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Advancing Sex- and Gender-Informed Approaches to Health in an Academic Medical Center

  • Lydia E. Pace
    Correspondence
    Correspondence to: Lydia E. Pace, MD, MPH, 1620 Tremont St., 4-416, Boston, MA 02120. Phone: +(617) 525-7545; fax: +(617) 525-7746.
    Affiliations
    Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts

    Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts

    Department of Medicine, Harvard Medical School, Boston, Massachusetts
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  • Grace L. Chen
    Affiliations
    Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts

    Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts
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  • Jaclyn Chai
    Affiliations
    Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts

    Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts
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  • Jill M. Goldstein
    Affiliations
    Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts

    Department of Medicine, Harvard Medical School, Boston, Massachusetts

    Department of Psychiatry, Harvard Medical School, Boston, Massachusetts

    Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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  • Piper Orton
    Affiliations
    Wellesley College, Wellesley, Massachusetts
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  • Deborah Bartz
    Affiliations
    Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts

    Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts

    Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts

    Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
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  • Janet Rich-Edwards
    Affiliations
    Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts

    Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts

    Department of Medicine, Harvard Medical School, Boston, Massachusetts
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  • JoAnn E. Manson
    Affiliations
    Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts

    Department of Medicine, Harvard Medical School, Boston, Massachusetts

    Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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  • Paula A. Johnson
    Affiliations
    Wellesley College, Wellesley, Massachusetts
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Published:December 14, 2017DOI:https://doi.org/10.1016/j.whi.2017.11.004
      Social science and basic and clinical research continue to demonstrate the powerful impact of sex and gender on health and disease across all organ systems and throughout the lifespan (
      • Legato M.J.
      • Johnson P.A.
      • Manson J.E.
      Consideration of sex differences in medicine to improve health care and patient outcomes.
      ,
      • Schiebinger L.
      • Stefanick M.L.
      Gender matters in biological research and medical practice.
      ). Gender and sex also influence responses to treatment, care provision, and use (
      • Legato M.J.
      • Johnson P.A.
      • Manson J.E.
      Consideration of sex differences in medicine to improve health care and patient outcomes.
      ). Gender and sex should be central components of the growing precision medicine movement. However, gender and sex remain inadequately considered in clinical care, medical research, and medical education and training. Further, strategies to promote consideration of sex and gender in the activities of academic medical centers (AMCs) are not well-described.
      Numerous AMCs have distinct women's health centers and initiatives that lead important efforts in women's health care, research, and teaching. Given the historic underrepresentation of women in basic and clinical research studies, critical clinical and public health issues specific to women, and the value of distinct approaches to women's health, we feel that there remains value in centers for “women's health” that pursue innovative efforts specifically to care for women. However, a risk of traditional women's health centers is their potential to serve as their own silos. These centers may isolate sex and gender considerations within a discrete set of activities rather than advocating for their inclusion throughout an AMC's initiatives (
      • Legato M.J.
      Beyond women's health.
      ). We argue that, in addition to women's health initiatives, establishing fundamentally multidisciplinary programs that can guide the incorporation of gender and sex throughout AMCs' departments and activities could help to advance precision medicine and health equity.
      The Mary Horrigan Connors Center for Women's Health and Gender Biology (Connors Center) at Brigham and Women's Hospital (BWH) serves as one example of a program that, in concert with BWH Department of Medicine's Division of Women's Health, has provided both women's health and the more inclusive field of sex- and gender-informed medicine with a distinct academic home but a cross-departmental presence and impact. This positioning has allowed the Connors Center to pursue a comprehensive array of activities that include developing multidisciplinary health care delivery programs, evaluating and informing health care policy, and training a workforce in sex- and gender-informed medicine.

      What Is Sex- and Gender-Informed Medicine?

