How gender theories are used in contemporary public health research

A purposeful sampling of public health papers expected to have a strong gender theoretical base was chosen to provide relevant and rich information. As gender theoretical development is difficult to publish in traditional medical or public health journals [12], we decided to select special issues in which the included papers have greater opportunities to develop gender theories.

A literature search was performed in May 2016 in PubMed and Web of Science with the search terms: ((gender[Title]) OR (femini*[Title]) OR (sex*[Title]) OR (masculin*[Title])). The search was limited to English language papers published since 2005, and in order to find special issues we first searched for editorials.

The inclusion criteria required editorials to be for a special issue with public health relevance, defined in a broad way as dealing with population health issues (e.g., health status, health behaviour and health care experiences). As such, editorials introducing special issues about clinical treatment of patients were excluded.

In total, we found 282 editorials in PubMed and (partly overlapping) 339 editorials in Web of Science (n = 621). The sex* search term yielded many excluded publications dealing with sexuality without any public health focus. In addition, most of the editorials were not related to any special issue and were therefore excluded. When the editorials did introduce a special issue, many of these issues had a narrow clinical focus that was out of scope for our analyses of public health research. We identified 13 special issues with public health relevance. All papers in these special issues were read and analysed in relation to two inclusion criteria:

No papers in the following seven special issues fulfilled these two criteria and were therefore excluded: Issues Ment Health Nurs. 2012 Dec;33(12) Maturitas 2011 Mar;68(3), Fam Med 2011 Mar;43(3), Violence Against Women. 2010 Feb;16(2): Int J Tuberc Lung Dis. 2008 Jul;12(7), Women Health 2007;46(1), Soc Sci Med. 2007 Mar;64(5).

The following six special issues contained at least one paper and therefore fulfilled our inclusion criteria (33 papers in total):

These Roman numerals will be used below for referring to the various special issues. A reference list of all included papers is available in Additional file 1.

As illustrated by the eight questions in Table 2b, we inductively identified the following eight ways of using gender theories in the reviewed material (the number of times each strategy was used is denoted in parentheses):

Gender theories were used to:

Jewkes & Morell [16] could be used as a good example in relation to several of the above identified strategies. Their Introduction was permeated by gender theories (strategy 2) such as the framework of gender and power, hegemonic masculinity, and social constructions of gender within power hierarchies. With qualitative methods, the paper inductively developed gendered concepts (strategy 3) in terms of various constructions of femininities in relation to HIV risk practices grounded in a framework of agency within structure. The results were interpreted (strategy 4) and discussed in relation to gender theories (patriarchy, male power, contextualised femininities etc.). Thus, strategies 2, 3 and 4 were identified. In addition, strategy 5 was also evident since gender theories were used to understand HIV risk practices.

The paper by Jordan-Young [17] is notable since it was the only one using strategy 7, i.e., how researchers integrate gendered aspects/theories into a gender blind medical theory. Jordan-Young made a critical feminist analysis of the congenital adrenalin hyperplasia (CAH) hypothesis (that steroids in utero shape “brain gender” and gender ‘atypical’ behaviour in humans) and expanded the ‘tunnel vision’ of the hypothesis to include gendered aspects of living with CAH (such as medical interventions, living with atypical genitals, how physical manifestation of CAH becomes entangled with lived gendered experiences).

Strategy 4 (to use theories in order to interpret findings) is related to (but not the same as) strategy 2 (integrating theories). Strategy 2 includes papers in which the gender theories were integrated in the whole paper or only in some part of the paper, often in the Introduction section. Even though it was not the aim of this paper to analyse how strongly the identified gender theoretical approaches contributed to developing gender theories, these eight ways do say something about how pronounced the gender theoretical approach was. The focus on gender theories is probably strongest when the aim of a paper is involved, such as in Muñoz-Laboy et al. [18], which includes gender theories about gender systems and constructions of masculinities in relation to health needs and risk behaviour. Furthermore, papers that develop gender concepts/ theories are often theoretically advanced.

From a public health perspective, strategy 5 (to use gender theories in order to understand health aspects) is more interesting than strategy 6 in which health issues are used to validate a gender theories, while the authors seem less interested in developing the health focus. To use gender theories in order to critique other gender theories (strategy 8) is part of the theoretical development within the field.

Some of the strategies were dependent on the methodology; to test a hypothesis (strategy 1) is primarily performed in quantitative research while concepts are mainly developed with qualitative methods.

Table 3 summarises which gender theories, health aspects and methodologies that were used in the analysed papers.

The table shows that many of the papers had an ambitious use of various gender theories as well as of a wide range of strategies. The strategies were used, seemingly independent of the health aspects. However, they differed in relation to the various methodological approaches. Almost all possible strategies were used in theoretical papers (strategies 1, 2, 3, 5, 6, 7 and 8) and in papers using qualitative methods (strategies 2, 3, 4, 5, 6 and 8). Theoretical papers do not have empirical results and therefore cannot use strategy number 4. Empirical qualitative papers seldom test hypotheses, and strategy number 1 was not used in these papers. Quantitative papers had the most limited use of strategies – they only used four of the eight strategies (number 1, 2, 4 and 5). Even though it is important to do studies that are stratified by women and men, there is a risk of the simplified use of categorical and biological explanations. Thus, the methodology might lead to a reductionist approach unable to move beyond stereotypical and dualistic understandings of women, men and health.

In relation to health aspects, Table 3 shows that seven of the included papers had a vague focus on ‘health’ (e.g., writing about health as an unspecified topic), while eight papers focused on reproductive health issues, and seven were about suicide. Surprisingly, the strong theoretical focus on gender in several of the papers was accompanied by an almost complete lack of theoretical reflections about the outcome (i.e., the health aspects) of the papers. In spite of the fact that the editorial of Current Sociology 2009 underlined the importance of ‘looking at health as a gendered issue in sociological research’ [19], there was a lack of awareness about gender theories in relation to the health outcome in most of the papers therein. A more distinct focus on the outcome as gendered was found in some of the papers of the special issues on suicide. For example, Oliffe et al. [20] stated that depression was a “decidedly unmasculine ailment”, seen as a woman’s disease and certain masculinities were constructed as risk behaviour including suicidal behaviour. In addition, another of the papers [21] used theories in writing about the mental health outcome, in this case the gendered construction of symptoms of mental health. Jordan-Young’s paper also included gendered analysis of the outcome in relation to living with congenital adrenal hyperplasia [17].

There was a notable lack of focus (apart from one paper about coronary heart disease) on major public health problems like cancer, diabetes, cardiovascular diseases and health behaviours. Furthermore, none of the studies were devoted to better understanding prevention and health promotion from a gender perspective.

Table 4 provides a brief background to the most commonly used gender theories in the analysed papers.

Interestingly, all of the gender theories featured in the reviewed papers were developed outside the field of public health/medicine, mainly in social science. In addition, the theories mirror the wide range of perspectives that exist in gender research.