Central Gender Theoretical Concepts in Health Research

8192019 Central Gender Theoretical Concepts in Health Research

httpslidepdfcomreaderfullcentral-gender-theoretical-concepts-in-health-research 16

Central gender theoretical concepts in healthresearch the state of the art

Anne Hammarstroumlm1 Klara Johansson1 Ellen Annandale2 Christina Ahlgren3

Lena Aleacutex4 Monica Christianson4 So1047297a Elweacuter1 Carola Eriksson1

Anncristine Fjellman-Wiklund3

Kajsa Gilenstam5

Per E Gustafsson1

Lisa Harryson1

Arja Lehti1 Gunilla Stenberg3 Petra Verdonk6

1Department of Public Healthand Clinical Medicine FamilyMedicine Umearing UniversityUmearing Sweden2Department of SociologyUniversity of York York UK3Department of CommunityHealth and RehabilitationPhysiotherapy UmearingUniversity Umearing Sweden4Department of Nursing UmearingUniversity Umearing Sweden5

Department of Surgical andPerioperative Sciences SportsMedicine Umearing UniversityUmearing Sweden6Department of MedicalHumanities VU UniversityMedical Centre EMGOInstitute for Health and CareResearch School of MedicalSciences AmsterdamThe Netherlands

Correspondence toAnne HammarstroumlmDepartment of Public Healthand Clinical Medicine FamilyMedicine Umearing University901 87 Umearing Swedenannehammarstromumuse

Received 26 February 2013Revised 29 July 2013Accepted 22 October 2013

To cite Hammarstroumlm AJohansson K Annandale Eet al J Epidemiol Community Health PublishedOnline First [ please includeDay Month Year]

doi101136jech-2013-202572

ABSTRACTDespite increasing awareness of the importance of gender perspectives in health science there isconceptual confusion regarding the meaning and the useof central gender theoretical concepts We argue that itis essential to clarify how central concepts are usedwithin gender theory and how to apply them to healthresearch We identify six gender theoretical concepts ascentral and interlinkedmdashbut problematic and ambiguousin health science sex gender intersectionality

embodiment gender equity and gender equality Ourrecommendations are that the concepts sex and gender can bene1047297t from a gender relational theoretical approach(ie a focus on social processes and structures) but withadditional attention to the interrelations between sexand gender intersectionality should go beyond additiveanalyses to study complex intersections between themajor factors which potentially in1047298uence health andensure that gendered power relations and social contextare included we need to be aware of the variousmeanings given to embodiment which achieve anintegration of gender and health and attend to differentlevels of analyses to varying degrees and appreciate that

gender equality concerns absence of discriminationbetween women and men while gender equity focuseson womenrsquos and menrsquos health needs whether similar ordifferent We conclude that there is a constant need to

justify and clarify our use of these concepts in order toadvance gender theoretical development Our analysis isan invitation for dialogue but also a call to make moreeffective use of the knowledge base which has alreadydeveloped among gender theorists in health sciences inthe manner proposed in this paper

INTRODUCTIONThere is growing recognition within the healthsciences that gender awareness is crucial to avoidgender bias in research1 In addition internationalresearch shows strong and abiding associationsbetween gender inequality and patterns of morbid-ity and mortality and there is accumulating evi-dence that lack of gender sensitivity can negativelyimpact the healthcare provided for women andmen1

Yet in spite of this increasing awareness there isa lack of conceptual clarity and need for more the-oretical development1 2 Self-evidently theoreticaldevelopments that build on concepts that are con-fused are likely to be confused themselves

Therefore we argue that it is essential to clarify theuse of central gender theoretical concepts within

health science We do this with the objective of contributing to greater conceptual stringency andof providing a coherent and dynamic conceptualisa-tion for gender research in the health sciences

SIX CENTRAL BUT PROBLEMATIC CONCEPTSWe have identi1047297ed the following six interrelatedgender theoretical concepts as central but problem-atic in health science and in need of clari1047297cationsex gender intersectionality embodiment and

gender equality and gender equity Through areading of key theorists who employ these conceptsin their work we identify how they can be used toilluminate health issues To cover multiple perspec-tives the authors of this paper are from several dis-ciplines including family medicine midwiferynursing physiotherapy public health rehabilitationmedicine sociology and sports medicine Foursmaller groups addressed one or two conceptsaccording to the following framework1 Background history and importance of the

concepts2 Basic underlying assumptions

3 Examples of their utilisation within the healthsciences

4 Problems in how the concepts have been usedor the use they lend themselves to

5 Our recommendations for future research ongender and health

All texts relating to the concepts were repeatedlyread and discussed by the full author group tostrive for consensus and stringency

SEX AND GENDERToday the concepts of lsquosexrsquo and lsquogenderrsquo are com-monly used to refer respectively to the biologicaland the social aspects of being a man or a woman

