery disease; renal transplantation; human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS); mental illness; and other (mainly invasive) procedures. The majority (94) examined coronary artery disease. It appears that men are more likely to undergo non-invasive investigations than women, but that subsequent investigation and treatment shows no clear evidence of gender differences. Men are more likely to undergo renal transplantation and, for those with HIV and AIDS, to receive azidothymidine (zidovudine, AZT) than women. There are some indications that disparities in favour of men also occur for those suffering from cardiac arrhythmias and cerebrovascular disease, and for those undergoing vascular surgery, hip replacement and heart transplantation. In contrast, women are more likely to undergo liver transplantation and cataract surgery. Mental health services may be provided differently for men and women. All these findings are limited by a lack of accurate denominator information and insufficient ability to adjust for prognostic factors. CONCLUSIONS: Differences in health care use can be due to demand factors (e.g. differences in the prevalence and severity of disease or in patient preferences), supply factors (particularly clinical judgement), or both. There is a need to examine these explanations thoroughly for gender inequalities in order to ensure that equity (lack of bias) is achieved. There is also a need for higher quality studies if differences are to be attributed conclusively to bias or not.     

Whither gender in urban health?

The past decade has witnessed the rapid expansion of the field of urban health, including the establishment of an international society of urban health and annual conference, the publication of several books and the growing popularity of a peer-reviewed journal on urban health. Relatively absent is an emphasis on the role of gender in urban health, despite scholarly and theoretical work on gender and place by feminist geographers, sociologists, public health researchers and others. This essay examines the treatment of gender within urban health and, drawing on insights from the social sciences, offers suggestions as to how urban health researchers might adopt an intersectional and gendered approach that will advance our understanding of the production of urban health for women and men.     

How did the recent increase in the supply of coronary operations in Finland affect socioeconomic and gender equity in their use?

STUDY OBJECTIVE: To explore how the increased supply of coronary bypass operations and angioplasties from 1988 to 1996 influenced socioeconomic and gender equity in their use. DESIGN: Register based linkage study; information on coronary procedures from the Finnish Hospital Discharge Register in 1988 and 1996 was individually linked to national population censuses in 1970-1995 to obtain patients' socioeconomic data. Data on both hospitalisations and mortality attributable to coronary heart disease obtained from similar linkage schemes were used to approximate the relative need of procedures in socioeconomic groups. SETTING: Finland, 2,094,846 inhabitants in 1988 and 2,401,027 in 1996 aged 40 years and older, and Discharge Register data from all Finnish hospitals offering coronary procedures in 1988 and 1996. MAIN RESULTS: The overall rate of coronary revascularisations in Finland increased by about 140% for men and 250% for women from 1988 to 1996. Over the same period, socioeconomic and gender disparities in operation rates diminished, as did the influence of regional supply of procedures on the extent of these differences. However, men, and better off groups in terms of occupation, education, and family income, continued to receive more operations than women and the worse off with the same level of need. CONCLUSIONS: Although revascularisations in Finland increased 2.5-fold overall, some socioeconomic and gender inequities persisted in the use of cardiac operations relative to need. To improve equity, a further increase of resources may be needed, and practices taking socioeconomic and gender equity into account should be developed for the referral of coronary heart disease patients to hospital investigations.     

For data’s sake: dilemmas in the measurement of gender minorities

Abstract

Gender-minority health disparity research is limited by binary gender measurement practices. This study seeks to broaden current discourse on gender identity measurement in the USA, including measurement adoption challenges and mitigation strategies, thereby allowing for better data collection to understand and address health disparities for people of all genders. Three data sources were used to triangulate findings: expert interviews with gender and sexuality research leaders; key-informant interviews with gender minorities in New Orleans, LA; and document analysis of relevant surveys, guides and commentaries. Ten key dilemmas were identified: 1) moving beyond binary gender construction; 2) conflation of gender, sex and sexual orientation; 3) emerging nature of gender-related language; 4) concerns about item sensitivity; 5) research fatigue among gender minorities; 6) design and analytical limitations; 7) categorical and procedural consistency; 8) pre-populated vs. open-field survey items; 9) potential misclassification; and 10) competing data collection needs. Researchers must continue working toward consensus concerning better practices is gender measurement and be explicit about their methodological choices. The existence of these dilemmas must not impede research on important health issues affecting gender minorities.     

Are there gender differences in the geography of alcohol-related mortality in Scotland? An ecological study

Background  

There is growing concern about alcohol-related harm, particularly within Scotland which has some of the highest rates of alcohol-related death in western Europe. There are large gender differences in alcohol-related mortality rates in Scotland and in other countries, but the reasons for these differences are not clearly understood. In this paper, we aimed to address calls in the literature for further research on gender differences in the causes, contexts and consequences of alcohol-related harm. Our primary research question was whether the kind of social environment which tends to produce higher or lower rates of alcohol-related mortality is the same for both men and women across Scotland.     

Are there sex and gender differences in acute exposure to chemicals in the same setting?

