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Print this Close window. Sex and gender are not equivalent concepts, even though these 2 variables are often used interchangeably by researchers. The precise use of variables is critical to ensure that research and theoretical work is of the highest quality. This article defines sex and gender and the importance of recognizing both of these variables as being unique and then demonstrates the benefit of measuring both of these variables using the cardiovascular disease literature as an exemplar.

Additionally, recommendations for scholars regarding the use of sex and gender in the research and theoretical literature are provided. TO ACHIEVE high levels of credibility, dependability, transferability, validity, and reliability in research, it is important that researchers pay close attention to the variables and phenomena that they are exploring or measuring. After all, one of the most fundamental steps of deing a research study is developing a research question or hypotheses and then making clear what variables will be considered within the study. Moreover, as scholars build and refine theories, they must carefully define concepts included within these theories, in order to ensure that the theories will accurately function to describe, explain, or predict phenomena.

The cardiovascular disease literature is used as an exemplar to demonstrate the benefit of considering both sex and gender. Two variables that are often confused and used incorrectly in the research and theoretical literature are sex and gender. It is not uncommon for researchers to substitute the term gender for the term sex. While scholars may use the term gender in a given article, many times they are actually operationalizing this variable more like sex and are ignoring the sociocultural dimensions central to the construct of gender.

It is imperative that scholars use variables and concepts correctly when conducting research or developing theory. While the terms are not interchangeable, sex and gender are often used incorrectly in the research and theoretical literature. Some confusion exists as to the differences between sex and gender and how scholars should use and interpret these terms.

This article defines sex and gender and then explores why it is important to recognize both sex and gender as unique variables, in the context of the cardiovascular research literature. Additionally, recommendations for scholars to integrate the variables sex and gender precisely are provided to help facilitate high-quality research and theory development. Every human being has both a sex and a self-identified gender. However, investigators only occasionally acknowledge both sex and gender in studies, making it difficult to tease out sex-based and gender-based differences.

The IOM defines gender as "a person's self-representation as male or female, or how that person is responded to by social institutions on the basis of the individual's gender presentation. Though "male," "female," and "intersex" are terms often reserved for discussing sex, terms more often used to describe gender include "man," "woman," and "transgender.

Indeed, gender is complex and involves multiple dimensions. Tannenbaum et al 16 have suggested that there are 4 major dimensions of gender important for researchers to address, including gender roles, gender identity, gender relations, and institutionalized gender issues. Gender roles are represented by the "behavioral norms applied to men and women in society, which influence individuals' everyday actions," and gender identity "describes how we see ourselves, and are seen by others, as female or male. While they are unique variables, sex and gender are not often measured in a precise and explicit way.

The nursing profession respects and values the rights and health of all human beings and recognizes the importance of key ethical principles such as beneficence and autonomy. However, to realize this imperative, researchers must ensure that all sexes and genders are being acknowledged in the literature. As investigators expand the scope of nursing research to encompass more individuals who identify as a gender minority or who are intersex, it is critical to accurately measure these variables.

As Eliason et al 22 have noted, there is a need for emancipatory efforts, especially related to transgender issues. Within nursing, there is a lack of knowledge regarding gender and sex issues not only in the clinical setting 23 but also in the educational setting. We must talk about sex and gender differences in order to acknowledge them, but we first have to uncover those differences, through research.

Regardless of sex or gender, more people die from cardiovascular disease than from any other cause in the United States and globally. For example, transgender individuals are at higher risk of cardiovascular disease and poorer health overall than many individuals who do not identify as transgender, 2930 and programs like Healthy People have called for improvements in transgender health.

The cardiovascular disease literature will be used here as an exemplar to illustrate the unique contribution that both variables provide to understanding sex- and gender-based differences in cardiovascular disease. Gender and sex are distinct, and both of these variables have an effect on cardiovascular health.

These examples are not meant to be exhaustive and only provide a glimpse into the importance of both sex and gender in the research literature. From a sex-based perspective, males and females are biologically different, and these differences affect cardiovascular disease rates. While a bit dated now, researchers engaged in the Women's Ischemia Syndrome Evaluation Study WISE 35 provided landmark information about differences between females and males in terms of heart disease. For example, the WISE study noted ificant differences in artery function, atherosclerotic plaque formation, and metabolism.

In addition to sex differences, gender differences are prominent and play a different role in moderating and mediating various cardiovascular phenomena. For example, several studies have explored the unique contribution of gender, in addition to sex, on health outcomes. As a part of this study, the researchers developed a Gender Index, incorporating a of variables to reflect the gender construct.

The researchers found that feminine gender, as measured by the Gender Index, conferred a larger amount of risk over the study period than sex alone, suggesting that even biologically male individuals had a higher risk of cardiovascular events if they identified with a more feminine gender. Thus, if the researchers had not specifically conducted a gender-based analysis, in addition to a sex-based analysis, they may have concluded that there were no differences between men and women. Additionally, the authors found that gender is indeed a construct located along a continuum, with some males assuming a feminine gender and some females reflecting a masculine gender.

