sex, gender and sexuality 101

What are we talking about when we talk about sex, gender, and sexuality? 

Sex: Sex is a term used to describe the biological characteristics of an individual, including chromosomal, anatomical, hormonal, and reproductive traits. Typically, sex is determined at birth by a physician or midwife–hence terms like “assigned female at birth” or “assigned male at birth.” Sex is oftentimes reduced to a male-female binary. This binary ignores intersex individuals, who have both male and female biological features [1]. 

Gender: Gender refers to the socially constructed characteristics of men, women, and non-binary people, including their responsibilities, appearances, relationships, and behaviors. These characteristics are often linked to the sex assigned at birth. Gender is not binary, and it exists on a spectrum. Gender identity describes a person’s internal sense of their gender. Calling someone “cisgender” means their gender identity aligns with their sex assigned at birth. Someone whose gender identity does not align with their sex assigned at birth may identify as transgender or non-binary. People can communicate their gender identity through a collection of behaviors, appearances, and other external features known as gender expression [1]. People often use preferred pronouns to respect or express gender identities. 

Sexuality: Sexuality encompasses people’s experiences of attraction and their sexual behaviors. People can be attracted to the same gender, a different gender, or multiple genders. They may identify their sexuality using sexual orientations, which include terms such as heterosexual, homosexual, bisexual, pansexual, or asexual. Sexuality is fluid: it can change over time and in different contexts [2].

Why do sex, gender, and sexuality matter in health care?

Research has demonstrated significant biases in health care that affect women and LGBT+ individuals. People of different sexes and genders may have different medical needs. However, the majority of medical knowledge overrepresents straight, cisgender, male presentations of illnesses [3]. Additionally, minority stress due to discrimination and victimization causes an increased risk of mental and physical illnesses [4]. These factors contribute to the reality of stark health disparities faced by women and LGBT+ individuals. For example, women are more likely to receive inadequate pain treatment compared to men [5]. Additionally, a study found women were significantly less likely to receive the proper diagnostic and therapeutic procedures for coronary heart disease [6]. Moreover, a recent study of the Danish health care system revealed that women were diagnosed later than men in the case of over 700 diseases [7].

Members of the LGBT+ community may also face discrimination in health care due to their sexual orientation or gender identity. Implicit and explicit biases by providers create significant health disparities in this population as compared to non-LGBT+ individuals. In fact, people who identify as LGBT+ have higher rates of cardiovascular disease, asthma, anal cancer, substance abuse, and suicide [8]. Transgender individuals are especially marginalized within health care systems, as they often struggle to access transition-related care or hormone replacement therapy. Widespread stigma against LGBT+ individuals may lead also groups like transgender patients to avoid health care out of fear [9]. We must implement strategies in order to reduce sex, gender, and sexuality biases and achieve health equity.

What do we know about sex, gender, and sexuality in medical and health professions education?

Medical institutions have historically failed to create equitable and inclusive educational environments for women and LGBT+ people. Women are underrepresented in preclinical and clinical medicine, as well as in medical leadership roles [13]. The gender wage gap remains pervasive, and women are less likely to receive recognition and rewards for their contributions compared to their male counterparts [10]. While women comprise about half of all medical school graduates in the United States, there are a number of fields in which women remain underrepresented, including hematology and surgery [11,12]. With regards to the LGBT+ community, there is a lack of data regarding the true number of students, physicians, and health care professionals that identify with this population. However, significant evidence suggests that these communities are underrepresented in medicine and health professions education [13]. 

Keeping in mind the health disparities that women and LGBT+ individuals face, it becomes imperative to ensure that physicians and health care professionals are aware of how to serve these groups. However, sex, gender, and sexuality are not adequately addressed in the curricula of medical and health professions education. In fact, LGBT+-specific content is not required in medical schools, despite evidence strongly supporting the benefits. One study demonstrated that only 8.1% of sampled medical school sessions discussed the influences of sex, gender, or sexuality on physiology and pathophysiology. Moreover, the sessions that covered this content largely focused on basic physiology and incidence rates; very few covered the nuances of sex, gender, and sexuality in diagnosis, treatment, prognosis, and drug effects [14]. Interventions that implement curricular content related to gender, sex, and sexuality have significantly improved student knowledge and clinical practices [15,16,17]. By addressing the current curricular gap, medical institutions can promote the development of socially aware health professionals. 

How does the Bias Checklist address sex, gender, and sexuality in health professions education content?

The Bias Checklist first asks: 

  • “Does the content include any mention of sex or gender? Does the content include any mention of sexual behavior, sexuality, or sexual orientation?”

