IGH Strategic Plan 2009-2012

Gender Matters!

Table of Contents

Message from the Scientific Director

In my first year as Scientific Director of the Institute of Gender and Health (IGH), I had the pleasure of working with Institute Advisory Board (IAB) members to develop a strategic plan, the details of which are set out in this report. With continuing advice from our IAB, the IGH is working towards implementing the ambitious goals we have set out in this plan.

The plan maps a course for the activities of the IGH from 2009 to 2012, through our annual allocation of strategic funding. This money will be directed toward capacity-building and supporting priority research areas. Additional dollars will be acquired by leveraging partnerships and working collaboratively with others.

Given that every cell is sexed and every person gendered, it stands to reason that gender and sex should be key considerations in examining the basic mechanisms of disease development, social determinants of health, health policy and services, and clinical interventions. Yet the IGH is still the only organization in the world with the mandate to fund research on gender, sex, and health.

The Institute has made many important achievements in the years since its inception. They include fostering the development of a research community dedicated to understanding how gender and sex influence health outcomes, and supporting studies on gender- and sex-related health impacts in such areas as violence, caregiving, immigrants and refugees, breast cancer, homelessness and housing, HIV/AIDS, occupational health, tobacco use, and reproductive health.

But much remains to be done. When I joined the Institute in January 2008, it had reached a pivotal point in its evolution and was ready to take a more strategic approach to its research funding. Members of the IAB agreed that it was time to build on our past successes by undertaking a comprehensive discussion about the Institute’s mission, vision, values, and strategic directions.

We felt that the period from 2009 to 2012 was a realistic one for achieving some short-term goals and setting in motion some longer-term ones. The process we followed in developing our strategic plan was a rigorous one that involved extensive background work—including the synthesis of cross-Canada interviews and consultations, which took place during the spring and fall of 2008. It culminated in a two-day workshop in November 2008, where, after thoughtful discussion and a thorough review of the background information and strategic priorities of the other CIHR institutes, the IAB agreed unanimously on the six strategic directions described in this report.

The strategic planning process has enabled us to take stock of the current state of research on gender, sex, and health and to identify potential partners for future work. The good news is that there is no shortage of opportunities. The field of research that explores gender influences and sex differences is now, more than ever, providing important insights into ways to improve the health of Canadians.

In keeping with our commitment to evaluate the impact and effectiveness of our funding programs on an ongoing basis, the IAB will regularly monitor and update the IGH’s strategic plan to ensure that it evolves in response to emerging priorities.

I am indebted to my staff and to the members of the IAB for their dedication and contributions to developing this plan, and welcome feedback and suggestions on how it should be enacted. I am confident that the strategic directions we have chosen in collaboration with our stakeholders will enable the IGH to continue to exert a positive influence on the health of women, men, girls, and boys—and to move closer to achieving its vision of a world in which gender and sex are key considerations in health research and its applications.

Introduction and Background

The Canadian Institutes of Health Research

The Canadian Institutes of Health Research (CIHR) is the major federal agency responsible for funding health research in Canada. Created under the CIHR Act, which came into force in June 2000, it comprises 13 institutes that are mandated to support health research in four major areas:

  • biomedical;
  • clinical;
  • health systems and services; and
  • population and public health.

Each institute is headed by a Scientific Director who receives guidance and advice from its Institute Advisory Board (IAB). IABs are made up of national and international representatives of the public, private, and non-profit sectors, including the research community and health practitioners. The institutes are formally accountable to both the president and governing council of the CIHR and, through the Minister of Health, to Parliament.

The CIHR was created to transform health research in Canada by:

  • funding more research on targeted priority areas;
  • building research capacity in underdeveloped areas such as population health and health services research;
  • training the next generation of health researchers; and
  • focusing on knowledge translation, so that the results of research are transformed into policies, practices, procedures, products, and services.

The CIHR's mandate is to excel, according to internationally accepted standards of scientific excellence, in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products, and a strengthened Canadian health-care system.

The values that guide the CIHR’s activities include:

  • excellence
  • scientific integrity and ethics
  • collaboration
  • innovation
  • public interest

In order to accomplish its mandate, the CIHR has articulated four strategic outcomes:

  • invest in world-class research excellence;
  • address health and health system research priorities;
  • accelerate the capture of health and economic benefits of health research; andachieve organizational excellence, foster ethics, and demonstrate impact.

