research study about gender and development

Gender and Development

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• Shelley Feldman 4  

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This chapter offers a brief historical overview of research focused on gender relations and practices within nongovernmental organizations (NGO) and state institutions, as well as national policies that have unfolded in Bangladesh. Research in the early years of Bangladesh’s independence focused on rural relations, household and reproductive labor, and the norms of purdah that guided programs and projects that sought to improve women’s lives and livelihoods. With the rise of the garment manufacturing sector in the 1980s, women’s entry into the urban labor market shifted attention to new issues related to the transformation of women’s work within the changing urban landscape and labor market. This new opportunity for women also drew attention to changing household and family relations and women’s increased mobility. Significantly, the garment sector is credited with helping to realize economic growth in the country, where Bangladesh is now positioned as a lower middle-income country, even as women’s central contribution to this effort often goes unremarked.

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This is, arguably, a narrow focus, limited to research that is directly tied to development issues. It does not include the rich and growing literature that offers gender and feminist analyses of, for example, nationalism, international relations, or religion.

UN Development Programme. 2010 Human Development Report: Asian countries lead development progress over 40 years. http://hdr.undp.org/en/media/PR6-HDR10-RegRBAP-E-rev5-sm.pdf

In 1977, the World Bank appointed a Women in Development Adviser and in 1984 mandated that its programs consider women’s issues. Reflecting the shift from WID to GAD, a 1994 policy paper sought to question policy and institutional constraints that maintained gender disparities and limited the effectiveness of development programs.

WID scholars and practitioners, for example, pressured US policy makers to include women in their activities, which resulted in the 1973 Percy Amendment to the US Foreign Assistance Act, requiring USAID’s programs to support efforts to integrate women into their respective national economies. To be clear, this presumed that integration meant, first, recognizing women as members of the body politic, and, second, neither understanding their exclusion nor challenging the development approach that excluded them.

During this period, academic women formed Women for Women , a research and advocacy group that examined women’s education (Islam, 1982 ), health and medical practices (Islam, 1980 , 1985 ), gender violence (Jahan, 1983 , 1988a , 1988b ), and women’s economic position (Huq et al., 1983 ; Jahan, 1975 ).

This was written for Development Alternatives with Women for a New Era (DAWN).

In moral regulation and rule I include critical engagements with the symbolic and practical work that purdah or credit, among other practices, produce, enable, and constrain.

This historicization of gender and development highlights the long-term process of women’s engagement in in-kind and wage work, a concern elided in most research on women yet central to critiques of the assumptions of the WID/WAD/GAD approaches to understanding gender relations. It is also noteworthy that these studies were supported by the Ministries of Agricultural and Local Government and Rural Development and funded with external financial support.

There is a vast literature on micro-credit and finance, far too broad to elaborate here, taking multiple sides in the debate on its value for empowering women or indebting women, focusing on credit or on patriarchy, and examining whether credit decreases or increases domestic violence against women. See, for example, Kabeer ( 1998 ), Karim ( 2008 , 2011 , 2014 ), Nijera Kori ( 1990 ), Goetz and Gupta ( 1996 ), Hashemi et al. ( 1996 ) and Rozario ( 2007 ).

Other NGOs also advocate for such freedoms but do not work as women’s or feminist institutions (see, e.g., Odhikar, Bangladesh).

Two excellent collections responding to Rana Plaza are Saxena ( 2020 ) and a special issue of Development and Change , Volume 50, Issue 5.

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Acknowledgment

This chapter is part of a project that has received funding from the European Union’s Horizon 2020 research and innovation program under the Marie Skłodowska-Curie grant agreement No 665958.

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Feldman, S. (2022). Gender and Development. In: Khondker, H., Muurlink, O., Bin Ali, A. (eds) The Emergence of Bangladesh. Palgrave Macmillan, Singapore. https://doi.org/10.1007/978-981-16-5521-0_12

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• Published: 17 April 2024

Towards Gender Harmony Dataset: Gender Beliefs and Gender Stereotypes in 62 Countries

• Natasza Kosakowska-Berezecka   ORCID: orcid.org/0000-0003-3503-3921 1 ,
• Tomasz Besta   ORCID: orcid.org/0000-0001-6209-3677 1 ,
• Paweł Jurek   ORCID: orcid.org/0000-0002-9958-3941 1 ,
• Michał Olech 2 ,
• Jurand Sobiecki 1 ,
• Jennifer Bosson   ORCID: orcid.org/0000-0003-2566-1078 3 ,
• Joseph A. Vandello 3 ,
• Deborah Best   ORCID: orcid.org/0000-0002-6715-0957 4 ,
• Magdalena Zawisza 5 ,
• Saba Safdar 6 ,
• Anna Włodarczyk   ORCID: orcid.org/0000-0003-2106-5324 7 &
• Magdalena Żadkowska 1  

Scientific Data volume  11 , Article number:  392 ( 2024 ) Cite this article

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• Human behaviour

The Towards Gender Harmony (TGH) project began in September 2018 with over 160 scholars who formed an international consortium to collect data from 62 countries across six continents. Our overarching goal was to analyze contemporary perceptions of masculinity and femininity using quantitative and qualitative methods, marking a groundbreaking effort in social science research. The data collection took place between January 2018 and February 2020, and involved undergraduate students who completed a series of randomized scales and the data was collected through the SurveyMonkey or Qualtrics platforms, with paper surveys being used in rare cases. All the measures used in the project were translated into 22 languages. The dataset contains 33,313 observations and 286 variables, including contemporary measures of gendered self-views, attitudes, and stereotypes, as well as relevant demographic data. The TGH dataset, linked with accessible country-level data, provides valuable insights into the dynamics of gender relations worldwide, allowing for multilevel analyses and examination of how gendered self-views and attitudes are linked to behavioral intentions and demographic variables.

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Background & summary.

The Towards Gender Harmony project ( https://towardsgenderharmony.ug.edu.pl/ ) started in September 2018 with more than 160 scholars who have built an international consortium that collected data in 62 countries and six continents. Our overarching goal was to analyze contemporary perceptions of masculinity and femininity using quantitative and qualitative methods, marking a groundbreaking effort in social science research. Such multinational research is important, as it helps us move beyond the WEIRD perspective of Western, Educated, Industrialized, Rich and Democratic countries which heavily predominates in psychology 1 , 2 , 3 .

It has been more than 30 years since a similar large cross-cultural study examined understandings of masculinity and femininity. John Williams and Deborah Best established that universally, across 26 countries, (1) communality is associated with femininity and agency is associated with masculinity, and (2) women view themselves as more communal than men and men view themselves as more agentic than women 4 . While communality and agency are universal dimensions of human evaluation 5 , 6 underlying gender stereotypes and gendered self-views, the measures used in Williams and Best to capture communality and agency were not subjected to rigorous psychometric procedures for ensuring scales’ cultural invariance and equivalence. Further, because some of the data reported in Williams and Best were originally collected around 1977, they do not reflect the influence of dramatic changes in gender roles that have altered contemporary gender stereotypes 7 . It is thus important to reexamine these gender constructs today but with culturally invariant and equivalent measures. Our dataset includes contemporary data reflecting individuals’ gendered self-views, their descriptive, prescriptive, and proscriptive stereotypes about women and men, and a selection of gender beliefs and attitudes reflecting the contemporary literature of social psychology and society as a whole.

What is more, our project is unique as it examines the under-researched topic of the universality of stereotypes about men who, according to results of research (carried out so far mainly within Western cultural contexts), face strong pressures for conformity to norms such as agency, dominance, pursuit of high social status, and avoidance of femininity 8 , 9 . Apart from including contemporary measures of gendered self-views, attitudes, and gender stereotypes, we have also collected relevant demographic data. As a result, our Towards Gender Harmony dataset, linked with accessible country/nation-level data, offers powerful insight into the dynamics of gender relations worldwide, allowing for multilevel analyses and examination of how gender beliefs are linked to behavioral intentions and demographic variables.

This dataset has been so far used to test men’s support for gender equality across countries 10 ; to establish cross-culturally valid, psychometric properties and correlates of precarious manhood beliefs 11 ; to examine binary gender gaps in agentic and communal self-views 12 ; to investigate whether the degree of endorsement of precarious manhood beliefs at the country level was associated with various risk-related health behaviors and outcomes 13 , to test the double standard in gender rules across countries 14 ; and to test whether country-level precarious manhood beliefs were associated with more negative attitudes, fewer rights, more restrictive laws, and reduced safety for LGBTQ+ groups 15 .

To gather data, we conducted a cross-sectional survey study employing a rigorous approach encompassing questionnaire development, data acquisition, data processing, and statistical analysis techniques. Our study aimed to investigate contemporary perceptions of masculinity and femininity across different regions of the world. We prioritize transparency and reproducibility, ensuring that our methods are accessible to fellow researchers.

Questionnaire development

To collect pertinent information, we meticulously designed comprehensive questionnaires (refer to the Measures section for detailed content). Participants completed a battery of scales measuring a broad range of variables concerning gender beliefs and gender stereotypes (the full list is available at https://osf.io/7tza3 ).

Data acquisition

We adopted the convenience sampling method, aiming to recruit a minimum of 200 participants from each country. We sent out invitations to researchers to participate in our project using mailing lists aimed at psychology researchers across the globe. These mailing lists included the International Association of Cross-Cultural Psychology, the International Academy for Intercultural Relations, and the European Association of Social Psychology. To reduce cross-national differences due to potential confounding variables (e.g., education, age) that might occur if relied on more heterogeneous samples, we asked each collaborator to obtain a university student sample of at least 100 women and men. We have also made special efforts to recruit colleagues from underrepresented countries and continents and contacted individual colleagues. Data collection occurred between January 2018 and February 2020, as part of a broader cross-cultural research project (accessible on OSF: https://osf.io/mq48y ). Our participants consisted of undergraduate students who volunteered their time and, in most countries, received no compensation. We obtained ethical approval from the Ethics Board for Research projects at the Institute of Psychology, University of Gdańsk (no. 11/2018) and local Institutional Review Boards, and all participants provided informed consent. The order of measures was randomized, and data collection was facilitated through the SurveyMonkey or Qualtrics platforms. In rare instances, participants completed paper surveys.

Data processing

We took steps to ensure data quality and integrity throughout the data processing phase. Subsequently, we conducted data cleaning procedures to identify and address missing values, outliers, and inconsistencies (detailed in the Data Records section).

By adhering to these rigorous data collection and processing procedures, we aimed to generate reliable and robust findings concerning contemporary perceptions of masculinity and femininity across diverse global contexts. This commitment to transparency and thorough methodology ensures that our research can be comprehended and replicated by other scholars in the field.

All the measures used in the project were translated into 22 languages (Armenian, Chinese, Croatian, Danish, Dutch, English, Filipino, French, Georgian, German, Italian, Lithuanian, Norwegian, Polish, Portuguese, Romanian, Russian, Serbian, Slovak, Spanish, Turkish, Ukrainian). Bilingual scholars in psychology used the back-translation procedure to create national versions of each scale. The English version of the scales was used as the basis for all translations.

Gendered self-views and gender stereotypes

Gendered self-views.

Participants indicated the extent to which 12 agency-related traits, 12 communality-related traits, 12 dominance-related traits, and 12 weakness-related traits described them on a scale from 1 (does not describe me at all) to 7 (describes me well). Traits were selected from a pool of 472 prescriptive gender stereotypes (see supplementary material for the adjectives selected, Table  S1 and https://osf.io/7tza3 ) 4 , 8 , 16 . In addition, using the same scale, they also rated the following traits: gifted in science, gifted in math, linguistically gifted, and gifted in humanities.