      Sex—the distinct biological and physiological traits that characterize men and women—and gender—the roles and attributes a society constructs for and associates with men and women—inform disease and health outcomes independently and together. In a biological context, sex-specific refers to a process that occurs in only one sex and sex-dependent reflects a shared occurrence with divergent manifestations in each sex. We use the term sex- and gender-informed to include sex specificity and sex dependence in biology, as well as the influence of gender. Of note, a sex- and gender-informed approach must include and value the experiences of sexual and gender minorities beyond the binary (
      • Streed Jr., C.G.
      • Makadon H.J.
      Sex and gender reporting in research.
      ).
      Academic medicine's inclusion of sex and gender as an important variable affecting research and clinical outcomes has evolved since the 1990s’ federal efforts to strengthen the field of women's health. From 1996 to 2007, the Office on Women's Health of the Department of Health and Humans Services designated National Centers of Excellence in Women's Health at 18 AMCs (
      • Milliken N.
      • Freund K.
      • Pregler J.
      • Reed S.
      • Carlson K.
      • Derman R.
      • McLaughlin M.
      Academic models of clinical care for women: The National Centers of Excellence in Women's Health.
      ,
      • Weisman C.S.
      • Squires G.L.
      Women's health centers: Are the National Centers of Excellence in Women's Health a new model?.
      ). This step signaled critical national recognition of the importance of dedicated efforts to pursue women's health care, research, and teaching within AMCs. Most Centers of Excellence host institutions retain academic and clinical structures to pursue women's health efforts (
      • Domino S.E.
      • Smith Y.R.
      • Johnson T.R.
      Opportunities and challenges of interdisciplinary research career development: Implementation of a women's health research training program.
      ,
      • Miller V.M.
      Why are sex and gender important to basic physiology and translational and individualized medicine?.
      ), and the discipline has established its place within many more AMCs. Women's health training opportunities have expanded to 8 residencies and 26 fellowship programs in the United States (
      Directory of Residency and Fellowship Programs in Women's Health, 2016.
      ).
      Although the field of women's health has historically addressed both sex and gender in its clinical and research efforts, considering the roles of sex and gender more broadly (rather than focusing on female sex or gender alone) allows more meaningful exploration of the physiologic and behavioral mechanisms involved in sex and gender differences (
      • Miller V.M.
      Why are sex and gender important to basic physiology and translational and individualized medicine?.
      ). By illustrating the implications of these differences for health and disease, such an approach can advance science and improve the health of all individuals (
      • McGregor A.J.
      • Templeton K.
      • Kleinman M.R.
      • Jenkins M.R.
      Advancing sex and gender competency in medicine: Sex & gender women’s health collaborative.
      ). However, both women's health and broader sex- and gender-informed initiatives require approaches integrated sufficiently to engage with and support translation of evidence to other disciplines, yet distinct enough to allow development of deep research and clinical expertise, obtain targeted funding, and advocate for changes in policy and practice. The Connors Center and the associated Division of Women's Health have functioned together to pursue this balance.

      Overview of the Connors Center

      The Connors Center was established in 2002 by some of this article's co-authors to catalyze and coordinate efforts in sex- and gender-informed medicine across BWH. The associated Division of Women's Health within the Department of Medicine is the academic home for 46 faculty members across 13 specialties with a primary research or clinical interest in the impact of sex and gender on health and health care. However, through its collaborative programs, the Connors Center engages 62 other faculty across 21 specialties. This hybrid model provides associated faculty with the structure and professional opportunities associated with an academic division, and the flexibility to overcome the administrative and technical boundaries of a single department and develop relationships with colleagues across specialties.
      The Connors Center and Division of Women's Health pursue the core academic clinical, research, and educational activities of an AMC. The program's clinical hub, the Gretchen and Edward Fish Center for Women's Health (Fish Center), houses clinicians in primary care and nine specialties. Connors Center faculty pursue research in sex-dependent and sex-specific medicine across an array of fields and methodologies including basic science, clinical research, epidemiology, and community and population research. Research funding from external sources for Connors Center-supported activities increased 19% between the 2013 and 2016 fiscal years, despite today’s challenging funding environment.

