The Canadian Institutes of Health Research (CIHR) is committed to the advancement of health research in all of its manifestations to produce evidence that will lead to improvements in the health of Canadians, more effective health services and a stronger health care system.
CIHR is taking a leadership role as part of the national and international movement to apply gender and sex based analysis (GSBA) in research.1, 2 This resource guide, designed to help peer reviewers and applicants consider when and how sex and gender are implicated in proposed research projects, is part of a larger initiative to advance GSBA throughout the CIHR thereby embedding it in the culture of health research in Canada. In autumn 2005, the Scientific Director of the Institute of Gender and Health, Dr. Miriam Stewart, and the Vice President Research of CIHR, Dr. Mark Bisby, presented a set of recommendations to the Standing Committee for Oversight of Grants and Awards Competitions and to the annual meetings of the Chairs and Scientific Officers of the CIHR Peer Review Committees. The committees endorsed the implementation of a set of policies and practices on gender and sex based analysis in the CIHR as outlined in the following recommendations to:
The production of this resource guide for use by CIHR peer review committee members and researchers represents the realization of the final recommendation.
Furthermore, these efforts entrench CIHR's compliance with the Federal Plan for Gender Equality that requires all government departments to implement gender-based analysis in the development of their policies and programs.3
Implementing gender and sex-based analysis (GSBA) in health research is fundamental to achieving research excellence. By encouraging the use of this analytical framework, the CIHR can contribute to knowledge about the ways in which sex and gender-and the interactions between them-influence the health of men and women. Gender and sex-based analysis accounts for genetic, physiological, social and cultural diversity in the production of new knowledge across all pillars of health research, ensuring a more relevant and accurate evidence base upon which to develop practice, programs, policies and further research endeavours. This new knowledge leads to new research questions that will contribute to more gender-sensitive information that can enhance the health of all.
Lastly, this resource guide is meant to initiate a conversation between CIHR, peer reviewers, and health researchers on the development of guidelines for the application of gender and sex-based in health research. Your comments are both welcome and necessary to ensure that this resource guide evolves in ways that will meet the needs of as wide an audience as possible. Please see A Work in Progress for information on providing feedback.
This guide was written and produced by
Denise L. Spitzer, PhD
under the auspices of the
Gender and Sex-Based Analysis Advisory Committee
Miriam J. Stewart, PhD
Scientific Director
Institute of Gender and Health
*************
Jean Gray, MD
(Chair)
*************
Stephanie Austin, PhD
Sandra Bentley, RSW
Madeline Boscoe, RN
Geneviève Dubois-Flynn, PhD
Patricia Erickson, PhD
Jamie Flamenbaum, PhD
Lorraine Greaves, PhD
David Hart, PhD
Danielle Julien, PhD
Yvonne Lefebvre, PhD
Louise Robert, PhD
Donna E. Stewart, MD
Deanna St. Prix-Alexander, MPA
As the definitions may vary across disciplines, we begin with an overview of the terms and concepts most often used in the context of GSBA. For instance, the term 'gender' has been used in social sciences for decades; however, its introduction into the medical lexicon is more recent. As a result, gender is sometimes mistakenly employed as an updated version of the term 'sex.'4 In this document, we employ definitions from Health Canada, similarly embraced by international bodies such as the World Health Organization and the European Union, as a shared language across all pillars of health research.2, 5, 6, 7 Importantly, we acknowledge the rich debate regarding the stability and validity of the binaries of nature and culture that underpin the concepts of sex and gender 8,9 and the difficulties in segregating sex and gender influences on health given the interactions between genes and environment.10
"Sex refers to the biological characteristics such as anatomy (e.g., body size and shape) and physiology (e.g., hormonal activity or functioning of organs) that distinguish males and females" (p.8).6 Sex differences may occur at the genetic/molecular, cellular, organ or organism level and result from complex interactions between genetic, hormonal and environmental factors that commence in the genetic and intrauterine environment and continue throughout the lifespan of an individual. 11, 12 Sex differences begin with the observation that every animal-derived cell has a sex.13 Within the context of a continuum of variation, males and females present disparate genetic profiles beyond those responsible for gonadal formation. It has been noted that as most phenotypic females possess two X-chromosomes, they may potentially express twice the gene product as males although doubles are generally suppressed through the process of X-chromosome inactivation also known as lyonization. Importantly, these gene products may be responsible for cellular function, metabolism and growth. Genes on X and Y-chromosomes can code for slightly different variants that may in turn produce different biochemical effects that may contribute to sex differences in physiological responses and function.13 These variations place all humans and animals on a continuum, and may also account for the reactions of males and females to certain pharmaceutical products, differing rates of autoimmune diseases and dissimilar symptom patterns of presentation for heart disease.6, 14, 15 Attention to sex-in all of its variation-is vital to understanding the bio-genetic underpinnings of health.
