Identifying and training deep learning neural networks on biomedical-related datasets.

This manuscript describes the development of a resources module that is part of a learning platform named 'NIGMS Sandbox for Cloud-based Learning' https://github.com/NIGMS/NIGMS-Sandbox. The overall genesis of the Sandbox is described in the editorial NIGMS Sandbox at the beginning of this Supplement. This module delivers learning materials on implementing deep learning algorithms for biomedical image data in an interactive format that uses appropriate cloud resources for data access and analyses. Biomedical-related datasets are widely used in both research and clinical settings, but the ability for professionally trained clinicians and researchers to interpret datasets becomes difficult as the size and breadth of these datasets increases. Artificial intelligence, and specifically deep learning neural networks, have recently become an important tool in novel biomedical research. However, use is limited due to their computational requirements and confusion regarding different neural network architectures. The goal of this learning module is to introduce types of deep learning neural networks and cover practices that are commonly used in biomedical research. This module is subdivided into four submodules that cover classification, augmentation, segmentation and regression. Each complementary submodule was written on the Google Cloud Platform and contains detailed code and explanations, as well as quizzes and challenges to facilitate user training. Overall, the goal of this learning module is to enable users to identify and integrate the correct type of neural network with their data while highlighting the ease-of-use of cloud computing for implementing neural networks. This manuscript describes the development of a resource module that is part of a learning platform named ``NIGMS Sandbox for Cloud-based Learning'' https://github.com/NIGMS/NIGMS-Sandbox. The overall genesis of the Sandbox is described in the editorial NIGMS Sandbox [1] at the beginning of this Supplement. This module delivers learning materials on the analysis of bulk and single-cell ATAC-seq data in an interactive format that uses appropriate cloud resources for data access and analyses.

How to be an effective ally.

Inclusivity in biomedical research provides many positive attributes, including increased productivity, higher creativity, and improved wellness for all. While marginalized individuals work tirelessly to achieve equity and inclusion, this task should not be left solely to those most affected by exclusionary tactics. These individuals and the organizations with whom they are affiliated would benefit from the support of an ally. An ally is defined as a person or organization that actively supports the rights of a marginalized group without being a member of it. Allies have a unique opportunity to play a pivotal role in promoting fairness, equity, and inclusion, and thus serve as positive change agents within an organizational setting. We summarize here the importance of being an effective and dynamic ally and offer guidance on how to achieve that goal.

Establishing the short course in transferable skills training program.

While PhD programs prepare graduate students to perform biomedical research, a defined systematic training program for transferable skills is generally lacking. When provided, this training is often informal, unstructured, or inconsistent. Therefore, there is a need to provide critical skills in marketing, relationship building, project management, and budgeting to prepare trainees to navigate into a productive, engaging, and rewarding biomedical research career. To address this gap in training, the School of Graduate Studies at Meharry Medical College has developed the SHort Course In transFerable skills Training (SHIFT) Program, a 1-year professional development program accessible to graduate students in the United States who are enrolled in graduate biomedical research related programs. The SHIFT Program has been launched to equip trainees with skills essential for success in all biomedical science careers. PhD students will be taught the primary constituents of career management through the use of four training modules. In Module I, students complete self-assessments and are assigned to a small peer-mentoring team with mentors. Module II consists of a 5-day workshop that encompasses instruction on the transferable skills identified as essential for career success. Module III entails monthly interactive discussions over a 6-month period involving case study review and mentor-guided discussions to further reinforce skills learned. In Module IV, students compile the information learned from Modules I-III to develop an Individual Development Plan that incorporates 3-5 specific, measurable, attainable, relevant, and time-based career goals. Collectively, the SHIFT Program will allow participants to train, practice, and refresh skills, empowering them to navigate career transitions and obtain success in the career of their choice.

Initiating your coronation.

