Abstract
Introduction:
The Sex and Gender Health Education (SGHE) Summit was a national collaboration that engaged educational thought leaders from various health professions to advance curricula by integrating sex- and gender-based evidence into health education.
Materials and Methods:
The SGHE Summit was held over a 2.5-day period April 2018 at the University of Utah. Pre- and postsummit surveys assessed attitudinal and knowledge changes.
Results:
A total of 246 health care professionals and trainees from U.S. and International Institutions attended. One hundred fifty-seven presummit surveys and 115 postsummit surveys were completed. Postsummit beliefs: SGHE is critical to precision medicine (100%); it is essential to include female animals in preclinical research studies (96%); sex and gender concepts could be used to improve men's health (99%). A teaching tool summarizes the initial questions to consider in SGHE.
Conclusion:
The SGHE Summit was the first multiprofessional large-scale national effort focused on the integration of sex and gender knowledge into the education of all health professionals. Summit participants now represent a national network of educators and clinicians who recognize the centrality of sex and gender to health professionals' knowledge and practice. These educational efforts will ultimately ensure a more personalized health care delivery.
Introduction
Sex- and gender-based health is the science of the similarities and differences in health and illness between men and women. According to the National Institutes of Health, “Sex refers to biological differences between females and males, including chromosomes, sex organs, and endogenous hormonal profiles. Gender refers to socially constructed and enacted roles and behaviors which occur in a historical and cultural context and vary across societies and over time.” 1 Sex and gender are inter-related variables that influence the etiology, risk factors, prevention, presentation, and response to treatment for all health conditions.
Sex and gender differences are increasingly recognized as a contributing factor to health disparities. Disparities can reflect differences in conditions that are specific to one sex or gender as well as those conditions that show differences in incidence, prevalence, morbidity, and mortality.
The evolution of sex- and gender-specific scientific knowledge and the establishment of an evidence base of differences have led us to understand that sex and gender have an impact on a patient's health. This understanding coupled with the lack of systemic integration into medical education 2 became the motivation for the Sex and Gender Medical Education (SGME) Summit in 2015, which provided a venue for collaboration among nationally and internationally recognized experts in developing a roadmap for the incorporation of sex- and gender-based concepts into medical education curricula, and highlighted the different methodologies and models for integrating Sex and Gender Based Medicine (SGBM) content into medical education. After the 2015 Summit, a toolkit and detailed summary proceedings were disseminated to all attendees, participating institutions, supporting organizations, national medical associations, and individuals.
After the success of the SGME Summit, the organizers agreed that future education was needed within all sectors of health care to help advance this knowledge and improve clinical practice. Interprofessional education (IPE) is becoming a more common component of medical school curricula in the United States. IPE programs are growing as they are increasingly viewed as a means of reducing medical errors and improving the health care system. 3,4
The Sex and Gender Health Education (SGHE) Summit was designed to build upon the success of the SGME Summit while creating an interdisciplinary network and providing resources for health professionals to support and progress the integration of sex and gender differences into health professionals' education. To expand multidisciplinary opportunities in SGBH, health education leaders convened from five major professions—medicine, nursing, pharmacy, dentistry, and allied health at The University of Utah in April 2018. Invited attendees included health education faculty, student leaders, and professional and nonprofit organizational representatives who were interested in progressing sex and gender inclusion into health professionals' education and thus into future clinical care.
With an overarching goal to achieve lasting sex and gender integration into health professionals' education, the SGHE Summit goals were as follows: (1) navigate organizational and institutional curricular change, (2) create a stepwise plan for sex and gender integration, (3) receive valuable assessment guidance from national experts, (4) obtain access to resources on sex and gender curricular materials, (5) enhance IPE through a sex and gender approach, and (6) engage health professional faculty and stakeholders.
Materials and Methods
The SGHE Summit was a collaborative effort of the American Medical Women's Association, the Texas Tech University Health Sciences Center's Laura W. Bush Institute for Women's Health, the Mayo Clinic Rochester, and the University of Utah. Planning for the Summit included the formation of an executive planning committee, multiprofessional senior advisory and scientific program committees, a poster committee, local host committee and the establishment of a summit informational website (
Pre- and postassessment surveys of participants' knowledge, attitudes, and perceptions were obtained and are presented through descriptive analysis.
Two workshops were developed: Workshop A: Integrating Sex and Gender into an Interprofessional Curriculum and Workshop B: Leading and Sustaining Curricular Change. Workshop A gave Summit participants an opportunity to recognize how the integration of sex and gender into educational curricula could present in a classroom model. In Workshop B, participants discussed challenges in initiating and developing a successful program back at their own institutions. The workshops utilized small-group and role-playing activities as evidence-based teaching delivery methods.