In his well-known concept of the lsquoone-sexmodelrsquo Laqueur concludes that from Aristotle untilthe Enlightenment women were seen as having thesame reproductive organs (and thus the same lsquosexrsquo)as men but womenrsquos organs were envisioned as aninverted (inside the body) but imperfect version of menrsquos3 During the 18th century this model wasreplaced by the lsquotwo-sex modelrsquo in which the devel-oping academic medicine emphasised the biologicaldifferences between men and women The conceptof sex came to be used in research about men andwomen no matter whether the focus was biologicalor sociocultural1 As a consequence biological

factors were wrongly attributed to what were actu-ally social and psychological determinants of

Hammarstroumlm A et al J Epidemiol Community Health 201301ndash6 doi101136jech-2013-202572 1

Theory and methods

JECH Online First published on November 21 2013 as 101136jech-2013-202572

Copyright Article author (or their employer) 2013 Produced by BMJ Publishing Group Ltd under licence



health For example much of womenrsquos illness was attributed tofemale reproductive anomalies During the 1970s the conceptof lsquogenderrsquomdashreferring to the social processes associated withbeing a man or a womanmdashbegan to be used by feministresearchers to break with the tradition of equating women withtheir negatively de1047297ned biology4 Although this feminist critiquewas important it fostered the neglect of biological factors infavour of gender and the social aspects of health and illness 1

It is now increasingly recognised that lsquosexrsquo and lsquogenderrsquo areessential to an accurate understanding of health and illness1

Table 1 shows the conceptualisations of each concept in recentresearch First the lsquostatic differencersquo perspective treats lsquosexrsquo andlsquogenderrsquo as dichotomous variables on an individual level5 Thisperspective is often used in the research tradition of lsquogender-speci1047297c medicinersquo6 7 which de1047297nes itself as lsquothe science of howmen and women differ in their normal function and in theexperience of diseasersquo6 Gender-speci1047297c medicinersquos strong focuson dualisms carries the risk of overemphasising differencesbetween men and women Also there is a risk of essentialismthat is the tendency to generalise differences to all groups of men and women independent of context8

By comparison gender can be seen as social and relationalprocesses in various contexts Dichotomous views are criticisedand the importance of applying a relational theory of gender (asde1047297ned in table 1) is emphasised Also the importance of ana-lysing gender in relation to other power structures (eg classraceethnicity nationality sexuality) is stressed (seeIntersectionality below) This perspective has mainly been devel-oped outside of health science and has been adopted principallyin qualitative research on illness experiences9 10 For exampleresearch on lay concepts of health has shown that lsquothe doing of health is a form of doing genderrsquo11 Onersquos identity as masculineor feminine in1047298uences health status and health behaviours canbe ways of demonstrating masculinities and femininities

The lsquosex in interaction with genderrsquo perspective focuses on

how lsquosexrsquo and lsquogenderrsquo in1047298uence each other12

(see Embodimentbelow for examples) This perspective also opens up the poten-tial for analyses of lsquosexrsquo as a continuum with multiple variationson the X and Y chromosomes hormonal levels and internal andexternal genitals

Based on these observations our recommendation for futureresearch is based on Connellrsquos relational theory of gender13 inwhich the focus moves from the individual to include the struc-tural level in which gender relations are integrated into arenassuch as the labour market and the healthcare system Thistheory can pro1047297tably be developed to give further analyticalattention to how lsquosexrsquo and lsquogenderrsquo are interrelated

INTERSECTIONALITY Intersectionality is based on the underlying assumption of het-erogeneity within the groups of lsquomenrsquo and lsquowomenrsquo and recog-nises that individuals are de1047297ned by multiple intersectingdimensions such as gender class ethnicity (dis)ability sexualityage etc The concept was inspired by postcolonial theory blackfeminism and queer theory and has its roots in Crenshawrsquos 14 15

argument that legal discrimination against black women canonly be understood if we appreciate that their experience is

greater than the sum of racism and sexismThe lsquoadditiversquo perspective developed as a critique of the

lsquostatic differencersquo perspective (outlined in the section on lsquosexrsquoand lsquogenderrsquo) as a precursor to intersectionality (as outlined intable 2) lsquo Additive perspectivesrsquo seek to move beyond the ana-

lysis of various gender differences along separate individualdimensions to instead address the relative importance of gender

compared with other factors In health research this leads toquestions such as Does gender or does class best explain themale or female excess in a particular health condition Or howdo class and gender interact to explain differences in menrsquos andwomenrsquos morbidity In each instance the underlying questionis where does the most explanatory power lie From this per-spective the health of men and women is conceptualised as anaccumulation of advantages and disadvantages

The additive perspective has been criticised for ignoring thatvarious axes of power do not necessarily act in unisonmdashbutoperate in complex waysmdashupon health16 One category such aslsquoracersquo takes its meaning from another such as lsquogenderrsquo and alsquonew uniquely hybrid creationrsquo emerges at the intersectionwhich becomes the unit of analysis17

