Sex and Gender

1.  Unit Introduction

This module provides:

• an overview of why sex and gender matter for addictions,
• definitions of the key concepts of sex and gender, and
• how sex and gender can be incorporated into addictions research, treatment and policy.

Key considerations for applying sex –and-gender-based analysis (SGBA) in research, treatment and policy are outlined, as well as examples of how sex and gender can be incorporated into addictions research across diverse research pillars.

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2.  Why include sex and gender in addiction?

It was not long ago that women were routinely excluded from large-scale clinical trials. For instance, most trials for the prevention of heart disease studied middle-aged males and excluded women because of a complex set of assumptions, including the perception that women’s hearts were the same as men’s. In this case and assumption of sameness led to unethical and neglectful treatment of women. Yet, one of the reasons that women were not included in these trials is because of the perception that women’s bodies (hormonally and reproductively) behaved very differently than men’s and that these factors would complicate the collection of safe and reliable data. Therefore, women were enough like men to warrant exclusion from clinical studies, yet, they were too different to be included as part of the same study. This confusing and paradoxical attitude towards sex difference in clinical trials demonstrates the complexities and problems attending to sex difference. The human subjects guideline have changed to require the inclusion of women in clinical trials, yet the question remains of how similarities and differences between men and women will be explored, studied, and compared (Fishman, Wick & Koenig, 1999 p. 18 [emphasis added]).

Sex and gender are increasingly being recognized as important determinants of health and essential aspects of health research (Health Canada, 2003, CIHR 2010, NIH 2011, 2013; IOM 2013; NIDA 2013, see also Gendered Innovations). Both biological (sex-based) and socio-cultural (gender-based) variables and factors contribute to health for individuals. Including sex- and gender based analysis in research can improve our understanding of sex and gender as determinants of health, and of how they interact with other determinants such as age, genetics endowment, ethnicity/race, early childhood experiences, socioeconomic status, geographical location, etc. (Johnson, Greaves & Repta, 2007).

The concepts of sex and gender have slowly been incorporated into health research, but the field of addiction is still lacking in this regard (Poole and Greaves 2007; Greaves, Poole and Boyle, 2015). Addiction is grounded in complex biological and sociocultural etiologies, therefore research on both sex and gender is critical to our understanding of addiction. In 2003, the National Institute of Health Research (NIH) summarized how sex and gender can influence substance use – from sex specific risk factors and pathways to gender-based contexts, responses and treatments. For example, sex-based differences in hormones affect neurochemical and behavioral responses to psychotropic drugs, including motivations to use them (Becker & Hu, 2008, Becker, Perry & Westenbroek 2012).  Gender-based factors can contribute to the pathways that lead to substance use, the physical and social consequences of substance use, and the preferred types of addictions treatment (Poole & Dell, 2005; Poole and Greaves, 2012; CWHN, 2012).

A thorough re-evaluation of sex- and gender-related factors is needed to strengthen our understanding of addiction and inform the development of appropriate, gender-sensitive prevention and treatment strategies.

Despite the demonstrated importance of sex and gender and the progress made in research in the past decade, the concepts are still frequently ignored or misunderstood, contributing to confusion regarding each of their contributions to health (Johnson, Greaves, & Repta, 2007). Including sex and gender in addictions research and treatment and diligently analyzing and publishing results, is crucial for the development of appropriate and effective research, policies, practices, and programs. Such efforts lead to better outcomes and are beneficial for all individuals dealing with addiction and related issues (CIHR, 2010).

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2.1 Defining Sex

We “…need to include both females and males and women and men in biomedical and clinical research because results from one group cannot be applied to the other. Ignoring the influence of sex in research compromises the validity and generalizability of the findings…” (Johnson et al, 2007 p. 5)

Sex is a multidimensional biological construct that encompasses anatomy, physiology, genes, and hormones that together create a human “package” that affects how we are labeled. Common conceptualizations of sex usually employ the female/male binary; however, in reality, individuals’ sex characteristics exist on a continuum that accounts for variation in anatomy, physiology, genes, and hormones.

