Time to implement sex and gender responsive policies and programmes
Authors: Sarah J Hawkes, Angela Y Chang
Journal: The Lancet Public Health (2024)

Given the power and ubiquity of the Institute of Health Metrics and Evaluation's work on mapping and estimating the Global Burden of Disease (GBD) and assessing the effect of health policies, it is sometimes difficult to remember that the first GBD estimates were published only 30 years ago in the 1993 World Development Report.1The World BankWorld development report 1993: investing in health. Oxford University Press, New York, NY1993Crossref Google Scholar The effect and influence of these global health metrics on priority setting, resource allocation, and decision making have been almost immeasurable, including in shaping health policy at both national and global levels.2Shiffman J Shawar YR Strengthening accountability of the global health metrics enterprise.Lancet. 2020; 395: 1452-1456Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar From the start,3Murray CJL Lopez AD Global and regional cause-of-death patterns in 1990.Bull World Health Organ. 1994; 72: 447-480PubMed Google Scholar GBD data have been disaggregated by sex and age, an approach that has not always been the norm in public health. A major bibliometric analysis of over 11 million articles in the medical research field found that sex-related reporting in public health research was present in only 36% of cases in 1980, rising to 69% in 2016 (in clinical medicine the change was from 59% to 67%, whereas biomedical papers remained at around only 30% of papers reporting on sex of participants).4Sugimoto CR Ahn YY Smith E Macaluso B Larivière V Factors affecting sex-related reporting in medical research: a cross-disciplinary bibliometric analysis.Lancet. 2019; 393: 550-559Summary Full Text Full Text PDF PubMed Scopus (193) Google Scholar The longitudinal nature of sex-disaggregated data with GBD permits important and interesting analyses across the decades. Investigating differences in disability-adjusted life-years (DALYs) in the top 20 most burdensome conditions between males and females across the lifespan over the past 20 years, Vedavati Patwardhan and colleagues5Patwardhan V Gil GF Arrieta A et al.Differences across the lifespan between females and males in the top 20 causes of disease burden globally: a systematic analysis of the Global Burden of Disease Study 2021.Lancet Public Health. 2024; 9: e282-e294Summary Full Text Full Text PDF Google Scholar call attention to some clear differences and potentially unexpected findings, including that sex differences become larger over the life-course but have remained relatively stable over time. The study prompts readers to ask important questions for further investigation—eg, what would a reasonable or acceptable difference between the sexes look like? Should policy makers expect interventions to reduce differences to zero? What would differences look like if disability weights (integral to the calculation of DALYs) were made sex-specific?6Salomon JA Haagsma JA Davis A et al.Disability weights for the Global Burden of Disease 2013 study.Lancet Glob Health. 2015; 3: e712-e723Summary Full Text Full Text PDF PubMed Scopus (748) Google Scholar Where differences appear to decline over time (eg, lung cancer), is this a good or a bad sign, and are rates of lung cancer increasing in females compared with males or are lung cancer rates in males decreasing at a faster rate? Our ability to raise these questions (and hopefully to explore answers and identify solutions) is only possible because the GBD studies have consistently disaggregated data by sex—something that has been called for many times over many years, but inconsistently applied. The UN Statistics Division, for example, urges all countries to record deaths by sex, age, and cause in civil registration records, population censuses, and health surveys in order for national policy makers to have empirical evidence on life expectancy and causes of death in men and women;7UN Department of Economic and Social AffairsIntegrating a gender perspective into statistics. United Nations, New York, NY2016Google Scholar and recent guidance from WHO has called for the adoption of standardised guidelines for reporting sex and gender in research and health estimates.8Heidari S Fernandez DGE Coates A et al.WHO's adoption of SAGER guidelines and GATHER: setting standards for better science with sex and gender in mind.Lancet. 2024; 403: 226-228Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Even with these apparently universal agreements on the importance of disaggregation, and the emergence of potentially powerful mechanisms to promote compliance, we still do not have uniformity, both in terms of what is being reported and how consistently. Some will raise concerns with the GBD methods as to how the sex of the hundreds of thousands of people in the original studies was identified and formed the basis of data disaggregation. Did the studies report on sex assigned at birth, current gender identity, or was sex or gender identity assigned by the study personnel rather than reported by the individual participant? How are the studies taking biases in vital registration (eg, death registration) into account in the many situations in which, for example, male deaths are more likely to be registered.9Adair T Gamage USH Mikkelsen L Joshi R Are there sex differences in completeness of death registration and quality of cause of death statistics? Results from a global analysis.BMJ Glob Health. 2021; 6e006660Crossref Scopus (6) Google Scholar Seeking the answers to these questions and more requires public health researchers not only to have a better understanding of the reporting of sex and gender (and gender identity), but to appreciate why this matters. Despite these and other caveats around measurement, a predominant concern remains that if GBD data are intended to influence health policy, then all too frequently sex-disaggregated data are overlooked or simply ignored in decision-making processes. Even with many decades of empirically robust and rigorous efforts by GBD to report sex differences, we have not seen the same level of attention paid to the question of integrating gender-responsiveness into responses aiming to reduce DALYs or lengthen life expectancy. Yet it is gender—ie, the unequal distribution of power and privilege in the systems and structures determining health and wellbeing—that is determining a large part of the observed health and life expectancy differences between people. It is beyond time in public health politics, policies, programmes, and practices to ensure we move from sex-disaggregation to gender-responsiveness that tackles the root causes of health inequities. We declare no competing interests. Differences across the lifespan between females and males in the top 20 causes of disease burden globally: a systematic analysis of the Global Burden of Disease Study 2021The notable health differences between females and males point to an urgent need for policies to be based on sex-specific and age-specific data. It is also important to continue promoting gender-sensitive research, and ultimately, implement interventions that not only reduce the burden of disease but also achieve greater health equity. Full-Text PDF Open Access