The consideration of sex/gender in quantitative health research: Challenges and methodological approaches regarding multidimensionality, dynamics across the life course, and intersectionality

To date, sex and gender have been integrated into most fields of quantitative health research based on a binary understanding, commonly operationalized as two distinct categories women and men, assuming homogeneity within each group. This prevailing current practice of sex or gender consideration in quantitative health research is increasingly criticized, emphasizing its inability to account for the high complexity of the entangled dimensions sex/gender and vari-ety of lived experiences. In recent years, there are growing demands for more sophisticated approaches allowing for consideration of the high complexity of sex/gender. Within current discourse multiple challenges and opportunities are discussed across the entire research pro-cess with regard to different methodological approaches. By pursuing four different research objectives, within this cumulative dissertation selected challenges in the consideration of sex/gender in quantitative health research were addressed from multiple angles. A mixed-methods approach was adopted that focused on different stages of the research process, including conceptualization, operationalization, analysis, and reporting:
1) In order to map instruments that are currently applied to operationalize sex/gender diver-sity in quantitative health research a scoping review was conducted. Findings indicate that most of the identified instruments were applied to measure dimensions of gender and were based on a binary understanding of sex/gender. 2) A conceptual framework of the dynamics of multiple social and biological dimensions of sex/gender was developed based on theoreti-cal work of multiple research disciplines. The framework states that in a constant interplay between personal factors, societal contexts, and an individual’s own life experiences, sex/gender dimensions develop and vary across the life course and different contexts. 3) An intersectional perspective was applied to account for population subgroups’ heterogeneity within the operationalization of sex/gender and data analysis. Thirteen of the 77 instruments identified in the scoping review (objective 1) operationalized gender in intersection with other social categories, particularly sexuality. In a case study on older adult’s active mobility and their environmental preferences and needs suitability of a data-driven approach to account for subgroup heterogeneity was shown. 4) An assessment matrix was proposed, that allows for the comprehensive evaluation of sex/gender consideration in quantitative health research. The developed matrix consists of 14 items each comprising different rating level, allowing for a systematic quality assessment.
Findings of this dissertation highlight that although there was an increase in instruments to operationalize sex/gender diversity in recent years, the majority is still based on a binary and static understanding of sex/gender. Further methodological approaches are needed that are suited to assess the multiple dimensions of sex/gender, their dynamics across the life course, and their mutual entanglements. This dissertation’s findings, particularly the proposed framework, provide a starting point for guiding further research. By strengthening the theo-retically sound consideration of sex/gender in quantitative health research, more valid find-ings can be gained to inform health care and promotion. In the long term, these approaches will contribute to more health equity for all sex/gender groups.