Tag Archive for: gender identity

Importance of considering minority stress when conducting cardiovascular health research in transgender, gender-diverse and non-binary populations

Authors: Raquel Rodriguez, BSc Kinesiology, McGill University | Editors: Romina Garcia de leon, Janielle Richards (Blog Co-Coordinators) | Expert Reviewer: Lindsey Thurston

Published: Friday November 1st, 2024

Transgender, gender-diverse, and non-binary (TGD) individuals are people whose gender identity does not align with their sex assigned at birth. TGD people face unique stressors related to their stigmatized gender identity and expression and are thus more likely to experience mental health issues compared to cisgender individuals, whose sex assigned at birth aligns with their gender identity. These unique stressors are known as minority stressors which include external conditions and events (i.e., discrimination and victimization) as well as internal factors (i.e., expectations of discrimination and internalization of negative societal attitudes). Increasing evidence indicates that TGD individuals face disparities in various cardiovascular (CV) risk factors and higher rates of CV morbidity and mortality compared to their cisgender peers. The population of individuals who identify as TGD is growing, as such, it is important to quantify minority stress when conducting cardiovascular research in TGD populations.

TGD & Minority Stress

The leading explanation for the health disparities observed between TGD and cisgender individuals is the minority stress theory. This theory states that, in addition to the common stressors faced by everyone, members of minority groups, including the TGD community, endure a greater range of unique stressors due to their minority status. These unique stressors are either external in nature (i.e., distal stressors) or are felt internally by the individual (i.e., proximal stressors). Distal stressors include experiences such as misgendering, stigma, discrimination, rejection, and victimization based on their gender identity. Proximal stressors include internalized stigma or transphobia, negative expectations, and concealing one’s gender identity. The theory also states that some of these individuals may also experience individual- and/or community-level resilience as a result of their minority status, allowing them to persist and thrive in the face of adversity against these stressors.

Minority Stress & How it Affects Cardiovascular Outcomes

Both internal and external stressors can negatively affect the body’s homeostasis. Psychosocial stress is an inevitable part of daily life and it is linked to an increased risk of CV disease (CVD) events. Acute and chronic mental stress are both associated with the long-term development of CV issues. Distal and proximal stressors raise the overall stress levels of TGD individuals beyond those faced by the cisgender population, negatively affecting CV health behaviours and increasing the risk of various poor mental and physical health outcomes, including CVD.

Minority Stress & Cardiovascular Health Behaviours

TGD populations have higher chances of negative CV outcomes and associated risk factors as a result of a variety of multifaceted health behaviours. TGD persons may participate less in regular physical activity than the cisgender population which puts them at a higher risk of developing CVD. Moreover, TGD adolescents have self-reported more disproportionately unsafe weight management and disordered eating behaviours compared to their cisgender peers. Research has reported elevated levels of alcohol use within the TGD population compared to the general population as a result of victimization, bullying, and minority stress.

Future Directions

Research in TGD populations should prioritize the unique impact of minority stress on cardiovascular health outcomes. Unlike research conducted on cisgender individuals, studies on TGD populations must consider distal and proximal stressors like discrimination and internalized stigma. Improved measurement tools that capture the full range of minority stressors are essential for reliable research findings. By incorporating these unique considerations, future research can contribute to a more accurate and comprehensive understanding of TGD health, ultimately leading to better health outcomes for this medically underserved and growing population.

Why is this topic important? 

This topic is important because the growing population of TGD individuals deserve and require proper and accurate healthcare services which stem from properly conducting research to accurately depict their physiological capacities. Researchers cannot conduct studies on this population in the same way as they do cisgender people as there are unique factors to consider when properly assessing the TGD population. The minority stress that they experience contributes to their cardiovascular capacities and therefore cannot be neglected when doing research on the TGD population.

Behind the Science: Rx For Heterosex – An Interview with Thea Cacchioni

Interviewee: Dr. Thea Cacchioni | Authors/Editors: Romina Garcia de leon, Janielle Richards (Blog Co-coordinators)

Published: August 2, 2024

Can you tell us about your research?

My original research area critically engaged the diagnostic category of female sexual dysfunction. I was concerned that women’s problems were being over-medicalized. This was in the wake of Viagra, and there was a race among pharmaceutical companies to find a Viagra-like drug for women. Whereas Viagra was a drug that was discovered ‘accidentally’, every option tested for women was ineffective. In the meantime, scientists and doctors connected to the pharmaceutical industry were discussing how to define women’s sexual problems, particularly given that frigidity was no longer seen as an acceptable term.  As part of this research area, I interviewed women with sexual problems – I heard of some physiological reasons for difficulties, particularly in the case of sexual pain, but interpersonal, social and political reasons were overwhelmingly more common (such as past experiences of sexualized violence, partner dissatisfaction, and so on). It was also clear that there was a lot of misunderstanding around what constitutes ‘normal.’ I also testified at the US FDA against one particular desire drug that was denied twice and then eventually approved after a very clever public relations campaign accusing the FDA of sexism.  

