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Sex vs. gender: cultural competence in health education research.

Over the past decade, much attention has been afforded by health education professionals to the importance of cultural competency which has resulted in the passage of resolutions, position statements, and the development of organizational policies (American Association for Health Education (AAHE), 2006; Cross, Bazron, Dennis, and Isaacs, 1989; Well Care of Georgia, Inc., 2009). Such competence is inextricably connected to the quality of care delivered and is a cross-cutting issue affecting all providers (Denoba, Bragdon, Epstein, Garthright, and McCann Goldman, 1998). Cultural competence in health education requires the consideration of differences across cultures and appropriate responses to these differences in planning, implementing, and evaluating programs and interventions (AAHE, 2006; Joint Terminology Committee, 2001). Cultural competence is reflected in the terminology used by professionals in the field throughout their interactions with target populations and therefore has powerful implications in practice and research settings.

The planning, implementing, and evaluating of culturally-focused programs and interventions has traditionally been devoted to race, ethnicity, or age as the demographic variables of interest. Race and ethnicity are variables that have long been collected as part of data sets. As the diversity of these variables expands, the quality of data collected aids health professionals to increasingly understand the distinct nature of society (Luquis, 2010). While it is critical to continue advocating for cultural competence as it relates to race and ethnicity, such labors do not diminish the need for promotion efforts as they relate to other characteristics of culture.

In studying health-related behaviors among different populations, health educators conduct formative research regarding the appropriate terminology to use so their instruments, materials, and programs will be understood by the target group. However, in reading the published findings in health education literature, it is often unclear as to the meaning of some terminology used for data collection and therefore, the translation of the research to the greater population is unclear. The focus of the present article is to explore how the faulty interchange of the terms sex and gender within health education research is problematic, creates confusion, and violates the premises of cultural competency.


It has become common in American society for every day conversations to include words used to designate sex and gender characteristics interchangeably. While many people have narrowed the use of the word sex to solely refer to sexual activity, the context for the word gender has expanded and has been used as a euphemism for the sex of a human being since the 1960s or 1970s (Caplan and Caplan, 2009; Diamond, 2002). Yet, according to the World Health Organization (WHO), sex (as a noun) refers to the biological and physiological characteristics that are differentiated by genes, hormones, and reproductive organs that are present at birth (World Health Organization, n.d.). Traditionally, sex has only included the biological categories of male and female. Gender, according to the WHO, is made up of socially constructed roles, behaviors, activities, and attributes (World Health Organization, n.d.). As such gender may vary across cultures and traditionally has been restricted to the designations of men (or masculinity) and women (or femininity). Disagreement about the accurate usage of these terms has pervaded society even up to the Supreme Court (Case, 1995; Diamond, 2002).

The practice of interchanging the terms sex and gender in research has been up for discussion in other disciplines including psychology, anthropology, and physiology (Gentile, 1993; Hoppe, Evans, Bertram, and Moritz, 2004; Unger and Crawford, 1993; Walker and Cook, 1998). Researchers in each of these fields have called for the separation of the terms sex and gender in order to increase the accuracy of studies being conducted in their respective fields. The 2001 Institute of Medicine (IOM) Report from the Committee on Understanding the Biology of Sex and Gender Differences provides perhaps the most convincing reason to separate the use of the terms in research. The report calls for researchers to be specific in their use of the terms sex and gender in publications to create consistency in professional literature. While numerous guidelines were provided in the report, three were given for using sex and gender correctly in human and animal research:

* In the study of human subjects, the term sex should be used as a classification according to the reproductive organs and functions that derive from the chromosomal complement;

* In the study of human subjects, the term gender should be used to refer to 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; and

* In most studies of nonhuman animals the term sex should be used (Hoppe, Evans, Bertram, and Moritz, 2004; Institute of Medicine, 2001). Such guidelines were outlined to aid in effective cross-discipline communication and the translation of research into practice.


To determine how frequently the terms sex and gender were exchanged in prominent health education research articles, a simple investigation was conducted during June 2010. Research articles published from 2007-2010 in two peer-reviewed journals affiliated with health education professional organizations were examined. Of the 63 data-based articles published in one of these journals, researchers reported the collection of sex data in 61 of the articles, yet reported the data as sex data in 14 (22.2%) of these articles and as gender in 47 (74.6%) articles. Of the 103 articles published in the second journal, researchers reported the collection of sex data in 87 of the articles, yet reported the data as sex data in 28 (32.2%) of these articles and as gender in 59 (67.8%) articles. These findings reveal a large number of health education professionals are using the terms sex and gender interchangeably within their research. This exchange of terms creates confusion among the readership as to whether the study findings are related to biological variables of interest or socially-constructed variables of interest. As identified in the Institute of Medicine's Report (2001), this exchange of terms decreases the effectiveness of cross-discipline communication and increases the potential for ineffective translation of research into practice. Furthermore, these findings have the appearance of inadequate cultural competence within health education research.