For example with additive perspectives a Canadian studyfound that poor self-rated health was related to race class andsexual orientation but not to gender18 However further inter-sectional analyses of the same data showed that each axis of inequality interacted signi1047297cantly with at least one other result-ing in the poorest self-rated health among homosexuals withpoor income as well as among South Asian women18 Thisexempli1047297es how the potential to visualise and explain healthinequalities increases when intersecting power dimensions areseen as more than the sum of additional components This isnot easily captured by the lsquoadditiversquo perspective which in ananalogy drawn from Choo and Ferree19 tends to conceptualiseintersections like street corners where several streets crosswithout an appreciation of how each is transformed by theothers

The place of gender in intersectional analysis has been thesubject of debate Some such as Hankivsky20 argue that theimportance of gender should be lsquoleft openrsquo in order to allow amore effective understanding of the complexities of healthexperience to emerge in analysis Others1 7 1 8 argue that as asocial institution gender lsquoconstructs and maintains the subordin-

ation of women as a group to menrsquo Hence gender is the mostvisible and pervasive part of social identity and should always bethe starting point of analysis17

We propose that the answer to the question of whethergender should be lsquoleft openrsquo as to its relevance in analysis(Hankivsky) or always kept as a lsquostarting pointrsquo (Shields) hingeson the health issue in question and the context of analysis (whois being studied where and when) Particular intersections of interest and the place of gender within them are lsquocontextdependentrsquo upon the wider social orders including power rela-tions of which they are a part It is therefore important to askwhy a category such as gender is stable or unstable at any pointin time why it is changing (or not changing) and with whatimplications for health and for other life experiences21

We suggest that intersectionality should go beyond additiveanalyses and study complex intersections as well as ensure thatgendered power relations and social context are included

EMBODIMENT Embodiment is a concept focusing on how the body interactswith the environment It originated in phenomenology and isbased on a view of the body-mind as a dialectic and holisticunit in contrast to the Cartesian split between body andmind22 23 The strive for holistic models of body health anddisease within the health sciences24 has led to a number of dif-ferent perspectives on the concept of embodiment and how touse it from among which we will describe three (table 3)

First the phenomenological conceptualisation is based onphilosopher Merleau-Pontyrsquos notion of lived experience

2 Hammarstroumlm A et al J Epidemiol Community Health 201301ndash6 doi101136jech-2013-202572

Theory and methods



focusing on how perceptions and consciousness are linked tothe body23 Among many others the physiotherapist and phil-osopher Bullington has developed Merleau-Pontyrsquos concept of the lsquolived bodyrsquo in medical rehabilitation She has shown thatchronic pain is a bodily and an existential phenomenon22 Inorder to be successful rehabilitation must be holistic andaddress the material body and the diminished sense of self aswell as the withdrawal from the surrounding society The lived

body is thus viewed as a fundamentally intertwined unity of mind-body-world23

Second the concept of social embodiment13 places greateremphasis on social processes and gender relations Using asocial constructionist perspective Connell emphasises thatbodies are at the same time agents in and objects of social prac-tices13 Bodily practices affect the formation of social structureswhich in turn generate new practices which involve and affectbodies in continuous processes where embodiment concernswhat bodies do and what is done to bodies25 Anorexia is anexample of a gendered form of social embodiment25 Anorexiaamong young women who live in a gender order in which theyare dependent on being attractive to men exemplify such asocialbodily feedback loop in response to societal norms aboutattractiveness women can starve themselves far beyond thenorm and then their bodies and lifestyle are pictured as theideal goal for other women through for instance lsquoPro-anarsquowebsites13 25

Third in the epidemiological framework of ecosocial theoryembodiment is conceptualised as the biological incorporation of the material and social world or in other words how bodiesare changedmdashtemporarily or permanentlymdashby environmentaland behavioural factors26 Krieger emphasises the multilevelnature of embodiment by integrating the soma the psyche andsociety in various historical and ecological contexts2 4 2 6 andviews the health impact of gender relations as one example of embodiment24 27 Although she acknowledges that human

beings have individual agency the main focus is on the role of societal conditions in the production of population health

inequalities24 and on biomedical formulations of healthdisease Fausto-Sterling and coworkers28 refer to Kriegerrsquosnotion of embodiment in their integration of embodimentwith developmental systems theory in order to illuminate howsexgender differences emerge during the 1047297rst years of lifeWhile enormous individual variability in behaviours exists atbirth the authors show how cultural gendered practices leadto different treatment of boys and girls and that this treatment

may have tangible and long-term effects on their bodies andbrains28 29

Embodiment is a promising concept for analysing how sexand gender become interwoven as part of life but healthresearchers seldom address the different usages and meanings of the concepts Our recommendation is that we need to be awarethat embodiment has been developed within different traditionswith various degrees of integration of gender and health per-spectives as well as with different levels of analyses

