Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Avenue, Boson, MA 02115, USA. E-mail: nkrieger{at}hsph.harvard.edu
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Accepted 18 February 2002
Open up any biomedical or public health journal prior to the 1970s, and one term will be glaringly absent: gender. Open up any recent biomedical or public health journal, and two terms will be used either: (1) interchangeably, or (2) as distinct constructs: gender and sex. Why the change? Why the confusion?and why does it matter?
As elegantly argued by Raymond Williams, vocabulary involves not only the available and developing meaning of known words but also particular formations of meaningways not only of discussing but at another level seeing many of our central experiences (ref. 1, p. 15). Language in this sense embodies important social and historical processes, in which new terms are introduced or old terms take on new meanings, and often earlier and later senses coexist, or become actual alternatives in which problems of contemporary belief and affiliation are contested (ref. 1, p. 22).
So it is with gender and sex.2,3 The introduction of gender in English in the 1970s as an alternative to sex was expressly to counter an implicit and often explicit biological determinism pervading scientific and lay language.28 The new term was deployed to aid clarity of thought, in a period when academics and activists alike, as part of and in response to that eras resurgent womens movement, engaged in debates over whether observed differences in social roles, performance, and non-reproductive health status of women and menand girls and boyswas due to allegedly innate biological differences (sex) or to culture-bound conventions about norms forand relationships betweenwomen, men, girls, and boys (gender) (Table 1). For language to express the ideas and issues at stake, one all-encompassing termsexwould no longer suffice. Thus, the meaning of gender (derived from the Latin term generare, to beget) expanded from being a technical grammatical term (referring to whether nouns in Latin and related languages were masculine or feminine) to a term of social analysis (ref. 1, p. 285; ref. 4, p. 2; ref. 5, pp. 13637). By contrast, the meaning of sex (derived from the Latin term secus or sexus, referring to the male or female section of humanity [ref. 1, p. 283]) contracted. Specifically, it went from a term describing distinctions between, and the relative status of, women and men (e.g. Simone DeBeauvoirs The Second Sex9) to a biological term, referring to groups defined by the biology of sexual reproduction (or, in the meaning of having sex, to interactions involving sexual biology) (ref. 1, p. 285; ref. 4, p. 2; ref. 5, pp. 13637).
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Yet, we do not live as a gendered person one day and a sexed organism the next; we are both, simultaneously, and for any given health outcome, it is an empirical question, not a philosophical principle, as to whether diverse permutations of gender and sex matteror are irrelevant. Illustrating the importance of asking this question, conceptually and analytically, Table 1 employs an ecosocial epidemiological perspective2,12 to delineate 12 examples,1324 across a range of exposureoutcome associations, in which gender relations and sex-linked biology are singly, neither, or both relevant as independent or synergistic determinants.25 These examples were chosen for two reasons. First, underscoring the salience of considering these permutations for any and all outcomes, the examples range from birth defects to mortality, and include: chromosomal disorders, infectious and non-infectious disease, occupational and environmental disease, trauma, pregnancy, menopause, and access to health services. Second, they systematically present diverse scenarios across possible combinations of gender relations and sex-linked biology, as singly or jointly pertinent or irrelevant. In these examples, expressions of gender relations include: gender segregation of the workforce and gender discrimination in wages, gender norms about hygiene, gender expectations about sexual conduct and pregnancy, gendered presentation of and responses to symptoms of illness, and gender-based violence. Examples of sex-linked biology include: chromosomal sex, menstruation, genital secretions, secondary sex characteristics, sex-steroid-sensitive physiology of non-reproductive tissues, pregnancy, and menopause.
As examination of the 12 case examples makes clear, not only can gender relations influence expressionand interpretationof biological traits, but also sex-linked biological characteristics can, in some cases, contribute to or amplify gender differentials in health. For example, as shown by case No. 9, not recognizing that parity is a social as well as biological phenomenon, with meaning for men as well as women, means important clues about why parity might be associated with a given outcome might be missed. Similarly, as shown by case No. 11, recognition of social inequalities among women (including as related to gender disparities between women and men) can enhance understanding of expressions of sex-linked biology, e.g. age at perimenopause. Because our science will only be as clear and error-free as our thinking, greater precision about whether gender relations, sex-linked biology, both, or neither matter for health is warranted.
KEY MESSAGES
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References |
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