Driving sex and gender integration in Australian health and medical research, policy, and healthcare delivery

Both sex and gender are terms used to describe a constellation of characteristics or constructs. Sex refers to a set of biological characteristics in humans and animals that can include chromosomes, hormones, or sex organs. Sex is usually classified as female or male, but there are natural variations in sex characteristics, and some people are born with sex characteristics that do not fit the medical norms for male or female bodies. Sex can change over the course of the lifetime and, in humans, may differ from their sex recorded at birth.

Gender in humans is distinct from sex, and comprises gender identity, behaviour, experiences, social norms, and power dynamics. Gender exhibits natural variation within the population, and may change over the lifespan. A person’s gender is not always binary (man or woman). Gender attitudes and behaviours are complex and change across time and place, and gender should be understood in relation to other social categories.

Sex and gender impact all health conditions (irrespective of whether they present in males, females, or both) – from prevalence, risk factors, and symptom presentation, to trajectory, prognosis, and treatment response. Consider the following ways that sex and gender matter to health:

• Some conditions present in only one sex, e.g., perimenopause, and prostate cancer.
• Some conditions can affect anyone (irrespective of sex or gender), but present disproportionately in one sex or gender. This is the case with anxiety disorders (which are twice as common in women relative to men), and Parkinson’s Disease (which is twice as common in males relative to females).
• Some conditions can affect anyone but present differently in people as a function of their sex or gender. For example, the symptoms of cardiovascular disease differ in males and females, and the risk for asthma changes across the lifespan in different ways for males and females.

Sex and gender are routinely ignored in health and medical research and healthcare practices. The overwhelming focus on males and men in medical research has meant knowledge on girls and women, people with variations in sex characteristics, and trans and gender diverse people is lacking – both for sex-specific health conditions (e.g., perimenopause) and for conditions that impact everyone (e.g., heart disease).

The underrepresentation of females and other marginalised sex and gender groups in research comes from a) a lack of understanding of the impact of sex and gender on health outcomes, b) the (erroneous) belief that females are more complicated to study than males due to the influence of ovarian hormones, and c) concerns about the safety of conducting research in people who are, or could become, pregnant.

Failing to properly account for sex and gender differences in health and medical research and practice has led to poorer health outcomes for all people. Consider the following:

• Treatments that were never adequately tested in women were found to be inappropriate (e.g., lower limb prostheses), ineffective or non-beneficial (e.g., lecanemab for Alzheimer’s Disease, or implantable cardioverter defibrillators for primary prevention of sudden cardiac death), or detrimental (greater proportion of adverse drug reactions) in women.
• There is no nationally representative measure of Australia’s LGBTQI+ populations, leading to significant gaps in evidence-based and appropriate health services. People within LGBTQI+ populations face disproportionate health risks in several areas, including higher rates of smoking, harmful alcohol and substance use, and higher rates of mental ill-health.
• Dominant forms of masculinity have negatively influenced men and boys’ willingness to seek help for their mental health. While women have higher rates of depression diagnoses, in Australia and worldwide, men are more likely to die by suicide.

There is now a global movement to introduce research policy to correct the sex and gender biases in health and medicine. For example, sex and gender policies in research funding have been adopted by the Canadian Institutes for Health Research (2006), Horizon Europe (2014) and the US’ National Institutes of Health (2016). A sex and gender policy framework for UK researchers, led by the Medical Science Sex and Gender Equity (MESSAGE) project, was launched in 2024. Such policies require researchers to demonstrate in their funding applications how they have considered or accounted for sex and gender (where relevant) in their research.

Australia lags behind international counterparts in developing sex and gender policies for health and medical research and practice. In 2024, a statement was released by the National Health and Medical Research Council and the Department of Health and Aged Care strongly encouraging all research to consider sex, gender, variations in sex characteristics and sexual orientation. The implementation of the Statement by NHMRC is anticipated in 2025.

An Australian Centre for Sex and Gender Equity in Health and Medicine is needed to bring Australia in line with international standards by advocating for policy change across sectors, facilitating evidence-based implementation of sex and gender policy, and building capacity in the workforce to ensure that sex and gender become routine considerations in health and medical research and practice. The benefits of such systemic changes to Australia include:

• Improved scientific rigour, reproducibility, and research integrity
• Maintain Australia’s position as a leading contributor to globally relevant health and medical innovations
• More equitable healthcare and systems
• Strong economic incentives – e.g., commercialisation opportunities for medical innovations that are fit for purpose in all sex and genders