Results
Attendees
Two hundred forty-six health care professionals and trainees from 137 institutions and organizations across five health professions (medicine, nursing, pharmacy, allied health, and dentistry,) attended in person, with many others participating online. One seventy-five scholarship grant applications were awarded.
Summit attendees hailed from 36 different states in the United States and international regions as far as Canada, South Korea, and the Caribbean. In-person attendees included 205 women and 41 men. The attendees' specialty or degree designations were MD/DO 78, DDS/DMD 23, PharmD 27, Nursing 29, Allied health 8, Doctoral Degree (specialty not specified) 44, Other 37 (Table 1). Twenty-two attendees had a public health degree.
Sex and Gender Health Education Summit Attendees by Specialty/Degree
Workshops A and B
Each workshop is further discussed in accompanying manuscripts; however, here we present brief descriptions of goals that were accomplished. Workshop A participants were able to (1) understand the breadth of evidence that adds to the understanding of sex- and gender-specific health in a variety of clinical scenarios, (2) utilize current active learning educational modalities to demonstrate inclusion of sex and gender into existing curricula, (3) create SMART objectives that demonstrate learning and assessment of sex and gender inclusive content, and (4) create a framework for initiating an integrative curricular change that is pertinent to specific professions. 5
Workshop B 6 participants created a framework to (1) understand the role of instructors, course/block directors, and curriculum committees in determining curricular content and change; (2) explain the impact of both internal and external factors to institutions (accreditation, clinical pressures) on shaping the curriculum; (3) convincingly articulate the importance of sex and gender knowledge for the maintenance of health and treatment of patients; and (4) develop confidence in the ability to persuade/negotiate a viewpoint around sex and gender curricular integration (ref SGHE Workshop B manuscript).
Participants survey responses
A survey was conducted at the beginning and end of the Summit using the Whova app. Summit survey respondent demographics are shown in Table 2, and survey results are shown in Tables 3 and 4. There were 157 presummit survey respondents, which included 131 faculty, 6 residents, 8 students, and 12 other respondents. Among these, there were 133 women, 19 men, and 4 who responded as other gender. There were 115 postsummit survey respondents, which included 89 faculty, 5 residents, 5 students, and 16 others. Among these, there were 96 women and 19 men.
Sex and Gender Health Education Summit Survey Respondents' Demographics
Presummit survey, N = 157; postsummit survey, N = 115.
Sex and Gender Health Education Summit Pre- and Postsurvey Results
Total respondents: presurvey, N = 157; postsurvey, N = 115. Did not reply: presurvey, N = 3 for all questions; postsurvey, questions 5, 6, 10, N = 4, all others N = 3.
Sex and Gender Health Education Summit Postsurvey Results
Total respondents, N = 115. Did not reply: six respondents for each question.
The summit was attended by individuals who were invested in promoting curricular excellence. Seventy-four percent of those completing the presummit survey had roles in curriculum development within their specialties. Eighty-seven percent thought that they were familiar with sex and gender differences in health and disease. Yet, even among these individuals, new knowledge was gained and attitudes changed. By the end of the summit, there was almost universal agreement that SGHE could improve men's health (99%) and was critical to precision medicine (100%). Almost all also agreed that we needed to include female animals in preclinical research studies (96%). The largest shift in attitude was in the belief that the FDA should consider recommending dosages based on the sex of the patient, which increased from 78% to 94%. Almost all respondents indicated that they would consider integrating sex and gender concepts into all of their educational sessions (95%). The overwhelming support for sex- and gender-based health among summit participants stands in contrast to the percentage of those indicating that sex and gender evidence was integrated across all 4 years of the curriculum at their institutions (14% presummit, 5% postsummit).
Discussion
Awareness, action, and accountability
The SGHE Summit was a historic undertaking as the first interprofessional conference to convene the five major health care professions—medicine, nursing, dentistry, pharmacy, and allied health—on the importance of SGHE. The full impact of the Summit will depend largely on the extent that the knowledge gained from the Summit can be implemented at educational institutions across the country, or what Dr. Lucinda Maine addressed in her capstone lecture as the Triple A: Awareness, Action, and Accountability.
The first task for those who attended the Summit was not only to increase their own awareness about the relevance of sex and gender for health education but also to increase awareness within their institutions. Simply asking the question, “Does sex and gender matter?” at every opportunity helps create the proper framework for understanding the issue. Being aware that educational resources are available for sharing among institutions can save valuable time and resources.
