Australia’s clinical guidelines shape our health care. Why do so many still ignore sex and gender?

You’ve heard of the gender pay gap. What about the gap in medical care?

Cardiovascular diseases – which can lead to heart attack and stroke – are one of the leading causes^[1] of death for women in Australia.

But women are less likely^[2] than men to receive preventive care for heart disease, such as appropriate medication. One study in New South Wales showed women admitted to hospital for a stroke were more likely^[3] to be first told by paramedics it was a migraine, headache, anxiety or nausea.

Despite these differences, official guidelines in Australia too often ignore the impact of sex and gender on health care. For example, a guideline on atrial fibrillation^[4] (irregular and often fast heartbeat) has limited information on sex and nothing on gender.

“Sex” refers to^[5] various biological characteristics by which at birth we are identified as female, male or intersex. “Gender” is a social and cultural concept in which people understand themselves to be a woman, a man or non-binary.

Our recent study^[6] reviewed 80 clinical guidelines. We found very few define sex and gender and the majority don’t mention gender at all. This has serious consequences for everyone, but especially for women, girls and gender-diverse people.

What are clinical guidelines for?

Clinical guidelines are recommendations about how to diagnose and treat a medical condition, based on research and usually developed by a team of specialists. Clinicians and other health workers are expected to use them to guide day-to-day health care.

For example, there are guidelines for physiotherapists on how to provide the best rehabilitation for someone after a heart attack^[7]. Other guidelines outline what a GP should do if a patient discloses intimate partner violence^[8].

Because clinical guidelines are based on research, they can report only what has been studied and published in peer-reviewed journals. This means where there are gaps in research, clinical guidelines are usually silent.

What we did

As part of a larger project^[10], the federal government asked our team to examine whether there are still clinical guidelines that do not take into account sex and gender differences.

There is no central database of Australia’s clinical guidelines. But in a comprehensive search, we found^[11] 80 published from January 2014 to April 2024.

These encompassed guidelines for conditions including various cancers, diabetes and attention-deficit hyperactivity disorder, designed for a range of health professionals such as general practitioners, medical specialists, physiotherapists and paramedics.

We searched every document for the following words:

• sex
• gender
• female
• male
• women
• men
• girl
• boy

If none of these words were found, we looked for “psychosocial” and “cultural”, to see if gender was considered without being named directly. We also read the text around each relevant word to understand its context and meaning.

What we found

Clinical guidelines in Australia too often do not offer guidance on incorporating sex and (especially) gender into health care.

We found:

• 15% of guidelines didn’t mention sex or gender at all. This includes recommendations about acute coronary syndrome from the National Heart Foundation^[12] and on e-mental health^[13] by the peak body for GPs. These guidelines did not even give the most basic information on sex differences in occurrence (of heart disease or mental health problems)

• only four guidelines (5%) defined the terms “sex” and “gender”

• 19% made no reference to clinical practice concerning sex. That is, there was no information on how symptoms and treatments might vary among biologically female, male and intersex bodies

• the majority (58%) ignored the role gender can play in clinical practice and how it might shape what treatment is most effective. For example, some women may be more comfortable being seen by a female doctor, for a range of personal or cultural reasons

• most (81%) did acknowledge biological sex in some way. But among those 65 guidelines there was great variation, ranging from a single statement about whether a condition (such as lung cancer^[14]) occurred more often in women or men, to detailed risk factors, prevalence, treatment and management, such as for advanced life support by paramedics^[15].

Why does this matter?

The male body has historically been considered^[16] the “standard” human. With hormonal changes and pregnancies^[17], women’s bodies have been seen as too complicated to be included in clinical research.

This means research has been conducted on men and then applied to women^[18], ignoring the differences that excluded them from the research in the first place.

If the standard body is implicitly that of a (white) male, discrimination against all other bodies is inevitable.

The Australian Institute of Sport’s guideline on concussion and brain health^[20] is one of just four guidelines that define sex and gender.

This is crucial, given growing evidence women footballers are at greater risk^[21] of concussion than men. But their approach is far from mainstream.

Gender-diverse people also require distinct health care and support, based on inclusive and non-discriminatory practice and policy. There is clear evidence^[22] the mental health of gender-diverse people is profoundly affected by how sensitive – or discriminatory – their health care is.

Eliminating discrimination

Discrimination can be explicit and overt.

But it can also simply come from a lack of imagination, based on the assumption some kinds of health care are sex- and gender-neutral.

For example, the treatment of skin – dermatology – could appear neutral, as everyone has skin. Yet social expectations about clothing, make-up and appearance are highly gendered, and these can influence how skin conditions develop and are treated.

Guidelines that offer detailed information on sex- and gender-aware practice, such as those by GP Supervisor Australia^[23], can contribute to challenging both explicit and implicit discrimination.

Ultimately, we hope this leads to equitable health care for people of all sexes and genders.

We recommend all developers of clinical guidelines look for evidence concerning sex and gender and, when they find none, say so. Funding bodies should also demand inclusion of sex and gender as a criterion to award money for medical research.

Silence on sex or gender implies that the topics aren’t important. This is far from the truth.

We acknowledge the contribution of the other members of our research team: Tomoko Honda, Steve McDonald, Sally Green, Karen Walker-Bone, and Ingrid Winship.

References

1. ^{^} leading causes (www.aihw.gov.au)
2. ^{^} less likely (pubmed.ncbi.nlm.nih.gov)
3. ^{^} more likely (pubmed.ncbi.nlm.nih.gov)
4. ^{^} a guideline on atrial fibrillation (www.heartlungcirc.org)
5. ^{^} refers to (www.abs.gov.au)
6. ^{^} recent study (onlinelibrary.wiley.com)
7. ^{^} after a heart attack (doi.org)
8. ^{^} patient discloses intimate partner violence (www.racgp.org.au)
9. ^{^} Media_Photos/Shutterstock (www.shutterstock.com)
10. ^{^} larger project (www.health.gov.au)
11. ^{^} we found (onlinelibrary.wiley.com)
12. ^{^} National Heart Foundation (doi.org)
13. ^{^} e-mental health (www.racgp.org.au)
14. ^{^} lung cancer (www.cancer.org.au)
15. ^{^} advanced life support by paramedics (www.ambulance.vic.gov.au)
16. ^{^} historically been considered (onlinelibrary.wiley.com)
17. ^{^} pregnancies (theconversation.com)
18. ^{^} then applied to women (www.mja.com.au)
19. ^{^} Inside Creative House/Shutterstock (www.shutterstock.com)
20. ^{^} concussion and brain health (www.concussioninsport.gov.au)
21. ^{^} greater risk (theconversation.com)
22. ^{^} clear evidence (bmcpublichealth.biomedcentral.com)
23. ^{^} GP Supervisor Australia (gpsa.org.au)