"Gender refers to the array of socially constructed roles and relationships, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to two sexes based on a differential basis. Gender is relational-gender roles and characteristics do not exist in isolation, but are defined in relation to one another" (p.14).5 All societies are divided between at minimum two categories of sex and gender that are often assigned unequal statuses. Gender roles, constructs and identities exist not as stable entities, but as expressions that are located along a continuum. Ethnicity, socioeconomic status, sexual orientation, geography and other social identifiers situate women and men differently in the social landscape necessarily complicating the relationships between gender, sex and health disparities defined by unequal access to health determinants.16 Notably these dynamic intersections do not produce uniform outcomes, but are constituted, performed and resisted in various ways by individuals and groups throughout the life cycle. Furthermore, the dichotomous pairings of male/female, masculine/feminine and heterosexual/homosexual do not reflect the variations in sex (i.e., intersex), gender and sexuality that represent lived experiences8, 9 which are seldom captured in health research especially in the context of other determinants such as ethnicity and socioeconomic status.17
Gender roles and constructs may have a direct impact on health. For example, care work is generally associated with the female gender role and may contribute to significant health problems attributable to the caregiving burden.18, 19 Moreover, men in some societies, including Canada, may be socialized to value risk-taking behaviours and to inhibit support and help-seeking activities both of which may be detrimental to men's health, although notably not all men embrace these roles throughout their lifetimes.20, 21 Taking gender in all its manifestations into account is essential to the task of generating meaningful health knowledge that can enhance the health of all.
"Sex/Gender-Sensitive Health Research investigates how sex interacts with gender to create health conditions, living conditions and problems that are unique, more prevalent, more serious, or for which there are distinct risk factors for women or men" (p.9).6 As groups of women and men tend to lead different lives that result in disparate environmental exposures and social pressures, responses to these factors are the result of an interaction of genetics, physiology, cultural, social and individual responses-in other words of the interplay of sex and gender. Sex and gender-sensitive health research, therefore, produces knowledge that reflects the complexity and diversity of human health.
"All societies are organized along what Hanna Papanek (1984) has called the 'fault lines' of sex and gender which means that women and men are thought of, treated and go about their lives as different kinds of people with different types of bodies and different roles, responsibilities and opportunities. This can result in women and men having different access to life choices and chances-including economic activity, educational attainment, health and care. Women's and men's health and health needs are different both because of differences in their bodies and also because of differences in how women and men live, work and play"; (p.2). 23
GSBA is meant to be applied within the context of a diversity framework,6 that attends to the ways in which determinants such as ethnicity, socioeconomic status, disability, sexual orientation, migration status, age and geography interact with sex and gender to contribute to exposures to various risk factors, disease courses and outcomes. These intersecting factors have significant impact on health and wellbeing.16, 25 Without these considerations, we may miss or misread the experiences of a significant portion of the population. Using a GSBA lens brings these considerations into focus and can help to formulate research, policies and programs that are relevant to the diversity of the Canadian populace.
