The inclusion of sex and gender in research methodology, funding, and publication: A systematic review

Importance: Gender inequity in access to and outcomes of orthopedic care demands research that properly analyses data based on sex and gender. Orthopedic surgeons have an obligation to mitigate gender inequity in the provision of care by addressing the sex and gender bias in orthopedic research methodology, grant funding, and publication demonstrated by this review. This study aimed to review the literature on known gender inequities in orthopedic care, as well as sex and gender bias in orthopedic research methodology, funding, and publication; and to then to outline mitigating strategies. Methods: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for articles published in English between 2000 and 2024. The databases searched included MEDLINE, PubMed, EMBASE, Scopus and Cochrane, and Scopus. Results: A total of 70 studies were identified that met inclusion criteria. Women often have poorer access to care and poorer outcomes than men for many common orthopedic procedures. Sex-specific analysis reached a maximum of 34% for combined basic science, translational and clinical research in major orthopedic journals. Women were less likely than men to be study participants. Orthopedic outcome measures do not adequately account for the epidemiological factors that predominantly affect women including pregnancy and care of the (often extended) family or differences in factors such as pain and return to work or sport. The probability of sex-related reporting was higher in papers with women as first and authors last, often in journals with lower impact factors. Women orthopedic researchers received only 55.2% of the funding of men orthopedic researchers. While women's first authorship increased statistically significantly from 1995 to 2020 (6.70%-15.37%, P < 0.001) manuscripts submitted by women were less likely to be published, and those with a woman first author demonstrated a lower citation rate. Mitigating strategies to address biases in research methodology and publication include adopting evidence-based Gender Specific Analysis ( GSA) methods into the orthopedic research process, considering GSA as a prerequisite for research grants and manuscript publication, increasing the diversity of orthopedic editorial boards, and supporting the careers of women in the orthopedic academic community through a more gender equitable environment and career-long mentorship and sponsorship. Conclusion and relevance: There are well-documented gender inequities in orthopedic care. Addressing the identified sex and gender bias in orthopedic research methodology, funding, and publication is a public health imperative. Mitigating strategies include education and the integration of sex and gender analysis in each step of the research to publication pathway, and increasing women in academic orthopedics through mentorship, sponsorship, and more inclusive department culture and policies.