      Translating Sex- and Gender-Informed Research to Transform Care Delivery

      Beyond the Fish Center, the Connors Center funds and coordinates gender- and sex-informed care across the hospital and within multiple specialties, including Women's Lung Health, Women's Neurology, Women's Sports Medicine, Women's Orthopedic and Joint Disease, Women's Mental Health, and Cardiovascular Disease in Women. Common features of these programs include leadership by Connors Center-affiliated experts; the generation of evidence regarding sex or gender differences in patients' clinical presentations, care, treatment responses, and experience of disease; and the application of this evidence to clinical care. In the Center for Arrhythmia Prevention in Women, for example, investigators use both large-scale epidemiologic studies composed of women and clinical trials that include women and men to investigate novel methods to predict and prevent atrial fibrillation in women, who are at higher risk of stroke and other complications. These findings inform the center's care of both women and men.
      Connors Center-affiliated faculty also study and implement gender-informed, patient-centered strategies addressing fragmentation of care that may particularly impact women (
      • McCloskey L.
      • Bernstein J.
      • Winter M.
      • Iverson R.
      • Lee-Parritz A.
      Follow-up of gestational diabetes mellitus in an urban safety net hospital: Missed opportunities to launch preventive care for women.
      ,
      • Scholle S.H.
      • Chang J.C.
      • Harman J.
      • McNeil M.
      Trends in women's health services by type of physician seen: Data from the 1985 and 1997-98 NAMCS.
      ). For example, Connors Center researchers are evaluating transitions of care for women after a preeclamptic pregnancy (
      • Skurnik G.
      • Roche A.T.
      • Stuart J.J.
      • Rich-Edwards J.
      • Tsigas E.
      • Levkoff S.E.
      • Seely E.W.
      Improving the postpartum care of women with a recent history of preeclampsia: A focus group study.
      ), and piloting a web-based program to engage new mothers in heart-healthy behaviors (Heart Health 4 Moms: Improving Health after Preeclampsia; available: http://www.hh4m.org/). In response to evidence about gender differences in lung cancer diagnosis delays (
      • Shugarman L.R.
      • Mack K.
      • Sorbero M.E.
      • Tian H.
      • Jain A.K.
      • Ashwood J.S.
      • Asch S.M.
      Race and sex differences in the receipt of timely and appropriate lung cancer treatment.
      ), the Women's Lung Cancer program developed a multidisciplinary clinical pathway to expedite diagnostic evaluation in women and other vulnerable patients with suspected lung cancer (Figure 1). The pilot program reduced time to diagnosis and treatment for these high-risk patients, especially women, and has been incorporated into the multispecialty BWH Lung Center.
      Figure thumbnail gr1
      Figure 1Lung cancer programming initiated and supported by the Connors Center.

      Informing Health Care Policy

      In the current dynamic health policy environment, academic researchers and clinicians play an important role in informing evidence-based, sex- and gender-informed health policy. The Connors Center launched the Women's Health Policy and Advocacy Program (WHPAP) in 2003 to inform evidence-based health care legislation, resource allocation for research, and clinical guidelines. One critical aspect of the WHPAP's work has been to disseminate research findings to the public and policymakers. For example, the WHPAP collaborated with Connors Center faculty in thoracic surgery and radiology to advocate for research in lung cancer in women (; Figure 1) and engaged psychiatry and neurology faculty to build awareness and raise funding to investigate sex differences in the risk for Alzheimer's disease (

      Johnson, P. A., Fitzgerald, T., Glynn, A., Salganicoff, A., Wood, S., & Goldstein, J. M. (2016). Precision medicine: How sex and gender drive innovation. Boston, MA: Brigham and Women's Hospital.