The Institute of Gender and Health

As one of 13 national research institutes in CIHR, the Institute of Gender and Health (IGH) makes an important contribution to current and future health challenges in Canada and globally.

The mission of the Institute is to foster research excellence regarding the influence of gender and sex on the health of women and men throughout life, and to apply these research findings to identify and address pressing health challenges.

Significant disparities exist in health-care access and health outcomes for women, men, girls, and boys. To address them requires a better understanding of how gender influences health behaviour and healthcare utilization, and how sex-based biological factors influence such things as risk factors for disease and response to treatments.

For example, Canadian women have a longer life expectancy than men (82.7 years, compared to 78 years), yet they tend to experience a heavier burden of chronic illness. Although the reasons for this are not fully understood, there is evidence that a better understanding of the influence of gender and sex could inform interventions and programs designed to improve the health and well being of all people.

The IGH is dedicated to generating evidence that will help close this apparent gap by ensuring that research considers the biological, clinical, health service, psychological, and social factors that influence the health of women and men at all stages of their lives. There is an ethical imperative to do so because accounting for gender and sex in health research has the potential to make health research more just, more rigorous, and more useful.

The Institute is committed to fostering collaboration and knowledge exchange across disciplines and research themes, developing new researchers, and ensuring that research evidence is used to improve the health of Canadians. The IGH works closely with the other 12 CIHR institutes - and a variety of organizations in the public and private sectors - to ensure that gender and sex are on their agendas.

Gender and Sex: Definitions and Context

Every person is gendered and every person is sexed. Although these terms are often used interchangeably, they have very different meanings.

Gender refers to the array of socially constructed roles and relationships, personality traits, attitudes, behaviours, values, relative power, and influence that society ascribes to women and men. Gender is often referred to in binary terms (i.e., feminine or masculine); however, there are many locations on the gender continuum.

Sex refers to the biological characteristics, such as anatomy (e.g., body size and shape) and physiology (e.g., hormonal activity or functioning of organs), that distinguish people identified as "female" from people identified as "male." Many of the attributes of sex exist on a continuum.

While it is important to clearly distinguish between gender and sex, and to use these concepts appropriately in research, it is also important to understand the dynamic relationships between them, or as one researcher has put it "to accept the body as simultaneously composed of genes, hormones, cells and organs - all of which influence health and behaviour - and of culture and history."1

Gender is an important determinant of health; however, the way it intersects with other determinants - such as income and social status, education and literacy, culture, social and physical environments, personal health practices and coping skills, biology, and genetic endowment - creates varied experiences and health statuses across populations.

These intersections raise important contextual considerations related to gender, sex, and health. For example, Canada's population is aging: in the 85 years between 1921 and 2006, seniors rose from 5 to 13 percent of the overall population and, by 2026, are expected to reach more than 21 percent. Canada's foreign-born population has also seen a dramatic increase, growing 13.6 percent (four times the rate of the Canadian-born population) between 2001 and 2006.

Another critical consideration in a nation with such diverse communities and geographies as Canada is the impact of location on issues related to gender, sex, and health. The cross-country interviews and consultations held as part of the IGH's strategic planning process highlighted unique concerns in our northern communities. And, while we must look more closely at the issues at play within our own health system, we must also look beyond our borders at global health issues and our commitments as part of the broader international community.

Strategic Research Directions

Members of the IAB agreed unanimously on six strategic research directions for the IGH, each of which describes a major focus of responsibility and commitment for the Institute. These directions encompass and will facilitate cross-themed work involving interdisciplinary research, links, and partnerships at the local, regional, national, and international levels.

Two of the strategic directions are over-arching capacity-building strategies:

  • advancing methods and measures, and
  • building partnerships in gender and health.

The other four are priority topic areas:

  • violence and health: impacts and implications;
  • sexual and reproductive health: improved decision-making;
  • clinical interventions: enhancing effectiveness; and
  • work and health: research into action.

