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. Author manuscript; available in PMC: 2025 Jan 1.
Published in final edited form as: Acad Med. 2023 Sep 13;99(1):16–21. doi: 10.1097/ACM.0000000000005444

Reflecting on Progress in and Establishing Benchmarks for Sex and Gender Health Education

Elizabeth Barr 1, Eliza Lo Chin 2, Connie B Newman 3, Mary K Rojek 4, Rebecca Sleeper 5, Sarah M Temkin 6, Janine A Clayton 7, Kejal Kantarci 8, Juliana M Kling 9, Alyson J McGregor 10, Londa Schiebinger 11, Kim Templeton 12, Thomas R Viggiano 13, Susan F Wood 14, Jan Werbinski 15
PMCID: PMC10840663  NIHMSID: NIHMS1926079  PMID: 37734039

Abstract

Sex and gender influence every aspect of human health, thus, sex- and gender-related topics should be incorporated in all aspects of health education curricula. Sex and gender health education (SGHE) is the rigorous, intersectional, data-driven integration of sex and gender into all elements of health education. A multisectoral group of thought leaders has collaborated to advance SGHE since 2012. This cross-sector collaboration to advance SGHE has been successful on several fronts, primarily developing robust interprofessional SGHE programs, hosting a series of international SGHE summits, developing sex- and gender-specific resources, and broadening the collaboration beyond medical education. However, other deeply entrenched challenges have proven more difficult to address, including accurate and consistent sex and gender reporting in research publications, broadening institutional support for SGHE, and the development and implementation of evaluation plans for assessing learner outcomes and the downstream effects of SGHE on patient care. This commentary reflects on progress made in SGHE over the first decade of the current collaboration (2012–2022), articulates a vision for next steps to advance SGHE, and proposes 4 benchmarks to guide the next decade of SGHE: (1) integrate sex, gender, and intersectionality across health curricula; (2) develop sex- and gender-specific resources for health professionals; (3) improve sex and gender reporting in research publications; and (4) develop evaluation plans to assess learner and patient outcomes.

Sex and gender are distinct but closely linked constructs that influence every aspect of human health.1 Sex is a multidimensional biological construct. Although sex is often categorized as a binary, substantial variation in sex-related variables of anatomy, physiology, genetics, and hormones, as well as differences of sex development and intersex conditions demonstrate that sex is better presented on a spectrum.2 A growing body of health research demonstrates how sex influences health and disease processes, including immune responses to pathogens,3 experience of symptoms such as pain,4,5 and medication metabolism.6 Gender is a multidimensional sociocultural and structural construct that encompasses gender identity, gender roles and norms, gendered behavior and expression, gendered relations, and gendered distribution of power.2,7 Health research also shows that gendered phenomena influence health and disease processes, including access to nutrition and health care, smoking prevalence, perceptions of disease, patients’ attitudes toward health care practitioners, and attitudes of health care practitioners.8,9 Structural sexism, gender inequality, and gender inequity interact with additional social and structural variables to shape human health.1,10,11

Given the far-reaching effects of sex and gender on health, sex- and gender-related topics should be incorporated in all aspects of health education curricula. However, despite the well-documented substantive influences of sex and gender on health, these concepts remain siloed and underdeveloped in medical, nursing, dentistry, pharmacy, and other allied health professions curricula.12,13 To respond to this persistent gap in training and education, a diverse group of thought leaders from medicine, dentistry, pharmacy, nursing, social sciences, and allied health professions, representing academic institutions, advocacy groups, and the federal government, have collaborated to advance sex and gender health education (SGHE) since 2012. In this commentary, we, as members of this collaboration, reflect on progress made in SGHE over the first decade of this collaboration (2012–2022), articulate a vision for next steps to advance SGHE, and propose 4 benchmarks to guide the next decade of SGHE.

