Influence of Sex and Gender on Musculoskeletal Conditions and How They Are Reported.

ABSTRACT: There is increasing evidence that musculoskeletal tissues are differentiallys regulated by sex hormones in males and females. The influence of sex hormones, in addition to other sex-based differences such as in anatomical alignment and immune-system function, impact the prevalence and severity of disease as well as the types of injuries that affect the musculoskeletal system and the outcomes of prevention measures and treatment. Literature specifically addressing sex differences related to the musculoskeletal system is limited, underscoring the imperative for both basic and clinical research on this topic. This review highlights areas of research that have implications for bone and cartilage health, including growth and development, sports injuries, osteoarthritis, osteoporosis, and bone frailty. It is clear that important aspects of the musculoskeletal system have been understudied. Consideration of how sex hormone therapy will affect musculoskeletal tissues in prepuberty, during puberty, and in adults is vital, yet little is known. The purpose of this article is to foster awareness and interest in advancing our understanding of how sex differences influence orthopaedic practice.

Sex differences in houselessness, injection drug use, and mental health conditions among people newly diagnosed with HIV in Manitoba, Canada from 2018 to 2021: a retrospective cohort study.

Background: Manitoba saw the highest number of new HIV diagnoses in the province's history in 2021 and is the only Canadian province not meeting any of the previous UNAIDS 90-90-90 targets. Our goal was to describe sex differences and syndemic conditions within an incident HIV cohort in Manitoba, and the HIV treatment initiation and undetectable viral load outcomes. Methods: This was a retrospective cohort study of all people 18 years and older newly diagnosed with HIV in Manitoba, Canada between January 1st, 2018 and December 31st, 2021. Data was collected as follows: before HIV diagnosis: chlamydia, gonorrhoea, syphilis, and/or hepatitis C antibodies. At the time of HIV diagnosis: age, sex, gender, race/ethnicity, sexual orientation. During follow-up: CD4 counts, viral load, HIV treatment, hospitalizations, and number of visits to HIV care. Main exposures evaluated: methamphetamine use, injection drug use, houselessness, and mental health conditions. Outcomes: started antiretroviral treatment and achieved an undetectable viral load. A descriptive statistical analysis was used. Findings: There were 404 new HIV diagnoses in Manitoba from 2018 to 2021; 44.8% were female, 55.2% male; 76.% self-identified as Indigenous, 13.4% white/European, 4.7% African/black; 86.6% cis-gender; 60.9% heterosexual, 13.4% gay, bisexual and men who have sex with men, and 1.7% lesbian. Injection drug use was reported by 71.8% and 43.5% of females and males respectively. Methamphetamine was the most frequently injected drug (62.4%). Amongst females, 81.8% experienced at least one of the following: houselessness (43.1%), mental health comorbidities (46.4%), and injection drug use (71.8%). Only 64.9% of all individuals had an undetectable viral load (61.1% females and 67.9% males), 56.5% among people experiencing houselessness, 59% among young people (≤29 years), and 60.1% among people who inject drugs. Interpretation: People newly diagnosed with HIV in Manitoba are disproportionately experiencing houselessness, mental illness, and injection drug use (mostly methamphetamine). This pattern is more pronounced for female individuals. These findings highlight the need for syndemic and gender-specific approaches, simultaneously addressing social and health conditions, to treat HIV. Funding: This work was supported by the Canadian Institutes of Health Research, The Manitoba Medical Service Foundation, The James Farley Memorial Fund and the Canada Research Chairs Program.

A Shadow of Doubt: Is There Implicit Bias Among Orthopaedic Surgery Faculty and Residents Regarding Race and Gender?

