Implementation of the sex and gender curricular assessment and revision toolkit: a mixed-method study

Abstract

Background

Historically, reliance on male research models has led to limited knowledge and education regarding the health of women. Since 2016, the National Institutes of Health’s “Sex as a Biological Variable” Policy launched growth in scientific knowledge of sex and gender (SG) differences. However, the inclusion of SG evidence lags in medical student education, thus inhibiting future physicians from providing comprehensive patient-centered care. The study intends to evaluate the Sex and Gender Curricular Assessment and Revision Toolkit (SG-CART) for bridging the SG educational gap.

Methods

A parallel mixed-method study was performed using workshop survey data and focus group qualitative feedback. The University of South Carolina School of Medicine Greenville (USCSOMG) conducted this study between October 2023 and December 2024. Participants were basic science and clinical USCSOMG faculty recruited voluntarily via email after attending the SG-CART faculty development workshop. Educational outcomes were assessed through pre-/post-knowledge assessment and retrospective post-then-pre skills self-assessment. Attitudes toward the SG-CART and workshop were also collected. Cognitive interviewing was conducted to support the initial validation of the assessment scale embedded within the SG-CART.

Results

Of the 63 faculty members attending the SG-CART workshop, 29 participants completed pre-/post-workshop surveys. Participant SG knowledge scores significantly increased. Participants’ confidence significantly increased in their ability to assess materials for inclusion of SG topics, incorporate SG into their teaching, and to locate SG evidence-based content for updating their curricula. Participants’ shared favorable attitudes toward the toolkit. Thematic analysis of transcripts from two focus groups (n = 10) identified three emergent themes: (1) Content & Clarity; (2) Applicability; (3) Usability.

Conclusions

The SG-CART was associated with improvement in immediate faculty knowledge and self-assessed skills regarding the integration of sex and gender perspectives in medical education. It offers a practical resource for educators to enhance their materials and facilitate integration into medical education. The use of this toolkit could ultimately lead to more inclusive and equitable healthcare education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-09562-4.

Background

Sex and gender (SG) are central biological and sociocultural variables that significantly impact health and disease [1] relevant to all patients. However, lack of awareness and knowledge about their impact has been reported among health professions students [2–5]. Although efforts have been made to incorporate SG into medical education, both nationally and internationally [6–19], SG-related content remains insufficiently or inconsistently integrated into medical education curricula [2–4, 20–30], including in postgraduate medical training [31–33]. This has resulted in the continued outdated education of future healthcare providers that is often harmful as women continue to receive care that is based on research conducted on men, or “discrepant clinical care” [34]. It has been suggested that SG-based content should be threaded through existing curriculum [3, 35, 36], e.g., successfully by Germany’s Charité [37, 38]. However, major barriers to curricular change include lack of sufficiently qualified educators [39, 40], time constraints [27, 41], knowledge gaps [36, 41–44], and the need for specific training regarding SG [43–47]. To address these challenges and facilitate the integration of SG-based content into medical curricula, the Sex and Gender Curricular Assessment and Revision Toolkit (SG-CART) and its accompanying workshop were developed to introduce faculty to SG-based medicine and provide a structured, step-by-step approach to curriculum update. This study aims to evaluate the implementation of the SG-CART and associated workshop, and to conduct an initial validation of the embedded assessment scale. The design and assessment of the SG-CART and accompanying workshop were informed by the Moore’s Outcomes Framework [48], providing a theoretical foundation for interpreting the outcomes of this study and situating them within the broader continuum of educational effectiveness.