Earning an advanced degree in biomedical sciences can be a challenging experience, and recent data indicate high levels of stress and anxiety among the current generation of learners. We propose here a new illustration for all graduate students to visualize their didactic journey as a coronation process. Before their coronation, trainees must undergo rigorous preparation. During the training, four key attributes, best described by the acronym COST (Credibility, Opportunity, Strength, and Tenacity), are cultivated. Throughout their academic journey, which is a critical period of intellectual and personal growth, the trainees will enhance their understanding of the responsibility of wearing a CROWN, which requires accepting the Cost of earning a diadem, Revolutionizing their thought construct, being Open to innovation and research, acknowledging that Wealth is intrinsically connected to their health, and Never forsaking their aspiration and pursuits. Executing these principles daily will provide a mechanism on which to rise to the stature of achieving individual career goals (i.e., being a Regent of your life). Actualization of this process requires sacrifice, maturity, and a sense of fearlessness. The results of taking this approach will lead to an educational legacy that establishes a pattern of academic success that can be emulated by future learners.

On the use of receiver operating characteristic curve analysis to determine the most appropriate p value significance threshold.

BACKGROUND: p value is the most common statistic reported in scientific research articles. Choosing the conventional threshold of 0.05 commonly used for the p value in research articles, is unfounded. Many researchers have tried to provide a reasonable threshold for the p value; some proposed a lower threshold, eg, 0.005. However, none of the proposals has gained universal acceptance. Using the analogy between the diagnostic tests with continuous results and statistical inference tests of hypothesis, I wish to present a method to calculate the most appropriate p value significance threshold using the receiver operating characteristic curve (ROC) analysis. RESULTS: As with diagnostic tests where the most appropriate cut-off values are different depending on the situation, there is no unique cut-off for the p significance threshold. Unlike the previous proposals, which mostly suggest lowering the threshold to a fixed value (eg, from 0.05 to 0.005), the most appropriate p significance threshold proposed here, in most instances, is much less than the conventional cut-off of 0.05 and varies from study to study and from statistical test to test, even within a single study. The proposed method provides the minimum weighted sum of type I and type II errors. CONCLUSIONS: Given the perplexity involved in using the frequentist statistics in a correct way (dealing with different p significance thresholds, even in a single study), it seems that the p value is no longer a proper statistic to be used in our research; it should be replaced by alternative methods, eg, Bayesian methods.

Advancing primatology through ethical and scientific perspectives on rhesus monkey (Macaca mulatta) cloning.

A critical turning point was reached in research with the recent success in cloning rhesus monkeys (Macaca mulatta), a major advancement in primatology. This breakthrough marks the beginning of a new age in biomedical research, ushered by improved somatic cell nuclear transfer techniques and creative trophoblast replacement strategies. The successful cloning of rhesus monkeys presents the possibility of producing genetically homogeneous models that are highly advantageous for studying complex biological processes, testing drugs, and researching diseases. However, this achievement raises important ethical questions, particularly regarding animal welfare and the broader ramifications of primate cloning. Approaching the future of primate research with balance is critical, as the scientific world stands on the brink of these revolutionary breakthroughs. This paper aims to summarise the consequences, ethical challenges and possible paths forward in primatology arising from rhesus monkey cloning.

The advancement of artificial intelligence in biomedical research and health innovation: challenges and opportunities in emerging economies.

The advancement of artificial intelligence (AI), algorithm optimization and high-throughput experiments has enabled scientists to accelerate the discovery of new chemicals and materials with unprecedented efficiency, resilience and precision. Over the recent years, the so-called autonomous experimentation (AE) systems are featured as key AI innovation to enhance and accelerate research and development (R&D). Also known as self-driving laboratories or materials acceleration platforms, AE systems are digital platforms capable of running a large number of experiments autonomously. Those systems are rapidly impacting biomedical research and clinical innovation, in areas such as drug discovery, nanomedicine, precision oncology, and others. As it is expected that AE will impact healthcare innovation from local to global levels, its implications for science and technology in emerging economies should be examined. By examining the increasing relevance of AE in contemporary R&D activities, this article aims to explore the advancement of artificial intelligence in biomedical research and health innovation, highlighting its implications, challenges and opportunities in emerging economies. AE presents an opportunity for stakeholders from emerging economies to co-produce the global knowledge landscape of AI in health. However, asymmetries in R&D capabilities should be acknowledged since emerging economies suffers from inadequacies and discontinuities in resources and funding. The establishment of decentralized AE infrastructures could support stakeholders to overcome local restrictions and opens venues for more culturally diverse, equitable, and trustworthy development of AI in health-related R&D through meaningful partnerships and engagement. Collaborations with innovators from emerging economies could facilitate anticipation of fiscal pressures in science and technology policies, obsolescence of knowledge infrastructures, ethical and regulatory policy lag, and other issues present in the Global South. Also, improving cultural and geographical representativeness of AE contributes to foster the diffusion and acceptance of AI in health-related R&D worldwide. Institutional preparedness is critical and could enable stakeholders to navigate opportunities of AI in biomedical research and health innovation in the coming years.