Descriptive stereotypes

Participants rated the same set of traits (12 agency-related, 12 communality-related, 12 dominance-related, 12 weakness-related) on a scale from 1 (more frequently associated with women than men) to 7 (more frequently associated with men than women). In addition, using the same scale, they also rated the following traits: gifted in science, gifted in math, linguistically gifted, and gifted in humanities.

Prescriptive and proscriptive stereotypes

Participants rated the prescriptive (desirable) and proscriptive (undesirable) nature of the traits (12 agency-related, 12 communality-related, 12 dominance-related, 12 weakness-related) by answering “How desirable is it in your society for a woman [man] to possess this trait?” on a scale from 1 (not at all desirable) to 7 (very desirable). In addition, using the same scale, they also rated the following traits: gifted in science, gifted in math, linguistically gifted, and gifted in humanities.

Gender Beliefs & Attitudes

Precarious manhood beliefs.

We administered a short version of the Precarious Manhood Beliefs (PMB) scale 17 . Based on an exploratory factor analysis of 7 items from Vandello et al . 17 , we selected four items with loadings >0.45 that conveyed beliefs that manhood is difficult to earn (“Some boys do not become men no matter how old they get,” “Other people often question whether a man is a ‘real man’”) and easy to lose (“It is fairly easy for a man to lose his status as a man,” “Manhood is not assured – it can be lost”). Participants indicated their agreement on a scale from 1 (strongly disagree) to 7 (strongly agree).

Gender essentialism

Participants’ essentialist beliefs were measured with five items (e.g., “Their underlying nature makes it difficult for men to learn to behave more like women 18 ) on a scale ranging from strongly disagree (1) to strongly agree (7).

Ambivalent sexism

We used six items from the short version of the Ambivalent Sexism Inventory (ASI) 19 , which measures Hostile Sexism (HS) and Benevolent Sexism (BS). We selected items from Rollero et al . 19 with factor loadings >0.50. HS items were: “Women seek to gain power by getting control over men,” “Women exaggerate problems they have at work,” and “When women lose to men in a fair competition, they typically complain about being discriminated against.” BS items were: “Women should be cherished and protected by men,” “Men are incomplete without women,” and “Women, compared to men, tend to have superior moral sensibility.” Items were answered on scales from 0 (strongly disagree) to 5 (strongly agree).

Ambivalence toward Men

We used six items from the short version of the Ambivalence toward Men Inventory (AMI) 20 , which measures Hostility toward Men (HM) and Benevolence toward Men (BM). We selected items from Rollero et al . 20 with factor loadings >0.50. HM items were: “Men will always fight to have greater control in society than women,” “Men act like babies when they are sick,” and “Most men sexually harass women, even if only in subtle ways, once they are in a position of power over them.” BM items were: “Men are more willing to put themselves in danger to protect others,” “Every woman needs a male partner who will cherish her,” and “A woman will never be truly fulfilled in life if she doesn’t have a committed, long-term relationship with a man.” Items were rated on a 0 (strongly disagree) to 5 (strongly agree) scale.

Collective action intentions to support gender equality

To measure intention to engage in collective behaviors for gender equality, we used items taken and modified from two scales. All items were rated on a scale from 1 (not likely at all) to 7 (very likely). Instructions started with a sentence stem (“To support gender equality, how likely it is that you would …”) followed by a list of actions. Four actions, modified from Tausch et al . 21 , included: “participate in demonstrations”; “sign a petition”; “block buildings or streets, and “disturb events, where advocates of inequality appear.” Six actions, modified from Alisat and Reimer 22 , included: “become involved with a group (or political party) focused on gender issues/gender equality (e.g., volunteer, summer job, etc.)”; “consciously make time to be able to work on gender issues/(support) gender equality (e.g., working part time for an organization, contribute to raise awareness about gender issues, choosing activities focused on gender issues over other leisure activities)”; “participate in a community event which focused on gender issues”; “Used online tools (e.g., Instagram, YouTube, Facebook, Wikipedia, Blogs) to raise awareness about gender issues/gender equality”; “Participated in an educational event (e.g., workshop) related to gender issues/gender equality”; “Spent time working with a group/organization that deals with the connection of the gender issues/gender equality to other societal issues such as justice or inequality”.

Identification with gender

Participants’ identification with their gender was measured with two items (“Being a member of my gender group is an important part of how I see myself”, “To what extent you consider yourself feminine/masculine”; based on van Breen et al . 23 . Responses ranged from 1 (not at all) to 7 (very much).

Awareness of gender inequalities

Participants’ awareness of gender inequalities was measured with one item: “Overall, our society currently treats women less fairly than it treats men”. Responses ranged from 1 (strongly disagree) to 7 (strongly agree).

Gender roles and expectations

The items “What do you think women should prioritize?” and “What do you think men should prioritize?” were asked to assess societal attitudes and beliefs regarding gender roles. Respondents answered using a scale from 1 (Having a family) to 7 (Having a career). These items provided insights into broader societal norms related to gender roles and expectations. Individual preferences were also measured by similarly asking respondents what they would prioritize themselves – having a family or having a career.

Zero-sum beliefs about gender status

Participants’ zero-sum beliefs about gender status were assessed in two ways. The first was by the six-item Zero-Sum Perspective on Gender Status Scale (ZSPGS) 24 . The scale consists of items reflecting zero-sum beliefs in specific domains: occupational (‘More good jobs for women mean fewer good jobs for men’), power (‘The more power women gain, the less power men have’), economic (‘Women’s economic gains translate into men’s economic losses’), political (‘The more influence women have in politics, the less influence men have in politics’), social status (‘As women gain more social status, men lose social status’), and familial (‘More family-related decision making for women means less family-related decision making for men’). The second method was a more general single-item zero-sum perspective of gender status measure: ‘Declines in discrimination against women are directly related to increased discrimination against men’. Response options for each item ranged from 0 (strongly disagree) to 5 (strongly agree).

Culture-related Relevant Measures

Autonomy and embeddedness values.

In this study, the 10-item scale for measuring Autonomy vs. Embeddedness values was employed, following Vignoles et al . 25 . This scale, derived from the Portrait Values Questionnaire 26 , assessed participants’ orientations towards Autonomy (e.g., “It is important to this person to think up new ideas and be creative; to do things one’s own way.”) vs. Embeddedness (e.g., “Living in secure surroundings is important to this person; to avoid anything that might be dangerous.”) values. Participants assessed how well the description matched their own characteristics or traits from 1 (very much like me) to 6 (not at all like me).

Power distance beliefs

Participants’ power distance beliefs were measured using four items 27 . These items (e.g., “There should be established ranks in society with everyone occupying their rightful place regardless of whether that place is high or low in the ranking”) measured attitudes about societal ranks, requesting salary increases, questioning authority decisions, and formal communication with superiors. Responses ranged from 1 (strongly disagree) to 7 (strongly agree).

Subjective socio-economic status

The Subjective Social Status Ladder 28 often referred to as the “Social Status Ladder”, was used to gauge an individual’s perception of their relative social position within their country. Respondents were asked to choose a number on the ladder from 0 (representing the lowest social status) to 10 (representing the highest social status) to indicate where they perceive themselves to be in comparison to others.

Attention checks

The survey also included three attention checks in which participants were asked to mark on a scale from 1 to 7 indicated numbers (“If you are reading this please choose 3”).

Demographic variables

At the end of the questionnaire demographic information was collected. We asked participants to declare their age, study major, gender identity, education level, marital status, number of children, citizenship, and sexual orientation/identity. We also measured migration background and ethnicity (with a list of major ethnic backgrounds, if necessary adjusted/extended to meet local cultural contexts). Additionally, we ask who fulfilled the role of financial provider in the family, who fulfilled the role of homemaker in the family, and how would they describe the place they grew up (a city, a town, the countryside/remote place/rural area. Finally, our demographic part included questions about religiosity and religious denomination as well as political orientation.

Data Records

The data comprising the TGH project results are stored in a single table. The data table is available in the repository 29 in three formats: csv, xlsx, and Rda. The dataset contains 33,313 observations, each in a separate row, and 286 variables, each in a separate column. A detailed description of the variables can be found in the Supplementary Excel File titled ‘CodebookTGH.xlsx’, available in the Towards Gender Harmony full dataset repository 29 , which also includes a link to an interactive map with descriptive statistics and a summary of selected published statistics – the map will be developed with more analyses. The variable description consists of the following components: ‘ID’ – a unique sequential number for the item/variable (ranging from 1 to 286); ‘Variable Name’; ‘Measure’ – reference to the measurement tool used to assess this variable (containing the respective item); ‘Scale’ – the dimension, the name of the theoretical variable composed of items assigned to the scale; ‘Label’ – the content of the survey item; ‘Level of measurement’ – information about the level at which the variable/response to the item is expressed (nominal, ordinal, interval, or ratio); ‘Values’ – the range of values the variable can take; ‘Value Labels’ – possible response categories.

The dataset contains only responses provided by the study participants. Aggregated variables requiring, for example, the averaging of selected items (according to the key) must be calculated separately. To facilitate this process, we provide R code enabling the calculation of selected variables ‘TGH total scores code.R’ is available in the repository 29 .

Sample composition

We summarize the sample composition, including sample size, gender distribution, and descriptive statistics regarding age, for 13 distinct world regions, as illustrated in Table  1 . Additionally, we have provided detailed data for the 62 countries under study in the Supplementary Table  1 . As previously mentioned, our participants consisted of undergraduate students who volunteered their time. After data cleaning, the final dataset comprises 33,313 observations from 62 countries across 13 world regions. As can be seen in Table  1 and Supplementary Table  1 , both country-level and regional-level samples exhibit variations not only in terms of sample size but also in gender distribution and age distribution parameters.

Technical Validation

Data cleaning procedure.

Data cleaning is a crucial preparatory step to ensure the quality and reliability of data for subsequent analysis and modeling tasks 30 . In the TGH project, the data-cleaning procedure involved the following steps:

Data Integration: Data from various countries were provided by collaborators in separate files. We combined data from multiple sources into a unified dataset, resolving any inconsistencies in variables or units.

Data Inspection: We examined the dataset to identify inconsistencies, missing values, or outliers. We paid particular attention to data integrity, making sure that values either fell within acceptable ranges or adhered to predefined rules including verification of completeness of the data in all the scales, congruity between nominal categories in different countries. During this stage, we removed records with incorrect responses to attention check questions.

Handling Missing Data: In the TGH database, no data imputation methods were applied. In most cases, records with missing values were retained in the database. Only observations with data gaps preventing the calculation of most measured variables were removed.

Outlier Treatment: Outliers were observed in the age variable. Some responses appeared to contain randomly entered numbers (e.g., 247). Observations with such responses were removed. In a few cases where birthdates were mistakenly entered as ages, we recalculated the age by subtracting the birthdate from the examination date and rounding to full years. Outliers in other variables that could potentially skew the analysis were neither removed nor adjusted.

Data Transformation and Scaling: Due to the use of different response scales (mainly single-item scales) in some countries compared to the standardized scale adopted for the entire study (e.g., using a scale from 0 to 6 instead of 0 to 5), linear transformations were applied to harmonize the data.

Data Formatting: To ensure data format consistency, some responses recorded as labels were encoded into numerical values. The mapping of labels to numbers can be found in the Supplementary Excel File titled ‘CodebookTGH.xlsx,’ available in the repository 29 .

Data Verification: The cleaned dataset underwent validation, including the estimation of reliability ratios for aggregated scores (see Technical Validation).

As a result of the aforementioned operations, 710 observations were removed from the initial dataset ( N  = 34,023). However, further processing is necessary, depending on the objectives of subsequent analyses and due to the presence of missing data in the dataset, to select a subset suitable for testing specific models that involve particular variables.