Males and females differ, for example, in:

• chromosomes (XX = female, XY = male; some individuals have other chromosomal arrangements, such as XXX, XXY, etc.)
• hormones
• body composition
• metabolism

All of these differences can affect the way that bodies respond to alcohol, drugs and therapeutics. Sex hormones in particular have been found to modulate the dopamine reward system- neurocircuitries that play a critical role in addiction and mental health disorders. In animal studies, sex hormones have been shown to have modulatory effects on dopamine activity in male and female rats exposed to drugs such as cocaine (Anker & Carroll, 2011 Becker, Perry & Westenbroek 2012).  In human studies, the menstrual cycle has been shown to affect the response of the dopaminergic system in females and that brain regions involved in processing emotions are differentially activated during the follicular phase compared to the luteal phase (Dreher et al. 2007). For males, they activated different regions of the brain than females when they anticipated rewards.

Other examples of sex differences in addiction include:

• Women who smoke are 20 to 70 percent more likely to develop lung cancer than men who smoke the same number of cigarettes (Manton 2000; Shriver et al. 2000)
• Teen girls’ smoking is associated with increased breast cancer risk (Band et al, 2002)

• Cocaine affects cerebral blood flow differently in men and women, and, among women, cocaine affects cerebral blood flow differently at different stages of the menstrual cycle (Kaufman et al, 2001).

Infant females with prenatal alcohol exposure have greater changes in heart rate and negative affect while males show greater changes in cortisol (Haley, Handmaker& Lowe, 2006)

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2.2. Defining Gender

Gender is linked to sex in how people are expected to present and behave according to socially sanctioned norms of what is expected from an often binary view of sex (i.e. male and female). The construct of gender reflects the socially prescribed and experienced dimensions of “femaleness” or “maleness” yet is variable and is socially, culturally and historically specific. The cultural values attached to gender result in socially prescribed gender roles that shape behaviours and support different and often unequal divisions and distributions of power.

…“in almost every society, higher power and prestige is conferred on individuals occupying masculine gender roles” (Johnson et al, p. 5). Gender interacts with other modalities of power including age, ethnicity, ability, sexuality, and class, typically marginalizing women, ethnic minorities and individuals who do not confirm to sex and gender norms.

Gender Identity can be thought of as a continuum from “masculine” to “feminine”, with each individual locating themselves at point(s) along the continuum. The point of location is not always stable and can change according to time, place and context with some individuals rejecting their prescribed gender, changing it altogether or opting to be gender neutral. Gender can be expressed, imposed or enacted in a range of ways such as dress, talk, occupation, and access to space and resources, money and nutrition.

Gender relations

Gender relations refer to how we interact with or are treated by people in the world around us, often based on our ascribed or embodied gender. These gender relations reflect differences in power, can affect opportunities, and also interact with other modalities of power including age, ethnicity, ability, sexuality, class and other identities. Gender relations exist at multiple levels, affecting personal, intimate relationships as well as interactions within larger units such as the family, the workplace or society at large.

Gender relations are an important point of analysis in the field of addictions. In the context of intimate relationships, women’s drug use may be accelerated or maintained through relationships with men who introduce and supply drugs and/or oppose the entrance of women into addiction treatment (Amaro & Hardy-Fanta, 1995).  Unequal gender relations can also impact the acquisition of drugs, the engagement of women to procure drugs via sex work or criminal activities, or exposing and using vulnerabilities to engage in mutual substance use. Some vulnerabilities can lead to an increase in violence or abuse, among any gender group.

Institutional gender 

Institutional gender reflects how power in society is often distributed based on gender categories that permeate political, educational, religious, media, medical and social institutions. These central and powerful institutions often reinforce and help to shape binary and unequal gender norms that define, produce, reproduce, and justify different expectations and opportunities for women and men and girls and boys. These institutions impose social control on women and men by regulating opportunities, impose limitations, dress codes, and govern access to resources, public space, leisure time and political power.

With respect to addictions, institutional gender inequities are reflected in research that has historically ignored or excluded women, meaning that we have less knowledge about how substance use impacts women then we do with men. Institutional gender is also reflected in the lower distribution of resources to women in need of treatment or detoxification, or the imposition of stigma on pregnant women and mothers who use drugs, tobacco or alcohol. These imbalances both reflect and perpetuate gender differences in power and resources, and can serve to keep vital program and policy changes from happening.

