Quantitative and Qualitative Analysis on Sex and Gender in Preparatory Material for National Medical Examination in Germany and the United States.

BACKGROUND: Sex- and gender-based medicine (SGBM) should be a mandatory part of medical education. We compared the quantity and quality of sex- and gender-related content of e-learning materials commonly used by German and American medical students while preparing for national medical examinations.
METHODS: Quantitative, line-by-line analysis of the preparatory materials AMBOSS 2017 and USMLE Step 1 Lecture Notes (2017) by KAPLAN MEDICAL was performed between April and October 2017. Subjects were allocated to one of the three main fields: clinical subjects, behavioral and social science, and pharmacology. Qualitative analysis comprised binary categorization into sex- and gender-based aspects and qualification with respect to the presence of a pathophysiological explanation for the sex or gender difference.
RESULTS: In relation to the total content of AMBOSS and KAPLAN, the sex- and gender-based share of the clinical subjects content was 26.8% (±8.2) in AMBOSS and 21.1% (±10.2) in KAPLAN. The number of sex- and gender-based aspects in the behavioral and social science learning material differed significantly for AMBOSS and KAPLAN (4.4% ± 3.1% vs 10.7% ± 7.5%; P = .044). Most of the sex- and gender-related content covered sex differences. Most learning cards and texts did not include a detailed pathophysiological explanation for sex- or gender-based aspects. The knowledge provided in the preparatory documents represents only a small part of facts that are already known about sex and gender differences.
CONCLUSIONS: The preparatory materials focused almost exclusively on biological sex differences and the sociocultural dimension in particular is underrepresented. A lot more evidence-based facts are known and should be integrated into the materials to reflect the importance of SGBM as an integral component of patient-centered medicine.

Introduction

Medical knowledge of biological sex differences as well as the awareness of socially constructed characteristics of the individual (gender) are recommended to use for diagnosis and therapy in daily clinical practice. Therefore, sex- and gender-based medicine (SGBM), as an integral component of patient-centered medicine, should be a mandatory part of medical education and national medical exams.[1,2]

Based on the definition of “sex and gender” used by the Canadian Institutes of Health Research (CIHR) and the Institute of Gender in Medicine in Germany, “gender” is a psychosocial construct comprising four main features: gender roles, gender identity, gender relations, and institutionalized gender. “Sex” refers to a set of biological attributes in humans and animals. It is primarily associated with physiological features including chromosomes, gene expression, hormone levels and function, and reproductive/sexual anatomy.[3,4] Neither sex nor gender should be looked at solely due to their reciprocal influence of each other, and their joint impact on health.[5] The study by Pelletier et al.[6] laid the groundwork for the objective measurement of gender. This new ability to quantify the effect size of gender aspects in studies will lead to much more knowledge about the risk factors that contribute to the onset of disease.

Incorporation and translation of new facts based on sex and gender research into educational programs is challenging though.[7,8] While medical curricula vary widely between universities, all medical students take nationwide standardized examinations, which therefore function as indicators for the governmental framework regarding the implementation of SGBM into medical education. Neither the German nor the American regulatory guidelines on medical licensing explicitly incorporate sex- or gender-based aspects in their learning outcomes apart from reproductive aspects and sexual disorders.[9-11]

To examine the extent of the implementation of SGBM and therefore the students’ sex- and gender-related medical knowledge, this study analyzes the learning material used to prepare for standardized national medical exams. All German medical students take the German state examination, a 3-day written, multiple-choice exam, at the end of their fifth year at university and before entering the 1-year clinical internship. The American counterpart with a comparable scope and value, the USMLE Step 1, is a 1-day written, multiple-choice exam, most medical students take at the end of their second year in medical school.

This study analyzes the e-learning materials of AMBOSS 2017 (https://amboss.miamed.de), a web-based knowledge platform used by 95% of German medical students to prepare for the German state examination,[12] and of USMLE Step 1 Lecture Notes (2017), an e-book series by KAPLAN MEDICAL, one of the leading companies in the test prep industry, and used by thousands of American students,[13] to test the hypothesis that the preparatory materials for the German and the American national medical exams incorporate sex- and gender-related content based on the already published scientific knowledge and that German and American medical students are therefore equally well prepared in the field of SGBM.