In addition to socio-demographic variables, the majority of variables under study are psychometric measures. As previously mentioned, the target variables are derived either by averaging/summing responses to items that make up the scale or by calculating them from the results of fitting CFA models. To assess the reliability of these measured variables, it is necessary to employ psychometric techniques. In this field, the most common method for estimating the reliability of such measurements is through the calculation of internal consistency coefficients, such as Cronbach’s (as recommended when raw scores are obtained by averaging/summing responses to items comprising a scale) 31 or McDonald’s omega (recommended when standardized scores are to be derived using CFA results) 32 . Table  2 presents both of these reliability measures for all target variables calculated on the total sample. Detailed data on reliability coefficients calculated for each country separately are provided in Supplementary Excel File titled ‘ReliabilityTGH.xlsx’, available in the repository 29 .

As can be seen in Table  2 , in the vast majority of cases, the reliability of variable measurements, as measured by the coefficient of internal consistency, exceeds the widely accepted cutoff point of >0.70 33 . Only in the case of five measures (i.e., Benevolent Sexism, Benevolence toward Men, Power Distance Beliefs, Autonomy Value, Embeddedness Value) did the results indicate reliabilities below the desired threshold. This partially can be attributed to the use of very short scales (<10 items) to measure these variables. Nevertheless it is advisable to exercise caution in interpreting the results, and it is recommended to thoroughly examine the reliability of measurements for these variables in individual countries (see Supplementary Excel File ‘ReliabilityTGH.xlsx’).

Given the cross-cultural nature of the data, it is essential to establish measurement invariance (MI) before conducting any analyses that compare results between countries. Measurement invariance refers to the consistency of a scale’s measurement properties across different groups or cultural contexts 34 . In simpler terms, it assesses whether the construct being measured is understood and interpreted in the same way across various groups or settings. Typically, researchers report three levels of measurement invariance, which are determined by parameters that are constrained to be equal across groups. The first level, configural invariance, requires the scale to demonstrate the same overall factor structure for all groups; the second level, metric invariance, necessitates that the scale items’ factor loadings be equal across the groups; and the third level, scalar invariance, demands that item intercepts be equal across groups.

For some variables in this study, such analyses have already been conducted and published 10 , 11 , 14 . These analyses involve assessing whether the measurement properties of a scale, such as factor loadings or item intercepts, remain consistent across different groups or countries. Establishing MI is crucial to ensure that any observed differences in the data result from genuine variations in the construct being measured and not from measurement bias or cultural differences.

Moreover, in the context of using the data to calculate country-level scores, it is advisable to test for psychometric isomorphism. Psychometric isomorphism extends the concept of MI by examining whether the underlying psychological structure of the measurement remains consistent across different levels, such as countries or cultures 35 . This analysis goes beyond examining the equivalence of mere measurement properties; it also investigates the constancy of the conceptual meaning and relationships among variables when considering the data at the country level.

These assessments of MI and psychometric isomorphism help ensure the validity and comparability of the data when conducting cross-cultural analyses and making country-level comparisons, providing a robust foundation for meaningful and reliable research findings.

Code availability

We provide R code enabling the calculation of selected variables. This code is available in the repository 29 under the name TGH total scores code.R. Its proper operation requires the use of the R environment at least version 4.3.1 and the tidyverse package 36 .

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Acknowledgements

The results presented in this paper are part of the larger project titled “Towards Gender Harmony” ( www.towardsgenderharmony.ug.edu.pl ), which involves many wonderful people. Here, we acknowledge our University of Gdańsk Research Assistants Team: Agata Bizewska, Mariya Amiroslanova, Aleksandra Globińska, Andy Milewski, Piotr Piotrowski, Stanislav Romanov, Aleksandra Szulc, and Olga Żychlińska for their assistance with programming the surveys and coordinating the collection of data at all sites. We are also thankful to all Towards Gender Harmony collaborators for their assistance in data collection.

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N.K.B. supervised the entire project and data collection. In addition, P.J. and M.O. and J.S. and T.B. were involved in dataset preparation, and P.J. and M.O. were responsible for data validation and data visualization. All Authors (N.K.B., T.B., P.J., M.O., J.S., J.B., J.V., D.B., S.S., A.W., M.Ż.) contributed to the acquisition, analysis, or interpretation of data for the work, and the drafting of the work or revising it critically for important intellectual contributions. All authors have approved this version of the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All persons designated as authors qualify for authorship, and all those who qualify for authorship are listed.

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Kosakowska-Berezecka, N., Besta, T., Jurek, P. et al. Towards Gender Harmony Dataset: Gender Beliefs and Gender Stereotypes in 62 Countries. Sci Data 11 , 392 (2024). https://doi.org/10.1038/s41597-024-03235-x

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Gender stereotypes in schools impact on girls and boys with mental health difficulties, study finds

Gender stereotypes mean that girls can be celebrated for their emotional openness and maturity in school, while boys are seen as likely to mask their emotional distress through silence or disruptive behaviours.

Children and teachers who took part in the study said they feared the mental health needs of boys might be missed at school, which makes them an 'at risk' group.

Researchers have warned of the negative impacts on girls where the manifestation of emotional distress such as crying or self-harm could become "feminised and diminished," so taken less seriously.

They have called for increased awareness of the role of gender in mental health services offered in schools and resultant inequalities.

The study was carried out by Lauren Stentiford, George Koutsouris, Tricia Nash and Alexandra Allan from the School of Education at the University of Exeter. They interviewed pupils at two secondary schools in England to ask them: 'Do you think that girls and boys experience mental health in the same way?'

One school was a mixed grammar school in a predominantly white, middle-class rural area and another was a mixed comprehensive school in a predominantly white, working-class urban area. The research took place in autumn 2022.

Researchers spoke to 34 students aged between 12 and 17. Seventeen students identified as female, 12 as male, and 5 as gender diverse. They also interviewed 18 members of staff, including a headteacher, school counsellor, SENCO, and classroom teacher.

The majority -- 43 out of 52 -- felt girls and boys experienced mental health in different ways because of stereotypes that girls are open about their emotions, but boys will hide them.

One pupil, Willow, said: "Girls are more inclined I feel to talk to each other about [mental health] because we're not told to repress our emotions." Another, Kayla, said: "Boys just don't, they barely tell anyone anything that they don't want to talk about because they feel like they'll be looked at and be told the phrase 'man up' or 'boys don't cry."

The phrase 'man up' was referenced multiple times by different staff members and students in both schools.

Participants spoke of persistent and troublesome expectations that boys should not show their emotions.

Dr Stentiford said: "There was a perception that girls are at an advantage over boys in receiving mental health support.

"Students and staff members tended to position girls as above boys in the hierarchy for mental health support because of their perceived emotional openness. Girls were seen as being more emotionally mature than boys and would actively look for help when they needed it.

"There was also evidence of participants understanding emotional distress as manifesting itself differently in girls and boys in school, with girls more likely to cry or withdraw, and boys more likely to engage in off-task or disruptive behaviours such as 'messing around' in class.

"The implications were that girls are seen as more likely to be identified quickly as in need of mental health support, whereas boys could be 'missed' because their disruptive behaviours are misinterpreted. Both girls and boys therefore remain 'trapped' in unhelpful gender stereotypes around mental health.

"The research suggests there is a new and emerging form of gender inequality, set against the context of a perceived growing mental health 'crisis' amongst young people.

"There are dangers around devaluing girls' wellbeing if 'emotional' girls are seen as unfairly advantaged and taking up time and support for mental health difficulties at the expense of boys, who are seen as particularly 'at risk' and a hidden problem."

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Materials provided by University of Exeter . Original written by Kerra Maddern. Note: Content may be edited for style and length.

Journal Reference :

• Lauren Stentiford, George Koutsouris, Tricia Nash, Alexandra Allan. Mental health and gender discourses in school: 'Emotional' girls and boys 'at risk' . Educational Review , 2024; 1 DOI: 10.1080/00131911.2024.2306947

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Gender therapy review reveals devastating impacts on teens

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A top Human Rights Council-appointed expert has welcomed the decision by all health authorities in the United Kingdom to halt the routine use of puberty-blockers offered to children as part of gender transition services, amid a sharp increase more widely in the number of teenage girls seeking such treatment and concerns that it might disrupt brain development.

The development is in line with several western European countries that have reportedly reduced access to similar gender identity treatments whose benefits were found to be “remarkably weak”, according to a National Health Service (NHS) England-commissioned review, published on 10 April by consultant paediatrician Dr. Hilary Cass.

UN Special Rapporteur Reem Alsalem also welcomed the commitment by the UK Secretary of State for Health and Social Care to implement the implications of the Cass Review.

It “has…very clearly shown the devastating consequences that policies on gender treatments have had on human rights of children , including girls… its implications go beyond the UK,” said the UN Special Rapporteur on violence against women and girls, Ms. Alsalem.

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Referrals spike

The independent rights expert cited the Review’s findings that between 2009 and 2016, the number of adolescent girls referred to NHS-England’s service for gender distress – or dysphoria - increased from just 15 to 1,071.

These referrals “breached fundamental principles, such as the need to uphold the best interest of the child in all decisions that affect their lives ”, the Special Rapporteur insisted, while transgender rights groups have maintained that there are long waiting lists for treatment.

Mental anguish

Noting the “extraordinarily high number of teenage girls” impacted by anxiety and depression in recent years, Ms. Alsalem said it was crucially important that health authorities stopped “rapidly initiating permanent gender transition pathways that usually begin with puberty blockers, which could cause temporary or permanent disruption to brain maturation ”.

Instead, girls potentially seeking “gender affirming interventions” should be offered more holistic psychological support, protected by legislation that should ensure “transition does not become the only option that is acceptable to discuss with them”.

‘Detransition’ support

The same opportunity for wider therapeutic support should also be available to “detransitioners” - individuals who have discontinued gender transitioning - “most of whom are girls”, Ms. Alsalem maintained, in support of the Review’s findings.

“ Far too long, the suffering of this group of children and adults has been ignored or discounted. The report’s findings and recommendation signals that they have been heard, seen, and that their specific needs have been recognised.”

Toxic debate

According to Dr Cass’s report, “many more” young girls are being referred for gender transition treatment today, marking a distinct change from the past, when most requests for medical help came from adolescent boys.

Reiterating an earlier call for tolerance regarding discussions surrounding gender treatments amid a “toxicity of the debate” identified by the Cass Review, Special Rapporteur Alsalem stressed that researchers and academics who expressed their views should not be “silenced, threatened or intimidated” .

Special Rapporteurs are not UN staff and are independent from any government or organization. They serve in their individual capacity and receive no salary for their work.

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Transgender and gender diverse curriculum in medical imaging programs: a case study

• Sidsel Pedersen 1 &
• Lynn Corcoran 1  

BMC Medical Education volume  24 , Article number:  454 ( 2024 ) Cite this article

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Transgender and gender diverse (TGD) individuals face barriers, including harassment and discrimination, when accessing healthcare services. Medical imaging procedures require personal information to be shared, such as date of last menstrual cycle and/or pregnancy status; some imaging exams are also invasive or intimate in nature. Terminology is based on binary sex creating an inherently cis-heteronormative environment. TGD patients fear being outed and often feel a need to function as educators and advocates for their care. Incorporation of inclusive healthcare curriculum related to TGD populations is an effective means of educating new health providers and promotes safer and more inclusive spaces in healthcare settings. Educators face barriers which hinder the creation and implementation of TGD content. The purpose of this study was to examine the impacts educators are faced with when creating and delivering TGD content in their medical imaging curriculum.