Background

The current multisectoral collaboration formally began with a Mayo Clinic workshop in 2012 that was convened “to address the need to integrate sex and gender concepts into medical education and training, to identify gaps in current medical curricula, to propose core competencies, and to share practical strategies for success.”14 Building on the generative conversations at this workshop, a series of international SGHE summits fostered collaborations among sex and gender thought leaders, researchers, curriculum innovators, and government representatives. The first SGHE summit in 2015 focused specifically on SGHE in medical school curricula; subsequent summits were intentionally interprofessional and included representatives from dentistry, nursing, pharmacy, physical and occupational therapy, and public health.15 For example, the 2018, 2020, and 2021 summits focused on competency domains and accreditation requirements across the health professions,16 interprofessional collaboration and core tenets for SGHE,17 and the intersectionality of sex and gender with other social and structural determinants of health, respectively.18

SGHE is the rigorous, intersectional, data-driven integration of sex and gender into all elements of health education. It applies to all people and is not limited to women’s health, sexual and reproductive health, or transgender health; although these topics are critically important parts of SGHE and health education in general and warrant additional integration into medical curricula as well.19,20 We are heartened that in the decade since the 2012 Mayo Clinic workshop, scientific understandings of sex and gender have continued to advance. For example, the American Medical Association adopted a policy in 2016 that states that understanding how sex affects disease will improve clinical care.21 However, confusion about the definitions of—and distinctions between—sex and gender remain pervasive in the scientific literature and the lay press, and the terms continue to be problematically conflated.22,23 SGHE is sometimes understood as focusing on sex, sexuality, and sexual orientation. Additionally, sex and gender health is sometimes interpreted as women’s health, while women’s health is at times thought to be as synonymous with obstetrics and gynecology. Decades of feminist activism and dedicated scientific advocacy have broadened the definition of women’s health to encompass all diseases that affect women, including cisgender, transgender, and gender-diverse women, as well as individuals assigned female at birth.24,25 Similar work needs to be done with respect to SGHE to achieve clear and consistent use of terminology, which is essential to avoid confusion about concepts and terms.26

Vision for the Future of SGHE and Benchmarks for the Field

Our cross-sector efforts to advance SGHE have been successful on several fronts, primarily developing robust interprofessional SGHE programs, hosting a series of international SGHE summits, developing sex- and gender-specific resources, and broadening the collaboration beyond medical education. However, other deeply entrenched challenges have proven more difficult to address, including accurate and consistent sex and gender reporting in research publications, broadening institutional support for SGHE, and the development and implementation of evaluation plans for assessing learner outcomes and the downstream effects of SGHE on patient care. In this section, we discuss progress made over from 2012–2022, propose 4 benchmarks to guide the next decade of SGHE (see Figure 1), and articulate our vision for advancing SGHE to be rigorous, intersectional, and data-driven.

Figure 1.

Figure 1

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Diagram of the 4 proposed (by the authors) benchmarks for advancing sex and gender health education (SGHE). The arrows indicate interrelationships among the benchmarks.

Benchmark 1: Integrate sex, gender, and intersectionality across health curricula

Significant progress has been made toward integrating sex and gender topics into health education, including the publication of medical textbooks and online materials dedicated to sex- and gender-specific care.27–29 Our vision for the continued integration of sex and gender in health education curricula is for continued curricular innovation and a critical examination of the interrelation of the influence of sex and gender with other biological, social, and structural determinants of health, such as disability, race, ethnicity, immigration status, socioeconomic status, structural racism, and structural sexism. The framework of intersectionality, which considers how socially constructed categories overlap and interact to create inequal outcomes for individuals and communities, facilitates the consideration of how complex social and structural factors effect health equity.30–32 As the integration of sex and gender into curricula continues, we encourage faculty, departments, and institutions to center intersectionality and health equity in these efforts.33–35

A thorough understanding and evaluation of the health curricular landscape is key to integrating sex and gender and advancing SGHE. Participants in the 2012 Mayo Clinic workshop set a goal of evaluating existing curricula to identify specific areas in which sex and gender content were missing and to fill the identified gaps. Over the subsequent decade (2012–2022), a few schools and groups have undertaken such curricular evaluations. Notable examples include the Sex and Gender Specific Health Task Force at Texas Tech University Health Sciences Center (TTUHSC) supported by the Laura W. Bush Institute for Women’s Health, and the American Medical Women’s Association’s (AMWA’s) Sex and Gender Health Collaborative. TTUHSC’s task force is an institutional-level, multidisciplinary group comprised of faculty representing each TTUHSC school; this group has developed educational materials and innovative educational models for use within TTUHSC—which are also disseminated nationally and globally—and produced an educational website with slide sets, interactive web-based modules, videos, and facilitator guides, as well as a repository of textbooks, a validated PubMed literature search tool, and survey/research integration tools.36 AMWA’s Sex and Gender Health Collaborative has organized over 200 premedical and medical students and residents into teams who, with the input of faculty experts, are creating fact sheets, YouTube videos, and social media posts with the aim of providing peer-to-peer education on how to influence curricular change. Other strategies that AMWA’s Sex and Gender Health Collaborative uses to promote awareness of sex- and gender-specific health care include film screenings, theater techniques, digital campaigns, and textbook distribution.28