Methods

Study design

We performed a parallel mixed-method study using a combination of pre- and post-intervention online surveys and focus group-based cognitive interviewing. The questionnaire used in this study was developed specifically for the purposes of this research and has not been previously published. The full questionnaire is provided in Additional File 1. The University of South Carolina Institutional Review Board (IRB) determined that the study did not meet the regulatory definition of human subject research and therefore did not require IRB oversight. All procedures nevertheless adhered to the ethical principles of the Declaration of Helsinki. Data collection was conducted between October 2023 and December 2024. Faculty were recruited via email and introduced to the SG-CART during faculty development workshops at the University of South Carolina School of Medicine Greenville (USCSOMG). Participation was voluntary. Recorded verbal consent was obtained from all focus group participants, and a written waiver of consent was granted by all survey participants. Incentives to complete the surveys included a $100 gift card draw and a $50 gift card for focus group participants. The reporting of this study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [49], and the completed checklist is provided in Additional File 2.

SG-CART and workshop development and implementation

In response to the lack of an established approach or assessment tool for evaluating the integration of sex and gender in the medical curricula, two of the co-authors (AM, MS) developed the Sex/Gender Responsiveness Assessment Scale for health education, adapted from two established assessment frameworks designed for policy and research: the World Health Organization (WHO) Gender Responsive Assessment Scale [50] and the Canadian Institutes of Health Research (CIHR) Sex/Gender-Responsive Assessment Scale [51]. The scale, which is now a core component of the SG-CART toolkit, was first piloted in a faculty training course at the Warren Alpert Medical School at Brown University in 2021 [52]. Based on participant feedback and with the aim of creating a structured, comprehensive and user-friendly toolkit, the prototype materials were subsequently expanded by the research team to include, in addition to the assessment scale, checklists for reviewing didactic lectures and bedside teaching activities. The toolkit also incorporates curated resources to support evidence-based curriculum updates, including the validated Sex and Gender-Specific Health PubMed search tool, a freely available literature search instrument [53], modules and slide library available on the Sex and Gender Specific Health [54] and reference to the comprehensive textbook How Sex and Gender Impact Clinical Practice: An Evidence-Based Guide to Patient Care [55].To support the dissemination and implementation, a dedicated faculty development workshop was created and held at the USCSOMG. Informed by the literature and the co-authors’ prior experience indicating that faculty members lack both confidence and foundational knowledge in SG [36, 39–44, 56], the activity was designed to achieve mid-level educational outcomes, specifically Level 3 (Learning) and Level 4 (Competence) within Moore’s Outcomes Framework [48]. The workshop’s specific topics and teaching strategies were selected by four authors (MS, MR, KQ, AM) to ensure they supported the development of competence. The SG-CART accompanying workshop intended to explain the historical gaps and the importance of a SG lens, the relevance of SG to clinical care, introduction of the SG-CART, along with an opportunity for faculty to assess their own curricular materials with respect to SG using the toolkit. The content of this accompanying educational workshop is presented in Table 1.

Table 1.

Sex and gender faculty development workshop content

Sex and Gender Faculty Development Workshop Components	Duration	Content Description
Foundational Knowledge	0.5 h	• What sex and gender health is; the historical context; terminology; impact on health; historical bias within research, medical education, and clinical care; implicit bias among healthcare providers and patients; unconscious bias in the healthcare system; and application of sex and gender knowledge to teaching and clinical care. • Clinical examples were adapted to fit the audience (e.g., Sports Medicine, Orthopedics, Emergency Medicine, Biomedical Sciences, Psychiatry).
Introduction to the SG-CART	0.5 h	• Introduction to each section of the SG-CART • Examples of how to assess sample curricular content with respect to bias, barriers, and strategies for inclusion of sex and gender in the curriculum by using the assessment instruments. • Clinical examples were adapted to the audience (e.g., depression, myocardial infarction, pharmacology).
Hands-on Activities	0.5–1 h	• Faculty were divided into small groups to apply the SG-CART to their own curricular materials (e.g., a case, PowerPoint slides, modules that they use for teaching). • In a peer review process, they shared their materials and their assessment with another group member who reviewed and provided feedback so that faculty members participated in assessing two sets of curricular materials—their own and that of a colleague. • During the workshop, they explored the resources suggested in the faculty toolkit for integrating relevant sex and gender content. • Faculty members were encouraged to continue updating their curricular materials with the faculty toolkit after the workshop.