Methods

AMBOSS is a continuously updated, web-based knowledge platform, offering, inter alia, a comprehensive set of learning cards that cover the topics tested in the German state examination. The annually revised KAPLAN e-book series comprises seven volumes, each tailored for an examination subject of the USMLE Step 1. The subjects included in the analysis were allocated to one of the 3 main fields: clinical subjects, behavioral and social science, and pharmacology. To increase comparability, subjects specific to only one of the learning resources were not included in the analysis.

For a systematic analysis of sex- and gender-related content, a last year medical student who has been trained in sex and gender medicine for 3 years at the Institute for Gender in Medicine at Charité—Universitaetsmedizin Berlin performed a line-by-line analysis of the preparatory materials between April and October 2017 and was observed by a senior medical scientist expert for SGBM. Furthermore, a second expert in the field analyzed a randomly selected and representative sample size of the reviewed content with an inter-rater reliability (IRR) of 92.50%.

For the quantitative analysis of the respective preparatory material’s sex and gender awareness, each AMBOSS learning card and KAPLAN e-book chapter were assessed for the presence of sex- or gender-based aspects with respect to the eight categories: epidemiology, prevention, pathophysiology, clinical presentation, diagnostics, therapy, prognosis, and pregnancy. A section counted as sex- and gender-aware if there was at least one sex- or gender-based aspect included. After determining each subject’s share of sex- and gender-related content, the overall sex- and gender-awareness percentage for every main field was calculated. We used the weighted arithmetic mean of the respective subjects’ sex- and gender-awareness scores, considering their differing shares of the overall content.

The second step comprised the qualitative coding of the preparatory material by (1) binary categorization into sex-based aspects (biological differences of women and men) and gender-based aspects (socially constructed traits/characteristics attributed to an individual) and (2) qualification with respect to the presence or absence of a (patho-)physiological explanation for the stated sex or gender differences.

Statistical analysis

Descriptive and statistical data analyses were conducted using Microsoft Excel for Macintosh 16.12 and IBM SPSS Statistics 24 (Released 2016; IBM SPSS Statistics for Macintosh, Version 24.0; IBM Corp., Armonk, NY, USA), respectively. Inter-rater reliability was measured as the percent agreement between raters. Data were expressed in percentages for nominal variables. Significance of differences in sex- and gender-related content was calculated using Pearson chi-square test. A P value less than .05 was considered statistically significant.

Results

The distribution of the allocated subjects differed slightly between AMBOSS and KAPLAN. The learning material allocated to the category clinical subjects was 51.76% in AMBOSS and 35.71% in KAPLAN; 9.41% in AMBOSS and 14.29% in KAPLAN for behavioral and social science; and 5.8% in AMBOSS and 14.29% in KAPLAN for pharmacology. Subjects which presented with little content or were specific to either AMBOSS or KAPLAN were excluded from the analysis (Supplementary Table 1).

Quantitative analysis of the percentage of sex- and gender-related content of all analyzed subjects showed 84.2% within the immunology/rheumatology section of AMBOSS and 50% within the KAPLAN counterpart (P < .1). Sex- or gender-based aspects were mentioned in 35.7% of the AMBOSS learning cards covering the subject occupational and environmental medicine. Its counterpart, the KAPLAN chapter social sciences, did not contain a single sex- or gender-based aspect (P < .05). Analyzing the psychiatry content, 46.9% in AMBOSS, compared to 76.9% of KAPLAN behavioral science section, mentioned sex- or gender-based facts (P < .1). For the following subjects, the difference between the percentage of sex- and gender-related content of the AMBOSS and the KAPLAN learning material was less than 10%: endocrinology/endocrine pathology, hepatogastroenterology/hepatogastrointestinal pathology, nephrology/renal pathology, pneumology/respiratory pathology, and pharmacology. Epidemiology was identified as the only subject in both preparatory materials that contained at least one sex- or gender-based aspect in every e-learning card or e-chapter (sex- and gender-awareness of 100%).