The next step is to turn awareness into action. This can be as simple as debriefing with colleagues, teaching one's mentors about the importance of sex and gender, using resources such as those available from the Laura W. Bush Institute for Women's Health at Texas Tech University Health Sciences, Canadian Institute of Gender and Health, or the National Institutes of Health Office of Research on Women's Health, encouraging others to use these materials and other available resources, and advocating for changes in curricular mapping software.
Attendees were encouraged to consider how sex and gender fit within their own organizations' visions and missions, and then to align SGHE efforts within that framework. For example, if the mission is to provide personalized care to patients, then providing care with a sex- and gender-focused lens becomes a critical component of fulfilling that mission because each patient has a sex and a gender. If the mission is to improve health outcomes, then considering the role of sex and gender is critical in understanding how health and illness are manifested in the community. For example, women are more likely to suffer injuries associated with sexual or intimate partner violence, while men are more likely to be victims of suicide or homicide. The same holds true for many diseases. For example, cardiovascular disease, a primary cause of mortality and morbidity in both men and women, is characterized by differences in pathophysiology, clinical presentation, and outcomes. 7 To improve outcomes, health systems will need to address differences in the prevention, diagnosis, and management of cardiovascular disease between men and women.
Turning awareness into action will require “measuring what matters.” To determine if we have deficiencies in how we are teaching about sex and gender or in how we are providing clinical care, we need to measure what we are doing. The development of Multiprofessional Achievable Required Knowledge (MARK) goals for sex and gender interprofessional health education will help create a competency-based approach to assessment. Multiple competencies can be associated with each entrustable professional activity (EPA) within the different health professions.
Measurement facilitates accountability, which can be demonstrated within different contexts. Sex and gender should be integrated into accreditation standards because these concepts are foundational in health and illness. Accountability should also be integrated into local and national examinations such as Objective Structured Clinical Examinations and board examinations, with examination questions being written by sex and gender experts. A sex- and gender-based framework should be integrated into curricular maps and surveys such as course evaluations and graduating student surveys. At the federal level, for example, the FDA and NIH, this framework should be factored into data, compliance, and funding.
Dr. Maine concluded that ultimately, faculty are accountable to their students and their patients. This necessitates the inclusion of sex and gender into health professions education, so that students learn how to provide appropriate and personalized care to each and every patient.
Recurring themes and keys to curricular change
Several recurring themes emerged over the course of the Summit, which serve as keys to curricular change.
Relevance of sex and gender
The first step associated with integrating sex and gender content into curricula is recognizing the relevance of sex and gender to research, education, and practice. As Dr. Marjorie Jenkins emphasized at the outset of the Summit, “Every patient has a sex and a gender.” This perspective should be the lens with which we approach each patient. Both biology (sex) and gender (roles, identities, expectations, and behaviors) affect health and illness, and are manifested in every single patient. Sex and gender are foundational variables in health care, and are integral to the delivery of personalized care.
The LGBTQ+ community's needs are included, but they are a subset of sex and gender health
The field of sex and gender health includes lesbian, gay, bisexual, transgender, queer (LGBTQ+) individuals, but it is not synonymous with the care of this special population because sex and gender health apply to all patients. Members of the LGBTQ+ community have unique health care needs that need to be recognized and addressed. Members of these groups often have difficulty receiving care because they fear discriminatory or dehumanizing treatment by health care providers. Suggestions offered to health care providers included asking such patients how they wished to be addressed and treating the anatomy that was presented.
Sex and gender intersect with public health
Sex and gender considerations are integral to public health in many ways, including access, treatment needs and interventions, epidemiology, and medical errors. Consider the example of substance abuse. Historically, alcohol abuse was more common in men, but women are catching up. This leads to sex-specific consequences such as increased breast cancer risk or testicular atrophy or breast enlargement. Alcohol and drug use are addictive and coping behaviors, and they increase the risk of intimate partner violence. In addiction treatment, sex hormones influence reward pathways. For many if not most diseases, the intersection of sex and gender can have epigenetic effects, which are observed on the population level. Ignoring sex and gender can contribute to medical errors, which are currently the third leading cause of death in the United States. The primary factor in medical errors is adverse drug events, which are more common among women. Sex and gender considerations are relevant for public health interventions and policies.
Interprofessional collaboration is key
Interprofessional discussions during workshops and small-group activities fostered a greater understanding of the relevance of sex and gender across multiple knowledge domains and practice areas. Participants shared insights from their own disciplines about the importance of sex and gender concepts in basic science, social science, clinical care, or curriculum development. The small-group experiences demonstrated the effectiveness of an interprofessional model that could be applied locally within institutions to engage both faculty and students.