Part A: pre-/post-workshop survey

Quantitative data were collected using online surveys administered to participating faculty immediately before and after the workshop. Baseline knowledge of foundational concepts related to SG in health and disease was assessed in the pre-workshop survey using a 10-item true/false questionnaire. The same knowledge assessment was re-administered in the post-workshop survey to evaluate knowledge acquisition resulting from the workshop. To minimize testing effects, neither correct answers nor scores were provided following the initial survey. All assessed concepts were covered during the workshop, allowing post-workshop changes to reflect learning rather than assessment feedback. The post-workshop survey also included a retrospective post-then-pre skills self-assessment [57] using a five-point Likert scale. In addition, attitudinal items assessed participants’ perceptions of the SG-CART and accompanying workshop (e.g., ease of use, helpfulness, utility). Prior experience with curricular evaluation and revision, as well as perceptions of how the workshop compared with previous experiences, were also assessed. Finally, open-ended questions were included to capture qualitative feedback and participants’ perspectives on the SG-CART materials.

Statistical analysis

The quantitative data were analyzed using R (version 2024.04.2 + 764). Categorical variables were summarized as absolute and relative frequency, and continuous variables were reported as median (interquartile range) or mean (standard deviation), as appropriate based on data distribution. Normality was assessed using visual inspection and the Shapiro-Wilk normality test.

For knowledge assessment, McNemar’s mid-P test was used to compare pre- and post-workshop proportions of correct answers to individual true/false items. Changes in overall knowledge scores, calculated as the total number of correct responses, were analyzed as continuous variables. For the retrospective post–then–pre skills self-assessment, Likert-scale responses were treated as continuous measures.

Continuous outcomes were compared using one-sided paired t-test for normally distributed data or one-sided Wilcoxon matched-pairs signed-rank test when normality assumptions were not met. Given an a priori directional hypothesis that the SG-CART would improve faculty knowledge and self-assessed skills, and that effects in the opposite direction were not theoretically expected, we used one-sided tests of significance to maximize power to detect positive effects. P < 0.05 was statistically significant. Effect sizes were also calculated to assess magnitude of observed changes.

Part B: focus group cognitive interviews

Focus groups were conducted to gather in-depth perspectives on the SG-CART and accompanying workshop, and to support the initial validation of the assessment scale embedded within it. A total of 10 faculty who attended the SG-CART workshop at USCSOMG were recruited to participate. Purposive sampling was used to select educators of different fields/departments (e.g., biomedical sciences, emergency medicine, psychiatry) and capture the diverse characteristics of participants (i.e., gender, age, teaching experience). Faculty with different levels of experience (e.g., professor, assistant professor, clinical assistant professor) and teaching medical students at different levels of their training (i.e., pre-clerkship, clerkship, residency) were recruited to ensure representation and transferability. Participants were divided into two separately held virtual focus groups lasting approximately one hour. Sessions were conducted without external observers.

Focused discussions were co-led by two women, an experienced moderator (KQ), a Clinical Professor and Chair of the Department of Biomedical Sciences, and a co-moderator (JS), an emergency medicine physician and Assistant Clinical Professor at the same institution with less experience in qualitative methods. Given the potential influence of collegial or hierarchical relationships on participant responses, moderators emphasized confidentiality, encouraged open dialogue, and engaged in reflexive discussions during data collection and analysis.

Focus group-based cognitive interviewing [58] was conducted using a semi-structured moderator guide. Participants were provided with a copy of the toolkit for review and were prompted to verbalize their perceptions and intended application. Think-aloud strategies and verbal probing [59] were used to determine how participants comprehended and used the assessment instruments included in the toolkit. Individual items of the assessment scale were systematically reviewed to evaluate participants’ understanding and determine whether terminology and definitions were clear and meaningful. Moderators summarized participants’ statements to provide opportunities for clarification and elaboration. Focus groups were stopped once saturation of information was obtained and no new topics emerged. The focus groups were recorded, transcribed verbatim, and deidentified. The accuracy of the verbatim transcripts was verified by one of the moderators who co-led the focus group (KQ, JS).