To help focus its discussions on strategies that are closely aligned with the IGH's mission and capacity, the IAB agreed in advance that each strategic direction had to meet the following criteria:

  1. addresses critical gender and health issues identified by stakeholders;
  2. reflects, supports, and builds on Canada's gender, sex and health research strengths;
  3. has strong potential for significant impact on the health of Canadians through research;
  4. helps bridge gaps between the current gender, sex and health research situation and the IGH mission; and
  5. has strong potential for partnerships that leverage CIHR and IGH intellectual capital and resources.

Capacity-Building Strategies

a. Advancing Methods and Measures

Many studies of gender, sex, and health have tended to compare women and men on a number of health indicators. While this is an important starting point for noting similarities and differences between the sexes, it does not illuminate the underlying mechanisms behind them or similarities and differences between specific groups of women or men. More sophisticated designs are required to uncover the nature of these relationships.

If the field of gender, sex, and health is to advance, current approaches need to be refined and new methods and measures developed to examine the effects of gender influences and sex differences on health outcomes. Methods and measures are the approaches, procedures, and rules that researchers use to reliably and validly collect and analyze data to address research questions.

Health researchers have begun to acknowledge the relevance of gender and sex considerations and are working to incorporate them into their research; however, these complex and multifaceted concepts are challenging to operationalize.

Recognizing the difficulty researchers face in designing studies that capture gender and sex, the IGH spearheaded the development of a set of guidelines for gender- and sex-based analyses. While these guidelines provide researchers with helpful suggestions, they do not resolve the challenges and contradictions inherent in research designed to capture gender and sex.

As such, advancing methods and measures for research on gender, sex, and health - including providing support for training - is a key capacity building strategy for the Institute.

b. Building Partnerships in Gender and Health

Because every human cell is sexed and every person is gendered, the IGH's work reaches into all fields of health. Yet the uptake of gender and sex considerations in health research is low, even among the other CIHR institutes.

The IGH is uniquely positioned to educate and influence other institutes and organizations about the need to include gender and sex considerations in health research by providing the tools necessary to conduct gender- and sex-based analyses (i.e., methods and measures) and offering direct research support through funding.

Establishing partnerships in priority areas that involve shared or overlapping mandates - including aging, mental health and mental illness, health systems access, and health promotion and prevention - is, therefore, a key means by which the IGH can build capacity in the health research community.

Priority Topic Areas

a. Violence and Health: Impacts and Implications

Violence is a broad category that includes everything from homicide and suicide to sexual violence, self-inflicted injury, bullying, and fighting - and myriad forms in between. Its reach in our society is pervasive. Violence affects women and men of all ages and has many manifestations that include gender and sex dimensions.

Violence is also one of the biggest health issues facing individuals, families, and societies today. It is estimated that injury and violence contribute to 14.5 percent of the burden of disease in the developed world and 15.2 percent in the developing world. Violence is overtaking infectious diseases as a main cause of premature death worldwide.

Approximately one in five of the world's women have been physically or sexually abused at some time in their lives. In Canada, seven percent of women report that they have been the victim of spousal violence. Among children and youth, rates of family-related sexual assault are highest for teenage girls, especially those aged 11 to 14. Among boys, rates are highest for those aged 3 to 9.

The suicide rate for Canadian men is more than double that for women, and males are also more likely than females to die from injuries. Among boys, fighting places a close second to motor-vehicle accidents as the most likely injury-causing activity to lead to significant medical treatment. Boys also report bullying others significantly more than girls do. Injuries caused by violence result in both physical and emotional disabilities, which take a toll on health-care systems and increase long-term health spending.

To solve this serious problem, we must apply a health perspective. We need to examine the causes and spread of violence and develop ways to prevent it. We must also work to limit the devastating physical and psychological effects on those who have been exposed to violence.

The aim of this strategic direction is to foster research that results in effective, evidence-based interventions focused on understanding, preventing, and addressing violence of all kinds.

b. Sexual and Reproductive Health: Improved Decision-Making

Sexuality and reproduction, while separate entities, are vital and often interconnected aspects of health. Virtually every issue related to these subjects is strongly influenced by gender and sex, including sexually transmitted infections (STIs), contraceptive use, pregnancy, sexuality, menopause/andropause, fertility, and reproductive choice.