The promulgation of GSBA is in part a response to research that either fails to account for sex and gender differences or presumes they exist without evidence. Generalizing from one sex or gender is highly problematic. Between 1977 and 1993, women of childbearing years were banned from participating in clinical drug trials in the United States until the efficacy and safety of the medications were established.26, 27 Fears regarding potential teratogenic effects and concerns about the impact of hormonal fluctuations associated with the female menstrual cycle were cited as reasons for the exclusionary practice.26, 27 GSBA advocates among the scientific and health consumer communities succeeded in removing the restrictions based on the need to test new substances on a diverse sample, especially as women are the major consumers of pharmaceutical products.28 The inclusion of women in clinical drug trials has allowed for the monitoring of adverse effects and for greater consideration of dosage given sexual differences in relative body size, hepatic clearance and metabolism of drugs.29 While women are still not equitably represented in clinical trials, an increasing number of drugs have been withdrawn due to elevated rates of adverse effects among women.14, 30, 31
By failing to capture the complexity and diversity of human health, serious omissions or errors in understanding can lead to poor evidence and inappropriate-potentially injurious-outcomes.32, 33
GBSA demands greater attention to the construction of measurements and variables in research. "There is a risk of overemphasizing sex differences in relation to other anatomical and physiological contributions to population variation . . . the relevant source of variation may be size difference, not the sex difference, and may not apply to small men or large women. It is undeniably easier to record sex rather than measure the relevant body dimensions, but it may not be as good a predictor (Bylund & Burstom, 2003)" (p. 159). 10
GSBA with its attendant sensitivity to sex and gender is vital to the production of ethical research. The Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans clearly states that women may not be excluded from research solely on the basis of sex or reproductive capacity.34 The document emphasizes that: "The inclusion of women in research is essential if men and women are equally to benefit from research. It advances both the commitment to justice and to rigorous scholarly or scientific analysis" (p.53).34 In addition, researchers must not exclude research participants based on sex, culture, religion, disability, sexual orientation or age unless there are valid and specified reasons to do so. More inclusive research contributes to more meaningful and accurate research outcomes that ultimately contribute to a healthier population.
The Federal Plan for Gender Equality (1995) recognizes the need to address sex/gender disparities in health that arise from the diverse and multiple realities of men and women, girls and boys.3 It called for more research on both sex differences in disease and the identification of the health needs of marginalized women. The Plan commits to the development and implementation of gender-based analysis within all government departments. CIHR's application of GSBA is, therefore, in harmony with the government's commitment to ethical and scientifically sound enquiries.
The following examples highlight the significance of attending to sex, gender and their interactions in health research. Neither the examples nor the accompanying questions are exhaustive; they should, however, stimulate reflection as to the salience of sex and gender across the four pillars of health research.
Why are women two to three times more likely to develop lung cancer than men? Why are non-smokers who develop the disease three times more likely to be female?35 One major clue to these findings may lie in the sex differences of gene expression. Female somatic cells have one randomly inactivated chromosome; however, between 10% and 15% of the genes on this chromosome can be expressed.36 The gene, gastrin-releasing peptide receptor (GRPR) appears to be linked with lung cancer. GRPR is activated during fetal development, but is turned-off once the organs are fully developed.35 In a recent study, 55% of non-smoking women expressed the gene, while none of the males did; among light smokers, 75% of the women as compared to 20% of the men showed this gene expression. As women have the potential to express higher amounts of the gene because they possess two copies, one from the inactive chromosome, this may put them at increased risk of lung cancer.35
Male life expectancy is generally lower than that of females due in large part to higher levels of risk taking particularly among younger men, negative health behaviours, and lower participation in preventative health measures.20 Men who embrace the dominant view of masculinity in our society are more vulnerable to health risks; however, this perspective is neither universal nor uniform throughout the lifecycle and is influenced by ethnicity, sexual orientation, socioeconomic status, geography, and age among other factors.20 As men age, over 80% in their 60s will suffer from at least one of the following conditions: cardiovascular diseases cancers, chronic obstructive pulmonary diseases, degenerative and metabolic diseases, visual and hearing loss, mental health problems, sexual dysfunction, dementia or endocrine disorders.37 Moreover, mortality rates-generally associated with low bone mineral density (BMD)-are higher in men for most osteoporotic fractures.38 Exercise, body size and alcohol consumption all have an impact on BMD as do the changing hormone profiles of individuals as they age.38, 39 Estradiol is vital to bone formation 40 and testosterone plays a role in BMD as well as liver function, muscle mass, immune function, erythropoiesis, and libido.39 Sex-hormone binding globulin (SHBG), however, increases with age, reducing the levels of bioavailable testosterone and estradiol.39 While the rate of decline of testosterone is similar in healthy men as in men with chronic illness, healthier men have androgen levels 10-15% higher than their counterparts.39