Qualitative analysis

Qualitative data from focus group transcripts and open-ended survey responses were analyzed iteratively. Thematic analysis was performed by two researchers (ZGT, JS), one of whom (ZGT) had no prior relationship with participants and did not attend the workshop or the focus groups, thereby providing an external analytic perspective. Each coder independently reviewed the data, wrote reflective notes, and applied an inductive, bottom-up coding approach. Coders then compared their analyses, provided critical feedback on interpretations, and reached consensus through discussion to generate themes aligned with the toolkit evaluation and initial validation objectives. These themes were subsequently validated by the focus group moderator (KQ).

Modifications to toolkit based on participant suggestions

Following the qualitative data analysis, four co-authors (ZGT, JS, MR, AM) reconvened to discuss and agree upon changes that reflected the focus group feedback to clarify and improve the toolkit. Modifications to the toolkit were made before its public dissemination.

Results

Respondents and participants

Overall, 63 participants attended the SG-CART faculty development workshops held at the USCSOMG between October 2023 and September 2024. Of those, 46% (n = 29) completed both pre- and post-workshop surveys. We held two separate focus groups of respectively 60 and 80 min, with a total of ten participants (n = 10). Previous experience with curriculum evaluation and revision of survey respondents is reported in Table 2.

Table 2.

Survey respondents’ previous experience with curriculum evaluation and revision

Previous Experience of Faculty	No (%)(n = 29)
Curriculum Evaluation
Individual teaching	14 (48.3)
Course evaluation	11(37.9)
Program evaluation	9 (31)
Using evaluation made by other	20 (69)
No curriculum evaluation experience	6 (20.7)
Curriculum Revision
Updating own teaching session	22 (75.9)
Updating course	18 (62.1)
Updating clinical program	9 (31)
No curriculum revision experience	5 (17.2)
Other	1 (3.4)*

* Revision of preclinical curriculum

Quantitative results

Knowledge sssessment

Foundational knowledge of SG-related concepts was assessed before and after the workshop using a 10-item true/false questionnaire. Mean total knowledge scores increased significantly from pre- to post-workshop (7.14 ± 1.92 vs. 9.07 ± 0.96), with a mean difference of 1.93 (95% one-sided CI, 1.41 to ∞). This improvement corresponded to a large effect size (Cohen’s d = 1.17). Item-level analysis demonstrated significant increases in the proportion of correct answers to 5 of the 10 knowledge-based questions (Table 3).

Table 3.

Knowledge-based questions with significant increase in proportion of correct answers

Knowledge Based Questions with significant differences in correct answers	Pre-Workshop Correct Answers n (%)	Post-Workshop Correct Answers n (%)	p-value
Accounting for sex as a biological variable is not a requirement for NIH funding approval.	8 (27.6)	21 (72.4)	0.003
Dosing of zolpidem (Ambien) is different for males vs. females.	13 (44.8)	26 (89.7)	< 0.001
Adverse drug reactions to therapeutic drugs are more common in females.	15 (51.7)	25 (86.2)	< 0.001
Clinical outcomes of acute coronary syndrome are worse for females than for males.	20 (69.0)	28 (96.6)	0.004
Sex and gender-based medicine is a fundamental aspect of precision medicine.	23 (79.3)	28 (96.6)	0.031

Retrospective post-then-pre skills self-assessment

Next, we examined changes in self-assessed skills using a retrospective post-then-pre design (Table 4). We observed a statistically significant improvement in participants’ confidence in their ability to assess their own materials for inclusion of SG content, to locate and incorporate new evidence regarding SG into their teaching and materials, and to integrate knowledge of SG into their curricula. Self-reported familiarity with SG concepts in health and disease also increased significantly following the workshop.