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2.3 Intersections of Sex and Gender

Sex and gender can interact and mutually shape one another—biology can affect gender and gender can affect biology—shaping health and producing differing health outcomes (Johnson, Greaves, & Repta, 2007). The interactions between sex and gender influence the risk of contracting infectious diseases or developing chronic diseases, as well the outcomes of a disease (Johnson, Greaves, & Repta, 2007). For example, women experience specific inequities related to sex and gender that impact their susceptibility to contracting HIV and the medical care they receive for HIV infection. Firstly, sex-based vulnerability occurs because is tied to the vagina being is physiologically more susceptible to contracting sexually transmitted infections (STIs) than the penis (Darroch & Frost, 1999). Secondly, gender-based inequities with respect to level of power in and control over sexual relationships and condom use place women at a greater risk of contracting HIV (Amaro & Raj, 2000). Lastly, gender roles related to family and childcare obligations may delay women’s seeking of treatment for HIV/AIDS (Johnson, Greaves, & Repta, 2007).

Sex and gender also intersect in important ways with a variety of other social factors and processes, such as age, race and racism, sexuality and homo- or trans- phobia or discrimination based on, socioeconomic status, geographical location, education, mental health status or, accessibility to health care.  Often, sex and gender-based inequities that women face may be further compounded among racialized or marginalized persons, when multiple and intersecting issues augment vulnerability and powerlessness. For example, Indigenous women in Canada face multiple and intersecting forms of oppression that can create barriers to their accessing meaningful health care services, increase participation in “high-risk” behaviours such as substance use, and increase their exposure to violence, thus in turn increasing their susceptibility in contracting HIV (Varcoe & Dick, 2008). Likewise, racism and transphobia can interact to put racialized trans persons who experience high levels of both at particularly high risk for HIV (Marcellin, Bauer, & Scheim, 2013), as well as mental health and substance misuse.

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3.1 Considering sex and gender in addictions research

Sex and gender are important components in the comprehensive understanding of addiction. Yet research in this area remains largely inadequate and underdeveloped. Key reports from National Institutes for Health and the Canadian Institutes for Health Research recommended the following to improve uptake of sex and gender in research:

• Incorporate sex and gender into the study design and analysis to elucidate the role of these important health determinants in addiction and treatment on a broader level
• Examine sex and gender differences in current populations of drug users employing appropriate methodologies and objective measures to ensure that the available evidence is accurate and up-to-date
• Investigate sex and gender influences using multi- and trans-disciplinary perspectives in order to promote insight into novel therapeutic targets
• Focus on evaluating the efficacy of sex- and gender-sensitive treatment programs in comparison to standard gender-neutral interventions in adequately designed randomized trials to determine whether these specific approaches lead to improved treatment outcomes
• Evaluate individual treatment outcomes among men and women that would provide valuable information for the development of personalized patient-centered treatment strategies

While Health Canada (2012) issued guidelines for the inclusion of women in clinical trials and the National Institutes of Health (2012) issued a report on the inclusion of women and minorities in clinical research, yet we still need guidelines to address:

• robustness of data
• adequate presentation and publication of data
• inclusion of women at all stages of the research process

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3.2 Considering sex and gender in addictions treatment

It is important to use research on sex and gender to inform clinical practice when it comes to managing and treating addiction among men and women and transgendered persons. First, it is necessary to implement appropriate education and prevention strategies for all substance users, but also tailored to men and women, and transgender persons individually.

Women also experience a greater burden of disease from substance dependence with respect to medical problems, health outcomes, and social impairment, elucidating the need for interventions that address these core areas of functioning for women.

• Behavioural therapy and social services can supplement current pharmacological treatments to use an integrated, holistic model of care
• Given how common gender-based violence and trauma are in women’s lives, and how commonly women identify self medication for trauma symptoms as related to their substance use, it is important to offer safe, gender specific, trauma informed addiction treatment
• Emphasizing the need for fundamental services, such as vocational counselling, childcare and parenting assistance, medical assistance, and smoking cessation among women is likely to significantly improve the treatment and management of substance use disorders and related harms

(Click to view larger image)

Source: FASD and Women’s Health: Setting a women centered research agenda  BCCEWH 2002 Reprinted with permission from the authors

