Multiple Gender Dimensions 45 3 Introduction Parkinson’s disease (PD) is the second most common neurodegenerative disease worldwide and an increasing challenge to global health due to its rapidly rising prevalence.1,2 This trend places a considerable burden on societies, individuals and health systems, as PD-related disabilities significantly reduce health-related quality of life (HRQoL).3 In addition, the current knowledge base around PD poorly represents the diversity of people that live with the disease. The under-representation of different socioeconomic and ethnic groups, as well as women in PD research, result in an incomplete picture of the true impact on individual quality of life. 4–7 There is a growing recognition of the need to increase diversity and representation in PD studies, especially a better consideration of sex and gender. Studies into sex-linked associations with PD have reported a higher risk in females of developing dyskinesia, and a lower risk of developing cognitive impairments compared to male patients.8,9 Nevertheless, the pathophysiological insights underlying such sex-specificity in determining PD-associated risks remain scarce. Furthermore, findings about the impact of gender on HRQoL among people with PD are inconclusive to date, highlighting the need for methodologically-sound sex and gender sensitive clinical research.10–12 Aside from potential differences in sex, which refer to a spectrum of biological and physiological characteristics, people with PD may also differ in gender, which refers to a multidimensional continuum of socially constructed behaviours, roles and relations associated with men, women and gender-diverse people.13 The association between sexlinked characteristics, gender-related aspects and a given health outcome, can depend on one, both or neither of the two concepts. Therefore, any investigation within this field requires critical conceptual clarity in the operationalization of sex and gender.14 Gender-related aspects are essential elements of people’s lived experiences and entail dynamic social norms and relations that influence health and quality of life.15 Studies that investigate the impact of gender on PD have almost exclusively focused on selfreported gender identity and rarely included other dimensions of gender. Moreover, if self-reported gender identity is included in PD research, it is often applied as an allencompassing representation of the construct “gender” and used interchangeably with the construct of “sex” or used as a proxy for biological sex-linked characteristics.10,16,17 This lack of conceptual clarity limits the generalizability of these research findings and contributes to an incomplete representation of gender, its potential interaction with sex-linked characteristics and its impact on health of people with PD.14
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