Table 4.

Retrospective post-then-pre self-assessed skills regarding sex and gender

	Retrospective Pre-workshop Self-Assessment* Median (IQR)	Retrospective Post-workshop Self-Assessment* Median (IQR)	p-value	Effect size (Cohen’s d)
I am familiar with the topic of sex and gender differences in health and disease.	4 (4–4)	4 (4–5)	0.010	0.48
I believe I have included sex and gender evidence as part of my courses and/or curriculum development.	3 (3–4)	4 (3–4)	0.004	0.53
I believe I have adequately incorporated the evidence of sex and/or gender-based differences in my educational activities.	3 (2–4)	3 (2–4)	0.609	0.09
I am comfortable incorporating new evidence about sex and/or gender-based medicine into my teaching.	3 (3–4)	4 (4–4)	< 0.001	0.71
I believe I frequently emphasize the intersection of sex and/or gender with other social determinants of health such as race and/or economic status in my educational activities.	3 (2–4)	3 (2–4)	0.084	0.32
I am confident in my ability to assess my curricular materials for inclusion of sex and gender content.	3 (2–4)	4 (4–4)	< 0.001	0.75
I am confident in my ability to assess someone else’s curricular materials for inclusion of sex and gender content.	3 (2–4)	4 (4–4)	< 0.001	0.72
I am confident in my ability to locate evidence-based sex and gender content for inclusion into my curricular materials.	2 (2–4)	4 (4–5)	< 0.001	0.83
I am confident in my ability to integrate knowledge of sex and gender differences into my curricular materials.	3 (3–4)	4 (4–4)	< 0.001	0.73

* On a five-point Likert scale of agreement [1 = Strongly disagree; 2 = Disagree; 3 = Neither; 4 = Agree; 5 = Strongly agree]

Attitudes toward the SG-CART materials and workshop

We then assessed attitudes toward the SG-CART materials and workshop (Table 5). Most respondents found the checklist instrument either easy to use (19 [65.5%]) or somewhat easy to use (9 [31%]), while only one participant found it not easy to use (3.4%). Similar results were found regarding the toolkit (easy to use, 18 [62.1%]; somewhat easy to use, 10 [34.5%]; not easy to use, 1 [3.4%]). The majority of survey respondents found the SG-CART materials helpful for updating their curricula (workshop, 23 [79.3%]; checklist, 23 [79.3%]; toolkit, 21 [72.4%]). The remaining survey respondents found the SG-CART materials somewhat helpful for updating their curricula (workshop, 6 [20.7%]; checklist, 6 [20.7%]; toolkit, 8 [27.6%]), while no participants found them unhelpful. Additionally, 4 out of 5 respondents intend to use the checklist (23 [79.3%]) and the toolkit (24 [82.8%]) in the future. When co-reviewing their teaching materials with their peers using the SG-CART, 37.9% [11] agreed with their partner to a great extent, 44.8% [13] to a moderate extent and 10.3% [3] to a small extent. Finally, 86.2% [25] of survey respondents perceived the assessment instruments included in the toolkit as reliable, and 79.3% [23] found this workshop to be a catalyst for additional changes to their curricular materials for SG content.

Table 5.

Perceived ease of use, helpfulness and intention to use of the SG-CART materials

Attitudes	No (%) (n = 29)
Ease of use of the checklist instrument
Easy	19 (65.5)
Somewhat easy	9 (31)
Not easy	1 (3.4)
Ease of use of the toolkit
Easy	18 (62.1)
Somewhat easy	10 (34.5)
Not easy	1 (3.4)
Helpfulness of workshop for updating own curricula
Helpful	23 (79.3)
Somewhat helpful	6 (20.7)
Not helpful	0
Helpfulness of checklist for updating own curricula
Helpful	23 (79.3)
Somewhat helpful	6 (20.7)
Not helpful	0
Helpfulness of toolkit for updating own curricula
Helpful	21 (72.4)
Somewhat helpful	8 (27.6)
Not helpful	0
Use of the Checklist in Future
Yes	23 (79.3)
Unsure	6 (20.7)
No	0
Use of the Toolkit in Future
Yes	24 (82.8)
Unsure	5 (17.2)
No	0