Cultural competency exists along a continuum, is context bound, and requires a lifelong development process. Whether one refers to the Purnell Model for cultural competence (2002) or the levels of competence identified by Cross and colleagues (1989), the element of consciousness is evident. It is the belief of these authors that the interchangeable use of the terms and references to sex and gender data within studies is due to a lack of consciousness, not intention. With greater awareness and discussions surrounding the appropriate use of the terms sex and gender throughout research, the health education profession can move closer to the competent end of the continuum and create opportunities for improved cross-discipline discussions regarding health issues among different cultures.

To fully achieve cultural competence is to experience a multifaceted and systematic transformation in the use of sex and gender terminology and references within the research interactions with populations. Researchers and health educators are held to a professional Code of Ethics that requires cultural competency as a responsibility to the public and profession. Article IV of this code identifies a health educator's responsibility to deliver health education with integrity and respect for the fundamental rights, dignity, confidentiality, and worth of all people by adapting strategies and methods to the needs of different populations (CNHEO, 2011). To achieve this competence within research is to accurately and consistently utilize terms such as sex and gender for effective communication with communities and other disciplines. Furthermore, such skills are necessary to ensure the recognition of health issues that may be affected by the differences between sexes and genders, and thus biological and socially-constructed factors. Therefore, accurately collecting, reporting, and translating sex or gender data into health education and promotion research is professionally responsible.


It is evident that the lack of clarity with the usage of the terms sex and gender not only occurs in society, but also within health education research. While this professional field is not the only one wrestling with this distinction in terminology, health educators can be leaders among all health-care providers in ensuring that the collection and translation of research data are accurate (Gentile, 1993; Hoppe et al., 2004; Unger et al., 1993; Walker et al., 1998). Additionally, as the translation of health education and promotion research into practice occurs, the accurate utilization of these terms may illuminate the need for additional attention to be given to the roles of sex and gender in the development of various health conditions according to biological versus social or lifestyle factors.

Researchers across the health education field may agree with the need to be clear and accurate with the use of sex and gender terminology, but may be unsure as to how this would be reflected or understood among their populations of study. Certainly if confusion of these terms occurs within the research, it is likely that participants would not recognize the difference if asked, "What is your sex?" and "What is your gender?" on the same questionnaire. Gentile (1993) recommends that an unambiguous terminology be used. He argues for the term 'biological sex' to ensure the distinction is perfectly explicit. Therefore, the questions would then be, "What is your biological sex?" and "What is your gender?" While this may not completely clarify the issue for participants, it does identify the presence of a distinction between sex and gender.

Beyond the clarification of sex and gender terminology, researchers need to be conscious of the flexibility and fluidity of the gender variable. A number of professionals within the behavioral and social sciences have explained how gender changes in different contexts and times (Diamond, 2002; Foucault, 1998; Rosenfeld, 2002; Walker et al., 1998). Therefore, dialogue needs to occur within the health education and promotion fields about methods that can be implemented to facilitate the identification of a participant's gender as it relates specifically to the context being studied. These methods may be as simplistic as adding a question for participant self-identification of gender to more complex methods of incorporating numerous questions that come together to create a more robust variable of gender. Regardless of the process utilized, researchers must not use the word gender to be reflective of a participant's biological sex or sex to be reflective of a participant's socially-constructed gender.

While it is important for the health education and promotion profession to have dialogue surrounding cultural competency and the accurate use of the terms sex and gender, it is necessary for individual practitioners to be reflective about their own work. The National Institutes of Health (NIH) has an online course called The Science of Sex and Gender in Human Health (National Institutes of Health, n.d.). According to the NIH, the course offers participants a basic scientific understanding of the major physiological differences between the sexes, their influence on illness and health outcomes, and their implications for policy, medical research, and health care. The course has been designed for researchers, clinicians, members of academia, and students in health professional schools. Since cultural competency is a lifelong process and a professional requirement, awareness of current competency levels is crucial for continued growth. Such process evaluation throughout a professional's work will result in a better translation of research and an enhanced level of communication across health-related disciplines.

This confusion of sex and gender terminology has taken several decades to occur and it may not be easy to return to a more accurate use of these terms in research or practical settings, but it is worth pursuing. The appropriate collection and reporting of sex and gender data within health education literature will reduce confusion about whether a biological construct or socially-determined construct is impacting the health issue of interest. Furthermore, the appropriate use of these terms will allow for more effective cross-discipline communication. Finally, using these terms separately to reflect their different meanings will be an improved reflection of cultural competency within health education research. With position statements, resolutions, and organizational policies highlighting the importance of cultural competency, the field of health education, as well as individual health education researchers, have a responsibility and are poised to be leaders within the health-care arena with the appropriate utilization of the terms sex and gender within research and its translation.


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Jeanne Freeman, PhD, CHES

Kaylee Knowles, BS

Jeanne Freeman, PhD, CHES, Western Washington University, PEHR Department, 516 High Street, Carver Gym 102, Bellingham, WA 98225-9067, Phone: 360-650-2125, Fax: 360-650-7447, Jeanne.Freeman@, Kaylee Knowles, BS, Western Washington University, PEHR Department.
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Author:Freeman, Jeanne; Knowles, Kaylee
Publication:American Journal of Health Studies
Article Type:Report
Geographic Code:1USA
Date:Mar 22, 2012
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