Genetic characterization of a captive marmoset (Callithrix jacchus) colony using genotype-by-sequencing.

The marmoset is a fundamental nonhuman primate model for the study of aging, neurobiology, and many other topics. Genetic management of captive marmoset colonies is complicated by frequent chimerism in the blood and other tissues, a lack of tools to enable cost-effective, genome-wide interrogation of variation, and historic mergers and migrations of animals between colonies. We implemented genotype-by-sequencing (GBS) of hair follicle derived DNA (a minimally chimeric DNA source) of 82 marmosets housed at the Southwest National Primate Research Center (SNPRC). Our primary goals were the genetic characterization of our marmoset population for pedigree verification and colony management and to inform the scientific community of the functional genetic makeup of this valuable resource. We used the GBS data to reconstruct the genetic legacy of recent mergers between colonies, to identify genetically related animals whose relationships were previously unknown due to incomplete pedigree information, and to show that animals in the SNPRC colony appear to exhibit low levels of inbreeding. Of the >99,000 single-nucleotide variants (SNVs) that we characterized, >9800 are located within gene regions known to harbor pathogenic variants of clinical significance in humans. Overall, we show the combination of low-resolution (sparse) genotyping using hair follicle DNA is a powerful strategy for the genetic management of captive marmoset colonies and for identifying potential SNVs for the development of biomedical research models.

Precision Medicine for Whom? Public Health Outputs from "Genomics England" and "All of Us" to Make Up for Upstream and Downstream Exclusion.

This paper problematizes the precision medicine approach embraced by the All of Us Research Program (US) and by Genomics England (UK) in terms of benefits distribution, by arguing that current "diversity and inclusion" efforts do not prevent exclusiveness, unless the framing and scope of the projects are revisited in public health terms. Grounded on document analysis and fieldwork interviews, this paper analyzes efforts to address potential patterns of exclusion upstream (from participating in precision medicine research) and downstream (from benefitting from precision medicine outputs). It argues that efforts for inclusion upstream are not corresponded downstream, and this unbalance jeopardizes the equitable capacities of the projects. It concludes that enhanced focus on socio-environmental determinants of health and aligned public health interventions as precision medicine outputs would be to the benefit of all and especially of those who are most at risk of (upstream as well as downstream) exclusion.

Impact of COVID-19 pandemic on physician-scientist trainees to faculty one year into the pandemic.

PURPOSE: Physician-scientists play a crucial role in advancing biomedical sciences. Proportionally fewer physicians are actively engaged in scientific pursuits, attributed to attrition in the training and retention pipeline. This national study evaluated the ongoing and longer-term impact of the COVID-19 pandemic on stress levels, research productivity, and optimism for physician-scientists at all levels of training. METHODS: A multi-institutional cross-sectional survey of medical students, graduate students, and residents/fellows/junior faculty (RFJF) was conducted from April to August 2021 to assess the impact of COVID-19 on individual stress, productivity, and optimism. Multivariate regression analyses were performed to identify associated variables and unsupervised variable clustering techniques were employed to identify highly correlated responses. RESULTS: A total 677 respondents completed the survey, representing different stages of physician-scientist training. Respondents report high levels of stress (medical students: 85%, graduate students: 63%, RFJF: 85%) attributed to impaired productivity concerns, concern about health of family and friends, impact on personal health and impairment in training or career development. Many cited impaired productivity (medical students: 65% graduate students: 79%, RFJF: 78%) associated with pandemic impacts on training, labs closures and loss of facility/resource access, and social isolation. Optimism levels were low (medical students: 37%, graduate students: 38% and RFJF: 39%) with females less likely to be optimistic and more likely to report concerns of long-term effects of COVID-19. Optimism about the future was correlated with not worrying about the long-term effects of COVID-19. Since the COVID-19 pandemic, all respondents reported increased prioritization of time with family/friends (67%) and personal health (62%) over career (25%) and research (24%). CONCLUSIONS: This national survey highlights the significant and protracted impact of the COVID-19 pandemic on stress levels, productivity, and optimism among physician-scientists and trainees. These findings underscore the urgent need for tailored support, including mental health, academic, and career development assistance for this biomedical workforce.