Qualitative results

Thematic analysis of the focus group transcripts and written feedback from open-ended survey questions led us to identify three major themes: (1) Content & Clarity; (2) Applicability; (3) Usability. Illustrative quotes for each sub-themes are provided, with minor editing to improve readability and comprehension, in Table S1 [see Additional file 3].

Content & clarity

The SG-CART materials were perceived by faculty as a teaching tool for people less familiar with sex and gender differences or as an organized way to approach updating curricular materials and seeing areas needing improvement. The importance of the educational session accompanying the SG-CART was also highlighted. The assessment instruments (both the scale and the checklists) were perceived as evaluative and helpful to determine how and to what extent SG should be addressed in existing materials. Overall, participants demonstrated a shared understanding of the scale’s purpose, and most items were interpreted as intended.

Although most of the terminology used in the SG-CART materials was well comprehended, some terms and definitions required clarification to avoid misinterpretation and to better distinguish between scale levels. Suggestions to replace ambiguous terminology were made, such as removing the Assessment scale terms “sensitivity” and “specificity” and opting for “aware” and “explanatory”. Adding a terminology glossary was also suggested.

Applicability

Overall, educators involved in the focus groups perceived the SG-CART materials as important and helpful. Participants perceived curricular revision using the SG-CART materials as an iterative process, allowing gradual improvements given the complexity of updating teaching materials. Tools that were presented in the workshop could be used concomitantly (e.g., searching the literature while assessing your lecture) or one step at a time. Participants also reflected on the importance of acknowledging knowledge gaps to learners especially when lack of evidence in SG may prevent them from reaching translational levels of patient care. Educators recognized the importance of balancing the learners’ educational needs with incorporating too much specific content. The SG-CART inspired faculty to identify improvement opportunities in their materials and find new angles and insights in their topics of expertise. Participants also discussed the potential for adapting the SG-CART materials, e.g. a collaborative community of educators approach, using artificial intelligence, reaching a broader audience, and addressing intersectional issues.

Usability

Faculty envisioned an additional succinct version of the toolkit without examples, for rapid subsequent use. For the workshop, they also suggested adding an asynchronous version. Some faculty found the step-by-step process easy to follow, while others found it necessary to have additional instruction. The presentation and various examples were seen as essential to learning. Faculty also commented on the ease of navigation through the material. Finally, considerations were raised about the level of dedication or time required to apply the SG-CART for all their material.

Discussion

Our results demonstrate that the SG-CART and its accompanying workshop seems to have achieved their intended educational outcomes, namely learning (Level 3) and competence (Level 4) as per Moore’s Outcomes Framework [48]. Findings suggest improvements in faculty members’ foundational knowledge of SG, as evidenced by gains in pre to post-knowledge assessments scores and participants’ self-reported knowledge gains. Self-assessed ability to evaluate and update curricular materials to better integrate sex and gender-related content seems enhanced following participation in the SG-CART workshop. Although based on subjective measures of competence, these observed gains, combined with the participant’s intention to use the SG-CART materials in the future, are promising, as previous literature supports the role of confidence and intention to change as important contributors to practice changes [60]. Key features of the SG-CART workshop, namely interactivity, use of multiple teaching methods, and emphasis on outcomes perceived as important by participants, have been associated with positive changes following continuing medical education [61]. Intentional alignment of teaching strategies with educational objectives, such as demonstrations, authentic practice using participants’ own teaching materials, feedback, discussion about anticipated barriers [48], may also have contributed to the observed educational gains.