• Although very little research has been dedicated to understanding appropriate mental health interventions for transgender persons (i.e. research has typically grouped transgendered persons with sexual minority groups), there is evidence that highlights the importance of strategies to increase social inclusion for trans people. Social support, reduced transphobia, and having any personal identification documents changed to an appropriate sex designation have been linked to significant reductions in suicide risk and depression (Bauer et al, 2015). Of particular importance is access to health care services for medical transition through hormones and/or surgery (Bauer et al, 2015).
• Gender-sensitive substance use treatment programs should be made accessible across various geographic jurisdictions on both a provincial and national scale. Some existing programs include:
  • Residential treatment for women – Womankind Addiction Service (Hamilton, ON), Jean Tweed Centre (Toronto, ON), Heartwood Centre (Vancouver, BC), Aventa Treatment Centre (Calgary, AB), Family Treatment Centre (Prince Albert)
  • Drop-in/outreach programs for pregnant women – Sheway (Vancouver), Herway Home (Victoria), Maxxine Wright Place (Surrey), Breaking the Cycle (Toronto) HER Pregnancy Program (Edmonton), Manito Ikwe Kagiikwe (The Mothering Project, Winnipeg) , See also Unit 3 for detail on Sheway’s model of care.
  • Centre for Addiction and Mental Health Rainbow Services (LGBTTTIQ) provides counselling to lesbian, gay, bisexual, transgender, transsexual, two-spirit and intersex people who are concerned about their use of drugs and alcohol. (Toronto, Ontario)
• Attention to the distinct sex- and gender-specific characteristics of addiction experienced by men is needed. Few resources are available on men-specific programming for addiction, however some resources are emerging on men-specific programming for childhood sexual abuse.
• Okoli, C. T. C., Torchalla, I., Oliffe, J. L., & Bottorff, J. L. (2011). Men’s smoking cessation interventions: A brief review. Journal of Men’s Health, 8(2), 100-108. doi:10.1016/j.jomh.2011.03.003
• Healing the Hurt: Trauma-Informed Approaches to the Health of Boys and Young Men of Color  fpg.unc.edu/~pas/PDFs/Drexel_HealingtheHurt_FullReport.pdf
• Wilken, T. (2008) Rebuilding Your House of Self Respect: Men recovering in group from childhood sexual abuse. 2nd edition. Hope and Healing Associates. http://www.silencetohope.com/

Fallot, R., & Bebout, R. (2012). Acknowledging and Embracing “the Boy inside the Man”: Trauma-informed Work with Men. In N. Poole & L. Greaves (Eds.), Becoming Trauma Informed (pp. 165-174). CAMH

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3.3 Considering sex and gender in public health policy

Rather than assuming that “one size fits all,” considering sex and gender is an important process that cues us to ask questions about similarities and differences between and among women and men. By introducing critical questioning and thinking about sex and gender, positive changes can be made in how programs are offered, how policies are designed, or how resources are allocated.

Numerous manuals have been published in Canada to guide program and policy makers on doing Sex-and-gender-based analysis (SGBA) (Johnson, Greaves & Repta, 2007; Clow et al, 2009; Poole and Greaves, 2012).  One such manual lists some questions that might be relevant to policy makers applying SGBA could include:

• How does the policy or program differentially affect women and men, boys and girls?
• Does the policy or program exclude consideration of one sex when it’s meant to be applicable to both sexes?
• Does the policy or program fail to differentiate based on gender identity?
• Does the policy or program exclude one sex in areas that are usually seen as particularly relevant to the other, such as family and reproductive issues about men or paid work about women?
• Does the policy or program take the family or household as the basic analytical unit when different consequences for women and men within the family or household can be anticipated?
• Does the policy or program take the male as the norm for both sexes?
• Is the policy or program different for the two sexes though their circumstances are equivalent?
• Does the policy or program assume that men and women are homogeneous groups when the impact of the issues being studied may be different for different groups of men and different groups of women?
• Does the policy or program account for differences based on culture, race, sexuality or gender identity?

Source:

In the field of addictions treatment and policy, questions policy makers might consider include:

• Do women and men develop a dependency on a substance at the same rate or through the same pathways?
• What makes men and women respond differently to methadone treatment?
• How do men and women experience the physical and social consequences of addiction differently?
• What types of addiction treatment programs work better for women? For men? How might culture or gender identity be taken into account?
• Do tobacco reduction strategies work the same way for men and women?

