You recently co-authored a Commentary in the renowned medical journal The Lancet. In it, you stressed the importance of sex and gender in medical research. How long have you been committed for this issue, and why is it important to you?

Angèle Gayet-Ageron:  My interest in this topic first arose while I was still a medical student in the late 1990s, when combination therapies for HIV first began to emerge. While working at the hospital, I was seeing a lot of people with AIDS who were in a very poor condition – this was a time when it was still almost impossible to treat the disease, and many of those affected died from it. In the public perception, AIDS was still very strongly linked with the homosexual community, so there was a high level of discrimination associated with it. This experience really shooked me and made me realize the importance of issues relating to discrimination and inequality in medicine early on in my career.

Sex and gender have a huge impact on our health in many ways, from acting as determinants for health risks to the symptoms and progression of illnesses, even the way patients are perceived by healthcare personnel and these have huge impact on their access to medical care.

How exactly do you define sex and gender in a medical context?

Sex is biological and is related to sexual chromosomes: Women usually have the XX chromosome combination and men XY, though there are many other variations as well. These chromosomes influence our hormones, which in turn affect our metabolic responses, cardiovascular systems, blood pressure, moods, the effects and side-effects of medicine on our bodies, and much more besides. Biology has a real impact on our health.

And gender?

Gender is the social equivalent to sex – a social construct based on features widely interpreted as sexual markers. You can have a biological sex – female, for example – but your gender identity can differ from this. You might identify as more or less feminine, more or less masculine, or neither. Your form of gender expression – the way you present yourself to the world – can also vary greatly.

«Good healthcare for everyone is only possible if sex and gender are taken into account right from the beginning of every research project.»

- Angèle Gayet-Ageron

Unfortunately, there is a lot of confusion around the term “gender”: It is often used solely to refer to sexual orientation or reduced to transgender identity. It has also been heavily politicized.

The topic is complex overall, but in terms of medical studies, sex and gender can often be boiled down to two simple questions: What sex were you assigned at birth? And how do you identify yourself? Some studies may require more detailed data, such as hormone levels and chromosome analyses. But the most important thing is to have these questions in mind and the information they could provide at an early stage of the research process.

Could you give us some specific examples of why it’s important to take sex into account when conducting medical research?

One classic example is the sleeping pill Zolpidem. Initial clinical studies failed to take sufficient consideration of patient sex, and when the drug was released, the same dose was prescribed for all patients. Later on, it was discovered that this dose was far too high for women: Because women metabolize the medication more slowly, its effects could persist until the next morning, reducing their ability to perform various tasks or drive a car safely, for example. If the statistical analyses in the clinical studies had been presented separately for participants of different sexes, this could have prevented many women from suffering severe and even fatal injury in accidents.

«Sex and gender are not an ideology – they are key factors in ensuring scientific quality and guaranteeing patient safety.»

- Angèle Gayet-Ageron

Heart attacks are another example. When I was at medical school, we were still being taught that heart attacks mainly affect stressed and overweight men aged 50 and over, and that they could be recognized by chest pains that could also spread to the arm and the jaw. But the symptoms in women are often very different: nausea, stomach ache, dizziness, tiredness. As a result, women were being diagnosed incorrectly or too late for far too long, leading to their deaths.

And what is the relevance of gender from a medical perspective? 

Many studies have shown that, in day-to-day medical experiences, women are taken less seriously, and their pain levels are often underestimated. For years, women who came to emergency rooms with chest pain were often assumed to be suffering from anxiety rather than a heart condition.

Another gender-related issue in medicine is that illnesses that mainly affect women are frequently given a lower priority – the research receives less funding, and the condition receives less attention overall. One example here is endometriosis, a condition suffered by millions of women around the world. Despite these numbers, for decades there was hardly any research into the issue, resulting in significant gaps in medical knowledge. Women would live for years with incredible pain before obtaining a diagnosis and appropriate treatment. Endometriosis has only started to be taken seriously since it became clear that it can reduce the chances of pregnancy.

If they’re so important, why are sex and gender still not given sufficient consideration in research? 

Medical research is still not inclusive enough in many areas. There has been progress in recent years though: In 2016, an international group of experts published the SAGER Guidelines for better integration of sex and gender equality in medical research. 

But while this represented a milestone, the guidelines were aimed primarily at people who publish medical journals, to provide them with a set of rules with which they could evaluate sex and gender equality in research articles that had been submitted to their journals. That’s far too late in the process! If researchers haven’t thought about collecting sex or gender-specific data right from the start, they can’t analyze that data further down the line.

Was that the reason why you helped to draw up SAGER Guidelines for Switzerland that were aimed at ethics commissions?

Yes. In 2023 we founded a workgroup and adapted the SAGER Guidelines for Swiss ethics commissions. At the heart of these guidelines is a checklist that researchers and ethics commissions can use to systematically check whether sex and gender have been taken into consideration in all the necessary areas of a planned study. In a research project on gender medicine and health as part of the national research program NFP 83, we will now investigate whether the new guidelines actually do lead to greater consideration of sex and gender among Swiss ethics commissions and researchers in practice.

Could you give us an example of an important aspect that’s often been overlooked in research projects before now?

Whenever I check a research protocol, I always look at the applicants’ plans for recruitment of study participants. If they always conduct their tests, examinations or surveys on Wednesday afternoons, for example, women without children are more likely to participate, while mothers caring for young children are largely excluded. In addition, pregnant women or women of childbearing age are still sometimes systematically excluded.

Researchers are often simply unaware of why sex and gender do play a role. Many of them don’t conduct thorough literature research before they start their studies. However, it is so important to ask yourself: Do sex or gender have a role to play in this disease or issue? Researchers who lack awareness in this area will automatically structure their studies in such a way that this information is missing at the end.

You’ve worked for a long time at the University Hospital and the University of Geneva and done a lot of work on this issue – co-founding the group “Medicine, Gender and Equality,” for example. In April, you became Director of the Institute for Social and Preventive Medicine (ISPM) at the University of Bern. What’s your experience been of the environment at the University of Bern, compared to Geneva?

Very positive. The Female Empowerment in Life Sciences network (FELS) brings together female researchers at various career levels in the fields of medicine and biology so that they can support each other. The Gender Equality Commission is also very active. And the fact that the University of Bern has created a new Professorship for Gender Medicine is a great sign that this issue is being taken seriously.

Where there’s still room for improvement in Bern is ensuring a more systematic integration of sex and gender into medical training and education. Lausanne and Geneva are very active in this area. We can make use of the network I built up in Geneva to implement the same structure here in Bern. I incorporate these elements into my own courses regularly. Together with the Professor of Gender Medicine, I want to anchor this issue even more strongly in teaching practice in the future.

In your latest piece in The Lancet, you stressed the importance of advocating for this issue, especially in the current political climate. What makes this topic so crucial to you right now?

With an American president who bans these topics and cuts funding for gender-related research, we’re experiencing a huge setback. And I also have the impression that here in Switzerland, too, there are people who may have remained silent in the past but now suddenly feel emboldened to speak out against these issues and dismiss matters of sex and gender as simply political opportunism. 

However, that viewpoint is fundamentally wrong. It’s not about ideology. It’s about justice, scientific accuracy, the importance of research results and reliable healthcare for all people – no matter whether they identify as male, female, or non-binary. If we ignore sex and gender, we impair the quality of diagnoses, pass over opportunities for treatment, and place patients of all genders at risk. Last but not least, we’re also putting our society’s trust in science at stake.  That is precisely why we must stand up for these issues more resolutely than ever.