We have little understanding of the influence that sex and gender may have on exposure to and measurement of occupational chemicals. If men and women are in the same physical environment, whether that be an occupational or an environmental setting, researchers need to question whether their acute exposure, as measured by administered and/or biologically effective dose, is the same. Not doing so may result in incorrect inferences being made about the risks associated with that exposure. Three critical questions arise specifically, do men and women differ in (1) their personal environments (immediate physical environments and personal attributes), (2) their absorption of the substance across the various biological barriers, and (3) the amount of active substance that reaches the target sites? Both contextual (e.g., smoking habits, diet, use of personal care products and jewellery, hobbies, stress, and use of medications) and biological (e.g., endocrine status) factors should be considered in answering these questions. Examples from the literature are provided to show that, depending on the chemical compound, there may be sex and gender differences in exposure to chemicals which can be manifested in sex differences in absorption, distribution, metabolism, storage, and excretion. An argument is developed to support the need to make information available, such as pharmacokinetic modeling studies in both men and women including appropriate age groups representing the spectrum of life stages and reproductive status.     

Does the gender of the standardised patient influence candidate performance in an objective structured clinical examination?

Context  The objective structured clinical examination (OSCE) requires the use of standardised patients (SPs). Recruitment of SPs can be challenging and factors assumed to be neutral may vary between SPs. On stations that are considered gender-neutral, either male or female SPs may be used. This may lead to an increase in measurement error. Prior studies on SP gender have often confounded gender with case.
Objective  The objective of this study was to assess whether a variation in SP gender on the same case resulted in a systematic difference in student scores.
Methods  At the University of Ottawa, 140 Year 3 medical students participated in a 10-station OSCE. Two physical examination stations were selected for study because they were perceived to be 'gender-neutral'. One station involved the physical examination of the back and the other of the lymphatic system. On each of the study stations, male and female SPs were randomly allocated.
Results  There was no difference in mean scores on the back examination station for students with female (6.96/10.00) versus male (7.04/10.00) SPs ( P  = 0.713). However, scores on the lymphatic system examination station showed a significant difference, favouring students with female (8.30/10.00) versus male (7.41/10.00) SPs ( P  < 0.001). Results were not dependent on student gender.
Conclusions  The gender of the SP may significantly affect student performance in an undergraduate OSCE in a manner that appears to be unrelated to student gender. It would be prudent to use the same SP gender for the same case, even on seemingly gender-neutral stations.     

Why gender matters in the solution towards safe sanitation? Reflections from rural India

While the topic of women and water, sanitation and hygiene is a widely accepted concern among academics and activists, it continues to be an issue in developing countries with serious consequences. Based on a qualitative research conducted in rural Uttar Pradesh, India, the paper affirms that sanitation issues for women and girls are compounded by inequitable gender norms that put them at greater risk of experiencing violence and multiple health vulnerabilities. Women, despite having a high demand for safe toilet facilities, continue to practise unsafe sanitation. The findings highlight the role of three structural constraints as the key factors influencing toilet construction and use: poverty, inadequate sanitation policy and its implementation and gender-based power dynamics at the household level. The paper concludes by emphasising the relevance of engendering sanitation programmes and policies by involving women and girls in the planning process to ensure that dignified and gender-sensitive sanitation solutions are developed. The paper also stresses the need to have measures for strengthening and effectively implementing a sanitation policy for the poor and for programmes to work with both men and women to address gender power relations which influence toilet adoption and use.     

Constructions of gender in Vietnam: In pursuit of the ‘Three Criteria’

Vietnam has advanced far beyond most other developing countries and, indeed, surpasses many developed countries in adopting a legal framework based on gender equality, and in creating institutions and programmes to support women's advancement. Inegalitarian gender norms have also persisted, however. The Vietnam Women's Union promotes women's educational, political and economic advancement but simultaneously exhorts women to pay attention to their Confucian role of maintaining family hierarchy and harmony. This paper presents findings from qualitative research examining gender relations at the grassroots level in central Vietnam. It argues that the Vietnam Women's Union could support women more effectively by promoting greater diversity in gender norms and by initiating a public discussion to address the pressures women face in trying to achieve ideals that are often experienced as contradictory and unattainable.

Résumé

En ce qui concerne l'adoption d'un cadre légal basé sur l'égalité des genres et la création d'institutions et de programmes pour soutenir la promotion des femmes, le Viet Nam est allé bien plus loin que la plupart des autres pays en développement et les dépasse vraiment de beaucoup. Cependant, des normes de genre inégalitaires persistent. L'Union des Femmes du Viet Nam soutient la promotion éducative, politique et économique des femmes, mais simultanément, elle exhorte celles‐ci à rester sensibles à leur rôle confucéen de maintien de la hiérarchie et de l'harmonie familiales. Cet article présente les résultats d'une étude qualitative qui a examiné les rapports de genre dans des populations locales du centre du Viet Nam. Il avance que l'Union des Femmes du Viet Nam pourrait soutenir les femmes plus efficacement en faisant la promotion d'une plus grande diversité des normes de genre et en lançant un débat public sur les pressions auxquelles les femmes sont confrontées en tentant d'atteindre des idéaux, souvent vécus comme contradictoires et inaccessibles.