In employing SGBA, it is also critical to recognize and consider the intersection of multiple aspects of individual identity and experience when it comes to explaining health, illness and opportunities for change, including income, class, race, language, sexual orientation, gender identity, education, geographic setting, age and/or life stage.  In addition,

SGBA is useful for thinking through non binary gender categories and how they may relate to addictions issues.

SGBA is an important process for policy makers in planning programs, developing policies and conducting research.

By requiring us to think broadly as well as specifically about who we are trying to serve and whose needs we are trying to meet, SGBA promotes inclusive policies, appropriate and cost‑effective services and good science, and ultimately can contribute to personalized medicine and tailored policy.

Activity: Applying SGBA in an Addictions Health Policy  

The Policy Issue: Tobacco Reduction

Approximately 1 billion men and 250 million women smoke tobacco cigarettes daily (Mackay & Eriksen, n.d.). Sex and gender affect the use and effects of tobacco for women and men. For example, differences in genetics, lung anatomy and physiology between women and men potentially increase the harm associated with women’s exposure to tobacco smoke (Mennecier et al, 2003).

Similarly, gender influences how, when, and where women and girls use or are exposed to tobacco (Clow et al, 2009). For example, unequal power dynamics between women and men may reduce women’s ability to control exposure to second‑hand smoke (Greaves et al, 2007). Due to these sex and gender differences in tobacco use, there is a critical need for a SGBA analysis of policies aimed to reduce tobacco use.

Gender-sensitive Policy-making:

While gender-blind policies may appear to be unbiased or regarded as neutral, they are frequently based on information pertaining to men’s activities and/or assume that women affected by the policies have the same needs and interests as men (Kabeer, 2003). In contrast, gender-sensitive policies aim to take into account the different social roles of men and women that lead to women and men having different needs. According to Kabeer’s framework, and the more recent framework developed by researchers working on women’s health promotion (Greaves, Pederson, & Poole, 2014), there is a continuum of approaches .to action on gender and health – from gender blind or unequal to gender transformative.

Figure reprinted with copyright permission from the authors

Gender-unequal, blind or neutral policies do not specifically target men or women, and are intended to affect both genders equally. However in ignoring gender norms, roles and relations, such policies may actually reinforce gender discrimination. A gender-neutral policy allocates resources to meet specific goals, such as reducing the number of young people who initiate smoking. For example, gender-neutral policy could include restrictions on places where smoking is permitted and increasing taxation of tobacco. While these types of policies are intended to be gender-neutral, their impacts most often are not, and opportunities are missed for approaches that redress inequities.

Gender-sensitive and specific policies identify specific strategies for men or women. Gender-specific policies acknowledge the different socioeconomic and cultural factors that contribute to health for men and women. For example, some tobacco control policies train health workers to use smoking cessation methods and messages that are specific to pregnant women. While such approaches acknowledge different norms and roles for women and men and their impact, they do not address underlying causes of gender differences and inequities.

Gender-transformative or redistributive policies acknowledge that women are often excluded or disadvantaged in terms of access to social and economic resources and involvement in decision-making because of political and economic inequality (WHO, 2010). The aim of gender-redistributive policies is to “rebalance the power structure to create a more balanced relationship between men and women” with strategies that target both sexes (WHO, 2010; p. 195) in gender synchronous ways. Gender transformative approaches include ways to transform harmful gender norms, roles and relations and promotes gender equality.

For example, Greaves and Tungohan (2007) suggest that integrating tobacco control policies with housing or child-care programmes has the potential to “transform gender relations.” Tobacco control thus has the potential to go beyond simply reducing women’s vulnerabilities to tobacco and to move towards the achievement of greater gender equity. (Greaves & Tungohan, 2007; Greaves, 2014).

Questions:

1. This section focuses on incorporating considerations of gender into tobacco policy? What might be an example of incorporating sex?

