Moving beyond Gender Identity 199 7 Moving beyond gender identity: the need for contextualization in gender-sensitive medical research. Gender is progressively recognized as a relevant social determinant of health in the field of biomedicine. In fact, a growing number of funding agencies and medical journals are requesting sex- and gender-sensitive analyses in applications and submissions.1 However, these mandates frequently lack methodological clarity about how sex or gender should be analysed in practice. Consequently, the biomedical field still heavily focuses on the impact of sex on health and disease, and gender is oftentimes operationalized as a somewhat fuzzy construct. Regardless of calls for the standardization of sex- and gender-related terminology there is currently no methodological gold standard.2 The operationalization of gender should aim at addressing its different dimensions. Research currently distinguishes between - at least - gender identity (e.g. being a woman, a man, non-binary), gender expression (i.e. how do I present my body and identity to the world) gender roles and norms (i.e. societal constructs that lead to shared ideas about what constitutes e.g. masculinity and femininity) and gender relations (the impact of gender on e.g. power dynamics in relationships). These dimensions explain the inherent challenge of representing a sociocultural construct such as gender within the biomedical context, where research mostly relies on quantitative methodology. In recent years, operationalization in biomedicine has primarily focused on the inclusion of gender identity alongside biological sex assigned at birth in large cohort studies (two-step method), although some combined instruments are being developed.3,4 The clinical utility of these novel approaches remains to be established. Even a multi-layered approach, disentangling the contribution of different gender dimensions towards quality of life5,6 represent only a first step towards an appropriate operationalization of gender in biomedicine and its translation into clinical action. Indeed, many of the currently available questionnaires in the field of health7 focus on abstract and culturallyprimed variables related to gender, such as household task divisions, or traits related to ‘masculinities and femininities’. The results identified with these questionnaires fall short of direct clinical actionability and oftentimes highlight the trickle-down effect of societal inequities on health. Gender is one element in a complex adaptive social system and its immutable quantification across time and place might be potentially impossible. In fact, social interactions and relationships are not fixed and gender-related variables constantly evolve; ‘what matters’ emerges in a particular real-world situation. Clinical research,
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