A structured curriculum supporting biomedical trainees' transition into independent academic positions and early career success.

The United States government makes a substantial investment in biomedical training programs each year. However, for most trainees, these opportunities do not translate into career progression in academic research pathways. Only about one-fifth of postdoctoral fellows eventually secure a tenure-track faculty position, and even among these candidates, attrition is high. Although a number of factors govern career choices and career longevity, the transition from trainee to faculty is a challenging process and requires knowledge and skills that are not necessarily developed during a traditional university experience. Many postdoctoral fellows receive adequate training in research skills and scientific communication, but new faculty report not being sufficiently prepared for the job search process and for starting their labs. To address this critical training gap, the ITERT core (Interdisciplinary Translational Education and Research Training) and the Office of Postdoctoral Fellows at the University of Texas MD Anderson Cancer Center implemented a structured course for both postdoctoral fellows and senior PhD students to provide formalized training for successfully navigating academic positions in biomedical research. Here we report on the pilot Navigating Academic Careers course conducted in 2021-2022 for 30 PhD students and postdocs. The nine-module course was conducted over 13 weeks in 25.5 h instructional sessions. The key educational objectives included 1) navigating the job application and the interview/negotiation process, 2) hiring, leading, and mentoring lab personnel and program support staff, 3) project administration and financial stewardship, 4) managing time and work-life balance and 5) developing collaborations, branding, personalized niche, and networking. Survey-based analysis at the time of the course was used to capture the participants' assessment of the course content, organization, and delivery, with a follow-up survey conducted approximately 2 years post-course (2024) to evaluate longer-term impacts of the training. Initial in-course assessment revealed that 89.9% of respondents found the scope and instructional content appropriate, and 91.1% found the course relevant and applicable to their career needs. Longer-term post-course evaluation indicated that 80% of respondents applied the learnings of the course, that 80% reported feeling more confident in navigating an academic job search, and that 66.6% continued to report agreement with the course preparing them for their current role/ongoing job search, with 46.7% already securing jobs in academic research, including as independent faculty. The outcomes of this pilot course suggest that integrating this into the broader postdoctoral training curriculum can enhance both the transition and early-career success of talented scientists-in-training into working professionals in biomedical careers, as faculty and science-trained staff.

A Coaching-Based Leadership Program for Women Postdoctoral Fellows at the National Cancer Institute that Cultivates Self-confidence and Persistence in STEMM.

Despite making strides in gender equality, women in Science, Technology, Engineering, Mathematics, and Medicine (STEMM) continue to face a persistent underrepresentation in leadership roles. In an effort to reverse this trend, the National Cancer Institute created the Sallie Rosen Kaplan (SRK) Postdoctoral Fellowship, a year-long coaching-based leadership training program. The SRK program aims to empower women to explore careers across a broad range of fields, including academia, industry, and government, and to excel in leadership positions in those fields. Analyzing a decade of data from 111 participants, we describe the positive impact of the SRK program on participant's self-reported capabilities. Increased self-confidence, improved time management and work/life balance, enhanced goal-setting and attainment skills, and strengthened communication and relationship-building abilities are highlighted as statistically significant outcomes. Moreover, the program's emphasis on coaching, mentorship, peer cohort support, and building lasting professional relationships also contributed to high ratings for satisfaction and value of the program. Successful programs like SRK can serve as a model for institutions striving to close gender gaps in leadership.

The landscape of biomedical research funding in Brazil: a current overview.

OBJECTIVE: The objective of this narrative review is to discuss the current state of research funding in Brazil. MATERIALS AND METHODS: This study is based on the most recent edition of the course Funding for Research and Innovation in the University of Sao Paulo School of Medicine which was a three-day course with 12 hours of instruction. The course brought together leading experts in the field to comprehensively discuss the current state of research funding in Brazil. Each speaker provided a presentation on a specific topic related to research funding. After the workshop, speakers assembled relevant topics in this manuscript. RESULTS: collaborative research is critical for securing research funding. It optimizes proposal competitiveness, amplifies societal impact, and manages risks effectively. As such, fostering and supporting these collaborations is paramount for both researchers and funding agencies. To maintain the highest integrity in research, investigators involved in these collaborations must disclose any relationships that could potentially influence the outcomes or interpretation of their projects. CONCLUSIONS: In Brazil, the mainstay of research funding stems from public entities, with agencies such as CNPq, CAPES, and state bodies like FAPESP, FAPERJ, FAPEMIG and others at the forefront. Concurrently, industry funding offers viable pathways, especially through industry-sponsored studies, investigator-led projects, and collaborative initiatives. The Brazilian funding landscape is further enriched by innovative platforms, including crowdfunding and the contributions of institutions like the Serrapilheira Institute. Internationally, esteemed organizations such as the National Institutes of Health (NIH) and the Bill & Melinda Gates Foundation stand out as potential funders.