In relation to the total content of AMBOSS and KAPLAN (Table 1), the sex- and gender-based share of the AMBOSS clinical subjects e-learning cards was 26.8% (±SD 8.2%) and the KAPLAN counterpart 21.1% (±SD 10.2%). The percentage of sex- and gender-related content within the behavioral and social science learning material differed significantly between AMBOSS and KAPLAN (4.4% ± 3.1% vs 10.7% ± 7.5%; P = .044). Within the main field pharmacology, 3.8% of the AMBOSS learning cards were sex- and gender-aware in comparison to 7.9% of the KAPLAN pharmacology chapters, however not significantly different.

Table 1.

Proportion of sex- and gender-related content of main fields in relation to total content of AMBOSS and KAPLAN.

Main field	AMBOSS (100%)	KAPLAN (100%)	P value
Clinical subjects
Total content (%)	51.76	35.71
S&G-related content (SD%)	26.83 (±8.2)	21.12 (±10.2)	.306
Behavioral and social science
Total content (%)	9.41	14.29
S&G-related content (SD%)	4.39 (±3.1)	10.71 (±7.5)	.044*
Pharmacology
Total content (%)	5.88	14.29
S&G-related content (%)	3.80	7.87	.341

Abbreviations: S&G, sex and gender; SD, standard deviation.

P < .05.

Figure 1A and B show the distribution of the sex- and gender-based aspects to the eight categories in the main fields clinical subjects and behavioral and social science. Approximately half of the sex- and gender-based aspects belonged to the category epidemiology. AMBOSS put further emphasis on the categories clinical presentation, diagnostics, and therapy. KAPLAN, however, focused on pathophysiology and clinical presentation. Learning material presenting facts concerning pregnancy was included in both. In the clinical subjects content, the following categories demonstrated significant differences between AMBOSS and KAPLAN: epidemiology (48.1% vs 39.7%; P = .024), pathophysiology (2.5% vs 28.5%; P < .001), diagnostics (9.8% vs 3.7%; P = .002), therapy (5.6% vs 0.7%; P = .001), and pregnancy (14.3% vs 9.4%; P = .045). The behavioral and social science content of AMBOSS and KAPLAN differed significantly in the following categories: pathophysiology (0% vs 14.6%; P = .002) and diagnostics (7.0% vs 0%; P = .009).

Figure 1.

Distribution of sex- and gender-based aspects to eight categories in the main fields: (A) clinical subjects, (B) behavioral and social science, and (C) pharmacology. Comparison of AMBOSS and KAPLAN.

*P < .05; †P < .1.

The pharmacological content of both AMBOSS and KAPLAN (Figure 1C) focused on sex- and gender-based aspects regarding therapy (43.6% vs 58.8%; P = .052), including differences in side effects between women and men and special instructions for the medical care of pregnant women, stating particular indications and contraindications.

The overwhelming majority of the sex- and gender-related content in the preparatory material covered sex-based and therefore biological aspects (Table 2). Neither the clinical subjects nor the pharmacology content of either learning resource contained a single gender-based aspect. With 86.0% and 86.5%, sex-based aspects also predominated in the behavioral and social science content of AMBOSS and KAPLAN.

Table 2.

Qualitative analysis of preparatory material separated according to sex-based aspects and gender-based aspects, comparison of AMBOSS and KAPLAN.

Main fields	Preparatory material with S&G-based aspects, n (%)
	AMBOSS	KAPLAN
Clinical subjects	551 (100)	267 (100)
Sex-based aspects	551 (100)	267 (100)
Gender-based aspects	0 (0)	0 (0)
Behavioral and social science	57 (100)	96 (100)
Sex-based aspects	49 (85.96)	83 (86.46)
Gender-based aspects	8 (14.04)	13 (13.54)
Pharmacology	78 (100)	85 (100)
Sex-based aspects	78 (100)	85 (100)
Gender-based aspects	0 (0)	0 (0)

Abbreviations: S&G: sex and gender.

Most learning cards and texts did not include a detailed pathophysiological explanation for sex or gender differences with a similar distribution pattern between the learning resources (Table 3). The pharmacology content contained the biggest share of explained sex- and gender-based aspects with 34.6% for AMBOSS and 23.5% for KAPLAN.

Table 3.

Qualitative analysis: list of two educational levels of the preparatory material with sex- and gender-related content: (1) with pathophysiological explanation and (2) with no pathophysiological explanation.