If you answer no, you will be prompted to consider whether your content should mention sex, gender, and sexuality.

The Bias Checklist asks the following related questions about content:

  • Are all genders represented in the content?

  • Is gender presented as part of a spectrum?

  • Does the content conflate gender identity with sexual orientation?

  • Does the content promote traditional gender roles?

  • Are symptoms, signs, other clinical findings and/or disease presentations (e.g., chest pain) referred to as "atypical" or "variant" when they occur in women?

  • Is the spectrum of sexual orientation represented in the content?

  • Does the content recognize the sexual health needs of patients with physical disabilities?

  • Does the content recognize the sexual health needs of patients with cognitive disabilities?

  • Does the content recognize the sexual health needs of older patients, including geriatric patients?

Below are some examples of common ways in which bias, shame, stereotype and stigma toward sex, gender, and sexuality can manifest in health professions education content:

  • Pediatric vignettes in which patients are invariably accompanied by a mother (never a father, two fathers, two mothers, grandparents, etc.) or only involve nuclear families with heterosexual, married parents and biological offspring

  • Suggesting that female students consider reproduction and family obligations in their career choices

  • Disproportionate course content/contact hours devoted to conditions that impact men more than women (e.g., time spent in pharmacology on drugs for erectile dysfunction vs. time spent on contraceptives)

  • Teaching students that intersex patients are really male or female, once diagnosed properly

  • Failure to use preferred pronouns for gender-nonconforming patients in clinical vignettes

  • Using language in clinical vignettes or discussions of history-taking such as "The patient ADMITTED to having sex."

  • Teaching students to take a sexual history that does not account for the full spectrum of sexual identities and encourages categorization

  • Teaching students to label sexual identities and behaviors as "high-risk"

  • Using value-laden terms like "prostitute" instead of the more neutral "sex worker"

  • Any comment about this subject that is meant to elicit laughter 

Last, the Checklist asks:

  • “Could the content be perceived as promoting stereotypes, bias, shame or stigma?”

What can we do to address this problem?

  • Example: Examples of biased content submitted to the Bias Checklist often reinforce gender roles and heteronormativity. Many vignettes describe male patients as having wives, or children as being brought to the office by their mother. These vignettes may not be biased on their own. However, in the absence of vignettes describing more diverse relationships and gender roles, these content examples may contribute to the marginalization of LGBTQ+ individuals and alternative family structures.

  • Example: Another form of biased content is the uniform association of certain diagnoses with certain genders—for example, autoimmune disorders with women, or migraine headaches with women versus cluster headaches with men. Again, a single description of a woman with an autoimmune disorder may not contain bias, but not all descriptions of these disorders should associate them with a particular gender.

  • Example: Other submissions to the Bias Checklist indicate the potential for bias in discussions of intersex individuals, for example, vignettes that imply that newborns with ambiguous genitalia must be diagnosed as being really male or female. 

  • Example: A Bias Checklist submission notes that a medication is described as potentially causing gynecomastia and impotence in men, with no mention of its effects for women. If applicable, this content should include a discussion of effects in women as well. 

  • Example: When discussing an abnormal oocyte division, educational content submitted to the Bias Checklist focuses only on the risk factor of the mother’s age. A discussion of other risk factors could avoid inadvertently blaming a woman for this condition.

Where can I go to learn more? 

I learn best by…

Reading

  • Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick by Maya Dusenbery

  • Bodies and Barriers: Queer Activists on Health edited by Adrian Shanker

  • Gender Medicine: The Groundbreaking New Science of Gender- and Sex-Related Diagnosis and Treatment by Marek Glezerman

  • Dijkstra AF, Verdonk P, Lagro‐Janssen AL. Gender bias in medical textbooks: examples from coronary heart disease, depression, alcohol abuse and pharmacology. Medical Education. 2008;42(10):1021-8. https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2923.2008.03150.x

  • Jenkins, M.R., et al. (2016). Sex and gender in medical education: a national student survey. Biology of Sex Differences, 7(45). https://doi.org/10.1186/s13293-016-0094-6 →

  • Schreyer, L. (2023). The Closeted Curriculum. Academic Medicine: 10.1097/ACM.0000000000005465. DOI: 10.1097/ACM.0000000000005465

Watching

Listening

NEED A CONSULTATION?

The following people have identified themselves as experts in sex and gender and are willing to be contacted with questions regarding your content.

  • Contact list coming soon!

HAVE SOMETHING TO ADD? 