BACKGROUND: Orthopaedic surgery continues to be one of the least diverse medical specialties. Recently, increasing emphasis has been placed on improving diversity in the medical field, which includes the need to better understand existing biases. Despite this, only about 6% of orthopaedic surgeons are women and 0.3% are Black. Addressing diversity, in part, requires a better understanding of existing biases. Most universities and residency programs have statements and policies against discrimination that seek to eliminate explicit biases. However, unconscious biases might negatively impact the selection, training, and career advancement of women and minorities who are underrepresented in orthopaedic surgery. Although this is difficult to measure, the Implicit Association Test (IAT) by Project Implicit might be useful to identify and measure levels of unconscious bias among orthopaedic surgeons, providing opportunities for additional interventions to improve diversity in this field. QUESTIONS/PURPOSES: (1) Do orthopaedic surgeons demonstrate implicit biases related to race and gender roles? (2) Are certain demographic characteristics (age, gender, race or ethnicity, or geographic location) or program characteristics (geographic location or size of program) associated with the presence of implicit biases? (3) Do the implicit biases of orthopaedic surgeons differ from those of other healthcare providers or the general population? METHODS: A cross-sectional study of implicit bias among orthopaedic surgeons was performed using the IAT from Project Implicit. The IAT is a computerized test that measures the time required to associate words or pictures with attributes, with faster or slower response times suggesting the ease or difficulty of associating the items. Although concerns have been raised recently about the validity and utility of the IAT, we believed it was the right study instrument to help identify the slight hesitation that can imply differences between inclusion and exclusion of a person. We used two IATs, one for Black and White race and one for gender, career, and family roles. We invited a consortium of researchers from United States and Canadian orthopaedic residency programs. Researchers at 34 programs agreed to distribute the invitation via email to their faculty, residents, and fellows for a total of 1484 invitees. Twenty-eight percent (419) of orthopaedic surgeons and trainees completed the survey. The respondents were 45% (186) residents, 55% (228) faculty, and one fellow. To evaluate response biases, the respondent population was compared with that of the American Academy of Orthopaedic Surgeons census. Responses were reported as D-scores based on response times for associations. D-scores were categorized as showing strong (≥ 0.65), moderate (≥ 0.35 to < 0.65), or slight (≥ 0.15 to < 0.35) associations. For a frame of reference, orthopaedic surgeons' mean IAT scores were compared with historical scores of other self-identified healthcare providers and that of the general population. Mean D-scores were analyzed with the Kruskal-Wallis test to determine whether demographic characteristics were associated with differences in D-scores. Bonferroni correction was applied, and p values less than 0.0056 were considered statistically significant. RESULTS: Overall, the mean IAT D-scores of orthopaedic surgeons indicated a slight preference for White people (0.29 ± 0.4) and a slight association of men with career (0.24 ± 0.3), with a normal distribution. Hence, most respondents' scores indicated slight preferences, but strong preferences for White race were noted in 27% (112 of 419) of respondents. There was a strong association of women with family and home and an association of men with work or career in 14% (60 of 419). These preferences generally did not correlate with the demographic, geographic, and program variables that were analyzed, except for a stronger association of women with family and home among women respondents. There were no differences in race IAT D-scores between orthopaedic surgeons and other healthcare providers and the general population. Gender-career IAT D-scores associating women with family and home were slightly lower among orthopaedic surgeons (0.24 ± 0.3) than among the general population (0.32 ± 0.4; p < 0.001) and other healthcare professionals (0.34 ± 0.4; p < 0.001). All of these values are in the slight preference range. CONCLUSION: Orthopaedic surgeons demonstrated slight preferences for White people, and there was a tendency to associate women with career and family on IATs, regardless of demographic and program characteristics, similar to others in healthcare and the general population. Given the similarity of scores with those in other, more diverse areas of medicine, unconscious biases alone do not explain the relative lack of diversity in orthopaedic surgery. CLINICAL RELEVANCE: Implicit biases only explain a small portion of the lack of progress in improving diversity, equity, inclusion, and belonging in our workforce and resolving healthcare disparities. Other causes including explicit biases, an unwelcoming culture, and perceptions of our specialty should be examined. Remedies including engagement of students and mentorship throughout training and early career should be sought.

Inclusion of Sex and Gender Differences in U.S. State Action Plans for Opioid Use and Opioid Use Disorder.

Background: States have developed action plans to address the "opioid crisis" over the past several years. While sex- and gender-based differences have been identified in complications of opioid use, risks of addiction to opioids, barriers to treatment of opioid use disorder, and associated stigma, it is unknown if or to what extent opioid plans consider or account for these differences. The objectives of this study were to analyze U.S. state opioid action plans and their inclusion of sex- and gender-specific concerns. Methods: A content analysis of 49 state plans was conducted in June 2020, assessing their inclusion of 14 variables covering provider education, pregnancy-related, and sex- or gender-based differences in opioid addiction and treatment. Results: Neonatal opioid withdrawal syndrome was the most common variable, noted in 57% of plans. Only 14% included pregnancy-related stigma, and 4% identified gender-specific stigma. Contraceptives and family-planning were included in 12% and 10% of plans, respectively. Two states included more than half of the variables and five plans made no mention of sex or gender differences. Conclusions: Few state plans contained sex- or gender-specific information, and those that did focused almost exclusively on childbearing, excluding other unique considerations of opioid-using-women of all ages. The results of this study could improve the care of women using opioids by informing the strategies of state agencies and impacting legislative efforts for prevention initiatives, substance use disorder treatment, and law enforcement programs.

Bone Health in the Transgender Population.

¼ Transgender women are more susceptible to low bone mineral density (BMD) before initiating gender-affirming hormone therapy (GAHT), and while bone density initially improves with GAHT, it gradually declines while still remaining above baseline. Transgender women older than 50 years have a comparable fracture risk as age-matched cisgender women. Transgender men typically have normal or increased BMD before initiating and while receiving GAHT and are not at increased risk of fractures.¼ Transgender youth who receive puberty-blocking medications experience either no change or a slight decrease in BMD that returns to baseline after initiating GAHT.¼ It is important to abide by the International Society for Clinical Densitometry guidelines whenever ordering, performing, or reading a BMD scan for a gender-diverse patient.¼ There are no specific guidelines concerning vitamin D and calcium supplementation or the use of bisphosphonates in the transgender population, so the current recommendation is to abide by the guidelines for cisgender individuals.