GENDER EQUALITY AND GENDER EQUITYThe concepts of gender equality and gender equity are based onthe assumption that the distribution of opportunities resourcesand responsibilities between women and men should not dis-favour either group To simplify gender equality concerns lsquoequalrightsrsquo (absence of gendered discrimination) while gender equityconcerns needs-based approaches30ndash32 What lsquorightsneedsrsquomeans in practice is strongly disputed33 34 We analyse two per-spectives on this dispute (lsquosamenessdifference rsquo and lsquofairnessrsquo) inrelation to the lsquorightsneedsrsquo perspective (table 4)

Sameness-difference The concept gender equality originated insocial science and feminism31 33 At the Beijing Conference onWomen (1995) it was criticised primarily by conservativegroups for ignoring that women and men sometimes differ33ndash35

However this is a misunderstanding since the concept of genderequality acknowledges similarities and differences betweenwomen and men32ndash34 Instead gender equity was suggested as a

concept acknowledging that women and men sometimes havedifferent needs for social and biological reasons33 34 But the

Table 1 Conceptualisations of lsquosexrsquo and lsquogenderrsquo

Sex Gender

Perspectives As static differenceAs sex in interaction withgender As static difference As social process

Origins Biomedic ine and morerecently in gender-specificmedicine6

Feminist biologists12 40 Theories of role differences and morerecently in gender-specific medicine6

Relational theory of gender

Underlyingassumptions

Individual traits Dualisticldquothe classification of livingthings as male or femalebased on their reproductiveorgans and functionsrdquo 7

Interplay between sex and genderSocial and biological processesldquofeminists must accept the body assimultaneously composed of geneshormones cells and organsmdashall of which influence health andbehaviormdashand of culture and historyrdquo12

Individual traits Dualisticldquogender a uniquely human concept asa personrsquos self-representation as maleor female which is rooted in biologyand shared by environment andexperiencerdquo7

Relational theory social constructivismbeyond dualisms agency withinstructuresldquoRelational theory usually understandsgender as multidimensional embracingat the same time economic relationspower relations affective relations andsymbolic relations and operatingsimultaneously at intrapersonalinterpersonal institutional andsociety-wide levelsrdquo25

Potentialproblems

Risk for essentialismExaggerates differencesbetween men and women

A risk of confusion of sex andgender

Focus only on the individual levelExaggerates differences between menand women

Needs deeper analyses of lsquosexrsquo and thebiological body

Strengths A critique of the male norm Goes beyond a static anddichotomous view on sex andgender

A critique of the male norm Process-oriented aware of theimportance of contextFocus on structural level


Theory and methods



concept gender equity was strongly opposed by feminist and

human rights groups arguing that this concept was open for sub-jective interpretations and could be used to justify discrimin-ation33 34 As a consequence UN policy documents generally usethe concept gender equality33 But in policy documents onhealth gender equity is still used since it is generally acceptedthat in relation to health men and women can have similar needsand different needs33 The lsquodifferencersquo perspective on genderequity increases the risk of overemphasising health differencesbetween women and men33

Fairness With the fairness perspective the concept genderinequalities has been assumed to refer to differences that arenot necessarily unfair while gender inequities refer to unfairdifferences between women and men3 3 3 4 The perspectivemay have emerged because some de1047297nitions of gender equity

emphasise the word lsquofairnessrsquo3 0 3 2 to clarify that fairness of policy can require a needs-based approach thus giving moreresources to one group (eg allocating substantial resources towomenrsquos pregnancydelivery-related health)3 0 3 2 The fairnessperspective is in accordance with the well-established broader(ie not related to gender) de1047297nition in public health research36

of health inequity as avoidable and unfair health differences(eg across social groups) and health inequality as health differ-ences that are not necessarily unfair (eg between young andold people) However to disconnect the concept gender equal-ity from assumptions of fairness is problematic as the concept

inherently refers to fairness and is widely used that way

In health science and social science a commonly used de1047297

n-ition of gender equality is Susan Moller Okin rsquos which empha-sises lsquofairness between women and men in all spheres of lifersquo31

In policy the concept gender equality has strong foundationsin international human rights law34 and calls for the lsquoabsenceof discriminationrsquo

30 or absence of lsquolimitations set by stereo-types rigid gender roles and prejudicesrsquo32 thereby relating thisconcept to fairness

We argue that gender equality should be de1047297ned as absence of discrimination and gender equity as meeting the needs of women and men whether similar or different To illustrate whatthis can mean in practice for research we describe below howthe research focus can determine which concept should beapplied as suggested for instance by Payne and Doyal33

Gender equality can refer to the societal power relationsbetween men and women as possible social determinants of health For example gender equality in marriagecohabitation(measured as shared household duties) has been shown to be adeterminant of mental health for women and men37 Gender equity can be an adequate concept for research on needs-basedprevention treatment and rehabilitation3 5 3 8 One example isresearch on gender inequities in unmet needs for hipkneesurgery which shows that though a majority of those receivingthe treatment are women there are also more women than menwho need treatment but do not get it39