Resumen

Vietnam ha progresado mucho más que otros países en desarrollo y sin duda sobrepasa ya a muchos países desarrollados en la adopción de una estructura legal sobre la igualdad de sexos y en crear instituciones y programas para apoyar el progreso de las mujeres. Sin embargo, en las normas aún persisten las desigualdades sexuales. La Unión de Mujeres Vietnamitas fomenta el progreso educativo, político y económico de las mujeres pero a la vez exhorta a las mujeres a seguir el modelo confuciano en el que la mujer se ocupa de mantener la jerarquía y la armonía familiar. En este artículo mostramos los resultados de un estudio cualitativo en el que se examinan las relaciones entre sexos a un nivel básico en Vietnam central. Argumentamos que la Unión de Mujeres Vietnamitas podría apoyar mejor a las mujeres fomentando una mayor diversidad en las normas de género e iniciando una discusión pública para abordar las presiones a las que se enfrentan las mujeres para conseguir ideales que muchas veces parecen contradictorios e inalcanzables.     

Assessing the measurement invariance of the RCADS-25 questionnaire across gender and child–parent dyads in the presence of multilevel data

Quality of Life Research - This study aims to assess the measurement invariance of the short version of the Revised Child Anxiety and Depression Scale (RCADS-25) across male and female adolescents...     

Self-rated health in relation to age and gender: influence on mortality risk in the Malmö Preventive Project

AIMS: A study was undertaken to examine whether poor self-rated health (SRH) can independently predict all-cause mortality during 22-year follow-up in middle-aged men and women. SUBJECTS AND METHODS: Data are derived from a population-based study in Malm?, Sweden. This included baseline laboratory testing and a self-administered questionnaire. The question on global SRH was answered by 15,590 men (mean age 46.4 years) and 10,089 women (49.4 years). Social background characteristics (occupation, marital status) were based on data from national censuses. Mortality was retrieved from national registers. RESULTS: At screening 4,261 (27.3%) men and 3,085 (30.6%) women reported poor SRH. Among subjects rating their SRH as low, 1,022 (24.0%) men and 228 (7.4%) women died during follow-up. Corresponding figures for subjects rating their SRH as high were 1801 (15.9%) men and 376 (5.4%) women. An analysis of survival in subjects reporting poor SRH revealed an age-adjusted hazard risk ratio (HR, 95%CI) for men HR 1.5 (1.4-1.7), and for women HR 1.4 (1.2-1.6). The corresponding HR after adjusting for possible social confounders was for men HR 1.3 (1.1-1.4), and women HR 1.1 (0.9-1.4). When additional adjustment was made for biological risk factors the association for men was still significant, HR 1.2 (1.1-1.3). CONCLUSION: Poor SRH predicts increased long-term mortality in healthy, middle-aged subjects. For men the association is independent of both social background and selected biological variables. The adjustment for biological variables can be questioned as they might represent mediating mechanisms in a possible causal chain of events.     

Split gender identity: problem or solution? Proposed parameters for addressing the gender dysphoric patient

Working with the gender dysphoric patient is complex because of the various clinical issues that arise. One issue that has not been addressed in the psychiatric literature is whether to address the patient with the biologically congruent pronoun or name or with the patient's preferred-gender pronoun or cross-gender name. This article presents clinical examples that allow a template to be developed for pronoun use in working with such patients. Whether the clinician uses biologically congruent names and pronouns may depend upon the patient's progress in adopting the cross gender role as well whether family or friends either know or accept such changes. In certain situations, such as meetings with family members, the therapist may address the patient with gender congruent names; whereas on other occasions use cross-gender pronouns or names.     

Can physical activity help explain the gender gap in adolescent mental health? A cross-sectional exploration

Studies find that physical activity links with mental health, females engage in less physical activity than males, and females have worse mental health than males. Less attention has been paid to the intersection of physical activity, mental health, and gender. Might physical activity explain links between gender and mental health in adolescence? Or does the mental health benefit of physical activity depend on gender? In addition, while physical activity correlates with better mental health overall, it may be more beneficial for some domains than others. Using four years of cross-sectional data from students (1,756 cases over four years, ages 13–18), we (1) confirmed gender differences in physical activity and mental health, replicating prior studies; examined gender (2) as a confounding variable and (3) as a moderator of the physical activity-mental health link; and (4) tested physical activity as a mediator between gender and mental health. In addition, we considered whether associations vary for different positive and negative mental health domains. Females reported poorer mental health; males engaged in more physical activity. Physical activity was associated with all markers of mental health, having stronger correlations with Engagement and Perseverance than other positive and negative domains. Results better supported a mediational model (physical activity mediating gender-mental health associations) than a moderation model (gender moderating physical activity-mental health associations). Findings indicate the value of physical activity as an adolescent mental health intervention and suggest that barriers to females’ participation in physical activity should be considered.