2. Frequently, tobacco policy has tended to exploit existing gender relations or accommodate, reinforce, and reproduce them. For example, tobacco control policies that specifically target women for “protection” can be viewed as paternalistic Programmes that target pregnant women or smoking at home in the presence of children can be viewed as accommodating and reinforcing women’s traditional gender roles without doing anything to change them. Can you think of an example of a policy that might do this?

Remember that gender intersects with other modalities of power including age, ethnicity, sexuality, class, etc. For example, women with limited education or vocational opportunities may have to work in settings such as restaurants, where they are more likely to be exposed to second-hand smoke. What might be an example of a gender-sensitive policy that also considers these intersections?

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4. Key considerations for integrating sex and gender based analysis (SGBA)

Calls for inclusion have both justice and “scientific” rationales, and these don’t always fully overlap. While inclusion is “right” to ensure that the benefits of research are shared by all and that the risks, too, are distributed fairly, including a group because they are identified as women needs to be justified on other grounds: are sex/biology or gender questions to be addressed? Further, if expectations of biological differences are the basis for inclusion, are there reasons to anticipate that differences between sexes will be more important than those within a sex? In other words, while the biological impact of sex differences must be considered, we must also be cautious and not assume all women are alike and/or that there is something fundamental (“essential”) about being a woman that pertains to all females. As well, we need to guard against making false assumptions that all male/female differences are necessarily biologically determined. Most important to avoid are assumptions that arbitrary biological traits are markers of innate differences between males and females (Lippman, p. 11-12).

Sex and gender based analysis refers to the process of integrating sex and gender into addictions research, treatment and policy (Clow et al 2009). There is no single formula for its application. This means that while the principles and concepts upon which SGBA is based remain constant, the application may vary depending on the research question and approach, the methods used, what is known or assumed about a specific population and the extent to which sex and gender perspectives already inform knowledge and action. Importantly, SGBA is iterative, which means that those doing the analysis must regularly reflect on their process and be able to adjust to include new directions and insights and address gaps.

Some important considerations for conducting SGBA include:

• you do not presume that differences exist between sexes/genders
• you do not presume that differences do not exist between sexes/genders
• you do not presume that a given sex, sexual orientation or gender identity is homogenous

Sex, sexuality, and gender are often oversimplified into binaries. For example, it is commonly assumed that:

• Sex = female/male
• Sexual orientation = homosexual/heterosexual
• Gender = men/women

As with many categories and concepts, a balance must be found between “lumping” (assigning examples too broadly) and “splitting” (refining definitions into too many categories to be useful).

The way forward will include defining sex and gender more carefully in your analysis and working toward a higher degree of precision in measuring and reporting on differences and similarities.

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5. Three Ways to Incorporate a Sex- and Gender-Based Analysis to Addiction Research

Johnson et al (2007) recommend the following strategies for incorporating SGBA into addictions research

• Revisit an original study
• Augment an existing research plan

Incorporate an SGBA from the outset

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5.1. Revisit an original study:

This approach is useful for studies that did not originally differentiate by sex and gender. It can provide a new analytical dimension; does not involve changing the original research question or design and can be used as a complementary stage of analysis after the research has taken place.

Questions you should ask

• Does the study take one sex as the norm?
• Does the research assume men and women are uniform within their sex/gender groups?
• Are measures of sex and gender appropriate?
• Does the analysis account for differences between the sexes and genders, and also within these groups?
• What questions, literatures, and theories are employed
• Are the terms “sex” and “gender” conflated or confused

Reanalyze the data

• can refine a researcher’s findings and improve claims about applicability of research
• interrogate the assumption that sex and gender are not relevant to the phenomenon under question
• interrogate the assumption that “women” and “men” are homogenous groups – probe for differences and similarities within and across the categories of sex and gender

Perform a secondary analysis

• goes further than “reanalyzing” the data
• uses previously collected data in a new study, with different:
  • organizations of data
  • statistical analyses
  • research questions
  • perspectives on the original research question

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5.2 Augment an existing research plan

• This approach is ideal for projects in the initial stages of research when minor additions & revisions are reasonable. It can also useful for researchers studying one sex or gender and want to extend or replicate their study to include other dimensions of sex or gender.