Table 2 Conceptualisations of intersectionality

Perspectives Additive Intersectional

Origins Critique of unitary experience of gendermdashthat isof the lsquostatic differencersquo perspective (see table 1)

In antidiscrimination debate as well as in postcolonial theory black feminism and queer theoryCrenshaw14 argued for a move away from lsquosingle-axis analysesrsquo of race and gender towards anappreciation that black womenrsquos intersectional experience is greater than the sum of racism andsexismStrengthened by poststructuralist emphasis on the deconstruction of binary sex and gender asprimary categories of experience15


The addition of other axes of inequality to genderto identify where most explanatory power lies

Dimensions of inequality do not simply accumulate Instead one category such as lsquo racersquo takes itsmeaning from another such as lsquogenderrsquo

Limitations Factors of interest for example gender socialclass are still conceptualised independentlyTendency to conceptualise gender in relation toan accumulation of advantages anddisadvantages

Decentres lsquogenderrsquo that is gender is not necessarily in focus of analysesChallenges of identifying and developing (mainly quantitative but also qualitative) methodologicaltechniques to study complex intersectionsFocus on new social groups identified at various intersections can lead to lsquocontext specialisationrsquoto the neglect of the wider social relations of gender that construct experience at intersections 19

Strengths Goes beyond sexgender as static difference todraw attention to differences within andsimilarities across the group of men and women

Promotes the analysis of new hybrid structures and identities which emerge at the intersections of inequality17

Table 3 Conceptualisations of embodimentPerspectives Phenomenology Social embodiment Epidemiological

Origins A dialectic and holistic body philosophy The bodyis an object that I have and a subject which I am23

Gender relational theory concernspatterned relations between and amongwomen and men that form gender as asocial structure13 25

Ecosocial theory emphasises the multilevel anddynamic interplay between processes and structuresrelevant for health and the production of populationhealth inequalities24


The lived body describes the daily experiences of having and being a body Mind-body-world isintertwined in a wholeness and cannot beseparated from each other22

The interplay between bodies socialrelations and social structure is a collectiveand reflexive process25

The material and social world changes the bodythereby creating population patterns of health anddisease24 26

Limitations Lacks the gender and the structural perspectives A general framework which needs furthercontextualisation

Dominant focus on structures rather than on agency

Strengths Offers an explicit holistic meaning of theembodiment concept in clinical practice

Acknowledges individual agency andsocietal structures Analyses various levels

such as individual group and societal

Uniquely developed for epidemiological research


Theory and methods



CONCLUDING REMARKSOur recommendations for future research on health and genderare that The concepts sex and gender can bene1047297t from a gender rela-

tional theoretical approach (ie a focus on social processesand structures) but with additional attention to the interrela-tions between sex and gender

Intersectionality should go beyond additive analyses to studycomplex intersections as well as ensure that gendered power

relations and social context are included We need to be aware of the various meanings given to

embodiment which achieve an integration of gender andhealth and attend to different levels of analyses to varyingdegrees

Gender equality concerns absence of discrimination betweenwomen and men while gender equity focuses on meetingwomenrsquos and menrsquos health needs whether similar ordifferent

An appropriate use of these concepts helps to address the pro-blems associated with static dualistic perspectivesmdashsuch assamenessdifference bodymind menwomen and socialbio-logicalmdashas well as the need for contextualisation of researchquestions and justi1047297cation of theoretical standpoints and there-fore holds the potential for more nuanced and higher qualityresearch

Gender research in the health sciences is a complex 1047297eld withgreat potential to make important theoretical contributions tothe wider scienti1047297c community Thus gender researchers inhealth science can take leadership in a way we have not donebefore Although theory development is relatively uncommon inthe health sciences compared with other disciplines it is vital tohave clear and well-developed concepts in order to developwell-speci1047297ed and appropriate research questions Thus healthscience has much to learn from gender research in relation tore1047298exive approaches theoretical development urge for concep-tual clarity and epistemological knowledge

The history of these six concepts shows that they are con-stantly evolving in response to changes in society as a

consequence of new research 1047297ndings and as part of ongoingtheoretical developments within the health sciences and the1047297eld of gender studies from which they generally deriveThey are powerful tools which if used more systematicallyand with greater precision than has been the case to datecould signi1047297cantly advance our understanding of experiencesand determinants of illness and disease Thereby they couldmake a difference to health science and health policy Hencethe analysis in this paper is an invitation for dialogue and a

call to make more effective use of the knowledge base whichhas already developed among gender theorists in healthsciences

What is already known

In spite of increasing awareness of the importance of genderperspectives in health science there is a conceptual muddlewithin the 1047297eld