Social and structural barriers and facilitators to HIV healthcare and harm reduction services for people experiencing syndemics in Manitoba: study protocol.

INTRODUCTION: In Manitoba, Canada, there has been an increase in the number of people newly diagnosed with HIV and those not returning for regular HIV care. The COVID-19 pandemic resulted in increased sex and gender disparities in disease risk and mortalities, decreased harm reduction services and reduced access to healthcare. These health crises intersect with increased drug use and drug poisoning deaths, houselessness and other structural and social factors most acutely among historically underserved groups. We aim to explore the social and structural barriers and facilitators to HIV care and harm reduction services experienced by people living with HIV (PLHIV) in Manitoba. METHODS AND ANALYSIS: Our study draws on participatory action research design. Guiding the methodological design are the lived experiences of PLHIV. In-depth semi-structured face-to-face interviews and quantitative questionnaires will be conducted with two groups: (1) persons aged ≥18 years living or newly diagnosed with HIV and (2) service providers who work with PLHIV. Data collection will include sex, gender, sociodemographic information, income and housing, experiences with the criminal justice system, sexual practices, substance use practices and harm reduction access, experiences with violence and support, HIV care journey (since diagnosis until present), childhood trauma and a decision-making questionnaire. Data will be analysed intersectionally, employing grounded theory for thematic analysis, sex-based and gender-based analysis and social determinants of health and syndemic framework to understand the experiences of PLHIV in Manitoba. ETHICS AND DISSEMINATION: We received approval from the University of Manitoba Health Ethics Research Board (HS25572; H2022:218), First Nations Health and Social Secretariat of Manitoba, Nine Circles Community Health Centre, Shared Health Manitoba (SH2022:194) and 7th Street Health Access Centre. Findings will be disseminated using community-focused knowledge translation strategies identified by participants, peers, community members and organisations, and reported in conferences, peer-reviewed journals and a website (www.alltogether4ideas.org).

Addressing Burnout Among Women Residents: Results from Focus Group Discussions.

Introduction: Physician burnout has been described as more common among women than men. Even if there are no gender-based differences in prevalence, risk factors, such as work/home integration/conflict and gendered biases, likely differ. Prior administrations of an annual resident wellness survey at a single urban academic institution confirmed that rates of burnout were higher among women, especially during the PGY-2 year. Methods: A series of focus groups of PGY-3 women residents across specialties were organized in 2019 at a single urban academic medical center. Given the number of participants, demographics were not collected to maintain participant anonymity. The moderator for all groups used a discussion guide consisting of eight open-ended questions based on a review of the literature. Results: Ten residents agreed to participate in one of four hour-long focus group discussions. While the residents identified some factors that were not gender-specific, they also discussed issues that they faced as women in medicine, including needing to work harder to prove themselves and unconscious gendered biases from faculty and patients. The residents thought that their well-being would be improved if their training programs better understood the experiences and needs of women residents and recommended a series of interventions, including improved mentoring and networking opportunities. Conclusions: Interventions to improve well-being need to consider gender-based differences. While mentoring and networking can help all residents, these may be especially useful for women and should be considered as a component of an overarching plan to improve diversity, equity, inclusion, and belonging.

Teaching of Cost-Effective Care in Orthopaedic Surgery Residency Training: A Survey of Residency Programs in the US.

Costs of healthcare in the US continue to rise at rates that are unsustainable. Prior studies, most of which come from non-surgical specialties, indicate that a variety of strategies to teach this material are utilized but without consensus on best practices. No studies exist regarding the teaching of cost-effective care in orthopaedic residency training programs. The goal of this study was to assess the landscape in this area from the perspective of program leadership. Methods: A survey was developed that was sent to orthopaedic residency program leadership via email through their interaction with the COERG. Additional programs were included to enhance diversity of responding programs. The survey, based on those published from other areas of medicine, included questions about the experiences of the respondents in learning about cost-effective care, as well as how faculty and residents learned about this topic. Results: Seventy one percent (30) of respondents noted that their faculty did not receive formal training in cost-effective care, and education in this area was likely to come from the department, especially review of practice data (12, 44%). Only 19% (8) of respondents agreed with the statement that "the majority of teaching faculty in our program consistently model cost-effective healthcare to residents". Few of the programs (10, 24%) had formal curricula for residents regarding cost-effective care, and the primary mode of education in cost-effective care was through informal discussions with faculty (17, 43%). Few residents (3, 13%) were able to easily find the costs of tests or procedures. Discussion: There is not consistent education in cost-effective care for orthopaedic surgery program leadership, faculty, or trainees. The results of this survey demonstrate a need for discussion of best practices, including increasing access to cost data at a local level, and engaging with the AOA, CORD, and the American Academy of Orthopaedic Surgeons more broadly in the development of standard education modules for faculty and residents, to improve the current and future delivery of cost-effective musculoskeletal care.