1. Add to or divide the sample

• add a sample of women to a study on men
• add a sample of men to a study on women
• divide a sample into men and women, rather than studying an issue without differentiating the sexes
• include female animals in animal studies
• run cell culture studies with both female and male cell lines

2. Add measures

• use sex and gender measures to further analyze complexities in research

3. Mix your methods

• use both qualitative and quantitative methods
• g., using a quantitative method, such as a large-scale survey or clinical test, followed up by qualitative interviews or focus groups
• g., start with qualitative study to bring issues to the surface that underpin future quantitative studies

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5.3 Incorporate SGBA from the outset

This approach helps investigators to adopt concepts of sex and gender into their research from the initial stages of planning so that sex and gender can be fully integrated into the framework and design. Studies in this category typically take three forms: 1. studies on females/women, 2. comparative studies on females/women and males/men, and 3. multilevel studies that examine multiple layers of sex and gender, that is, the individual, group, institutional, and social layers of sex and gender.

1. Women/Female Only Studies

• ensure the theoretical framework and methodology are suitable for studying females, that these frame the types of questions that can be asked, the ways the data will be collected, the manner in which the findings are given over to analysis
• investigate differences among females
• ensure sample is representative of the population to which you will generalize the results
• investigate effects of gender in biological health studies – what is it about women’s experiences that make their health issues distinct

2. Comparison Studies

• illuminate the differences between the groups
• investigate trends and patterns over time to find gaps and differences

3. Multilevel Studies

• examine many layers of sex and gender
• g., examining the interplay between genes and the environment and how this affects the health of individuals
  • g., looking at the relative contributions and interplays between sex, gender and diversity variable, taking into account that “women” and “men” are heterogeneous groups

Examples of sex and gender analysis in addictions research from across research pillars

It is important to note that all research pillars and disciplines investigating addiction can incorporate sex and or gender into their study designs. Quantitative, qualitative and mixed methods can be applied. Below is a sample of studies from across research pillars-conducted by trainees and mentors in the Intersections of Mental Health Perspectives in Research Training program.

Biomedical

Uban K. A., Comeau W. L., Ellis L. A., Galea, L. A. M. & Weinberg, J. (2013). Basal regulation of HPA and dopamine systems is altered differentially in males and females by prenatal alcohol exposure and chronic variable stress. Psychoneuroendocrinology. Vol. 38(10): 1953–1966

Uban, K. A., J. H. Sliwowska, et al. (2010). Prenatal alcohol exposure reduces the proportion of newly produced neurons and glia in the dentate gyrus of the hippocampus in female rats. Hormones and Behavior. 58: 835-843.

Weinberg, J, J H Sliwowska, N Lan, and K G C Hellemans. 2008. “Prenatal Alcohol Exposure: Foetal Programming, the Hypothalamic-Pituitary-Adrenal Axis and Sex Differences in Outcome.” Journal of Neuroendocrinology 20 (4): 470–88. doi:10.1111/j.1365-2826.2008.01669.x.

Population and Public Health

Richardson L, Greaves L, Jategaonkar N, Bell K, Pederson A, and Tungohan E. (2007) Rethinking an Assessment of Nicotine Dependence: A Sex, Gender and Diversity Analysis of the Fagerstrom Test for Nicotine Dependence. Journal of Smoking Cessation. Volume 2, Number 2 pp. 59-67.

Edalati, H. E. and M. D. Krank (2012). Multilevel analysis of longitudinal alcohol and marijuana use as a function of gender, neglect, and violence in adolescents. Alcoholism: Clinical & Experimental Research. 36.

Clinical

Farstad, S. M., von Ranson, K. M., Hodgins, D. C., El-Guebaly, N., Casey, D. M., & Schopflocher, D. P. (2015). The influence of impulsiveness on binge eating and problem gambling: A prospective study of gender differences in community adults. Psychology of Addictive Behaviors, 29, p. 805-812.

Torchalla, I, V Strehlau, K Li, I A Linden, F Noel, and M Krausz. 2014. “Posttraumatic Stress Disorder and Substance Use Disorder Comorbidity in Homeless Adults: Prevalence, Correlates, and Sex Differences.” Psychology of Addictive Behaviors 28 (2): 443–52. doi:10.1037/a0033674.

Woodin, E. M., Caldeira, V., Sotskova, A., Galaugher, T., & Lu, M. (2014). Harmful alcohol use as a predictor of intimate partner violence during the transition to parenthood: Interdependent and interactive effects. Addictive behaviors, 39(12), 1890-1897.