Women are two to three times more likely to be affected by multiple sclerosis (MS) than men. In addition, women acquire MS younger than men-most often the relapsing-remitting pattern-in contrast to men who generally develop the unremitting and progressive disease variety. While little is known about why the incidence of MS is higher in women than men, MS in women is often remitting during pregnancy.41, 42, 43 Estrogens have been implicated in lessening the severity of the T-cell autoimmune conditions during pregnancy and indeed, a Phase I clinical trial treating women with MS with oral estriol has demonstrated a significant decrease in the lesions in relapsing-remitting MS patients as compared to baseline.44 Might treatment with estrogens be helpful in lessening the severity of the condition for men? Palaszynski et al45 used the mouse model of experimental autoimmune encephalomyelitis (EAE) to compare the response of female and male rodents to treatment with estriol. They found that estriol decreased the mean clinical disease scores in females and males as well as the load of pro-inflammatory cytokines.45 The one sex difference observed was that males but not females had an increase in one of the cytokines, IL-5. The authors point out that Glatiramer acetate, an approved therapy for MS, also increases levels of IL-5. Not only is estriol as good for males as for females, but the added induction of IL-5 in males might provide further protection from MS.
Aspirin reduces the risk of cardiovascular events in both men and women at similar rates; however, sex-specific analysis shows that there are differences in the advantages that women and men receive from the medication. Men benefit from a reduced risk of myocardial infarction yet may experience increased odds of succumbing to hemorrhagic stroke. Women taking aspirin for preventative therapy reduce their chances of experiencing ischemic strokes; however, the therapy appears to have no impact on rates of myocardial infarction or hemorrhagic strokes. Analyzing this data according to sex may have implications for clinical practice.46
How are sex and gender implicated in workplace health? Inverse associations between status and health have been reported in occupational hierarchies.47 High demand/low control jobs accompanied by frustrated ambitions and the erosion in self-esteem can induce autonomic and neuro-endocrine stress responses.48 In Canada, women, especially from ethnic minority communities, are disproportionately likely to occupy low wage, high demand, low control positions and may, therefore, be more vulnerable to these effects.49, 50 Men from ethnic minority communities are also over represented in similar positions; furthermore, they are also less likely to ask for, or receive, social support-a factor that can mitigate the effects of these stressors.51, 52 Research on workplace configurations and occupational exposures have often focused on men's experiences and are based on men's general size and ergonomic needs. Messing53 demonstrated that the pace and requirements of work for female and male workers may be disparate resulting in differing, but equally serious, patterns of injury. Ethnicity and socioeconomic status are also implicated in these issues. McDuffie54 has drawn attention to pesticide exposure among farmwomen, a hazard that was presumed to be primarily a male problem. Moreover, as women tend to possess greater adiposity and chlorinated hydrocarbons are fat soluble, total body pesticide concentrations may often be higher among women than men. Caution must be used however as sex should not be deployed as a proxy for weight, height or body fat estimations.10
In the traditional model of sickness, an individual who becomes ill is able to relinquish responsibilities and rest at home. Home is often regarded as a refuge from the pressures of work and the outside world, but is home a haven for everyone?56 For far too many women in Canada and around the world, home is a site of family violence.57, 58 Furthermore as women are still primarily responsible for home and child care, home often means unceasing demands from children and other family members and the increased burden of household tasks.18, 59 The intersections between paid and unpaid work have repercussions for health. Studies show that while men's blood pressure declines when coming home, women's often rises.60 Married men in Canada live an average of eight years more than never married men; married women survive an estimated three years longer than single women.61 The Framingham Heart Study has found that women with three or more children are twice as likely to develop heart disease than counterparts with fewer or no children. Moreover, having more family members62 has a negative impact on the mental health of female manual workers.63
The following questions are provided as a general checklist for applicants and reviewers. Given the breadth and depth of CIHR funded research-biomedical, clinical, health services and population health-, the questions are general, and may not be equally relevant to all disciplines or methodologies. Applicants should give careful consideration as to how their research addresses these queries and should, where applicable, provide detailed response to these questions in their proposals. See "Further Readings" for additional information.