A case study of medical imaging programs at a Canadian post-secondary institute was undertaken. Data was collected via semi-structured interviews with faculty. Relevant institutional documents such as strategic plans, policies/procedures, websites, and competency profiles were accessed. Framework analysis was used to analyze the data.

The study found seven themes that influence the development of TGD curriculum as follows: familiarity and comfort with the curriculum and content change process; collaboration with other healthcare programs; teaching expertise; management of course workload and related. duties; connections to the TGD community; knowledge of required TGD content and existing gaps in curriculum; and access to supports.

Conclusions

Understanding educators’ perspectives can lead to an increased sense of empowerment for them to create and incorporate TGD curriculum in the future. Many post- secondary institutions are incorporating an inclusive lens to educational plans; this research can be used in future curriculum design projects. The goal is improved medical imaging experiences for the TGD population.

Peer Review reports

There is an urgent need to improve medical imaging experiences of transgender and gender diverse (TGD) people. Across healthcare programs, including medical imaging programs, TGD curriculum is inadequate [ 1 , 2 , 3 , 4 , 5 ]. By including TGD curricula in educational programs, graduates will be better prepared to provide safer and inclusive environments for this marginalized group which can potentially lead to better health outcomes. A robust understanding of the barriers that faculty face when trying to develop TGD content is needed to ensure that TGD curricula is incorporated into Medical Radiologic Technology (MRT) education.

Transgender and gender diverse patients are often faced with discrimination, stigma, microaggressions, and physical violence when seeking medical care [ 6 ]. Transgender and gender diverse patients include those patients with gender identities or expressions that differ from the gender socially attributed to the sex assigned to them at birth [ 7 ]. Almost 50% of TGD participants in the Trans PULSE Canada [ 8 ] survey described having an unmet healthcare need in the past year. Transphobia has been acknowledged as a major barrier for TGD patients in healthcare [ 9 , 10 ]. To ensure equitable, fair, and safe treatment, healthcare providers must demonstrate entry-to-practice competencies when working with TGD populations [ 11 , 12 ]. Floyd et al. [ 13 ] identified a lack of cultural competence, social stigma, and cis-heteronormative environments as barriers that TGD patients are faced with in radiology departments. A cis-heteronormative environment is based on several assumptions: everyone identifies as the gender they were assigned at birth; those who do not are considered abnormal; and everyone is heterosexual [ 14 ]. As such, these environments are unwelcoming for TGD people. A study of transgender and gender nonbinary (TGNB) patient experiences by Grimstad et al. [ 15 ] found that 70.8% of respondents reported having at least one negative imaging encounter. In the same study, nearly one-third of respondents had to take it upon themselves to educate staff to receive appropriate care.

A review of TGD curriculum implementation in medical imaging programs found that educators acknowledged the importance of adding sexual and gender minority content to curriculum, however they lacked training, resources, and institutional support to develop appropriate content [ 16 ]. There is a gap in TGD content and curriculum in medical imaging programs, but there is also a lack of focus on why educators are not incorporating this type of content into their courses [ 16 ]. This study will lead to a deeper understanding of this issue. Ultimately, this study contributes to the understanding of development and delivery of TGD education in medical imaging programs as well as having the potential to improve the patient experience for TGD people seeking care in the health system.

Case study methodology was used in this study to facilitate development of theory, evaluation of programs, and development of interventions [ 17 ]. This method is also fitting for early, exploratory research where there is minimal understanding of the phenomena [ 18 ]. The aim of this study was to examine the impacts educators are faced with when creating and delivering TGD content in their medical imaging curriculum. The setting for this exploratory single case study was a polytechnic post-secondary institution in western Canada. A polytechnic institution uses an experiential learning model whereby learners engage in theoretical learning combined with applied, practical skills. The diagnostic imaging portfolio consisted of three medical imaging programs: Diagnostic Medical Sonography (DMS), Medical Radiologic Technology (MRT), and Nuclear Medicine Technology (NMT).

Data collection

Data was collected from two sources: semi-structured interviews and institutional documents.

Semi-structured interviews were conducted in-person and online with nine faculty members from the following imaging programs: DMS, MRT, and NMT. The study was introduced to potential participants during a medical imaging faculty meeting. A follow-up email was sent to faculty with a recruitment poster containing information including details related to the study such as anonymity, confidentiality, and safe keeping of data. Semi-structured interviews were conducted using an interview guide; they ranged from 30 to 50 min in length. Interviews were digitally recorded and transcribed using Otter.ai. Participants were given the opportunity to review their transcripts. Following participants’ approval of their transcripts, identifiers were removed to ensure anonymity. This study was approved by the Athabasca University Research Ethics Board and the Research Ethics Board of the polytechnic post-secondary institution in which the research took place.

Institutional and disciplinary documents

Current post-secondary institutional documents as well as documents relating to the MRT discipline were collected. This data was collected because in case study methodology, use of multiple data sources enhances the reliability of the study [ 19 ]. Institutional documents providing details regarding the equity, diversity, and inclusion (EDI) strategy of the post-secondary polytechnic institution were accessed and reviewed. Additionally, a review of the polytechnic’s social media platforms was undertaken. Program specific documents linked to curriculum development were also accessed and reviewed. Disciplinary documents from the national professional association and national accrediting body related to MRT such as competency profiles were another data source. See Table  1 for a list of institutional and disciplinary documents.

Data analysis

Framework Analysis was used in the analysis of this case study. It is a practical approach that provides a way to manage multiple data sets, including interview transcripts and documents [ 20 ]. The overall objective of Framework Analysis is to identify, describe, compare, and contrast key patterns and themes [ 20 ]. The five stages of Framework Analysis are data familiarization, framework identification, indexing, charting, and mapping/interpretation. 20 During data familiarization, immersion in the raw data was completed by reading interview transcripts and documents. Key themes and samples illustrating these themes were tentatively identified. Coding was done in the framework identification stage [ 20 ]. Interview transcripts, institutional and disciplinary documents were coded with the goal of building a functioning framework whereby the themes were conceptually related to one another. Indexing involves an iterative process of systematically linking the framework to the data [ 20 ]. During this stage, categories and subcategories were developed across the data sets and a systematic indexing of this data was established. The charting process involves a considerable amount of abstraction and synthesis while facilitating a summary of the indexed data [ 20 ]. With the formation of charts, indexed themes were categorized. During the final stages of Framework Analysis, mapping and interpreting, comparison of potential areas of interest was completed by examining variations within the categories and subcategories while looking for clusters of data [ 20 ]. Interpretations demonstrated associations and relationships across the data sets.

Two major categories were identified: Individual Attributes and Collective Influences. Individual attributes are qualities held by the educator that impact their ability to develop and delivery TGD content including career choice and educational background; knowledge of and comfort with the curriculum and content change process; awareness of and personal experiences with the TGD community; and an inherent inquiry mindset. Collective influences address the impact that the post-secondary institution has on the individual attributes including visibility of EDI strategies; onboarding processes; and collaboration with healthcare system partners.

Individual attributes

Career choice and educational background.

The reasons participants chose a career in medical imaging and their educational background revealed similarities and differences. Participants indicated biology and anatomy were interesting and that they had always felt they wanted a career in healthcare but not as a physician or nurse. Medical imaging was suitable for those that desired something with a technical focus, yet still allowed for direct patient contact. Though the initial rationale for choosing medical imaging as a career may have had some similarities, the pathway was often unique. For seven of the nine participants interviewed graduating from a medical imaging program was not their first post-secondary experience.

The transition from working clinically as a medical imaging technologist to becoming an educator was also worthy of exploration. Participants mentioned that they had enjoyed working with students in the clinical setting as a technologist, and often gravitated towards formal preceptor roles. They reflected on their own time as a student and remembered instructors that were positive role models. Educators entered the classroom setting with various personal and professional backgrounds and these individual attributes were reflected in their teaching.

Knowledge of and comfort with the curriculum and content change process

Knowing how instructors were informed of curriculum changes and how these changes were implemented in the classroom, labs, or in practicum was important in understanding how instructors thought about and carried out these changes. Differentiating curriculum and content was a starting point. Participants described curriculum as the official learning objectives and outcomes of the course. The curriculum is housed in course outlines which were identified as legal contracts between the students and the post-secondary institution. Accreditation standards and entry-to-practice competencies were referred to when participants explained the curriculum in their own words. Curriculum was described as rigid and onerous with the recognition that it was slow to change and there were processes and timelines for doing these revisions. Alternately, participants described content more dynamically in terms of their teaching practice; content was easy to change and flexible. Legacy content was defined as content from previous course deliveries that was passed down from one instructor to the next. Some participants relied heavily on legacy content for the first delivery of a course offering while others felt more comfortable creating their own content.

With institutional documents, there were policies and procedures pertaining to curriculum review and course outlines, which provided guidance to instructors regarding the content change process. Some instructors mentioned that they gained experience with these processes as part of program redesigns; not all participants had been part of that process. Participants mentioned that curriculum changes were supported, when necessary, but they often felt making content changes could be done with little oversight and as required for course improvement. Overall, the participants understood the importance of curriculum and why the lengthier process to change was required.

Awareness of and personal experiences with the tgd community

Many participants had personal experiences with TGD populations and reported knowing general information about the community. Participants mentioned that concepts such as use of pronouns, gender neutral washrooms, and inclusive space signage were more visible in public spaces such as bookstores, coffee shops, and restaurants. Participants that had personal relationships with a TGD community member were empathic to the negative experiences of these people in the healthcare system.

Participants also sensed a change in the student body on campus. More students openly identify as being part of the 2SLGBTQ + community and participants noted they had students in their classrooms that belonged to the community. The participants reflected on ways that they had begun making their classrooms safer and more inclusive spaces. One participant mentioned asking students to provide names and pronouns during introductions to the lines of communication to any student that may need it.

Inherent inquiry mindset

An inherent inquiry mindset involves the desire for continuous learning and professional growth; this was identified as an attribute of participants in this study. This mindset was one reason for their switch from being a practicing technologist in the healthcare system to becoming a faculty member at an educational institution. This was evident by statements such as:

“I always have desire to learn new things;” “I need to learn the content more in depth before teaching it in the classroom;” “I am a lifelong learner;” “I want to know more about learning theories;” and “when there is a lack of current resources I do further digging to learn more.” There was a clear theme that the desire and need for continuous learning was seen as a benefit to the role of being an educator. Many of the participants expressed the need for continuing their professional growth as well-suited to working in an educational institution with structure and processes.

The visibility of the inherent inquiry mindset theme was also supported in several of the institutional documents. Within the strategic plan there was mention of commitment to excellence where recognition and support of employee excellence is highlighted by way of “hire for a growth mindset curiosity and collaboration.” [ 21 , p. 4]. A recent job posting within in the DI portfolio also alluded to an inherent inquiry mindset as an attribute for the position: “Demonstrates a positive and respectful attitude and has a growth mindset; Committed to quality and engages in continuous improvement; Reflective about personal and professional growth.” [ 22 , p. 4].

Collective influences

Visibility of edi strategies.

A key factor for participants was the strength and visibility of an institutional EDI strategy. Participants indicated that there was a sense that the institution prioritized EDI initiatives across campus, and in the document review and interviews it was evident that all institutional levels were engaged with the EDI strategic plan.

Onboarding processes

Many participants reflected on their transition from working in the healthcare system to becoming a faculty member. There were several indications of formalized institutional onboarding including structured courses and mandatory faculty training. Participants had unique experiences with the onboarding process and for some there was minimal time between hire date and start date in the classroom, which led to minimal onboarding being completed.