The incidence of STIs is a key indicator of sexual health. There was a 70 percent increase in reported cases of chlamydia in Canada between 1997 and 2004, suggesting that the sexual health of Canadians merits increased attention. Statistics suggest that youth are disproportionately affected: while young people represent 14 percent of the Canadian population, they reported over two-thirds of the chlamydia infections during this period. Data on teen condom-use suggest that young women are considerably less likely than young men to report having used a condom during intercourse. Young males, on the other hand, are more likely than young females to report having had multiple partners in the past year.

Studies also show that the average number of children born per woman in Canada in 2006 was 1.59 - the highest rate since 1996, yet lower than the replacement rate of 2.1. On average, women in this country are having their first child at a later age (29). As maternal and paternal age increases, issues related to fertility and assisted human reproduction will continue to gain prominence. Environmental factors also influence fertility and reproductive outcomes. For example, one Canadian study attributed the declining number of males being born in a First Nation community to environmental exposure to chemicals.

By adopting sexual and reproductive health as a strategic research direction, the IGH aims to i) improve understanding of the gender and sex aspects of both sexual and reproductive health and how they may be interrelated; and ii) develop appropriate interventions that can support healthy decision-making.

c. Clinical Interventions: Enhancing Effectiveness

Gender and sex are not adequately considered in relation to clinical interventions involving the use of pharmaceuticals, devices, diagnostics, and clinical programs. By identifying clinical interventions as a strategic research direction, the IGH is committed to ensuring that they are accessible, appropriate, and effective with respect to gender and sex.

To date, clinical interventions have tended to be gender- and sex-blind. Medications are not tested specifically to determine if their effects differ in women and men, yet we know that gender and sex influence drug adherence, absorption, and side effects.

Although women report higher rates of disability related to knee pain, they are less likely to undergo joint-replacement surgery - and those who do are not necessarily given a replacement that suits their anatomy. The health research community's increasing recognition of these important differences has led to such advancements as the development of synthetic knees designed specifically for women's bodies.

When women and men seek health care they may also receive different treatments because of gendered stereotypes that shape the way patients and health-care providers perceive heath and illness, as exemplified by the fact that men are less likely to report symptoms of pain. Gender dynamics can also affect patient-provider interactions.

There are a number of key issues related to this priority area, including quality and safety, patient satisfaction, and care management and clinical pathways. To address them, the IGH will support evidence-informed research in this area and the uptake of evidence by clinicians and policy makers.

d. Work and Health: Research into Action

Work roles and workplaces involving both paid and unpaid work are greatly influenced by factors related to gender and sex.

Although the majority of Canadians over the age of 15 engage in paid work, participation in the labour force is approximately 10 percent lower for women (61.6 percent) than men (72.3 percent). Of the 30 countries in the Organisation for Economic Cooperation and Development, Canada has the fifth largest gender pay-gap, with women earning almost 30 percent less than men for full-time work.

More than 90 percent of Canadians also engage in unpaid work (including housework, caregiving, and maintenance), with a slightly higher percentage of women participating than men. Over the past decade, men have increased the number of hours they spend on unpaid work; however, they still lag behind women in this respect.

These and other work-related differences between women and men raise some important issues related to sex, gender, and health. For example, acute injury on the job resulted in an average of nearly 500 deaths in Canada annually between 2002 and 2004, and some 300,000 compensated claims for lost time. Men have significantly higher on-the-job injury rates than women, on average, due largely to the kind of work they perform. Some researchers argue that this is partly due to gendered assumptions that shape the measurement of occupational health.

Unpaid work (caregiving, in particular) is also associated with diminished physical and mental health - including increased risk of heart disease, lower levels of self-care, and increased mortality. The fact that working women continue to bear an unequal burden for child care and unpaid housework has implications both in terms of occupational health and the effects of insufficient rest and leisure. The challenge in this strategic direction will be for the Institute to address these issues by supporting research that will improve understanding of the health implications of gender and sex considerations related to work.

The Path Forward

The IGH strategic research plan is a living document that will evolve over time. It represents both the effort and the means to mobilize talk into action, build on existing initiatives, and translate knowledge arising from research into policies and practices.