What the manuscript adds to the literature

Clari1047297cation and development of key concepts in genderresearch in health science namely sex and genderembodiment intersectionality gender equity and genderequality By addressing the problems associated with staticdualistic perspectivesmdashsuch as samenessdifference bodymindmenwomen and socialbiologicalmdashas well as the need forcontextualisation of research questions and the justi1047297cation of theoretical standpoints an appropriate use of these conceptsholds the potential for more nuanced and higher qualityresearch in health sciences

Table 4 Conceptualisations of gender equality and gender equity

Gender equality Gender equity

PerspectivesSamenessdifference Fairness Rightsneeds

Samenessdifference Fairness Rightsneeds

O ri gins Pol icy debates33 Policy definitions30 32 Social science andfeminism31 33

Policy debates33 Policy definitions30 32 Policy definitions 30 32


Assumed to denoteexact samenessbetween women andmen33 34

Sees inequalities asdifferences that arenot necessarilyunfair33 34

lsquoAbsence of discriminationrsquo30

or of lsquolimitations set bystereotypes rigid gender rolesand prejudicesrsquo32

Women and menare sometimessimilar andsometimesdifferent33 34

Sees inequities asunfair and avoidabledifferences33 34

Meeting the needs of women and menwhether similar ordifferent30 32

Potentialproblems

Can disfavour onegender by treatingthem exactly thesame even whenthey have differentneeds34

Ignores the stronghuman-rights andfairness background of the concept genderequality34

More complex and can bedifficult to interpret what thismeans in practice but oursuggestion is to use thisconcept for social determinantsof health

Risk of emphasis onhealth differencesbetween womenand men33

Is not compatiblewith common usagewhere both conceptsrefer to fairness

Risk of subjectiveassessment of whatare the needs of women and men

Strengths Is easier to measuresince it asks forexactly the samelevel of resourceallocation forwomen and men

Is in accordance withone well-knowndefinition of lsquohealthequalityrsquo36

Has a strong human-rightsbasis Is considered relativelymeasurable and objective Is inaccordance with how theconcept is mainly used anddefined

Acknowledgesdifferences betweenwomen and men

Is in accordance withone well-knowndefinition of lsquohealthequityrsquo36

Clarifies theimportance of needs-basedapproaches to genderin health withoutfocusing ondifferences


Theory and methods



Acknowledgements The authors would like to thank Professor Raewyn Connellfor encouraging them to write a state of the art paper about how to use gendertheories in health research as well as for valuable comments on their manuscript

Contributors All authors participated in designing the article and deciding on theanalytical framework AH KG and CA wrote the section on sex and gender AL CELA MC AH and EA wrote the section on intersectionality AF-W GS and PEG wrotethe section on embodiment LH SE KJ and PV wrote the section on gender equalityand gender equity AH initiated and led the work process Together with KJ shecompiled the full manuscript and wrote the introduction and conclusions EA read

commented and developed the 1047297

nal draft All authors have read and approved the1047297nal manuscript

Funding The project was 1047297nanced by the Swedish Research Council grant numbers344-2006-7280 and 344-2011-5478

Competing interests None

Provenance and peer review Not commissioned externally peer reviewed

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20092 King BM Point a call for proper usage of ldquogenderrdquo and ldquosexrdquo in biomedical

publications Am J Physiol Regul Integr Comp Physiol 2010298R1700ndash13 Laqueur T Making sex body and gender from the Greeks to Freud Cambridge

MA Harvard University Press 19904 Oakley A Sex gender and society London Maurice Temple Smith Ltd 1972

5 Hammarstroumlm A Annandale E A conceptual muddle an empirical analysis of the useof lsquosexrsquo and lsquogenderrsquo in lsquogender-speci1047297c medicinersquo journals PloS ONE 20127e341936 Legato MJ Gender-speci1047297c medicine the view from Salzburg Gend Med

2004161ndash37 Wizemann TM Pardue M-L eds Exploring the biological contributions to human

health does sex matter Washington The National Academies Press 20018 Hammarstroumlm A A tool for developing gender research in medicine examples from

the medical literature on work life Gend Med 20074(Suppl B)S123ndash329 Johansson EE Bengs C Danielsson U et al Gaps between patients media and

academic medicine in discourses on gender and depression a metasynthesis Qual Health Res 200919633ndash44

10 Ridge D Emslie C White A Understanding how men experience express and copewith mental distress where next Sociol Health Ill 201133145ndash59

11 Saltonstall R Healthy bodies social bodies menrsquos and womenrsquos concepts andpractices of health in everyday life Soc Sci Med 1993367ndash14

12 Fausto-Sterling A The bare bones of sex Part 1-sex and gender Signs J WomenCult Soc 2005301491ndash1527

13 Connell R Gender in world perspective Cambridge Polity 200914 Crenshaw K Demarginalizing the intersection of race and sex a black feminist

critique of antidiscrimination doctrine feminist theory and antiracist politics U Chi Legal F 1989139ndash67