[Benefits and approaches of a quality management system in biomedical research laboratories]. / Vorteile und Ansätze eines Qualitätsmanagementsystems in biomedizinischen Forschungslaboratorien.

Quality in biomedical research is a much-discussed topic among experts, research institutes, and funding organizations. Quality issues are frequently reported in the scientific and general press (e.g., stability of study results after test retake - "replication crisis"). Quality management systems are a globally accepted and established tool to guide and manage quality and to address quality problems. However, the notion of quality management is often met with resistance among researchers: low resources, too much regulation, restriction of research, and unnecessary bureaucracy are counter-arguments.The idea of implementing a quality management system for research laboratories is nothing new worldwide. There are various approaches by scientists and organizations to establish a quality management system in research laboratories and to develop a value-added system for themselves. Their expectations are an optimization of the research processes as well as an increase in effectiveness and efficiency.This report summarizes publications concerning quality measures and management in biomedical research and explains the background and advantages of quality management systems in organizations, laboratories, and research. A currently ongoing project of the Robert Koch Institute is presented as an outlook. The article is based on a literature review in English and German. In addition, internationally and nationally applicable and relevant guidelines were considered.

Informed consent of the patient for medical intervention for conducting biomedical research.

OBJECTIVE: Aim: is to find out the peculiarities of informed consent of the patient for medical intervention during biomedical research. PATIENTS AND METHODS: Materials and Methods: The dialectical method was used as a universal and general scientific method, which made it possible to consider the peculiarities of the content of the patient's informed consent. Using the logico-semantic method, the essence and features of biomedical research with the patient's participation were determined. The formal-legal method is used to analyze adaptation processes of biomedical research. System-structural method were applied when comparing the content of the patient's informed consent in separate legislation. The work also used such methods of cognition as comparative-legal, systemic-logical, and logical-legal. CONCLUSION: Conclusions: "Informed consent" includes not only the concept of consent itself, i.e. the free decision of a person, but also an explanation of a specific case or research procedure. And it largely depends on the specialist. Will he be able to convey and explain the patient's problem, illness, actions correctly, fully and in an accessible form? Yes, free consent is given by a person, but the doctor also influences this decision to some extent. Patients' freedom in choosing medical care methods is somewhat limited.

Constitutional and legal status of the subject during biomedical research.

OBJECTIVE: Aim: To find out the peculiarities of constitutional and legal status of the subject during biomedical research. PATIENTS AND METHODS: Materials and methods: A synergistic approach helps predict possible fluctuations and vectors of development, taking into account various social and technical processes of influence on the status of the subject; comprehensive - involves the analysis of the research subject within the framework of a combination of different scientific schools, concepts and methods and provides opportunities for the development of unified standards, benchmarks, principles and general norms of legal regulation. CONCLUSION: Conclusions: The constitutional-legal status of the subject is the position of the subject (patient, object of research) established and established by the norms of constitutional law, which distinguishes him as a special subject of legal relations in the process of conducting biomedical research and consists of a set of rights and obligations and specifics of the legal liability of its participants.

Bibliometric Study of the Advances Made in Clinical Dermatological Research in Spain from 2015 through 2021: Update of the MaIND Project and Interactive Online Map. / Estudio bibliométrico sobre la evolución de la investigación clínica dermatológica española entre 2015 y 2021: actualización del proyecto MaIND y mapa interactivo en línea.