Work within existing frameworks
There is no doubt that implementing broad curriculum change can be challenging, but integrating sex and gender into existing curricula does not have to be difficult. These concepts can be woven into existing competency frameworks, particularly if an educational need or a knowledge gap has already been identified. Course materials can be examined for sex and gender bias. The first step may be as simple as either adding a few extra lecture slides or changing the sex of case patients and examining how that impacts interpretation of the case, especially diagnostic and treatment decisions.
Use available resources
Many resources are available to facilitate curricular integration, so that reinventing the wheel is not necessary. Open-source training modules, case materials, and other curricular materials are available through the Laura W. Bush Institute for Women's Health and the Sex and Gender Health Collaborative (a program of the American Medical Women's Association). Extensive resources for researchers and faculty are available through the Canadian Institutes of Health and the National Institutes of Health Office of Research on Women's Health. A comprehensive list of sex and gender resources can be found in the proceedings from the 2015 SGME Summit (
Align with professional competencies and EPAs
Summit participants were exhorted to work toward change within their own health professions. Understanding the competencies and EPAs that guide curriculum development will be critical to change. Although there is some variation in competencies and EPAs across professions, there are also many common themes. Aligning curricular goals to competencies and EPAs within one health profession can serve as a model for change within other health professions.
Students are allies in SGHE
Students have been allies and effective grass roots advocates in highlighting the importance of sex and gender within their institutions. Students have asked questions, asked for curriculum reform, and participated in curriculum audits of sex and gender content. Students have also successfully advocated for sex and gender to be recognized as an essential knowledge domain at the Michigan State Medical Society.
A teaching tool to illuminate gender bias across domains
Over the past three decades, a great deal of research has documented differences between women and men across many domains, but these differences are not well understood by many clinicians or educators. Misunderstanding can lead to unintentional bias that translates into suboptimal patient care and medical errors. Although some bias is conscious, the majority of bias is unconscious. Asking appropriate questions can help elucidate potential bias. Examples of initial questions to consider that will illuminate potential gender bias can be found in Table 5. These questions can serve as a teaching tool for faculty and students. They can easily be used with case presentations, in journal clubs, and with many other teaching methods. These questions are the underlying questions that Summit presenters and participants have asked to be better scientists, clinicians, and educators.
Sex and Gender Health Education Teaching Tool: Sex and Gender Bias Questions Across Domains
Asking questions about bias will improve not only clinical care, but it will also affect how we address health problems on a societal level through public health initiatives. The task for health profession educators is to uncover these biases for themselves and for their students. Providing faculty development about integrating sex and gender into curricula will be essential for success.
Conclusion
The SGHE was a national collaboration dedicated to engaging educational thought leaders from various health professions to create a roadmap for integrating sex- and gender-based evidence into health education. This was the first large-scale national effort directed toward the integration of sex and gender knowledge into the education of all health professionals.
Summit participants now form a national network of educators and clinicians who recognize the centrality of sex and gender to health professionals' knowledge and practice. They have the tools to begin creating networks within their home institutions. Some participants have already begun collaborating to share knowledge and resources. Follow-up surveys will assess the impact of the Summit at both the local and the national levels. As new resources become available, that information will be shared with Summit attendees. A future Summit (planned for 2020) will provide opportunities to engage even more curriculum leaders within the health care landscape.
These educational efforts to integrate sex and gender into multiple health professions curricula will ultimately ensure more personalized health care delivery.
Footnotes
Acknowledgments
Special thanks to the SGHE Summit Administrative team including Katherine Jenkins, Summit Logistics lead; Leanne Johnston, Administrative Program Coordinator, Center of Excellence in Women's Health Utah, BIRCWH and WRHR Programs; Laura Gardner, Summit Social Media Lead, MD Candidate 2019, University of Utah School of Medicine. Additional gratitude to SGHE Summit Outreach Team that includes Kristine Lalic, coordinator, Adina Greene, Lori Horhor, Sally Kim, and Tannaz Safari.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
Funding for the Summit was provided by the American Medical Women's Association (AMWA), the Laura W. Bush Institute for Women's Health (LWBIWH), the Mayo Clinic, the University of Utah Health as well as Texas Tech University Health Sciences Center School of Medicine, University of Utah School of Dentistry, National Association of Nurse Practitioners in Women's Health, Brown University Division of Sex and Gender in Emergency Medicine, Florida State University College of Medicine, and consumer education and advocacy organization, HealthyWomen.