Using data from a different registry, Norris and colleagues 46 applied a sequential linear modeling approach and explored overall health status in patients with coronary artery disease and how both sex and gender contributed to this status.

Norris et al 46 used the Gender Index to measure a person's gender. Interestingly, sex only ed for a very small difference in overall health status, while gender contributed ificantly more information to the statistical model.

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They used a structural equation modeling approach that uncovered the unique contribution that gender role makes on quality of life for these patients. Gender may also play a role in other aspects of cardiovascular health. In their comprehensive review of studies exploring gender as a risk for cardiovascular disease, O'Neil et al 33 discovered that many health behaviors are related to gender.

For example, during childhood, males may be socialized to "display stoicism and reject strong and intimate friendships," 33 p which may lead to weaker social support networks.

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As a result, unhealthy, antisocial behaviors like drinking excessive alcohol may occur, and a lack of emotional processing may contribute to a higher cardiovascular risk for men. Indeed, addressing cardiovascular disease remains a priority for the transgender population. Though the evidence is a bit dated and few recent studies have explored the issue, the literature has demonstrated that sex and gender play a role in the way that women's MI symptoms are addressed by health care providers and how women are treated.

For example, women have reported feeling that they were not as involved in their cardiovascular care as they should have been and that secondary prevention strategies were not discussed with them in detail following cardiovascular events. That is a person's physical appearance as a male or female sex may convey some importance, while gender roles and stereotypes also add to the aforementioned issues. Additionally, while it is also unknown whether the differences are due to sex, gender, or both, women and men may present with ACS symptoms in a different way than men.

It is also important to note that gender- and sex-based differences exist within not only the cardiovascular literature but also many other areas of research. The importance of recognizing both sex and gender as unique variables has been noted in many different areas, such as communication patterns and styles, 63 traumatic brain injury, 64 schizophrenia, 65 health care utilization and performance measurement, 66 critical care outcomes, 67 diabetes, 41 and medication use and adherence. Understanding that sex and gender are unique, how can researchers best differentiate between these 2 variables and decide which to use in a study?

How can editors and reviewers play a role in increasing the recognition of sex and gender as distinct and important variables? Given that there is a current, widespread lack of attention to the distinction between sex and gender in the existing published literature, how should we interpret and use these studies?

This section of the article addresses these questions and provides some general recommendations.

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Care must be taken when deciding whether to use sex, gender, or both in a research study. Sex and gender should never be assumed to be the same.

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If a researcher jumps to a decision prematurely without much thought, a helpful exercise may be for that researcher to take a time out and to ask themselves "Do I really mean sex, or am I actually interested in gender?

Or, do I need to measure both sex and gender? It is good practice for researchers to reflect carefully prior to making a decision. Researchers should examine the extant literature for evidence of any sex- or gender-based differences that might require the researcher to consider one or both of these variables in a study.

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If there is not sufficient evidence in the literature, then the researcher may be wise to consider both gender and sex as potentially important demographic variables. If researchers are interested in examining differences in a target population based strictly on biologic differences, sex is most likely the most appropriate variable to select.

On the other hand, if a phenomenon or intervention could be affected by environmental or sociocultural factors specifically related to norms of men and women within society, then gender would be the most appropriate variable. For a of research questions, exploring sex and gender differences could be important.

A researcher might ask, for example, "Are the differences in the experience of chest pain during a myocardial infarction due to sex, gender, or both? Once a researcher determines whether sex, gender, or both will be measured, it is important to make the rationale for that choice clear, especially when publishing the of findings. Once a researcher decides whether to measure sex, gender, or both within a study, the question turns to how the variable s should be measured. No matter how the variable s is ultimately measured, the researcher should include a description of how it was measured, so that it is clear to readers.

In general, variables can be measured at 4 levels: nominal, ordinal, interval, and ratio. Additionally, variables are often either directly or indirectly measured. Direct measurement is easier when a variable or construct is directly observable, while indirect measurement is used when a variable or construct cannot be directly observed. Because gender is not directly observable, it is not often feasible to measure it in a direct way, and observation studies that claim to measure gender via observation may be inappropriate.

While sex may usually be directly observable, as many as 1 in 50 people may have chromosomal compositions that do not strictly match a male XY or female XX genotype. Gender can be measured nominally by simply asking participants to list their gender. While this type of measurement is straightforward and allows the research participant to self-identify however they want, because gender is a complex construct, this sort of identification does not allow for the examination of traits underlying gender, such as degree of femininity or a gender role score.

It would not be feasible to create a score based on gender, if it is only queried in a nominal way, limiting some quantitative analysis. It is also possible to list several options for gender and ask participants to select their gender. If participants are forced to choose from a list, the researcher is then challenged to be inclusive.

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