A more recent area of research that is more personal to me is Polycystic Ovarian Syndrome (PCOS). As a gender studies professor, I find it to be quite fascinating that 4-10% of women globally have this diagnosis, yet there is such little public discussion about it. This is an area that is also of interest given that it’s related to the standards of femininity and successful heterosexuality in ways that are similar to my past area of research. PCOS includes symptoms such as hairiness, acne, infertility, and weight gain. These are all things that do not fall into a hetero-feminine norm. My research in PCOS involves doing in-depth interviews with individuals with PCOS. An interesting aspect of this sample is that out of 30, 15 people identify as queer, with 5 identifying as non-binary or trans. I’m interested in the way that experiences of PCOS may differ depending on gender and sexual identity. 

What led you to do this work?

I have lived experiences with PCOS. I’ve had the diagnosis for over 20 years, and I’m very familiar with how difficult it is to engage with medical professionals around this diagnosis. There’s a lot of misunderstanding or lack of awareness within the medical community, and that was part of my interest. My PCOS symptoms are mainly weight gain, irregular menstruation, and struggles with fertility. On top of this, I had an added distress because I felt like I wasn’t being a ‘good feminist’ for worrying about these things. This interested me. I think trends, theory and politics have helped me come to terms with this dichotomy I was experiencing. I also think that I’ve come further into body acceptance through body-positive movements that we’re seeing through fat activism.

Could you share any findings from your research?

One finding that I continue to see in the PCOS participants is that non-binary people show fewer signs of distress towards their symptoms and embrace them as part of their gender identity. I think the queer sample overall, had a lot more support in their relationships in terms of embodying these traits. There is less pressure in terms of fertility, and thinness, as well as acceptance of acne or weight gain. That’s not to say that you can’t be queer and feminine-identified or concerned with fertility or weight gain, of course. Another trend that I noticed was that distress over these symptoms was a sense of feminist consciousness (which I saw in both heterosexual and queer samples). Individuals with a positive relationship with their bodies because of their feminist consciousness had less symptom-related distress.  In terms of their experiences with the medical system –  most of them had pretty terrible experiences with doctors who would simply tell them to lose weight. However, it’s very hard to lose weight when you have PCOS. 

Another noticeable observation was that a lot of PCOS patients sought naturopathic remedies. This may be driven by the lack of support from their doctors. In sessions with naturopaths they can converse about their symptoms for longer periods and feel heard. A lot of people are turning to holistic medicine, and I think that’s something the medical profession has to address. In general, we see frustration with medicine, a tendency to rely on advice from naturopaths and influencers and so-called hormone experts. I think that it gives individuals a sense of control. Yet many times, these individuals will prescribe many supplements that have very little results.

Where do you hope this research will go in a couple of years?

I would love to expand my research to diverse people with PCOS. Although my study was diverse and had some diversity in terms of gender identity, I would like to take that further.  I would also like to look into the question of race, ethnicity, nationality, culture, religion, and how that may influence your experiences with PCOS. All of these factors may shape norms of sex, gender, and sexuality, all of which come into play when discussing PCOS and distress.

For instance, another problem with the medical approach is that it’s very connected to the body mass index (BMI). There are a lot of critiques of the BMI, and so I think that also that’s another point around where people with PCOS are losing proper care, because if it’s just centred on BMI, it can be misleading – you can be very muscular with PCOS and not fit within a healthy weight on the BMI. 

Where to read more about Dr. Cacchioni’s work? 

Book: “Big Pharma, Women and the Labour of Love”

Sex-and-Gender-Based Considerations in Exercise-Based Randomized Controlled Trials in Individuals with Stroke: A Road of Opportunities Ahead


Author: Elise Wiley, Ph.D. Student, McMaster University | Editors: Alex Lukey and Arrthy Thayaparan (Blog Coordinators) 

Published: March 19th, 2021

There is a growing body of research focused on the biological differences between males and females in pharmaceuticals, risk factors, pathology, severity, and prognosis of different diseases [1]. In contrast to this large body of evidence related to sex-based differences, we know far less about how gender impacts the risk of disease. For example, how does the risk for stroke or heart attack differ in a heterosexual man versus a transgender non-binary individual? While more research is accounting for sex differences, this is not the case for gender identity. The lack of sex and gender considerations are causing a significant gap in knowledge for many health conditions.