Email us at biaschecklist@gmail.com with any of the following:

  • Recommendations for additional important content to include above, or suggested corrections or clarifications → use the subject header “Sex and Gender 101 - Correction”

  • Suggestions for additional questions to add to the Bias Checklist → use the subject header “Sex and Gender 101 - Checklist Question”

  • Suggestions for additional resources for learning more → use the subject header “Sex and Gender 101 - Learn More”

  • Examples of curricular bias, including before and after versions of content → use the subject header “Sex and Gender 101 - Example”

  • Your name, credentials, affiliation, area(s) of expertise, and brief biography or summary of qualifications if you are willing to serve as an expert consultant → use the subject header “Sex and Gender 101 - Consultant”

References

  1. Council of Europe. (2023). Sex and Gender. Gender Matters. https://www.coe.int/en/web/gender-matters/sex-and-gender

  2. Ventriglio, A., & Bhugra, D. (2019). Sexuality in the 21st Century: Sexual Fluidity. East Asian Archives of Psychiatry, 29(1), 30–34. https://search.informit.org/doi/abs/10.3316/INFORMIT.264090806459055

  3. Hamberg, Katarina. (2008). Gender Bias in Medicine. Women’s Health, 4(3), 237-243. https://journals.sagepub.com/doi/epub/10.2217/17455057.4.3.237 

  4. Skuban, T., et al. (2022). Restriction of Access to Healthcare and Discrimination of Individuals of Sexual and Gender Minority. International Journal of Environmental Research and Public Health, 19(5), 2650. https://doi.org/10.3390/ijerph19052650

  5. Hoffmann, D. E., & Tarzian, A. J. (2001). The girl who cried pain: a bias against women in the treatment of pain. The Journal of Law, Medicine & Ethics, 29(1), 13–27. https://doi.org/10.1111/j.1748-720x.2001.tb00037.x

  6. Ayanian, J. Z., & Epstein, A. M. (1991). Differences in the Use of Procedures Between Women and Men Hospitalized for Coronary Heart Disease. The New England Journal of Medicine, 325(4), 221–225. https://doi.org/10.1056/NEJM199107253250401

  7. Westergaard, D., et al. (2019). Population-wide analysis of differences in disease progression patterns in men and women. Nature Communications, 10(666). https://doi.org/10.1038/s41467-019-08475-9

  8. Morris, M., et al. (2019). Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers. BMC Medical Education, 19(325). https://doi.org/10.1186/s12909-019-1727-3

  9. White Hughto, J. M., et al. (2017). Barriers to Gender Transition-Related Healthcare. Transgender Health, 2(1), 107–118. https://doi.org/10.1089/trgh.2017.0014

  10. Nocco, S. E., & Larson, A. R. (2021). Promotion of Women Physicians in Academic Medicine. Journal of Women's Health, 30(6), 864–871. https://doi.org/10.1089/jwh.2019.7992

  11. Liblik, K., et al. (2022). Underrepresentation and undertreatment of women in hematology. Research and Practice in Thrombosis and Haemostasis, 6(5), e12767. https://doi.org/10.1002/rth2.12767

  12. Klifto, K. M., et al. (2020). Women Continue to Be Underrepresented in Surgery. Journal of Surgical Education, 77(2), 362–368. https://doi.org/10.1016/j.jsurg.2019.10.001

  13. Kelly, T., & Rodriguez, S. B. (2022). Expanding Underrepresented in Medicine to Include Lesbian, Gay, Bisexual, Transgender, and Queer Individuals. Academic Medicine, 97(11), 1605–1609. https://doi.org/10.1097/ACM.0000000000004720

  14. Thande, N. K., et al. (2019). The Influence of Sex and Gender on Health. Journal of Women's Health, 28(12), 1748–1754. https://doi.org/10.1089/jwh.2018.7229

  15. Streed, C.G., & Davis, J.A. (2018). Improving Clinical Education and Training on Sexual and Gender Minority Health. Current Sexual Health Reports, 10, 273–280. https://link.springer.com/article/10.1007/s11930-018-0185-y

  16. Click, Ivy, et al. (2020). Transgender health education for medical students. The Clinical Teacher, 17, 190-194. https://doi.org/10.1111/tct.13074

  17. Cooper, Robert, et al. (2023). Affirming and Inclusive Care Training for Medical Students and Residents to Reduce Health Disparities Experienced by Sexual and Gender Minorities. Transgender Health, 8(4). https://doi.org/10.1089/trgh.2021.0148

Contributing Writer(s)

Katie M. Farkouh, MD Candidate

Sophie Pollack-Milgate, BA

last updated September 28, 2023