Collaboration with healthcare system partners

It was evident that close collaboration with healthcare system partners is required for the programs to achieve and maintain accreditation standards. The relationship between partners and faculty is maintained through a variety of committees. There is a focus on a continuous improvement process to ensure that program curricula meet the needs of healthcare system partners as well as the national competency profiles.

Revision of the research question

As is common in case study research methodology, ongoing examination and interpretation of the data led to refinement of the foundational research question. The revision of the research question is required to ensure that it remains focused and within the scope of the study [ 15 ]. In this study the research question was revised to: How do individual attributes and collective influences impact educators when they are creating and delivering TGD content into medical imaging programs?

Seven themes were identified: familiarity and comfort with curriculum and content change process; collaboration with other healthcare programs; teaching expertise; management of course workload and related duties; connections to the TGD community; knowledge of required TGD content and existing gaps in curriculum; and access to supports. The seven themes that were identified through the data analysis relate to the influences that impact educators when they are creating and delivering TGD content. A connection was drawn between the individual attributes and collective influences that were identified in the results section. See Table  2 .

Familiarity and comfort with the curriculum and content change processes

Individually, participants mentioned varying levels of knowledge and comfort with the curriculum change process at the institution. Many described that they aligned the content directly with the formal course outline. Those that had taken part in a curriculum review and redesign had a better understanding of how to complete changes. From the institutional perspective, documents revealed that there was a formal policy and procedure in place whereby an annual review of curriculum is expected to be completed by leadership and faculty. The process for changing curriculum can be onerous and follows a rigorous cycle with a strict timeline. The instructors vocalized that more guidance around this process could be helpful when discussing the ability to add TGD content. “At times, when I would ask for guidance, or help with certain things [changing content], I felt like I maybe didn’t get as much support as I would have liked.” (Participant #2).

Collaboration with other healthcare programs

Participants had little knowledge of what initiatives in TGD content were being implemented outside of their own course, program, or portfolio. There was a reference to subject matter experts from within the institution, but they were not specifically involved in course content development. Participants alluded to the possibility of having the institution support the creation of a core course within the healthcare programs as many patient-centered competencies for the TGD community were transferable among healthcare providers. Having a core course would ensure experts could collaborate to help create and facilitate common competencies and ensure the terminology and messaging was consistent across the programs. “I wonder if there is a way to go to an expert, and then continue the conversation in our courses” (Participant #8).

Teaching expertise

Instructors at the institution are hired as subject matter experts of their profession and applicants do not require formal teaching education or classroom experience to be hired. A variety of in-house facilitated teaching development courses are offered, to help prepare new instructors for classroom delivery. Courses focus on teaching strategies and delivery of content, “The course through [institution], which deals with lecture creation, content creation as well as grading and feedback” (Participant # 4). Some participants had challenges attending some of these offerings due to scheduling conflicts. There were also a few participants who started teaching a short time after being hired and were only able to complete the courses after already teaching in the classroom.

When instructors are assigned new courses to teach, they rely heavily on legacy content. Much of their time is spent learning the material in a way that makes them feel comfortable teaching it in the classroom. The lack of TGD legacy content made it challenging for faculty members to include TGD outcomes.

Management of course workload and related duties

Participants often mentioned that the biggest barrier to developing and creating new content of any kind was lack of time, “We are developing on the fly as we are teaching” (Participant #3). It was evident faculty felt they were overcommitted and that completing major course updates while managing other work-related duties was a challenge. When instructors were given new courses to teach, they often mentioned that they spent a large amount of time learning the material prior to the start of the course. Participants mentioned that they understood the importance of adding TGD content into the program, but with additional demands of assignable duties and maintaining a work/life balance many did not feel they had the time required to adequately create new content. In the context of limited time, it is important to consider reasons why TGD curriculum is not prioritized by faculty leaders.

Connections to the TGD community

All participants were able to accurately define transgender and gender diversity in their own words but often felt unsure that they were using the correct terminology and questioned their own knowledge around the terms. Personal connections to the TGD community varied among the participants; some mentioned having family members, relatives, or friends who identify as part of the TGD community, others felt there was an increase in their awareness based on social media influences and mainstream media. Many participants were open in sharing some of the experiences that they have encountered and how those experiences influenced their current practice inside and outside of the classroom. “I feel free to add it [inclusive teaching practices] because it matters to me, but there has not been a very strong push [from leadership] that you have to add it” (Participant #4).

There was an expressed interest to learn more about the TGD community and how, as faculty members in a cis-heteronormative environment, they could better support and reflect the needs of the TGD community authentically in their courses. During the interviews, participants recognized that an authentic connection to the community was a key factor in learning about the community and their needs in the healthcare setting. “ You can do a lot of work as an ally, but there is nothing like the experience of a person who is living it ” (Participant #4).

Knowledge of required tgd content and gaps in existing curriculum

During the interviews, there were challenges in defining what was meant by the term “TGD content.” It was clear that there was an overwhelming sense that the programs did not currently include specific TGD content. Participants identified courses in which they believed TGD content could be included. Professional practice was a suitable course in which topics related to TGD patients could be added.

All programs work very closely with healthcare stakeholders to ensure that students are well prepared to enter the workforce. Some participants mentioned that they were interested in incorporating TGD content into their courses despite the lack of prompting from healthcare system partners. This deviated somewhat from the standard that is often seen in programs where incorporating changes to content mimics changes in healthcare (as seen with advancements in technology or updates of protocols). There were concerns expressed that if students were taught new standards in the program that they might experience some pushback from healthcare partners when entering practicum.

Access to supports

Several participants expressed a desire for access to additional resources and supports with TGD content in the classroom: “You can read, and you can read, and you can read. It would be nice with a facilitated workshop” (Participant #7). Many participants mentioned that they had some access to resources required to increase their own knowledge about general EDI topics, but limited access to specific resources dedicated to the TGD community. These supports were often through professional bodies and open-education resources with other post-secondary institutions.

Instructors did not feel that they had enough knowledge and expertise to teach this TGD content in the classroom. There was fear of saying something wrong and unintentionally offending people. The institutional EDI strategic plan included assurances the resources would be available to update curriculum. During the interviews many participants were unaware of any support currently in place within the institution that could help them in their desire to create more TGD content and inclusive classrooms. “That is why we are in the healthcare field is to make patients feel better in a really difficult time in their lives and you can’t really accomplish that task if you are ignorant” (Participant #10).

Transgender and gender diverse content in healthcare curriculum is a novel topic of study. Studies related to increasing EDI content in nursing, medicine, dentistry, pharmacy, and social work can provide further insight for institutional curriculum reforms relating to TGD content [ 23 , 24 , 25 , 26 , 27 ]. In this study, individual attributes and collective influences converged to influence TGD content and curriculum development in medical imaging programs. Themes emerged linked to specific roles associated with both institutional supports and the individual faculty members; this finding is supported by previous research [ 23 , 28 ].

The role of the institution

The significance of institutional support should not be down-played, as without.

leadership support many initiatives and diversity projects would not be possible [ 23 , 27 ]. Perceived ambivalence from leadership or a lack of institutional oversight to include diversity topics impedes faculty members’ abilities to effect change [ 24 ]. Ensuring that all faculty members are provided with resources and training to increase their confidence in these topics is imperative; faculty members report feeling unprepared and worried about using incorrect terminology with students [ 24 , 27 ]. It is important to prioritize accessibility of resources by providing support for faculty to attend education sessions. In this study, participants mentioned that the visible EDI strategies on campus, and support from leadership around various EDI topics encouraged them to work toward development of content and curriculum. A robust institutional strategy can ensure that TGD content is integrated across all program courses as part of the instructional design. Use of consistent language throughout course outlines is imperative. Instructors rely heavily on the course outlines when updating their course content. When updated and consistent language and terminology is used in course outlines, it is more likely this will be replicated in the course content.

The role of faculty

Faculty members have a perceived lack of knowledge and expertise on EDI topics which is a barrier to development and incorporation of EDI content [ 23 ]. If there is only a single faculty member that has the skills and knowledge related to EDI, they are left isolated and carry a large burden of responsibility similar to Indigenous faculty members solely teaching Indigenous content [ 24 ]. Mentoring programs and multi-professional education opportunities can increase awareness and strengthen relationships between faculty members and in turn build competence and confidence around EDI content development [ 29 , 30 ]. Engaging with TGD community members through conversations, mentoring programs, or simulation scenarios can lead to faculty members gaining an improved sense of connectedness to the community and can expand their knowledge and comfort level [ 29 , 31 , 32 ].

The themes in this study are not positive or negative. This is a complex and layered issue and as such, the themes should not be considered an itemized list that can be addressed. The process of addressing barriers to inclusion of TGD content in the curriculum is iterative. With deliberate strategies in place, the capacity of faculty members is developed related to TGD content and care of TGD patients. Over time, the curriculum reflects this development in knowledge. Ultimately, this shift is actualized in the students’ clinical practice with the goal of improving care of TGD patients.

Limitations

There are several limitations related to this study. The definition of a “case” and the approach to undertaking case study research might be considered limitations because there is contention among scholars as to what constitutes a case as well as to the various theoretical traditions used to examine a particular case [ 33 ]. The case for this study involved a medical imaging faculty in a single post-secondary polytechnic institution in Canada which represents a limited sample both in size and diversity related to the identities of participants being interviewed which limits generalizability. The inclusion of several post-secondary institutions across health disciplines would be a compelling next step for future research in this area. In addition, this study was limited to TGD curriculum; it did not include an exploration of development of medical imaging curriculum for intersex people. This topic is also worthy of further study.

Implications

This study highlights the medical imaging educator’s perspective of the influences that currently preclude the development of TGD curriculum. This understanding can lead to an increased awareness of facilitators and barriers for educators to consider when developing TGD content in their courses. Many post-secondary institutions are incorporating an inclusive lens to their strategic plans; this research can be used as a resource for future curriculum design projects. Ensuring that the curriculum is updated will not only help meet accreditation requirements with current national competency profiles but may promote an inclusive learning environment for students. Including this curriculum in medical imaging programs will better prepare graduates in creating an inclusive and safer space for TGD patients in medical imaging settings. From an educational perspective, this study can serve as a guide for increasing awareness of and overcoming factors that currently impact faculty members in creating and delivering TGD. Further commitment and support from leadership will ensure that faculty members feel supported with including and developing TGD content in their courses.

This study also highlights the need for further research in this area. Many of the.

influences that impacted faculty in this study can be linked to the post-secondary polytechnic institution in which it was conducted. This includes the onboarding processes, policies, and procedures as well as institutional strategic plans. To gain a better understanding of these and other barriers similar case studies could be completed at other post-secondary institutions. Completion of a multi-site case study could also be warranted to compare results from medical imaging programs nationally.

This case study was undertaken with the goal of learning more about what impacts an educator is faced with when creating and delivering TGD content in their courses. Collective institutional support is a key factor for enabling individual educators to create and deliver TGD content. These supports begin during the onboarding phase of new faculty, and should include information about curriculum development process, EDI strategies, and additional learning opportunities where faculty members can increase their knowledge and connections with the TGD community. Though appropriate and sustained leadership support can be seen as a catalyst for change, the execution and work must come from the entire faculty. A comprehensive approach where all levels of the institution work together is required to overcome the barriers that currently preclude incorporation of TGD curriculum.

Data availability

The dataset related to documents from the public domain retrieved and analyzed during the current study are available from the corresponding author on reasonable request. The dataset related to interview transcripts generated and analyzed during the current study are not publicly available due to ethical approval. Contact Sidsel Pedersen/[email protected] to request the data from this study.