We recognize that such curricular revisions require significant institutional and faculty effort and encourage the adoption of existing resources, such as those developed by the National Institutes of Health’s Office of Research on Women’s Health (ORWH),37–40 AMWA’s Sex and Gender Health Collaborative, TTUHSC’s Sex and Gender Specific Health Task Force, and Stanford University’s Gendered Innovations initiative,41 to aid these efforts. Targeted funding opportunities, such as the ORWH-led research education program, Galvanizing Health Equity Through Novel and Diverse Educational Resources, are also available to support the development of SGHE courses, curricula, or methods.42

Benchmark 2: Expand access to SGHE resources for health professionals

Building on the above benchmark and the successes related to it to date, we encourage both the development of additional comprehensive SGHE resources for professionals across the health ecosystem, as well as the expansion of access to existing resources. Previous efforts related to the planning, delivery, and mapping of SGHE curricula revealed stark differences among health professions and relevant educational standards.12,13,43 That is, each health profession has unique language, categorizations, and accreditation standards associated with sex and gender content. The Sex and Gender Health Educational Tenets, which emerged from the 2020 SGHE summit, address the diversity of professional needs and provide common language that can be used by all health professionals, regardless of the specific discipline or training program.17 Medical students frequently lead the charge for curricular change,44,45 and we are supportive of expanding opportunities such as the AMWA’s Sex and Gender Health Collaborative to encourage students to lead the development of curricular SGHE resources.

Another element of this benchmark is the development and dissemination of sex and gender continuing education resources for professionals in practice. For example, the ORWH, in partnership with the Food and Drug Administration’s Office of Women’s Health, developed a set of online continuing education modules that explore sex and gender for a range of health conditions.38

Additionally, patients and advocates play an important role in shaping health professionals’ understandings of health. To this end, in response to a fiscal year 2022 Congressional request to evaluate National Institutes of Health research related to the health of women, the ORWH invited comments from the public; 1 in 5 commenters identified clinician training as a priority (53/247, 21%).46 Ongoing engagement with the public, including through lay publications and engagements with communities, can promote a person-centered approach to SGHE and the development of sex- and gender-specific resources.47

Benchmark 3: Improve sex and gender reporting in research publications

While many journals have adopted the Sex and Gender Equity in Research (or similar) guidelines, guideline adherence is inconsistently enforced.23,48 Efforts to enhance and enforce policies about the reporting of sex and gender in journals continue, and improved sex and gender reporting is a high priority for SGHE. From our perspective, inconsistent sex and gender reporting is rooted in 3 main issues: (1) limited understandings of sex- and gender-informed research designs; (2) a perception among some in the health research community that accurate and precise sex and gender reporting is secondary to or separate from the primary scientific findings; and (3) limited institutional will among some funders, institutional review board members, publishers, and journal editors to enforce existing guidelines.

We believe that advancing SGHE can help to address each of these issues. Curricular enhancements and resource development, as outlined in the above benchmarks, can enhance knowledge around sex and gender in research design. Resources exist in this space, including many developed outside of the United States, with notable examples from the Canadian Institutes of Health Research and Elsevier’s Researcher Academy.49,50 There is also a project underway through AMWA’s Sex and Gender Health Collaborative to create educational opportunities for the Collaborative Institutional Training Initiative to increase awareness of the effects of sex and gender on health among institutional review board members and to encourage them consider these variables as they review submitted proposals. Additionally, there are free, widely available introductory SGHE workshops aimed at students, trainees, and early-stage investigators that could facilitate understanding of—and commitment to—existing best practices for reporting sex and gender. Funders, institutional review board members, journal editors, and publishers are important allies in advancing this benchmark, and SGHE efforts targeted toward these audiences can inform future discussions about developing and enforcing SGHE-related policies.

Benchmark 4: Develop evaluation plans to assess learner and patient outcomes

Rigorous assessments of both learner and patient outcomes are critical for the implementation of sex and gender medicine and to increase institutional support for SGHE among decision-makers. Participants at the 2012 Mayo Clinic workshop set a goal to monitor change on this through key performance indicators, and this goal remains relevant today. SGHE thought leaders continue to advocate for change with other curricular governing bodies and medical education organizations, including the Association of American Medical Colleges, the Liaison Committee on Medical Education, and the Accreditation Council for Graduate Medical Education. Additional opportunities should be sought out to strengthen partnerships and promote assessment efforts.