From 2009 to 2012, the strategic directions outlined in this report will be used to guide the Institute's work, develop funding opportunities, and evaluate and report on its activities. They will also frame the IGH's engagement with partners who can help make headway in these priority areas.

With the assistance of all of its stakeholders, the IGH looks forward to improving the health of women and men and ensuring that gender and sex become key considerations in health research.

Appendix A

IGH Management Team

Dr. Joy Johnson, Scientific Director

Zena Sharman, Assistant Director

Abigail Forson, Assistant Director, Ottawa (current)

Shareen Khan, Finance Manager and Project Officer

Ntunga Masozera, Project Officer

Monica Penner, Executive Assistant

IGH Advisory Board

Dr. Blye Frank (Chair)
Dalhousie University

Dr. Joan L. Bottorff (Vice-chair)
University of British Columbia Okanagan

Dr. Elizabeth Banister
University of Victoria

Dr. Françoise Baylis
Dalhousie University

Dr. Guylain Boissonneault
Université de Sherbrooke

Sally Brown
Heart and Stroke Foundation of Canada

Dr. Gary Garber
University of Ottawa

Carol Hiscock
The Arthritis Society

Abby Hoffman
Health Canada

Dr. Olga Kovalchuk
University of Lethbridge

Dr. Peter Leung
University of British Columbia

Dr. John Oliffe
University of British Columbia

Dr. Jens Pruessner
McGill University

Dr. Donna Stewart
University of Toronto

Mr. Yves Tremblay
Université Laval

Dr. Bilkis Vissandjée
Université de Montréal

Members of the Institute Advisory Board at the time this plan was created:

Dr. David Hart (Chair), University of Calgary; Dr. Elizabeth Banister, University of Victoria; Dr. Guylain Boissonneault, Université de Sherbrooke; Sally Brown, Heart and Stroke Foundation of Canada; Dr. Blye Frank (Vice-chair), Dalhousie University; Dr. Gary Garber, University of Ottawa; Dr. Sharon Hemond Hrynkow, National Institutes of Health; Ms. Carol Hiscock, The Arthritis Society; Abby Hoffman, Health Canada; Dr. Joan L. Bottorff, University of British Columbia Okanagan; Dr. Peter Leung, University of British Columbia; Dr. Michelle Mullen, University of Ottawa; Dr. John Oliffe, University of British Columbia; Dr. Donna Stewart, University of Toronto; Dr. Yves Tremblay, Université Laval; Dr. Bilkis Vissandjée, Université de Montréal; and Dr. Douglas Wilson, University of Alberta.

Appendix B

Strategic Planning Methodology

The purpose of the IGH's strategic planning process was to identify and describe strategic research directions for the Institute for the period from 2009 to 2012 and to identify possible opportunities for synergy. The process, which took place from April to December 2008, involved four key phases:

Phase I (April-May 2008): Process terms of reference were developed.

Phase II (May-October 2008): A comprehensive database of background documents was developed to inform the planning process.

Phase III (May-November 2008): Consultations were held with approximately 250 stakeholders and partners in every province and territory using a range of techniques - including face-to-face group consultations in Kelowna and Vancouver (BC), Calgary (AB), Toronto (ON), Montréal (QC), and Halifax (NS); videoconference consultations in Edmonton (AB), Saskatoon (SK), Fredericton (NB), Charlottetown (PE), and St. John's (NL); face-to-face individual consultations in Whitehorse (YT), Yellowknife (NT), and Iqaluit (NU); consultations with Canadian and international participants at the Canadian Conference on International Health; and telephone interviews with key informants and written submissions from across the country.

Participants included interested parties from academic institutions, the federal and provincial governments, CIHR, health and community organizations (local, national, and international), as well as individual researchers.

Phase IV (November 2008): The Strategic Planning Workshop was held in Montréal, with all IAB members and IGH staff in attendance. Information from the background documentation and consultations was reviewed and discussed, and consensus was achieved on six strategic research directions.

  1. Fausto-Sterling, A. (2005). "The bare bones of sex: Part 1 - Sex and gender." Signs: Journal of Women in Culture and Society, 30(2), 1491-1527.
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