The SG-CART educational materials help fill an important gap in medical education. Previous studies have identified limited faculty knowledge, confidence, and skills as key barriers to the integration of SG-related content into curricula [36, 39–44, 47]. Only a few comprehensive faculty training activities in SG-based medicine have been described. Most existing efforts do not take a broad approach to SG-based medicine, but rather address narrower topics such as gender binary biases, SG minorities [62], sexual orientation, or gender identity [63]. One of the strengths of this study is the heterogeneity of its participants, which included faculty from a variety of fields, with differing levels of familiarity with SG-based medicine. Given that individual characteristics have been shown to influence openness to the concepts related to sex and gender [32, 64, 65], our results are very promising. Previously, it has been recommended to identify “a faculty champion or ‘change agent’ who can drive curricular integration.” [35] As mentioned by Celik et al., “‘ambassadors. can stimulate and promote the adoption of new ideas… and can be seen as internal opinion leaders.” [46] Although women have been reported to play a prominent role in the incorporation of SG content into medical education [14, 66], engagement across faculty groups remains important. Developing initiatives that support participation from faculty with varying levels of initial interest or experience could facilitate broader and more sustained curricular uptake. For example, at the Medical University of Innsbruck, lecturers of different fields challenged to give a gender-specific lecture in their area of expertise as part of a Gender Medicine series found the opportunity “caused them to deal more consciously with the medical relevance of sex- and gender-specific differences” [67].

Our faculty development workshop included education on the relevance of incorporating SG content into teaching, which participants identified as a key component of the session. In addition to the provision of SG-specific educational material, attention must be directed towards the existence of a hidden curriculum and the importance of fostering an inclusive institutional culture [68, 69]. Recommendations include ongoing faculty training in SG-sensitive medicine and unconscious bias, along with the promotion of inclusive language, the avoidance of stereotypes, and the visible representation of diverse patient groups throughout the learning environment [68]. Evidence suggests that these elements are not consistently present across institutions [69–71]. These aspects have been emphasized in the SG-CART. As mentioned by Verdonk et al., leadership engagement and institutional support are contributing factors in the successful integration of SG into medical curricula [72].

One of the added values of the SG-CART is its evaluation component, composed of the assessment scale and checklists. As raised by Barr et al., “a thorough understanding and evaluation of the health curricular landscape is key to integrating sex and gender and advancing SGHE [sex and gender health education].” [73] At the time the SG-CART was developed and implemented, no formal evaluation method for inclusion of SG content had been published. Since then, a number of publications have reported strategies for evaluating the curriculum for SG inclusion. For example, checklists for well-established healthcare inequities, including but not limited to SG, are now available to help faculty identify and address biases and stereotypes [74, 75]. In addition, a recently published paper presents a new model, also adapted from the WHO Gender Responsive Assessment Scale, to evaluate the depth of integration of sex and gender-sensitive medicine in curricular content and associated learner’s competences [76]. To the best of our knowledge, however, the SG-CART is the first to initiate a validation process.

Cognitive interviewing, which has been shown to be effective for establishing both content and construct validity [77, 78], provided important validity evidence for the assessment scale embedded within the SG-CART by examining participants’ comprehension of item wording, definitions and underlying constructs. This process also allowed us to identify design flaws, and informed iterative revisions to item wording and definitions to improve clarity, alignment with respondents’ mental models, and relevance to medical education contexts. Although the SG-CART’s initial reception was extremely favorable, integration of user feedback to refine the overall format was also achieved based on our findings. The revised toolkit is available with changes that reflected the focus groups’ findings [see Additional file 4]. Despite the availability of exhaustive reviews of available SG resources [36, 76], decision was made to prioritize a limited set of resources that serve as entry points for faculty new to the topic. A one-page quick guide version of the toolkit for users who became facile with the toolkit and preferred brevity was also created and made available [see Additional file 5].

Limitations

As a one-of-a-kind toolkit and study, it faces limitations. First, the small sample size and the single, well-resourced U.S. institutional context may limit generalizability, particularly to institutions in other countries, under-resourced settings, or educational contexts with different cultural norms. However, the SG-CART core concepts may be transferable with appropriate contextual and cultural adaptation.