15 Hill Collins P Black feminist thought knowledge consciousness and the politics of empowerment Boston Unwin Hyman 1990

16 Sen G Iyer A Who gains who loses and how leveraging gender and classintersections to secure health entitlements Soc Sci Med 2012741802ndash11

17 Shields SA Gender an intersectionality perspective Sex Roles 200859301ndash11

18 Veenstra G Race gender class and sexual orientation intersecting axes of inequality and self-rated health in Canada Int J Equity in Health 2011103

19 Choo HY Marx Ferree M Practicing intersectionality in sociological research acritical analysis of inclusions interactions and institutions in the study of inequalities Sociological Theory 201028129ndash49

20 Hankivsky O Womenrsquos health menrsquos health and gender and health implicationsof intersectionality Soc Sci Med 2012741712ndash20

21 McCall L The complexity of intersectionality Signs 2005301771ndash80022 Bullington J Embodiment and chronic pain implications for rehabilitation practice

Health Care Anal 200917100ndash9

23 Merleau-Ponty M Phenomenology of perception London Henley NJ RoutledgeHumanities Press 1962

24 Krieger N Epidemiology and the peoplersquo s health theory and context OxfordOxford University Press 2011

25 Connell R Gender health and theory conceptualizing the issue in local and worldperspective Soc Sci Med 2012741675ndash83

26 Krieger N Embodiment a conceptual glossary for epidemiology J Epidemiol Community Health 200559350ndash5

27 Krieger N Genders sexes and health what are the connectionsndashand why does itmatter Int J Epidemiol 200332652ndash7

28 Fausto-Sterling A Coll CG Lamarre M Sexing the baby Part 1 ndash What do wereally know about sex differentiation in the 1047297rst three years of life Soc Sci Med 2012741684ndash92

29 Fausto-Sterling A Coll CG Lamarre M Sexing the baby Part 2 applying dynamicsystems theory to the emergences of sex-related differences in infants and toddlers Soc Sci Med 2012741693ndash702

30 WHO Mainstreaming gender equity in health Madrid Statement WHO Europe200131 Moller Okin S Justice gender and the family New York Basic Books 198932 International Labour Of 1047297ce ABC of women workersrsquo rights and gender equality

200033 Payne S Doyal L Re-visiting gender justice in health and healthcare In

Kuhlmann E Annandale E eds The Palgrave handbook of gender and health care Basingstoke Palgrave Macmillan 201021ndash35

34 Facio A Morgan MI Equity or equality for women-understanding CEDAWrsquos equalityprinciples Ala Law Rev 2008601133ndash70

35 Sen G Oumlstlin P George A Unequal unfair ineffective and inef 1047297 cient Gender inequity in health why it exists and how we can change it Final report to theWHO Commission on Social Determinants of Health 2007

36 Kawachi I Subramanian SV Almeida-Filho N A glossary for health inequalities J Epidemiol Community Health 200256647ndash52

37 Harryson L Novo M Hammarstroumlm A Is gender inequality in the domesticsphere associated with psychological distress among women and men Results

from the Northern Swedish Cohort J Epidemiol Community Health 201266271ndash6

38 Doyal L Gender equity in health debates and dilemmas Soc Sci Med 200051931ndash9

39 Borkhoff CM Hawker GA Wright JG Patient gender affects the referral andrecommendation for total joint arthroplasty Clin Orthop Relat Res20114691829ndash37

40 Birke L Feminism and the biological body Edinburgh Edinburgh University Press1999


Theory and methods



health For example much of womenrsquos illness was attributed tofemale reproductive anomalies During the 1970s the conceptof lsquogenderrsquomdashreferring to the social processes associated withbeing a man or a womanmdashbegan to be used by feministresearchers to break with the tradition of equating women withtheir negatively de1047297ned biology4 Although this feminist critiquewas important it fostered the neglect of biological factors infavour of gender and the social aspects of health and illness 1

It is now increasingly recognised that lsquosexrsquo and lsquogenderrsquo areessential to an accurate understanding of health and illness1

Table 1 shows the conceptualisations of each concept in recentresearch First the lsquostatic differencersquo perspective treats lsquosexrsquo andlsquogenderrsquo as dichotomous variables on an individual level5 Thisperspective is often used in the research tradition of lsquogender-speci1047297c medicinersquo6 7 which de1047297nes itself as lsquothe science of howmen and women differ in their normal function and in theexperience of diseasersquo6 Gender-speci1047297c medicinersquos strong focuson dualisms carries the risk of overemphasising differencesbetween men and women Also there is a risk of essentialismthat is the tendency to generalise differences to all groups of men and women independent of context8