Stroke is a leading cause of disability and death worldwide [2]. Over the past 20 years, there has been a growing body of literature showing that exercise-based interventions are beneficial in improving physiological and psychosocial health markers in individuals with stroke [3]. However, the extent to which sex-and gender-based considerations were implemented into exercise trials in individuals with stroke has not been previously reviewed. 

In this blog post, I will share results from a study that I conducted, which aimed to examine the extent to which stroke researchers include sex-and gender-based considerations in their exercise trials. In this study, we surveyed publications of exercise trials in stroke and applied the Sex and Gender Equity in Research (SAGER) tool as a framework to determine whether sex and gender considerations were implemented in each section of a study (i.e., introduction, study design/methods, results and discussion) [4]. We were also interested in examining whether the incorporation of sex- and gender-based considerations had increased since the publication of the SAGER guidelines in 2016. 

I will preface the summary of the results by stating that we have a long way to go in addressing sex-and gender-based considerations in exercise-based trials in individuals with stroke. Over the past ten years, sex-and gender-based considerations have gained recognition for their importance in health research. This is thanks to the pioneer Canadian researchers in the field of sex and gender research who advocated for more inclusive research practices. Unsurprisingly, before 2016, the vast majority of stroke and exercise studies did not include any sex or gender considerations in any section of the research article. After 2016, we found a slight increase in the proportion of studies incorporating sex-based considerations since the publication of the SAGER guidelines. However, we also noted that researchers continued to use terminology related to “sex” and “gender” interchangeably. 

Of note, there were no exercise-based studies in stroke that included gender-based considerations. While this is unsurprising, I do wonder why we, as researchers in the field of exercise and stroke, have neglected gender in our studies? Is it that there isn’t enough awareness of the available gender-based resources to guide its inclusion or assessment? Or is the reason more deep-seated? It is important to acknowledge that it is indeed challenging to incorporate gender-based considerations into research studies when self-reported gender measures are unavailable, and there is no firm consensus on how various constructs of gender are to be measured [5]. 

We hope that our research findings will serve as a call to action for researchers in the field of exercise and stroke to acknowledge the opportunities that lie ahead in being able to address the knowledge gaps related to sex-and gender-based considerations in exercise trials in individuals with stroke. We must continue to reinforce the idea that although sex and gender are interrelated, they are not interchangeable. I urge researchers to consult the resources that I’ve provided to ensure that their participants are being addressed properly. It may also be that there is a greater onus on journal editors to ensure that, at minimum, authors submitting to their journal are incorporating proper sex and gender terminology. 

Stroke researchers are well-equipped to move forward in the area of sex and gender research. We have access to resources such as the SAGER  guidelines, the CIHR e-learning modules Integrating Sex and Gender in Health Research, and the Gender-based Analysis Plus course [4,6,7].

As an advocate for sex and gender implementation in health research, the findings from this work suggest that we have a long way to go, but the positive trend is encouraging. I am optimistic for the years to come and continue to be inspired by my fellow researchers who advocate for enhanced sex and gender implementation in health research.  

References 

1.     Melloni Chiara, Berger Jeffrey S., Wang Tracy Y., et al. Representation of Women in Randomized Clinical Trials of Cardiovascular Disease Prevention. Circulation: Cardiovascular Quality and Outcomes. 2010;3(2):135-142. doi:10.1161/CIRCOUTCOMES.110.868307
2.     Campbell BCV, De Silva DA, Macleod MR, et al. Ischaemic stroke. Nature Reviews Disease Primers. 2019;5(1):1-22. doi:10.1038/s41572-019-0118-8
3.     Saunders DH, Sanderson M, Hayes S, et al. Physical fitness training for stroke patients. Cochrane Database of Systematic Reviews. 2020;(3). doi:10.1002/14651858.CD003316.pub7
4.     Heidari S, Babor TF, De Castro P, Tort S, Curno M. Sex and Gender Equity in Research: rationale for the SAGER guidelines and recommended use. Research Integrity and Peer Review. 2016;1(1):2. doi:10.1186/s41073-016-0007-6
5.     Lacasse A, Pagé MG, Choinière M, et al. Conducting gender-based analysis of existing databases when self-reported gender data are unavailable: the GENDER Index in a working population. Can J Public Health. 2020;111(2):155-168. doi:10.17269/s41997-019-00277-2
6. Government of Canada CI of HR. IGH Learning – CIHR. Published September 2, 2015. Accessed February 25, 2021. https://cihr-irsc.gc.ca/e/49347.html
7. Government of Canada CI of HR. Gender-Based Analysis Plus (GBA+) at CIHR – CIHR. Published May 15, 2018. Accessed June 5, 2020. https://cihr-irsc.gc.ca/e/50968.html