Why should the obstetrics and gynaecology community care about sex and gender issues in health?

Over the past two decades, there has been increasing appreciation from researchers, funders, editors and healthcare professionals of the importance of understanding how sex and gender interact with health outcomes.1–3 In order to correctly interpret these interactions, standard terminology is necessary. The Institute of Medicine's definition of sex and gender4 is the most widely used, where sex is ‘the classification of living things, generally as male or female according to their reproductive organs and functions assigned by chromosomal complement’ and gender is a ‘person's selfrepresentation as male or female, or how that person is responded to by social institutions based on the individual's gender presentation.’ At present, there is no consensus about how to measure gender in the general population, but some existing nonbinary terms are recognised, such as ‘intersex’, where biological sex as defined by anatomic, gonadal or chromosomal characteristics is not consistent with ‘female’ or ‘male’, and ‘transgender’, where gender identity does not fit with biologic sex at birth. These terms and others are essential knowledge in obstetrics and gynaecology. A comprehensive list of such terms has recently been published in the New England Journal of Medicine,5 and a recent issue of Royal Australian and New Zealand College of Obstetricians and Gynaecologists’ O&G Magazine explores nonbinary gender issues.6 Evidence demonstrating the importance of sex and gender in health has accumulated in recent years, particularly in the area of cardiovascular health. For example, by exploring sex and gender differences in heart disease and stroke, we now know that in acute coronary syndrome, women frequently present with symptoms such as weakness, fatigue, nausea and dyspnoea. These are different from ‘conventional’ presentations (ie the most common presenting symptoms for men), leading to delays in appropriate diagnosis and worse outcomes for women.7 Subsequent advocacy, in large part driven by the ‘Go Red for Women’8 campaign, has aimed to dispel the myth that heart disease is an older man's disease, raising awareness of heart disease and stroke as the number one killer of women. Greater awareness of how sex and gender impact on clinical presentation, symptoms, diagnostic and therapeutic approaches in cardiovascular disease has in turn reduced the number of early deaths from myocardial infarction in women.9 Similarly, in endocrinology, revision of the diagnostic criteria for osteoporosis to include a malespecific reference range for low bone mineral density has led to better evaluation of fracture risk in men.10 These cases illustrate the importance of considering sex and gender differences in clinical practice. As the ANZJOG readership is by and large mostly or entirely concerned with women's reproductive healthcare provision, it may seem that sex and gender differences have little relevance to daily practice. In fact, sex and gender considerations are likely extremely relevant to the health of both our patients and ourselves. Below, we present key areas where considering the impact of sex and gender may have implications for training and clinical practice in obstetrics and gynaecology.