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SP conceived the research problem and overarching question for this study. SP and LC worked together on the details regarding the study design and methods. Data collection and analysis was undertaken by SP. LC cross-checked data analysis. The first draft of the manuscript was written by SP. Both authors read, reviewed, and revised subsequent versions of the manuscript. Both authors read and approved the final manuscript.

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Why sex and gender matter in implementation research

Cara tannenbaum.

1 Insitute of Gender and Health, Canadian Institutes of Health Research, Ottawa, Canada

2 Université de Montréal, Montréal, Canada

Lorraine Greaves

3 British Columbia Centre of Excellence for Women’s Health, Vancouver, Canada

Ian D. Graham

4 University of Ottawa, Ottawa, Canada

Associated Data

All data generated or analysed during this study are included in this published article.

There has been a recent swell in activity by health research funding organizations and science journal editors to increase uptake of sex and gender considerations in study design, conduct and reporting in order to ensure that research results apply to everyone. However, examination of the implementation research literature reveals that attention to sex and gender has not yet infiltrated research methods in this field.

The rationale for routinely considering sex and gender in implementation research is multifold. Sex and gender are important in decision-making, communication, stakeholder engagement and preferences for the uptake of interventions. Gender roles, gender identity, gender relations, and institutionalized gender influence the way in which an implementation strategy works, for whom, under what circumstances and why. There is emerging evidence that programme theories may operate differently within and across sexes, genders and other intersectional characteristics under various circumstances. Furthermore, without proper study, implementation strategies may inadvertently exploit or ignore, rather than transform thinking about sex and gender-related factors. Techniques are described for measuring and analyzing sex and gender in implementation research using both quantitative and qualitative methods.

The present paper describes the application of methods for integrating sex and gender in implementation research. Consistently asking critical questions about sex and gender will likely lead to the discovery of positive outcomes, as well as unintended consequences. The result has potential to strengthen both the practice and science of implementation, improve health outcomes and reduce gender inequities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-016-0247-7) contains supplementary material, which is available to authorized users.

Efforts to integrate sex and gender throughout all phases of the health research cycle have been rising sharply over the past two decades [ 1 – 4 ]. Since 2010, the Canadian Institutes of Health Research has been requiring researchers to indicate whether their research protocol accounts for sex or gender, using the term “sex” to refer to the biological attributes that distinguish male from female, and the term “gender” to refer to men and women’s socially constructed roles, identities and behaviors [ 5 , 6 ]. As of 2016, the U.S. National Institutes of Health Research asks applicants to explain how they plan to factor consideration of sex as a biological variable into their research design and analysis [ 7 , 8 ]. The Gender Advisory Group to the European Framework Program for Research and Innovation also mandates the Gender Dimension across all sectors [ 9 ]. Journal editors are encouraged to increase accountability around sex and gender reporting requirements, by using the Sex and Gender Equity in Research (SAGER) guidelines [ 10 , 11 ]. These events beg the question: how have research methods in implementation science addressed sex and gender? For the purpose of this article, we will use the term implementation research and practice (IRP) to include knowledge translation, implementation research and practice.

The opening argument for this debate article is that to date, despite the evidence on the impact of sex and gender on health, research methods in the field of implementation have neglected sex and gender considerations. An analysis of selected literature in IRP supports this proposition. For example, a review of the tables of contents and indexes of three popular implementation science texts [ 12 – 14 ] reveals that none devote a chapter to the role of sex and gender in implementation science. Only one includes gender in the index [ 14 ], which refers to a chapter in the text with a few lines describing how many sexually transmitted infection interventions targeting racial/ethnic minorities are gender specific and how the strategies to reach men and women may differ [ 15 ].

Searching the top 10 articles of 2015 as reported by Implementation Science (see Additional file 1 : Appendix 1) for the words sex or gender shows that only one makes a minor mention of gender as it relates to controlling for ‘clinician gender’ in a modeling exercise [ 16 ]. Sex and gender also do not appear to play a prominent role in implementation theories. For example, in Nilsen’s review [ 17 ] of implementation theories, models and frameworks, only 2 make minor references to gender [ 18 , 19 ]. One simply includes ‘gender’ as one of the barriers to optimal clinical practice under the category “health care professional/physician barriers” [ 18 ] and the other includes a footnote about a study they were citing, that “a fourth factor, gender of participants, was also related to program outcomes but was not included in their subsequent analysis” [ 19 ]. Furthermore, neither of the germinal papers on the Theoretical Domains Framework [ 20 , 21 ], a widely used and influential framework [ 22 ] that guides assessment of barriers to implementation, makes any reference to sex or gender. There is a domain in the framework that focuses on ‘social/professional role and identity’, which could capture elements of sex and gender, but usually tends to be limited to assessing professional roles and almost never identity, let alone sex or gender identity.

Turning to the knowledge synthesis literature on implementation, the Cochrane Collaboration’s Methods Equity group [ 23 ] is active in increasing awareness of the need and methods for sex and gender analysis in systematic reviews [ 23 – 25 ]. Both the Effective Practice and Organisation of Care (EPOC) and Consumers and Communication review groups have official guidance in their resources for authors on equity [ 26 , 27 ]. A recent assessment of a sample of systematic reviews from these two groups however, reveals limited consideration of sex and gender in the written report. For example, of 12 EPOC and seven Consumer and Communication reviews published between July 2014 and May 2015, none addressed sex or gender in the analysis or implications sections of the report (Personal Communication, Jennifer Petkovic, Peter Tugwell and Vivian Welch on behalf of the Campbell and Cochrane Equity Methods Group, April 13, 2016). It is possible that the review authors did consider sex and gender in their analyses and determined it was unimportant. However, they failed to report this.

Little research has been undertaken or reported to inform how sex and gender impact IRP, as evidenced by this analysis of key texts, well-used conceptual models, and Cochrane reviews on implementation strategies. The objective of this paper is to describe the rationale for why and how sex and gender should be considered in IRP.

What is sex? What is gender?

A first step for understanding how to integrate sex and gender in IRP involves operationalizing the two terms, and recognizing different components of gender. The term sex refers to a biological construct, whereby an individual is defined as being male or female according to genetics, anatomy and physiology [ 6 , 7 , 11 , 28 – 32 ]. Researchers should use the term sex when describing the number of male or female patients or committee members, or when stratifying outcomes by male versus female participants or health care providers. It is more appropriate to say what the distribution by sex of a sample or target audience is, than to use the term ‘gender distribution.’ This is because gender is a multifaceted and fluid construct, influenced in a temporal manner by social and cultural contexts and environments to create gender norms [ 6 , 7 , 11 , 28 , 30 – 35 ]. Gender norms influence commonly accepted ways of how people behave, how they perceive themselves and each other, how they act and interact, and the distribution of power and resources in society [ 6 , 28 , 31 – 35 ]. Gender can be structured by, and operating within ethnicity, indigenous status, social status, sexuality, geography, socioeconomic status, education, age, disability/ability, migration status, and religion, requiring an intersectional approach to implementing practices, programs and policies [ 36 , 37 ]. The acronym “PROGRESS” can be used to remember these variables: place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital [ 38 ]. Researchers often understand gender as a function of gender roles (e.g. child care, housework), gender identity (e.g. personality traits such as being sensitive to the needs of others or having leadership abilities), gender relations (e.g. social support), and institutionalized gender (e.g. career opportunities, personal income, educational background) [ 6 , 28 , 34 ]. Gender as a broad term can also refer to the expressions and identities of girls, women, boys, men, and gender diverse people [ 39 , 40 ]. For this reason, definitions of sex and gender are evolving as science changes, and it remains challenging to easily separate the biological from the social. Sex and gender are often interrelated, interactive and potentially inseparable [ 6 , 11 ]. Given the epistemology of knowledge, and the social nature of implementation and behavior change, the effect of gender and other identity factors, either alone or in combination, can serve as barriers or enablers to the outcome or impact of IRP interventions.

Measuring and understanding sex and gender

Collecting and analyzing data on sex in IRP is relatively simple if using typical male and female categories. Sex can be self-reported, designated by an examination of external genitalia, or genetically determined based on an XX, XY or intersex genotype [ 11 ]. Data on sex-related factors can include measuring sex hormones, body and organ size, metabolism, or fat tissue distribution [ 41 ]. Gender is more complex, and can be operationalized along four different constructs: gender roles, gender identity, gender relations and institutionalized gender [ 6 , 28 , 31 , 32 ]. Table  1 defines these four constructs, gives examples of key questions that can be asked of each in IRP, and lists measures and methods for use in IRP research [ 6 , 28 , 31 , 32 , 42 – 44 ].

Relevance of four gender constructs to implementation research and practice

Traditionally, individuals are asked to categorize their sex as male or female and many assumptions, often based in gender and not biology, are made on the basis of their responses. Researchers are now rethinking this approach to be more inclusive of gender identity and expression [ 39 ]. A two-step approach to measuring sex and gender identity could first ask individuals to indicate their sex assigned at birth (male/female), and then ask the same individuals how they currently self-identify, which could include male, female, trans male/trans man, trans female/trans woman, gender queer/gender non-conforming; and provide space to self identify as another option not provided [ 40 ]. Similarly, participants could also be given the option to disclose sexual orientation and whether they consider themselves part of the lesbian, gay, bisexual or transgender (LGBT) community.

The scales in Table  1 list measures that can be used to quantify different dimensions of gender. Researchers can also create gender scales using gender-related variables of relevance to their particular research topic [ 45 , 46 ]. Pelletier et al. created a composite gender score using 7 characteristics: 1) status on primary earner; 2) personal income; 3) number of hours per week spent doing housework; 4) status of primary person responsible for doing housework; 5) level of stress at home; 6) masculine traits; and 7) feminine traits. They were able to demonstrate that gender, independent of sex, predicts poor outcome after acute coronary syndrome, pointing to new areas of intervention [ 44 ].

Qualitative methods are also useful for the collection of data on specific dimensions of gender. Case studies, ethnography, narrative and descriptive qualitative approaches can provide evidence and contextualized insight across a range of participants’ personal characteristics, including those of sex and gender. Qualitative methods can also be used to explore concepts of institutionalized gender, and to gain a more in-depth understanding of gender as a barrier or enabler to the use of implementation interventions, the uptake of the evidence-informed clinical interventions or program and the outcomes of implementation efforts. A number of texts, casebooks, examples and online courses are available that provide guidance on how to conduct sex and gender science using commonly employed quantitative and qualitative methods [ 6 , 32 , 42 , 43 ].