Main fields	Preparatory material with S&G-based aspects, n (%)
	AMBOSS	KAPLAN
Clinical subjects	551 (100)	267 (100)
With explanation	96 (17.42)	38 (14.23)
No explanation	455 (82.58)	229 (85.77)
Behavioral and social science	57 (100)	96 (100)
With explanation	2 (3.51)	4 (4.17)
No explanation	55 (96.49)	92 (95.83)
Pharmacology	78 (100)	85 (100)
With explanation	27 (34.62)	20 (23.53)
No explanation	51 (65.38)	65 (76.47)

Abbreviations: S&G, sex and gender.

Discussion

The results indicate that the preparatory materials frequently used for preparing for the German and the American national medical exams contain sex- and gender-related content. Nevertheless, there is a lack of quantity and quality in regard to covering SGBM topics.

The main findings of the data analysis are as follows: (1) the overall lack of explicitly gender-related content in AMBOSS and KAPLAN, (2) the lack of a higher educational level regarding the comprised sex- and gender-based aspects in both preparatory materials, and (3) the significantly higher share of sex- and gender-related content incorporated in the main field behavioral and social science in KAPLAN compared to AMBOSS.

The vast majority of the included SGBM aspects in both learning materials comprised sex differences. This imbalance between biological facts (sex) and gender-based content (sociocultural aspects) could be explained by the challenge of measuring gender accurately. The study by Pelletier et al[6] laid the groundwork for the objective measurement of gender. They ranked patients having suffered from premature acute coronary syndrome on a masculinity/femininity-continuum according to their answers to a detailed questionnaire on sociocultural (gender) determinants (eg, income, education, social networks, environment, health literacy, cultural values), thus determining an individual’s gender score in addition to an individual’s biological sex. When implemented in clinical trials, this questionnaire will support and advance further research on sociocultural risk factors for diseases, and the obtained findings could lead to new gender-based preventive approaches.

Nevertheless, there are already sex- and gender-based facts that should be added as soon as possible to the exam questions pool. For example, atrial fibrillation increases embolic risk in women more than in men. Thus, at a societal level, women bear a greater burden of stroke than men.[14-16] Heart failure (HF) is commonly associated with reduced ejection fraction (HFREF). However, this connection is predominantly found in men, whereas women more often suffer from HF with preserved ejection fraction (HFPEF).[17-19] These symptoms occur based on diastolic dysfunction. Increased arterial pulse wave velocity (PWV ⩽ 9.7 m/s) and waist circumference >80 cm in postmenopausal women are associated with an increased risk of myocardial diastolic dysfunction.[20] Peripartum cardiomyopathy is a potentially life-threatening condition with multiple predisposing factors.[21] Therefore, it should be added to the exam topics as well. Diabetes is a stronger risk factor for vascular disease in women than in men.[22] Clinical presentation of systemic lupus erythematosus differs between women and men.[23-25] Women present with earlier onset of disease and more frequent relapses of multiple sclerosis (MS). However, progression is faster, and outcome is worse in men with MS.[26,27] A lot more evidence-based facts should be included in the exam questions pool. For additional information and literature on these facts, please refer to Table 4 highlighting knowledge gaps by way of example.

Table 4.

Examples of sex- and gender-related content identified in selected sections, facts not included in the learning materials, and knowledge gaps identified for future research.

