General Introduction 11 1 While the importance of the inclusion of SABV and GASV in biomedical research is increasingly acknowledged in research policies, the introduction of gender in the (bio) medicine research practices has encountered difficulties and resistance in the past and present. First attempts at introducing ‘gender’ in (bio)medical research and education frequently meant an interchangeable use with the term ‘sex’, and often without specification how ‘sex’ was being operationalised.15 Efforts to address this practice in medical education revealed an initial lack of interest among medical students, as well as faculty, about the topic of gender, scepticism regarding the relevance of gender in medicine and a lack of time or willingness to learn about gender.16–19 While SABV is gaining popular and preferential interest in biomedical research, critics of SABV in both social and precision medicine argue that an intensive focus on solely documenting differences in biological sex characteristics risks producing decontextualised results with limited relevance to human health and clinical practice.20–22 Treating sex characteristics as binary (male/female) biological variables, uncoupled from research context, social environment, intersecting demographics and lifestyle variables, lacks the precision evidence-based medicine claims to seek.23 Differences and similarities in sex characteristics reflect both biological and sociocultural influences and (bio)medical researchers should be careful to address observed differences between men and women solely as biological sex-related differences, regardless of their causes.24 Investigating gender as socialisation characteristics allows us to contextualise observed sexrelated similarities and differences and to reflect upon societal realities and developments within and between patient populations. However, for the investigation of gender in medicine, there is currently no clear consensus on terminology or standards how to operationalise this construct. This makes gender-sensitive studies in medicine currently difficult to operationalise, let alone replicate. Furthermore, biomedical and health researchers are still developing their own understanding of gender as a dynamic multidimensional sociocultural construct. Operationalising gender dimensions in medical research This thesis is informed by the theoretical concepts of ‘doing gender’ (West and Zimmerman 1987) and ‘gender performativity’ (Butler 1988).25,26 Both theories view gender as a performative accomplishment compelled by social norms and sanction. Gender includes behavioural and psychological traits that are stereotypically associated with one of the sexes and are facilitated and restricted by social consequences. Gender ascribes similarities within one sex and differences between sexes. Based on these differences and similarities, cultural ideas describe what is regarded as normative behaviours for each of the sexes and which roles and responsibilities are socially (performatively) desired. From this perspective, cultural comprehension of what e.g. a ‘man’ or a ‘woman’ is, evolves from what is understood as both differences and sameness. This process of
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