Health systems and services

Benoit, Cecilia, Camille Stengel, Lenora Marcellus, Helga Hallgrimsdottir, John Anderson, Karen MacKinnon, Rachel Phillips, Pilar Zazueta, and Sinead Charbonneau. 2014. “Providers’ constructions of pregnant and early parenting women who use substances.” Sociology of Health & Illness no. 36 (2):252-263. doi: 10.1111/1467-9566.12106.

de Finney, S., Greaves, L.,  Janyst, P., Hemsing, N., Jategaonkar, N., Browne, A.J., Devries, K., Johnson, K., & Poole, N. (2013). “I had to grow up pretty quickly”. Cultural and gender contexts of Aboriginal girls’ smoking. Pimatisiwin: A Journal of Indigenous and Aboriginal Community Health, 11(2), 151-170.

Poole, N., & Bopp, J. (2015). Using a community of practice model to create change for Northern homeless women. First Peoples Child & Family Review, 10(2), 122-130.

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6. Summary and suggested reading

Key points

• Sex and gender are increasingly being recognized as important factors, variables and health determinants and therefore as essential aspects of health research, especially in the field of addiction
• Sex and gender are fluid, related and interact, but are often understood as binary according to social and cultural norms. Yet individuals define themselves and get defined, in relation to these concepts in diverse, contradictory and often fluctuating ways according to time, culture and context
• Rather than assuming that “one size fits all,” sex- and gender-based analysis (SGBA) reminds us to ask critical questions about similarities and differences between and among women and men.
• Sex- and gender-based analyses are crucial for developing appropriate and effective health and addictions research, policies, practices, and programs that lead to better outcomes for individuals dealing with addiction and related issues
• Integration of sex and gender in research can be applied across disciplines using qualitative, quantitative or mixed methodologies, and by modifying or improving measures

Suggestion for further reading

• Oliffe, J. L., & Greaves, L. (Eds.). (2011). Designing and conducting gender, sex, and health research. Sage Publications.

Gender, Sex and Health Research Guide: A Tool for CIHR Applicants

What a Difference Sex and Gender Make: A Gender, Sex and Health Research Casebook

Clow, B, Pederson, A., Haworth-Brockman, M., & Bernier, J. (2009). Rising to the Challenge: Sex- and Gender-Based Analysis for Health Planning, Policy and Research in Canada.

Johnson, J.L., Greaves, L., & Repta, R. (2007). Better Science with Sex and Gender: A Primer for Health Research. Vancouver: Women’s Health Research Network.

Online courses:

Sex and Gender in Biomedical Research

Women’s College Hospital: Women’s Exchange SGBA resources

BCCEWH: methods for SGBA

Canadian Women’s Health network: SGBA resources

Rising to the Challenge: SGBA e-learning resources

NIH Methods and techniques for integrating the biological variable of sex into preclinical research

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7. Unit References

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Madeo, B., Zirilli, L., Caffagni, G., Diazzi, C., Sanguanini, A., Pignatti, E., … Rochira, V. (2007). The osteoporotic male: Overlooked and undermanaged? Clinical Interventions in Aging, 2(3): 305–312.

Marcellin, R.L., Bauer, G.R., & Scheim, A.I. (2013). Intersecting impacts of transphobia and racism on HIV risk among trans persons of colour in Ontario, Canada. Ethnicity and Inequalities in Health and Social Care ;6(4):97–107.

Mennecier, B., Lebitasy, M.P., Moreau, L., Hedelin, G., Purohit, A., Galichet, C., et al. (2003). Women and small cell lung cancer: social characteristics, medical history, management and survival: a retrospective study of all the male and female cases diagnosed in Bas‑Rhin (Eastern France) between 1981 and 1994. Lung Cancer; 42(2): 141‑152.

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Paton, L.M., Alexander, J.L., Nowson, C.A., Margerison, C., Frame, M.G., Kaymakci, B., Wark, J.D. (2003). Pregnancy and lactation have no long-term deleterious effect on measures of bone mineral in healthy women: A twin study. American Journal of Clinical Nutrition, 77(3): 707–14.

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