The case for considering sex and gender in implementation research methods

Emerging evidence suggests that sex and gender are important in decision-making, stakeholder engagement, communication and preferences for the uptake of interventions. Furthermore, when gender norms, identities and relations are ignored, unintended consequences may occur. The following five scenarios give examples of when and why sex and gender should be measured and considered in implementation research:

• When the implementation of an intervention requires decision-making on the part of individuals or organizations . Decision-making is a critical component of behavior change interventions, and plays a key role in the uptake of new organizational practices and programs [ 47 ]. Research from the fields of business and management offer insights for IRP on important sex and gender factors related to decision-making [ 48 – 50 ]. Qualitative research conducted by Deloitte Consulting with 18 large business organizations suggests that female executives have a tendency to be more attuned to micro-level signaling during meetings, and may favour discovery options and iterative thinking during decision-making processes [ 48 ]. Male executives tend to end a conversation once they connect with a good idea or solution. Their female counterparts are inclined to be more inquisitive, wanting to hear everyone’s thoughts before deciding, and taking more time to find the ideal solution. Different leadership traits among male and female leaders can therefore influence the outcome of decision-making processes [ 49 , 50 ].
• When sex and gender dynamics may play a role in stakeholder engagement and conflict resolution . A survey queried reasoning methods among 624 corporate board directors, of whom 75 % were male and 25 % female [ 51 ]. Female directors scored significantly higher scores on the complex moral reasoning dimension, which implies attending more to relationships and to the challenge of balancing multiple stakeholders’ interests. Females may also engage in more collaboration and consensus building, not only to make sound decisions but also to elicit common support for a course of action [ 49 , 50 ]. The outcome of an implementation intervention may therefore depend on the sex and gender dynamics in each particular context.
• When communication strategies are being tested, as sex and gender may be differentially responsive to the choice of language used, the strength of persuasion of the communication strategy, and the way promotional information is processed . This is why sex and gender form the basis for market segmentation in the fields of marketing and consumer behaviour, where subtle changes in language and emotional appeal can have a differential effect on men and women’s attitudes towards the brand advertised and purchase intentions [ 52 ]. The way messages and interventions are primed or packaged to reflect gender norms or stereotypes may also influence the outcomes of health promotion interventions. For instance, priming individuals to the perception that women eat healthier foods than men leads both male and female study participants to prefer healthy foods, whereas priming masculinity results in unhealthy food preferences [ 53 ]. When the packaging and healthiness of the food are gender congruent (i.e., feminine packaging for a healthy food, masculine packaging for an unhealthy food) both male and female participants rate the product as more attractive, report that they would be more likely to purchase it, and even rate it as tasting better compared to when the product is stereotype incongruent.
• When negative or harmful gender stereotypes may impede the uptake and outcomes of an IRP initiative [ 54 ]. A realist review of the implementation of school-based interventions to prevent domestic abuse for children and young people reported that lesbian, gay, bisexual and transgender youth felt excluded from the programmes, as the content did not address gender identity or sexual orientation in high-risk populations [ 55 ]. Similarly, data suggest that masculine norms around emotional control and self-reliance are associated with recurrent non-suicidal self-injury [ 56 ]. Stigma related to healthcare seeking for male depression and suicide [ 57 , 58 ], may explain why women are more likely to benefit from psychosocial treatment for the prevention of suicide and suicidal ideation compared to men [ 59 ]. Some studies purport that gender bias in prescription patterns among health care providers results in more women receiving treatment with antidepressants for mental health [ 60 ] and pain symptoms, but only among female clinicians [ 61 ]. Men, on the other hand, may be preferentially managed with orthopaedic surgery to manage knee arthritis [ 62 ].
• When gendered power relations may inadvertently skew the uptake of information focused on women’s health needs, such as maternal and child health, sexual and reproductive health, or family planning [ 63 ]. This occurs in cultures and settings where male partners and head of households play a large role in female’s health-seeking behaviour due to their authority and decision-making role. For example, the introduction of health programs enhanced by mobile phone technologies overall fosters women’s empowerment in low-income countries [ 64 ]. However, in some cases these programs exacerbated gender relations and gender inequalities, such as when women were pressured to give the phones provided by the program to their husband if he did not already own a phone, or when conflicts about phone use led to cases of spousal abuse.

The World Health Organization outlines a spectrum of gender-responsive programs, illustrating the progression from the exploitative use of gender stereotypes in IRP messaging, through to accommodation and ultimate transformation to gender equity (Fig.  1 ) [ 65 , 66 ]. Making active choices reflecting content, messaging and decision-making processes during the implementation of an intervention can have a critical impact on gender equity for women and men. Gender transformative approaches are preferred as they anticipate unintended barriers and consequences and address the causes of gender-based health inequities where they exist [ 67 ]. For example, during implementation of a tobacco control program, investigators can decide to use motivational recruitment techniques that appeal to a person’s health and self-respect, as opposed to messaging that invokes and reinforces stereotypical gendered norms of sexual attractiveness, beauty claims or images based on masculinity or femininity [ 63 ]. Recent guidance based on qualitative research suggests de-linking messages for men and for women when promoting tobacco reduction during pregnancy and post partum, since the uptake of the intervention can be hindered by negative couple dynamics if the partners have different smoking behaviours or attitudes about smoking during this period [ 68 – 70 ]. Another transformative approach to encourage uptake of smoking cessation interventions would be to focus on a wider range of non-stereotypical gendered roles that include fathering for men and work for women as potential motivators.

A continuum of approaches for integrating sex and gender. Reproduced with permission from: Lorraine Greaves, Ann Pederson, Nancy Poole (Eds). Making It Better: Gender Transformative Health Promotion. Canadian Scholar’s Press/Women’s Press. 2014. Available at http://promotinghealthinwomen.ca/wordpress/wp-content/uploads/2015/02/Continuum-of-Approaches_colour.pdf Accessed March 20, 2016

Sex and gender can be therefore be pivotal at multiple points along the IRP process, from the content and messaging surrounding the intervention, to decision making around the uptake and unintended consequences of an intervention. Asking sex and gender questions can also elucidate enablers and barriers to the adoption of complex behavioral interventions. For example, examining the outcome of implementing a multidisciplinary cardiac rehabilitation program merits asking whether women or men have less time to devote to recovery and prevention activities due to gender-based expectations regarding their responsibilities at home. The potential advantages of including sex and gender in the study of other complex behavioral interventions (e.g., hand hygiene, reducing clinician's opioid prescribing, reducing falls in hospital, increasing vaccination rates, and obesity prevention) require further investigation. Measuring the way sex and gender influences these interventions may help elucidate potential mechanisms and contexts behind the success or failure of various IRP efforts, as shown in the examples above on tobacco cessation, healthy eating, depression and suicide, pain, heart disease and domestic violence.

Some research questions to drive the selection of methods

Researchers can start by asking a series of questions about how sex and gender can have an impact on their implementation initiative in order to determine the best way to measure and analyze the effect of sex and gender. First, how might sex or gender affect decision-making and stakeholder engagement, or facilitate or impede the uptake of evidence-informed practice, programs, policies? Second, how might sex based characteristics or prevailing gender norms or gender roles serve as barriers or enablers to the uptake of evidence-informed practices, programs, policies? Third, when and how should the communication strategy, wording or messaging be tailored across sex, gender or other identity characteristics? Fourth, when using participatory/collaborative or integrated knowledge translation research approaches, could the sex and gender of the researchers and knowledge users matter, and if so, how? Similarly, how might gender relations as a function of dyads or interpersonal dynamics within an organization, community, workplace or institution influence the outcome of the intervention? And finally, should the research protocol consider examining whether there are unintended impacts of implementation that exacerbate or diminish sex, gender or other diversity-related inequities? Table  2 lists a series of questions for researchers to consider when designing their IRP research. Additional opportunities for integrating sex and gender in IRP as relates to models of health systems research have been reviewed in detail elsewhere [ 33 ].

Some sex and gender research questions for researchers studying implementation

Another way to study issues of sex and gender in IRP resides in the realist approach which attempts to answer the question, “What works, for whom, in what circumstances, and why?” [ 47 ] This is accomplished through the identification and examination of underlying generative mechanisms or program theories associated with the implementation intervention or program, the conditions or contexts under which the mechanisms operate, and the pattern of outcomes produced. Realist evaluators may wish to examine sex and gender through the lens of this Context-Mechanism-Outcomes configuration for the evaluation of new initiatives, programs and scale-up [ 71 , 72 ].

Through this lens, context can be defined as the particular sub-groups for whom the outcomes were successful, the gender relations between the stakeholders, the sex and/or gender of the individuals who implemented the intervention, and the institutional, socio-economic, cultural and political conditions. Mechanism refers to the explanation of how a particular program’s resources work to change the reasoning and responses of participants to bring about the adoption of the clinical intervention or program that results in both intended and unintended outcomes. Outcomes are the impacts of the intervention. Some questions of how sex and gender considerations can align with the Context-Mechanism-Outcomes configuration are: How do gender roles, gender identity, gender relations, and institutionalized gender influence the way in which an implementation strategy works, for whom, under what circumstances and why? Or, how do program theories operate/work within and across sexes, genders and other diversity characteristics, in what circumstances and why? Finally, research results should be disaggregated and reported by sex or gender groups [ 11 ]. It is important to report whether there are similar effects or differences.

When critically appraising the publications of implementation research, reviewers should increasingly ask whether the reports consider sex and gender during a study’s life cycle, and if so, how? Table  3 provides a beginning list of questions that can be asked of implementation research to help the reader assess whether sex and gender have been adequately considered, and the extent to which this may have influenced the study findings and conclusions.

Questions to ask when appraising an implementation research or practice initiative for inclusion of sex and gender considerations

This paper argues that sex and gender should always be considered in implementation research. Considering sex and gender should be an essential component of IRP. Failing to integrate sex and gender may neglect an important determinant of knowledge use, reducing the effectiveness of implementation interventions, inadvertently reinforcing sex neutral claims and negative gender stereotypes, and possibly creating or increasing gender and health inequities in care and health outcomes. Only by consistently investigating sex and gender in a critical and reflective manner that addresses underlying gender inequities, will the field of IRP reach its full potential for meeting the requirements of scientific rigour, excellence and maximal impact.

Acknowledgments

We express gratitude to Jo Rycroft-Malone, Professor of Implementation & Health Services Research, Bangor University, United Kingdom, for providing direction to get out of the “realist swamp.” We also thank Krystle van Hoof, Assistant Director of the CIHR Institute of Gender and Health for her thoughtful comments, and Justin Presseau, Scientist at the Ottawa Hospital Research Institute for insightful discussions about sex and gender in implementation research and the Theoretical Domains Framework. IDG is a recipient of Canadian Institutes of Health Research, Foundation Grant Scheme, Inaugural competition, FDN #143237.

Institute of Gender and Health, Canadian Institutes of Health Research.

Availability of data and materials

Authors’ contributions.

CT, LG and IDG conceived and drafted the article. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

All authors consented.

Ethics approval and consent to participate

Not applicable.

Abbreviations

Additional file.

Appendix 1. List of the top implementation science papers published in 2015. (DOCX 19 kb)

Contributor Information

Cara Tannenbaum, Email: [email protected] .

Lorraine Greaves, Email: ac.cb.wc@sevaergl .

Ian D. Graham, Email: ac.irho@mahargi .

Study Uses Wearable Devices to Examine 3- to 6-Year-Olds’ Impulsivity, Inattentiveness

Wearable Technology Gives Caregivers Insight to Help Children Control Their Attention and Behavior 

Why do some young children struggle to sit through a story one day but not the next? Why do they rush impulsively into one activity but not another? Parents and teachers often focus on individual differences as they prepare children for formal schooling, but traditional measurement approaches make it difficult to study fluctuations in children’s behavior. 

In a new study, researchers sought to understand children’s impulsive and inattentive behaviors in early education classrooms by having students use wearable devices called accelerometers to collect an intensive time series of their movement at school. The study found that children modulated their behavior across periods of the school day and their self-regulation declined across the school week. In addition, children with greater self-regulation were more consistent in applying it across school days. 

The study, by researchers at the University of Pennsylvania and the University of Texas at Austin, appears in Child Development , a journal of the Society for Research in Child Development . 

“When a child has difficulty sustaining attention or sitting still, it disrupts their learning and can disrupt the classroom,” explains Andrew Koepp, a postdoctoral scholar in psychology at the University of Pennsylvania and the study’s lead author. “Research has consistently found that difficulties controlling attention and behavior in childhood predict more difficulties later in life, such as lower educational attainment and more financial problems.” 

Parents’ and teachers’ reports of children’s behavior are subjective and general, rather than specific. Observations in schools and the lab require substantial time and resources, and usually fail to capture ranges of behavior. Wearable devices record data continuously and unobtrusively over a period of days, making them useful in collecting repeated observations. 