      ). WHPAP faculty served on the Institute of Medicine panel that developed national recommendations for women's preventive services to be covered without cost-sharing under the Affordable Care Act (
      Institute of Medicine of the National Academies
      Clinical preventive services for women: Closing the gaps.
      ). These recommendations have contributed to increased uptake of preventive services by millions of U.S. women (
      • Carlin C.S.
      • Fertig A.R.
      • Dowd B.E.
      Affordable Care Act's mandate eliminating contraceptive cost sharing influenced choices of women with employer coverage.
      ,
      • Gunja M.
      • Collins S.
      • Doty M.
      • Beutel S.
      How the Affordable Care Act has helped women gain insurance and improved their ability to get health care.
      ). In 2014, the Connors Center convened a national policy summit to call for increased federal attention to sex differences and demographic subgroup data in biomedical research and clinical trials. This summit and accompanying report (

      Johnson, P. A., Fitzgerald, T., Salganicoff, A., Wood, S., & Goldstein, J. M. (2014). Sex-specific medical research: Why women's health can't wait. Boston, MA: Brigham and Women's Hospital.

      ) contributed to subsequent National Institutes of Health requirements to consider sex as a key variable in research studies. The WHPAP also conducts policy research to examine the impact of state and federal health policies on gender-specific care delivery and outcomes, for example, the use of preventive care in low-income Massachusetts women after state-level payment reform (
      • Clark C.R.
      • Soukup J.
      • Riden H.
      • Tovar D.
      • Orton P.
      • Burdick E.
      • Johnson P.A.
      Preventive care for low-income women in Massachusetts post-health reform.
      ) and contraceptive use after the Affordable Care Act eliminated cost sharing (
      • Pace L.E.
      • Dusetzina S.B.
      • Keating N.L.
      Early impact of the Affordable Care Act on oral contraceptive cost sharing, discontinuation, and nonadherence.
      ,
      • Pace L.E.
      • Dusetzina S.B.
      • Keating N.L.
      Early impact of the Affordable Care Act on uptake of long-acting reversible contraceptive methods.
      ). All of these activities are facilitated by the Connors Center's multidisciplinary perspective, which we feel is critical in promoting scientifically sound and equitable health policies.

      Building and Advancing the Gender-Informed Medicine Workforce

      To transform and advance sex- and gender-informed medicine, AMCs must build a workforce with the necessary knowledge and skills (
      • Miller V.M.
      • Rice M.
      • Schiebinger L.
      • Jenkins M.R.
      • Werbinski J.
      • Nunez A.
      • Shuster L.T.
      Embedding concepts of sex and gender health differences into medical curricula.
      ,
      • Rojek M.K.
      • Jenkins M.R.
      Improving medical education using a sex- and gender-based medicine lens.
      ). To engage clinicians at the start of their training, the Connors Center has recently initiated efforts at Harvard Medical School to incorporate sex- and gender-informed medicine into medical school curricula, beginning with a cross-campus course for students transitioning from the classroom into their core clerkships. The Connors Center also houses multidisciplinary fellowships—the Global Women's Health Fellowship, Family Planning Fellowship, Women's Mental Health Fellowship, and the federally funded Building Interdisciplinary Research Careers in Women's Health Fellowship—through which it has trained 54 fellows. The Connors Center also hosts leadership development activities for faculty across all BWH departments. Based on interviews with national leaders, Connors Center staff defined competencies for effective leadership in sex- and gender-informed medicine. These competencies have been incorporated into fellows' training and a recurring workshop for junior faculty.