This draft resource guide will be enriched and refined with your input and feedback. Please give consideration to the following questions:
We are counting on your feedback to ensure that this resource guide is both meaningful to you as researchers and peer reviewers, and is true to CIHR's commitment to gender and sex-based analysis in health research.
Please send your comments to:
Dr. Louise Robert
Assistant Director
Institute of Gender and Health
160 Elgin Ave., 9th floor
Postal Locator 4809A,
Ottawa, Ontario K1A 0W9
Canada
Email: lrobert@cihr-irsc.gc.ca
Phone: (613) 954-0616
Fax: (613) 954-1800
1. Caron, J. (2003). Report on Governmental Health Research Policies Promoting Gender or Sex Differences Sensitivity. Ottawa: CIHR Institute of Gender and Health.
2. European Women's Health Network. (2001). Gender-Based Analysis in Public Health Research, Policy and Practice: Documentation of the International Workshop in Berlin. Berlin: Berlin Centre for Public Health, Euopean Women's Health Network, and German Society for Social Medicine.
3. Status of Women Canada. (1995). Setting the Stage for the Next Century: The Federal Plan for Gender Equality. Ottawa: Status of Women Canada.
4. Fishman, J., Wick, J. and Koenig, B. (1996). "The Use of 'Sex' and 'Gender' to Define and Characterize Meaningful Differences Between Men and Women." In Agenda for Research on Women's Health for the 21st Century: A Report of the Task Force on the NIH Women's Health Research Agenda for the 21st Century. Volume 2. Bethesda, Md: NIH. Pp. 15-20.
5. Health Canada. (2000). Health Canada's Gender-Based Analysis Policy. Ottawa: Minister of Public Works and Government Services Canada.
6. Health Canada. (2003). Exploring Concepts of Gender and Health. Ottawa: Minister of Public Works and Government Services Canada.
7. World Health Organization. (2002). Integrating Gender Perspectives in the Work of WHO. Geneva: WHO.
8. Preves, S. (2003). Intersex and Identity: The Contested Self. New Brunswick, N.J.: Rutgers University Press.
9. Herdt, G. (ed.) (1996). Third Sex, Third Gender: Beyond Sexual Dimorphism in Culture and History. New York: Zone Books.
10. Messing, K., and Stellman, J. (2006). "Sex, Gender and Women's Occupational Health." Environmental Research 101: 149-162.
11. Lockshin, M. (2001). "Genome and Hormones: Gender Differences in Physiology: Invited Review: Sex Ratio and Rheumatic Disease." Journal of Applied Physiology 91: 2366-2373.
12. Celayir, S. (2002) "Is There a 'Bladder Sex'? The Relation of Different Sex Hormones and Sex Hormone Receptors in Bladder in Childhood." Medical Hypotheses 59(2): 186-190.
13. Wizemann, T. and Pardue, M. (eds). (2001). Exploring the Biological Contributions to Health: Does Sex Matter? Washington, D. C.: National Academy Press.