Transforming the cultures of both health education and health care requires time and given the institutional and disciplinary diversity of stakeholders in SGHE, a one-size-fits-all approach to evaluation and assessment would not be practical. However, the following guiding principles can inform the development and implementation of clear, reproducible evaluation plans that identify key performance indicators to assess both SGHE outcomes for learners at all career stages and the downstream effects of SGHE on patient care. First, engage students, faculty, deans and other academic leadership, patients and advocates, and other stakeholders early in the development of an evaluation plan to promote the alignment of this plan with the institutions’ culture and institution’s and patients’ needs. Second, address structural and individual biases in assessment practices51 and implement interventions (e.g., near-peer mentoring52) to mitigate these biases. Third, develop and implement frameworks to assess the downstream effects of SGHE on patient care.53

Conclusions

The field of SGHE has advanced significantly in the past decade. We are encouraged by successes in the field and look forward to capitalizing on these successes with continuing strategic efforts. Ongoing engagement of multiple, diverse stakeholders, including students and faculty of schools of medicine, nursing, pharmacy, dentistry, and allied health professions; researchers; scientific journal leadership; patients and advocates; curricular governing bodies; medical education organizations; and government representatives can ensure that SGHE remains responsive to the changing landscape of sex and gender health research. Each member of the health education ecosystem has a role to play in advancing the rigorous, intersectional, data-driven integration of sex and gender topics across health education, whether developing SGHE curricula de novo, incorporating existing sex- and gender-specific resources into curricula, championing sex- and gender-informed research to build the evidence base for SGHE, or supporting students and those in practice in their efforts to advance SGHE. We are optimistic that when we look back in another decade, the progress made will be measurable and transformative.

Acknowledgments:

The authors thank the reviewers and editors for their constructive feedback on this commentary.

Footnotes

Other disclosures: J.M.K. reports consulting for Proctor and Gamble, Triangle Insights Group, and Everyday Health. E.L.C. reports receiving an honorarium from Pfizer.

Ethical approval: Reported as not applicable.

Disclaimers: E.B., S.M.T., and J.A.C. are employees of the National Institutes of Health. The views and opinions expressed in this commentary are those of the authors only and do not necessarily represent the views, official policy, or position of the U.S. Department of Health and Human Services or any of its affiliated institutions or agencies.

Contributor Information

Elizabeth Barr, Office of Research on Women’s Health, National Institutes of Health, Bethesda, Maryland.

Eliza Lo Chin, American Medical Women’s Association, and assistant clinical professor of medicine (voluntary), University of California, San Francisco, San Francisco, California..

Connie B. Newman, New York University Grossman School of Medicine, New York, New York, and past president, American Medical Women’s Association.

Mary K. Rojek, University of South Carolina School of Medicine Greenville, Greenville, South Carolina..

Rebecca Sleeper, Texas Tech University Health Sciences Center, Jerry H. Hodge School of Pharmacy, Lubbock, Texas..

Sarah M. Temkin, Office of Research on Women’s Health, National Institutes of Health, Bethesda, Maryland.

Janine A. Clayton, National Institutes of Health, and director, Office of Research on Women’s Health, National Institutes of Health, Bethesda, Maryland.

Kejal Kantarci, Mayo Clinic Women’s Health Research Center, Mayo Clinic Rochester, Rochester, Minnesota.

Juliana M. Kling, Department of Medicine, Mayo Clinic Arizona, and dean, Mayo Clinic Alix School of Medicine Arizona, Phoenix, Arizona.

Alyson J. McGregor, South Carolina School of Medicine Greenville, Greenville, South Carolina.

Londa Schiebinger, Stanford University, and founding director of Gendered Innovations in Science, Health & Medicine, Engineering, and Environment, Stanford University, Stanford, California.

Kim Templeton, University of Kansas Medical Center, Kansas City, Kansas.

Thomas R. Viggiano, Mayo Clinic College of Medicine and Science, Rochester, Minnesota..

Susan F. Wood, Department of Health Policy and Management, George Washington University Milken Institute School of Public Health, Washington, DC.

Jan Werbinski, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan..

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