Second, the voluntary nature of participation in both the workshop and the study likely attracted faculty with a pre-existing interest in SG-based medicine, introducing potential self-selection bias that challenges external validity [79]. In addition, the relatively low survey response rate raises the possibility of nonresponse bias and further reduces representativeness. Findings should be interpreted as reflecting the perspectives of engaged faculty rather than the broader faculty population.

Third, the retrospective post–then–pre self-assessment, intentionally selected to reduce response-shift bias, may be subject to recall and social desirability biases that can overestimate effects [80]. Furthermore, self-assessed skills reflect perceived rather than demonstrated competence. While increases in confidence and familiarity are important precursors to behavior change, future studies should examine whether these perceived gains translate into measurable curricular revisions or sustained educational impact. Because some participants were colleagues or members of the researchers’ department, social desirability bias may have influenced focus group responses and limited participants’ willingness to offer critical appraisal of the toolkit.

Fourth, the knowledge assessment consisted of a limited number of non-validated true/false items, which may not capture the full depth or complexity of SG-related concepts. Improvements in knowledge scores may be partially attributable to testing effects [79], including familiarity with question formats or guessing associated with binary response options. Additionally, the absence of a control group limits causal inference, as improvements cannot be attributed exclusively to the workshop without comparison to a non-intervention group.

Finally, this study did not examine the impact of the SG-CART on actual curricular change or learner-level outcomes. Its effectiveness for sustained widespread incorporation of SG content in diverse educational settings and its adaptability to other health professional education programs should be explored in subsequent studies. Additional research is also needed to complete validation of the assessment tools, including formal evaluation of reliability and sensitivity to change.

Conclusions

This study suggests that the SG-CART and accompanying workshop is a promising approach for faculty development. It appears to be associated with immediate improvement in faculty knowledge, self-assessed skills, and perceptions regarding the integration of SG perspectives in medical education. During this initial evaluation, the SG-CART was perceived as a practical resource for educators to enhance their materials. Findings from the focus groups informed refinements to the assessment scale and provided contextual insight into faculty experiences with the SG-CART. Implementation of this toolkit and faculty development session could lead to broader integration of SG content into medical curricula, advancing efforts toward more inclusive and equitable healthcare education.

Abbreviations

SG

Sex and gender

SG-CART

Sex and Gender Curricular Assessment and Revision Toolkit

USCSOMG

University of South Carolina School of Medicine Greenville

WHO

World Health Organization

Authors' contributions

MS, KQ, MR and AM conceptualized and designed the study. ZGT, JS and KQ acquired, analyzed and/or interpreted the data. ZGT, JS, MR and AM drafted the manuscript. All authors read and approved the final manuscript. All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Funding

This work has received financial support from Office of Research on Women’s Health of the National Institutes of Health in the form of Galvanizing Health Equity Through Novel and Diverse Educational Resources (GENDER) Research Education Program (R25) grant awarded to AM, KQ and MR (award number R25LM014335) and from Département de médecine de famille et de médecine d’urgence, Université de Montréal in the form of research scholarship awarded to ZGT.

The National Institutes of Health had no role in the design and conduct of the study; the collection, management, analysis, or interpretation of the data; the preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Data availability

The data that support the findings of this study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was reviewed by the University of South Carolina Institutional Review Board (Reference Number: Pro00128552), which determined that it was not subject to the Protection of Human Subject Regulations in accordance with the U.S. Code of Federal Regulations 45 CFR 46, constituting a formal Declaration of Not Research. All research procedures nonetheless adhered to the principles outlined in the Declaration of Helsinki. Participation was voluntary. Informed consent was obtained from all participants prior to data collection. Recorded verbal informed consent was obtained from all focus group participants, and all survey participants provided a written waiver of informed consent in accordance with Institutional Review Board decision.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.