14. Greenberger, P. (2001). "FDA Does a Poor Job of Monitoring Drugs for Sex Difference." Journal of Women's Health & Gender-Based Medicine 10(3): 829-830.
15. Brower, V. (2002). "Sex Matters: In Sickness and in Health, Men and Women are Clearly Different." European Molecular Biology Organization (EMBO) Reports 3(1): 921-923.
16. Spitzer, D. (2005). "Engendering Health Disparities." Canadian Journal of Public Health 96 (Suppl. 2): s78-s96.
17. Simard, M., Julien, D., and Jodoin, M. (2004). Taking into Account Sex and Gender in Research Designs and Output Research Report on Ongoing Birth Cohort Studies. Ottawa: CIHR Institute of Gender and Health.
18. Armstrong, P. and Armstrong, H. (2001). Thinking It Through: Women, Work and Caring in the New Millennium. Halifax: Maritime Centre of Excellence for Women's Health.
19. Brewer, T. (2001). "Gender Socialization and the Cultural Construction of Elder Caregivers." Journal of Aging Studies 15(3): 217-236.
20. Courtney, W. (2000). "Engendering Health: A Social Constructionist Examination of Men's Health Beliefs and Behaviors." Psychology of Men and Masculinity 1(1): 4-15.
21. Galdas, P., Cheater, F., and Marshall, P. (2005). "Men and Health Help-Seeking Behaviour: Literature Review." Journal of Advanced Nursing 49(6): 616-623.
22. Moerman, C. and Mens-Verhulst, J. (2004). "Gender-Sensitive Epidemiological Research: Suggestions for a Gender-Sensitive Approach Towards Problem Definition, Data Collection and Analysis in Epidemiological Research." Psychology, Health & Medicine 9(1): 41-52
23. Jackson, B., Pederson, A., and Boscoe, M. (in press). Gender-Based Analysis and Wait Times: New Questions, New Knowledge. Winnipeg: Women and Health Care Reform Group.
24. Canadian Institutes of Health Research (CIHR). 2005-6 CIHR Grants and Awards Guide, Section 1-A4.
25. Thurston, W. and Vissandjée, B. (2005). "An Ecological Model for Understanding Culture as a Determinant of Women's Health." Critical Public Health 15(3): 229-242.
26. Caschetta, M. (1993). "The Identity Politics of Biomedical Research-Clinical Trials, Medical Knowledge and the Female Body." SIECUS Report (October): 1-6.
27. Fourcroy, J. (1994). "Women and the Development of Drugs: Why Can't a Woman be More Like a Man?" Annals of the New York Academy of Sciences 736: 174-195.
28. Mintzes, B. (2003). How Safe Are Our Medicines? Monitoring the Risks of Drugs After They are Approved for Marketing. www.whp-aspsf.ca/en/documents/how_safe.html
29. Rademaker, M. (2001). "Do Women Have More Adverse Drug Reactions?" American Journal of Clinical Dermatology 2(6): 349-351.
30. Rogers, W. (2004). "Evidence-based medicine and Women: Do the Principles and Practice of Evidence-based Medicine Further Women's Health?" Bioethics 18(1): 50-71.
31. General Accounting Office. (2001). Drug Safety: Most Drugs Withdrawn in Recent Years Had Greater Health Risks for Women. Washington, D. C.: Gao.
32. Doyal, L. (2002). Sex, Gender and the 10/90 Gap in Health Research. Geneva: Global Forum on Health.
33. Greaves, L., et al. (2000). CIHR 2000: Sex, Gender and Women's Health. Vancouver: BC Centre of Excellence for Women's Health.
34. Canadian Institutes of Health Research, Natural Sciences and Engineering Council and the Social Sciences and Humanities Research Council. (2005 [1998]). Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans. Ottawa: Public Works and Government Services Canada.
35. Kreeger, K. (2002). "Sex-Based Differences Continue to Mount." The Scientist 16(4): 26.
36. Christensen, K., Østravik, K. and Vaupel, J. (2001). "The X Chromosome and the Female Survival Advantage: An Example of the Intersection Between Genetics, Epidemiology and Demography." Annals of the New York Academy of Sciences 954: 175-183.