In this study, researchers sought to capture children’s behavior directly rather than relying on teachers’ recall of that behavior, hypothesizing that impulsive and inattentive behaviors would be identifiable through intensive observations of their gross motor activity at school. 

By having the children wear accelerometers, researchers collected 2.7 million observations of about 60 children (ages 3 to 6, primarily white and of high socioeconomic status) enrolled in five preschool or kindergarten classrooms at a university laboratory school in central Texas in the fall of 2021; they also asked teachers about children’s behaviors and movement. Machine learning analyses indicated that children’s typical forward acceleration correlated strongly with lower teacher-reported inhibitory control and attention. 

Impulsivity and inattention are believed to emerge from a lack of self-regulation—a broad term for a set of dynamic processes that facilitate the adaptive control of thoughts, emotions, and behavior through both central nervous systems and physiological systems. Using forward movement intensity as a proxy for self-regulation, researchers partitioned the intensive time series to find that: 

• Children modulated their behavior across periods of the school day, 
• Children’s self-regulation declined across the school week, supporting the idea that self-regulation is a resource that can be depleted through repeated use in everyday settings like school, and 
• Children with greater self-regulation showed greater consistency in applying it across days. 

In addition, the study found that the onset, intensity, and duration of children’s gross-motor, full-body movement through space was strongly associated with teachers’ reports of children’s self-regulatory behavior in the classroom. The best predictor was one that captured sustained acceleration (combining onset, duration, and changes in intensity). Surprisingly, sustained acceleration was more strongly related to inhibitory control and attention than to impulsivity. 

“Our study showed that wearable technology can automate the detection of impulsive and inattentive behaviors, facilitating within-child investigations of children’s self-regulation,” says Elizabeth Gershoff, professor of human development and family sciences at the University of Texas at Austin, who coauthored the study. “We also showed that children’s motor actions reveal mental processes that are not directly observable.” 

The authors suggest that tools like the ones they used can yield insights to assist parents and teachers in helping children develop the skills to control their attention and behavior so they can pursue goals and interests. For example, it may be useful for educators to understand that young children may be most calm and ready to learn earlier in the school week and encourage them to adopt a strengths-based approach that focuses on times when children can regulate behavior.  

This research was supported by the National Academy of Education/Spencer Foundation, the University of Texas at Austin, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Science Foundation and the University of Pennsylvania.

Summarized from Child Development , “Leveraging an Intensive Time Series of Young Children’s Movement to Capture Impulsive and Inattentive Behaviors in a Preschool Setting,” by Koepp, A. (University of Pennsylvania), and Gershoff, E. (University of Texas at Austin). Copyright 2024 The Society for Research in Child Development. All rights reserved. 

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LGBTQ Movement Suffers Blow Due to New Study Challenging Push for Child Gender Transition

Posted: April 19, 2024 | Last updated: April 19, 2024

New Longitudinal Study Questions Child Gender Transition

The research found that 78% of participants experienced no gender dissatisfaction. 19% saw decreased dissatisfaction over time, while only 2% reported increased dissatisfaction.

Permanent physical alterations like hormones and surgeries pose risks that can't be undone if gender feelings change. Strict guidelines are needed to limit irreversible treatments for minors.

Conservative Concerns

Some conservatives argue this study confirms skepticism about facilitating childhood gender transitions. Patrick Brown of the Ethics and Public Policy Center said, "This study provides even more reason to be skeptical towards aggressive steps to facilitate gender transition in childhood and adolescence."

He argued that for most, "prudence and caution, rather than a rush towards permanent surgeries or hormone therapies, will be the best approach for teenagers struggling to make sense of the world and their place in it."

Ongoing Debate

This research comes as more US children receive medical interventions to transition gender. The implications intensify an ongoing debate about treatment for transgender youth.

While some see medical intervention as lifesaving, others view it as harmful or unnecessary for those still developing a sense of identity. Additional research on child development and gender is needed to determine best practices.

Research Finds Most Gender Dysphoria Resolves by Adulthood

The study, published in Archives of Sexual Behavior, followed more than 2,700 individuals from preteen years into their mid-twenties.

Over 15 years, researchers periodically surveyed participants about their gender identity feelings, finding a notable decline in dissatisfaction as they grew up.

Change of Mind By Age 25

Initially, around 11% of children expressed some form of gender discontent. However, by age 25, only 4% still felt this way, showing that these feelings often resolve during maturation.

The Tracking Adolescents' Individual Lives Survey studied 2,772 people to explore gender dissatisfaction, defined as unhappiness with the assigned birth gender, and connections to self-image, mental health, and sexual orientation.

History of The LGBTQ Movement

In the 1950s, the Mattachine Society and the Daughters of Bilitis became two of the first major LGBTQ organizations in the U.S., raising awareness of the challenges faced by gay and lesbian people.

The Stonewall Riots of 1969 marked a pivotal moment that catalyzed the modern LGBTQ rights movement. When police raided the Stonewall Inn, a popular gay bar in New York City, patrons fought back, leading to days of protest.

Fighting Discrimination and Demanding Recognition and Rights

Activists campaigned to remove homosexuality from the American Psychiatric Association's list of mental illnesses and passed laws prohibiting discrimination based on sexual orientation.

The AIDS epidemic of the 1980s and 1990s spurred further action as activists fought for research funding and policies to address the health crisis.

Multiple Wins For The LGBTQ Movement

By the 2000s and 2010s, the LGBTQ movement achieved several hard-fought victories. The U.S. Supreme Court struck down laws prohibiting same-sex relationships and marriage.

However, discrimination and barriers to equality persist. The movement continues campaigning for laws banning discrimination in employment, public accommodations, and medical care.

The History of The Transgender Movement and Transgender Children

For centuries, some cultures have recognized the concept of a "third gender" for those who did not fit into the typical gender binary.

The first known gender reassignment surgery took place in Germany in the 1930s. In the 1950s and 1960s, doctors began performing "sex change" operations with increasing frequency.

When Did The Transgender Movement Join The LGBTQ Movement

The transgender movement joined the broader LGBTQ movement in the 1970s and 1980s. Up until that point, the gay rights and transgender rights movements had operated mostly separately.

While the histories of the gay and transgender movements are distinct, they also share many parallels. Bringing the two movements into a broader LGBTQ coalition has helped amplify both causes and build strength in numbers.

The Rise of the Trans Rights Movement

The transgender rights movement began gaining momentum in the 1970s. Activists fought for legal protections and against pathologization by medical and psychiatric institutions.

The 21st century has seen significant strides in transgender rights and recognition. More children can now socially and medically transition at younger ages with the support of their families and doctors.

Wait-and-See Approach

The study suggests a "wait-and-see" approach may be most prudent for kids with gender dysphoria. Rather than rushing into hormone therapy or surgery, adopting a cautious stance allows a child's gender identity to unfold and solidify during adolescence and young adulthood.

The researchers found that 78% of participants experienced no change in gender dissatisfaction over 15 years, while 19% saw a decrease. Only 2% exhibited an increase.

Risks of Early Transition

While some children require medical support, more research is needed to determine appropriate criteria and guidelines. Irreversible physical changes and life-long hormone dependence are serious considerations, especially for minors.

Critics argue that minors are not capable of providing fully informed consent for such impactful procedures. They posit that transition may do more harm than good for kids whose gender dysphoria would have otherwise resolved naturally over time.

Study Methodology and Key Findings

The study utilized data from the Tracking Adolescents' Individual Lives Survey (TRAILS), an ongoing research project launched in 2001 to explore mental health and social development in individuals from early adolescence into young adulthood.

Participants were surveyed at multiple points, starting at ages 11 and 12 and again at ages 19 and 25. Researchers evaluated responses related to gender identity and dissatisfaction to determine how feelings changed over time.

Key Findings in the Netherlands Study

The study's findings highlight three distinct trajectories for gender identity development. Most participants (78%) reported no feelings of gender dissatisfaction.

However, 19% indicated decreasing dissatisfaction over time, while 2% showed increasing dissatisfaction into young adulthood. Females were more likely to report gender dissatisfaction, which was also linked to poorer self-esteem and higher rates of emotional and conduct problems.

Reaction From Transgender Advocates and Critics

Transgender advocates argue that the research does not account for the mental health benefits of gender transition for those who continue to experience gender dysphoria into adulthood.

"For the minority of trans youth who need it, medical intervention can be lifesaving," said Rachel Percelay of the Transgender Law Center. However, critics point out that the findings highlight the risks of premature medical intervention for children and the need for stricter guidelines.

Exercise Extreme Caution When It Comes to Transitioning Minors

"This evidence suggests we should exercise extreme caution before facilitating medical transition among minors," said Dr. Paul Hruz, a pediatric endocrinologist. Hruz emphasized that most children with gender dysphoria will overcome these feelings naturally by adulthood if given proper counseling and support.

"Rather than immediately proceeding to hormonal and surgical interventions, helping children feel comfortable with their biological sex may be a preferable approach for many," he said.

Study Authors Acknowledge The Study Does Have Limitations

The authors acknowledge the study's limitations, including the uncertainty of whether participants were representative of the general population and the possibility of response bias.

However, they maintain that the results provide valuable insight into the developmental course of gender identity in children and adolescents.

The findings suggest that gender dysphoria in children and adolescents may be more transient than previously thought and highlight the need to consider alternative treatment approaches, such as counseling, before pursuing medical intervention.

A Need To Take A Pause With Minors Seeking Transitioning

"This research should give pause to reckless practitioners who are too quick to prescribe irreversible treatments to minors dealing with issues of gender identity," wrote Michelle Cretella, executive director of the American College of Pediatricians.

Cretella called for an end to "unscientific gender ideology" that promotes medical intervention for children. In contrast, advocates argue that treatment should remain patient-centered. "For trans youth, the most important thing is that they have autonomy and self-determination over their own bodies and health care," Percelay said.

Alternatives to Medical Interventions for Gender Dysphoric Youth

Medical intervention for children and teenagers with gender dysphoria has become increasingly controversial, especially in light of new research indicating these feelings may subside over time.

As an alternative to hormone therapy and gender reassignment surgery, some experts recommend a "watchful waiting" approach for youth. This involves ongoing counseling and mental health support without medical intervention.

Counseling and Therapy Before Medical Intervention

For many gender dysphoric youth, counseling and therapy can help address underlying issues contributing to distress over their gender identity and provide coping strategies to manage these feelings.

Both individual and family counseling are effective for some children. Counseling may explore how societal gender expectations influence a child's views of themselves and address anxiety, depression, or trauma that could exacerbate feelings of gender dysphoria.

Social Transitioning as An Alternative

Some families find that allowing a child to socially transition to their preferred gender through a change in hairstyle, clothing, and name can help alleviate distress.

This approach allows a child to explore their gender identity before pursuing medical intervention. Social transitioning is considered a reversible approach, unlike hormone therapy or surgery.

Gender Dissatisfaction Declines into Adulthood

This extensive research provides compelling evidence that gender transition surgeries should not be rushed into for children and teenagers struggling with gender identity issues.

As the study shows, feelings of gender dissatisfaction naturally decline for most individuals as they mature into adulthood. With up to 80% of children resolving their gender uncertainty in the long run, these findings emphasize the need for extreme care when considering permanent medical procedures for minors.

Protecting Children Should Be A Priority

For youth navigating complex gender feelings, evidence-based guidelines must be implemented to avoid irreversible physical changes that most grow to regret.

This research delivers a sobering reality check on the spiking popularity of childhood gender transitions. Medical interventions come with permanent, life-altering consequences that this study proves are unnecessary for the large majority questioning their gender.

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