      Challenges and Next Steps

      One of the most critical challenges facing AMCs' incorporation of sex- and gender-informed medicine is the limited evidence regarding the impact of such approaches (
      • Brittle C.
      • Bird C.E.
      Literature review on effective sex- and gender-based systems/models of care.
      ). Studies demonstrate that women receiving care in women's health centers report high satisfaction and receive high-quality preventive services (
      • Brittle C.
      • Bird C.E.
      Literature review on effective sex- and gender-based systems/models of care.
      ). Further, we know that clinical consideration of sex and gender can lead to more appropriate treatment decisions, for example, in atrial fibrillation where sex is a critical variable in anticoagulation decisions (
      • Legato M.J.
      • Johnson P.A.
      • Manson J.E.
      Consideration of sex differences in medicine to improve health care and patient outcomes.
      ). However, data are needed to demonstrate the effect of translation of such evidence on clinical care processes and outcomes, for both women and men. In addition, there remain very limited data to demonstrate that multidisciplinary programs to promote sex- and gender-informed medicine serve to advance the field and human health. Programs like the Connors Center must demonstrate their impact on the content and outcomes of medical education; on postgraduate training opportunities in sex- and gender-informed medicine; on research equity and the proportion of males and females enrolled in preclinical and clinical research; and on AMCs' training, clinical, and research environments, including the number of specialties engaged in activities that include a focus on sex and/or gender.
      Developing programs like the Connors Center entails significant logistical challenges, including the pursuit and allocation of funding. Traditional research funding sources often conform to the same traditional specialty-specific divisions that characterize AMCs. The Connors Center was launched with philanthropic seed funding and operational support from BWH. Over time, the Connors Center’s collaborative approach has led to success in building new research funding streams, and growing philanthropic support, which increased more than 20% from 2013 to 2017. As a result, the center has required less hospital operating support every year.

      Conclusions

      Growing understanding of the critical roles of sex and gender requires AMCs to integrate sex- and gender-informed approaches to clinical practice, research, and training across all of medicine's traditional disciplines. The Connors Center's structure and relationship with the clinical Division of Women's Health allow it to lead multidisciplinary work throughout BWH while maintaining its own strong academic and administrative presence. This model has promoted innovative models of care, facilitated high-impact research, shaped health policy, and supported medical education and faculty development. Research is needed to rigorously assess the impact of the Connors Center's approach on care delivery, research, and medical training, and guide adoption of similar approaches at other AMCs.

      Acknowledgments

      The authors thank Dr. Yolonda L. Carlson for her leadership in women’s lung health and her partnership with the Connors Center, Margaret Kruithoff for her assistance describing the interdisciplinary women's lung health work, and Sahitya Raja for her editorial assistance.

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      Biography

      Lydia E. Pace, MD, MPH, is a general internist and researcher, Division of Women's Health; Director, Women's Health Policy and Advocacy, Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital; and Instructor of Medicine, Harvard Medical School.

      Biography

      Grace L. Chen, BA, was previously a research assistant in the Division of Women's Health, Brigham and Women's Hospital and now serves as an Affordable Care Act Navigator and Organizer at Planned Parenthood of the St. Louis Region and Southwest Missouri.

      Biography

      Jaclyn Chai, MPH, is the Administrator of the Division of Women's Health, Brigham and Women's Hospital.

      Biography

      Jill M. Goldstein, PhD, is Professor in the Departments of Medicine and Psychiatry at Harvard Medical School and Senior Scientist at Brigham and Women's Hospital. She previously served as the Director of Research for the Connors Center.

      Biography

      Piper Orton, MBA, served as Director of Women's Health Programs for the Connors Center and is now the Vice President for Finance and Administration at Wellesley College.

      Biography

      Deborah Bartz, MD, MPH, is Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School, and Director of Education for the Connors Center.

      Biography

      Janet Rich-Edwards, ScD, MPH, is Associate Professor of Medicine at Harvard Medical School and Associate Professor of Epidemiology at Harvard T.H. Chan School of Public Health and Director of Developmental Epidemiology for the Connors Center.

      Biography

      JoAnn E. Manson, MD, DrPH, is the Michael and Lee Bell Professor of Women's Health, Harvard Medical School and Chief, Division of Preventive Medicine, Department of Medicine, at Brigham and Women's Hospital. She served as Interim Executive Director for the Connors Center.

      Biography

      Paula A. Johnson, MD, MPH, was Executive Director, Connors Center for Women's Health and Gender Biology; Chief, Division of Women's Health, Brigham and Women's Hospital; and Grayce A. Young Family Professor of Medicine, Harvard Medical School. She is President of Wellesley College.