37. Lunenfeld, B. (2002). "The Ageing Male: Demographics and Challenges." World Journal of Urology 20: 11-16.
38. Johnell, O., Kanis, J. and Gullberg, G. (2001). "Mortality, Morbidity, and Assessment of Fracture Risk in Male Osteoporosis." Calcified Tissue International 69: 182-184.
39. Feldman, H., Longscope, C., Derby, C., Johannes, C., Araujo, A., Coviello, A., Bremner, W. and McKinlay, J. (2002). "Age Trends in the Level of Serum Testosterone and Other Hormones in Middle-Aged Men: Longitudinal Results from the Massachusetts Male Aging Study." Journal of Clinical Endocrinology and Metabolism 87(2): 589-598.
40. Kholsa, S., Melton, J., and Riggs, B. (2001). "Estrogens and Bone Health in Men." Calcified Tissue International 69: 189-192.
41. Dunna, S.F.and Finlay A.Y. (1989) "Psoriasis: Improvement During and Worsening After Pregnancy." British Journal of Dermatology 120: 584.
42. Abramsky, O. (1994) "Pregnancy and Multiple Sclerosis." Annals of Neurology 36: S38-S41.
43. Silman, A.J. (2002) "Contraceptives, Pregnancy, and RA." Annals of the Rheumatic Diseases 61: 383.
44. Sicotte, N., Liva S., Klutch R., Pfeiffer P., Bouvier S., Odesa S., Wu T.C., and Voskuhl R.R. (2002) "Treatment of Multiple Sclerosis with the Pregnancy Hormone Estriol." Annals of Neurology 52: 421-428.
45. Palaszynski, K. M., Loo, K. K., Ashouri, J. F., Liu, H., and Voskuhl, R. R. (2004) "Androgens are Protective in Experimental Autoimmune Encephalomyelitis: Implications for Multiple Sclerosis." Journal of Neuroimmunology 146: 144-152.
46. Berger, J., Roncaglioni, M., Avanzini, F., Pangrazzi, I., Tognoni, G. and Brown, D. (2006). "Aspirin For the Primary Prevention of Cardiovascular Events in Women and Men: A Sex-Specific Meta-Analysis of Randomized Controlled Trials." Journal of the American Medical Association 295 (3): 306-313.
47. Borg, V., Tage S. Kristensen and Burr, H. (2000). "Work Environment and Changes in Self-Rated Health: A Five-Year Follow-Up Study." Stress Medicine 16:37-47.
48. Siegrist, J. and Marmot, M. (2004). "Health Inequalities and the Psychosocial Environment-Two Scientific Challenges." Social Science & Medicine 58: 1463-1473.
49. Lewchuk, W., de Wolff, A., King, A. and Polyani, M. (2003). From "Job Strain to Employment Strain: Health Effects of Precarious Employment." Just Labour 3: 23-
50. Chard, J., Badets, J., and Howatson-Leo, L. (2000). "Immigrant Women." In Women in Canada: A Gender-Based Statistical Report. Ottawa: Statistics Canada. Pp. 189-217.
51. Williams, D. (2003). "The Health of Men: Structured Inequalities and Opportunities." American Journal of Public Health 93(5): 724-731.
52. Muhonen, T. and Torkelson, E. (2003). "The Demand-Control-Support Model and Health Among Women and Men in Similar Occupations." Journal of Behavioral Medicine 26(6): 601-613.
53. Messing, K. (2000). "Ergonomic Studies Provide Information about Occupational Exposure Differences Between Women and Men." Journal of the American Medical Women's Association 55(2): 72-75.
54. McDuffie, H. (1994). "Women at Work: Agriculture and Pesticides. Journal of Occupational Medicine 36(11): 1240-1246.
55. Krieger, N. (2003). "Genders, Sexes and Health: What Are the Connections-and Why Does it Matter?" International Journal of Epidemiology 32: 652-657.