INTRODUCTION: A clinical dermatological research was conducted in Spain from 2005 through 2014 as part of the MaIND project with the provinces or centers with the highest number of published articles. However, a low level of evidence in scientific production was confirmed as the overall result. The aim of this study is to update the Spanish clinical dermatological research in bibliometric terms from 2015 through 2021 with comparisons between both periods of time. MATERIAL AND METHODS: We conducted a bibliometric study to replicate the methodology used in the article to be updated. We included articles whose corresponding authors' affiliation was a Spanish dermatological center, which met the criteria for clinical research in dermatology, including a level of evidence ≤4. RESULTS: A total of 1,674 out of the 10,199 articles met the inclusion criteria. An interactive map representing quantitative and qualitative indicators calculated for the 2005-2021 is presented here. In the study period, we found an increasing trend both in the number of published articles (P<.002) and in the mean number of citation-years per article (P<.01). A total of 22 of the articles had a level of evidence >4, with a positive trend towards more articles having a higher level of evidence (P<.03). ACTAS DERMOSIFILOGRÁFICAS still maintains its position as the journal with the highest number of articles received (18%, a total of 302 articles). CONCLUSIONS: The results of this study show that, in Spain, the scientific production of dermatology represents an upward trend in quantity, impact, and level of evidence.

Committing to genomic answers for all kids: Evaluating inequity in genomic research enrollment.

PURPOSE: Persistent inequities in genomic medicine and research contribute to health disparities. This analysis uses a context-specific and equity-focused strategy to evaluate enrollment patterns for Genomic Answers for Kids (GA4K), a large, metropolitan-wide genomic study on children. METHODS: Electronic health records for 2247 GA4K study participants were used to evaluate the distribution of individuals by demographics (race, ethnicity, and payor type) and location (residential address). Addresses were geocoded to produce point density and 3-digit zip code maps showing local and regional enrollment patterns. Health system reports and census data were used to compare participant characteristics with reference populations at different spatial scales. RESULTS: Racial and ethnic minoritized and populations with low-income were underrepresented in the GA4K study cohort. Geographic variation demonstrates inequity in enrollment and participation among children from historically segregated and socially disadvantaged communities. CONCLUSION: Our findings illustrate inequity in enrollment related to both GA4K study design and structural inequalities, which we suspect may exist for similar US-based studies. Our methods provide a scalable framework for continually evaluating and improving study design to ensure equitable participation in and benefits from genomic research and medicine. The use of high-resolution, place-based data represents a novel and practical means of identifying and characterizing inequities and targeting community engagement.

Publishing particulars: Part 3. General writing tips, editing, and responding to peer review.

In Part 3 of this Perspective on Publishing Particulars, I begin by providing several general writing tips to consider when developing a manuscript for publication. I then discuss the process involved in rigorously editing research papers and advance some important considerations for manuscript submission. I next share my thoughts and recommendations when attempting to interpret and respond to comments from the manuscript peer review process. Finally, I discuss author responsibilities after a manuscript is accepted for publication. Overall, this portion of the 3-part commentary seeks to complete a broader discussion on publishing in the biomedical sciences aimed at better informing early-stage investigators about many of the nuances of this critical area of professional development.

Considering hormones as sex- and gender-related factors in biomedical research: Challenging false dichotomies and embracing complexity.

The inclusion of sex and gender considerations in biomedicine has been increasing in light of calls from research and funding agencies, governmental bodies, and advocacy groups to direct research attention to these issues. Although the inclusion of both female and male participants is often an important element, overreliance on a female-male binary tends to oversimplify the interactions between sex- and gender-related factors and health, and runs a risk of being influenced by cultural stereotypes about sex and gender. When biomedical researchers are examining how hormones associated with gender and sex may influence pathways of interest, it is of crucial importance to approach this work with a critical lens on the rhetoric used, and in ways that acknowledge the complexity of hormone physiology. Here, we document the ways in which discourses around sex, gender and hormones shape our scientific thinking and practice in biomedical research, and review how the existing scientific knowledge about hormones reflects a complex and dynamic reality that is often not reflected outside of specialist niches of hormone biology. Where biomedical scientists take up sex- and gender-associated hormones as a way of addressing sex and gender considerations, it is valuable for us to bring a critical lens to the rhetoric and discourses used, to employ a sex contextualist approach in designing experimentation, and be rigorous and reflexive about the approaches used in analysis and interpretation of data. These strategies will allow us to design experimentation that goes beyond binaries, and grapples more directly with the material intricacies of sex, gender, and hormones.