By comparison gender can be seen as social and relationalprocesses in various contexts Dichotomous views are criticisedand the importance of applying a relational theory of gender (asde1047297ned in table 1) is emphasised Also the importance of ana-lysing gender in relation to other power structures (eg classraceethnicity nationality sexuality) is stressed (seeIntersectionality below) This perspective has mainly been devel-oped outside of health science and has been adopted principallyin qualitative research on illness experiences9 10 For exampleresearch on lay concepts of health has shown that lsquothe doing of health is a form of doing genderrsquo11 Onersquos identity as masculineor feminine in1047298uences health status and health behaviours canbe ways of demonstrating masculinities and femininities

The lsquosex in interaction with genderrsquo perspective focuses on

how lsquosexrsquo and lsquogenderrsquo in1047298uence each other12

(see Embodimentbelow for examples) This perspective also opens up the poten-tial for analyses of lsquosexrsquo as a continuum with multiple variationson the X and Y chromosomes hormonal levels and internal andexternal genitals

Based on these observations our recommendation for futureresearch is based on Connellrsquos relational theory of gender13 inwhich the focus moves from the individual to include the struc-tural level in which gender relations are integrated into arenassuch as the labour market and the healthcare system Thistheory can pro1047297tably be developed to give further analyticalattention to how lsquosexrsquo and lsquogenderrsquo are interrelated

INTERSECTIONALITY Intersectionality is based on the underlying assumption of het-erogeneity within the groups of lsquomenrsquo and lsquowomenrsquo and recog-nises that individuals are de1047297ned by multiple intersectingdimensions such as gender class ethnicity (dis)ability sexualityage etc The concept was inspired by postcolonial theory blackfeminism and queer theory and has its roots in Crenshawrsquos 14 15

argument that legal discrimination against black women canonly be understood if we appreciate that their experience is

greater than the sum of racism and sexismThe lsquoadditiversquo perspective developed as a critique of the

lsquostatic differencersquo perspective (outlined in the section on lsquosexrsquoand lsquogenderrsquo) as a precursor to intersectionality (as outlined intable 2) lsquo Additive perspectivesrsquo seek to move beyond the ana-

lysis of various gender differences along separate individualdimensions to instead address the relative importance of gender

compared with other factors In health research this leads toquestions such as Does gender or does class best explain themale or female excess in a particular health condition Or howdo class and gender interact to explain differences in menrsquos andwomenrsquos morbidity In each instance the underlying questionis where does the most explanatory power lie From this per-spective the health of men and women is conceptualised as anaccumulation of advantages and disadvantages

The additive perspective has been criticised for ignoring thatvarious axes of power do not necessarily act in unisonmdashbutoperate in complex waysmdashupon health16 One category such aslsquoracersquo takes its meaning from another such as lsquogenderrsquo and alsquonew uniquely hybrid creationrsquo emerges at the intersectionwhich becomes the unit of analysis17

For example with additive perspectives a Canadian studyfound that poor self-rated health was related to race class andsexual orientation but not to gender18 However further inter-sectional analyses of the same data showed that each axis of inequality interacted signi1047297cantly with at least one other result-ing in the poorest self-rated health among homosexuals withpoor income as well as among South Asian women18 Thisexempli1047297es how the potential to visualise and explain healthinequalities increases when intersecting power dimensions areseen as more than the sum of additional components This isnot easily captured by the lsquoadditiversquo perspective which in ananalogy drawn from Choo and Ferree19 tends to conceptualiseintersections like street corners where several streets crosswithout an appreciation of how each is transformed by theothers

The place of gender in intersectional analysis has been thesubject of debate Some such as Hankivsky20 argue that theimportance of gender should be lsquoleft openrsquo in order to allow amore effective understanding of the complexities of healthexperience to emerge in analysis Others1 7 1 8 argue that as asocial institution gender lsquoconstructs and maintains the subordin-

ation of women as a group to menrsquo Hence gender is the mostvisible and pervasive part of social identity and should always bethe starting point of analysis17

We propose that the answer to the question of whethergender should be lsquoleft openrsquo as to its relevance in analysis(Hankivsky) or always kept as a lsquostarting pointrsquo (Shields) hingeson the health issue in question and the context of analysis (whois being studied where and when) Particular intersections of interest and the place of gender within them are lsquocontextdependentrsquo upon the wider social orders including power rela-tions of which they are a part It is therefore important to askwhy a category such as gender is stable or unstable at any pointin time why it is changing (or not changing) and with whatimplications for health and for other life experiences21

We suggest that intersectionality should go beyond additiveanalyses and study complex intersections as well as ensure thatgendered power relations and social context are included

EMBODIMENT Embodiment is a concept focusing on how the body interactswith the environment It originated in phenomenology and isbased on a view of the body-mind as a dialectic and holisticunit in contrast to the Cartesian split between body andmind22 23 The strive for holistic models of body health anddisease within the health sciences24 has led to a number of dif-ferent perspectives on the concept of embodiment and how touse it from among which we will describe three (table 3)

First the phenomenological conceptualisation is based onphilosopher Merleau-Pontyrsquos notion of lived experience


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Documents

Central Gender Theoretical Concepts in Health Research