56. Del Vecchio Good, M.J. (1992). "Work as a Haven from Pain." In Pain as Human Experience: An Anthropological Perspective, M.J. Del Vecchio Good, P. Brodwin, B. Good and A. Kleinman, eds. Berkeley: University of California Press. Pp. 49-76.
57. Klein, R. (ed.) (1998). Multidisciplinary Perspectives on Family Violence. London: Routledge Press.
58. Murray, B. and Welch, C. (1995). "Attending to Lavender Bruises: A Dialogue on Violence in Lesbian Relationships." In Listening to the Thunder: Advocates Talk About the Battered Women's Movement, L. Timmins, ed. Vancouver: Women's Research Centre. Pp. 109-126.
59. Bird, C. 1999. "Gender, Household Labor, and Psychological Distress: The Impact of the Amount and Division of Housework." Journal of Health and Social Behavior 40(1): 32-45.
60. Adams, O. (1990). "Life Expectancy in Canada-An Overview." Health Reports 2(4): 361-376.
61. Gjerdingen, D., McGovern, P., Bekker, M., Lundberg, U. and Willemson, T. (2000). "Women's Work Roles and Their Impact on Health, Well-Being, and Career: Comparisons Between the United States, Sweden, and the Netherlands." Women & Health 31(4): 1-20.
62. Artazcoz, L., Borrell, C., and Benach, J. (2001). "Gender Inequalities in Health Among Workers: The Relation with Family Demands." Journal of Epidemiology and Community Health 55: 639-647.
Caron, J. (2003). Report on Governmental Health Research Policies Promoting Gender or Sex Differences Sensitivity. Ottawa: CIHR Institute of Gender and Health.
Courtney, W. (2000). "Engendering Health: A Social Constructionist Examination of Men's Health Beliefs and Behaviors." Psychology of Men and Masculinity 1(1): 4-15.
Desmeules, M. and Stewart, D. (2003). Women's Health Surveillance Report: A Multi-Dimensional Look at the Health of Women. Ottawa: Canadian Institute for Health Information.
Doyal, L. (2002). Sex, Gender and the 10/90 Gap in Health Research. Geneva: Global Forum on Health.
Eichler, M. (1997). "Feminist Methodology." Current Sociology 45(2): 9-36.
European Women's Health Network. (2001). Gender-Based Analysis in Public Health Research, Policy and Practice: Documentation of the International Workshop in Berlin. Berlin: Berlin Centre for Public Health, Euopean Women's Health Network, and German Society for Social Medicine.
Greaves, L., Hankivsky O., Amaratunga, C., Ballem, P., Chow, D., De Koninck. M., Grant, K., Lippman, A., Maclean, K., Maher, J., Messing, D. and Vissandjée. B. (1999). CIHR 2000: Sex, Gender and Women's Health. Vancouver: BC Centre of Excellence for Women's Health, British Columbia Women's Hospital and Health Centre.
Hankivsky, O. (2005). "Gender Mainstreaming versus Diversity Mainstreaming: A Preliminary Examination of the Role and Transformative Potential of Feminist Theory." Canadian Journal of Political Science 38(4):
Health Canada. (2000). Health Canada's Gender-Based Analysis Policy Ottawa: Minister of Public Works and Government Services Canada.
Health Canada. (2003). Exploring Concepts of Gender and Health. Ottawa: Minister of Public Works and Government Services Canada.
Herdt, G. (ed.) (1996). Third Sex, Third Gender: Beyond Sexual Dimorphism in Culture and History. New York: Zone Books.
Krieger, N. (2003). "Genders, Sexes and Health: What Are the Connections-and Why Does it Matter?" International Journal of Epidemiology 32: 652-657.
Lefebvre, Yvonne. (1996). Women's Health Research in Canada. Paper commissioned for Canada-USA Women's Health Forum. Ottawa: Health Canada.
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