Pathology	AMBOSS	KAPLAN	FACTS not included and KNOWLEDGE GAPS
Cardiology
Atrial fibrillation (AF)	Epidemiology: M > F		More women than men live with atrial fibrillation because of age dependency and greater longevity in women. Atrial fibrillation increases embolic risk more in women than in men.Women with stroke are more likely to have atrial fibrillation (leading to embolic stroke) and hypertension than men with stroke.[14] Adjusted data do suggest a lower case fatality in women.[15] Thus, at a societal level, women bear a greater burden of stroke than men, largely driven by their longer life expectancy and the higher risk of stroke with advancing age.In AF patients, female sex is associated with an age-dependent moderate risk of stroke and should be regarded as a stroke risk modifier relevant in the presence of other CHA2DS2-VASc risk stroke factors, rather than an independent stroke risk factor.AF patients aged <65 years, with a CHA2DS2-VASc score of 1 due to female sex have low annual stroke rates (generally <1%) and do not need any antithrombotic therapy.Women with AF and ⩾1 additional stroke risk factor (ie, with a CHA2DS2-VASc score of ⩾2) should be considered for OAC.[16]
	Prognosis: CHA2DS2-VASc score for estimating the risk of stroke in patients with AF, Sc = sex category (ie, female sex)
Dilated cardiomyopathy (DCM)	Epidemiology: M: F = 3:1		Epidemiology data based on traditional definition of heart failure with reduced ejection fraction (HFREF).Female and male patients with HF who are treated in European hospitals differ in terms of clinical manifestations. In the Euro Heart failure survey, systolic HF, known as HF with reduced ejection fraction (HFREF), was found predominantly in men, whereas women presented with HF with preserved (normal) ejection fraction (HFPEF) or diastolic HF.DCM is a heterogeneous condition manifest in a diverse group of patients due to a combination of underlying genetic susceptibility and environmental insults.[28] Women with DCM have better survival compared to men, which may partly be due to less severe left ventricular dysfunction and a smaller scar burden.[29] Takotsubo CMP (TTC):Initial clinical presentation of TTC often mimics ST-elevation myocardial infarction (STEMI), including acute chest pain, ST-segment elevation, and raised cardiac biomarkers.[30] TTC mostly occurs in postmenopausal women and has been associated with acute stress, smoking, alcohol abuse, and hypercholesterolemia.[31] It is yet unclear why TTC is more often observed in women.Peripartum Cardiomyopathy (PPCM) is a potentially life-threatening condition typically presenting as heart failure with reduced ejection fraction (HFREF) in the last month of pregnancy or in the months following delivery in women without another known cause of heart failure. Predisposing factors for PPCM seem to be multiparity and multiple pregnancies, family history, ethnicity, smoking, diabetes, hypertension, pre-eclampsia, malnutrition, age of mother (with older mothers being at greater risk), and prolonged use of tocolytic beta-agonists.[21]
		Pregnancy: some cases are related to pregnancy
Ischemic Heart Disease	Epidemiology: M > F (2:1)	Epidemiology: cardiac ischemia is most often seen in middle-aged men and postmenopausal women	Epidemiology data based on traditional pathophysiology with catheter-based obstruction of main coronary arteries. In women, more often ischemic heart diseases without obstruction of the main coronary arteries occur because of heterogeneous diseases and/or microvascular dysfunction, known as INOCA (myocardial ischemia with no obstructive coronary arteries)[32] and MINOCA (myocardial infarction with nonobstructed coronary arteries).[33]
	Clinical presentation: frequently only retrosternal “pressure” (as opposed to pain) in women, exclusively unspecific vegetative symptoms possible	Clinical presentation: atypical presentation of myocardial infarction with little or no chest pain is seen most frequently in women
Endocrinology
Diabetes mellitus	Clinical presentation: urogenital—erectile dysfunction	Clinical presentation: diabetic neuropathy can cause sexual impotence	Diabetes is a stronger risk factor for vascular disease in women than men.Diabetes confers a 44% greater excess risk of coronary heart disease (CHD) and a 27% greater excess risk of stroke in women than in men, independent of sex differences in other major risk factors.[22] Knowledge gap:The evidence is incomplete and the reasons behind women’s excess vascular relative risk from diabetes are not fully understood. Further research is therefore needed to provide further insights.
	Pregnancy: gestational diabetes, a glucose tolerance disorder arising or being diagnosed for the first time during pregnancy
Graves disease	Epidemiology: F > M (5:1)	Epidemiology: women are affected more frequently than men	Thyroid diseases afflict far more women than men. Hypothyroidism and hyperthyroidism are about 10 times more common in women than in men. Thyroid nodules and thyroid cancer are about three times more common in women than in men.[34] Men treated with antithyroid drugs had fewer adverse events (9% vs 18%) and treatment discontinuation (5% vs 16%) compared to women.[35]
	Diagnostics: enlarged thyroid gland (F > 18 mL, M > 25 mL)
Hepatogastroenterology
Cholelithiasis	Epidemiology: 6 F mnemonic for risk factors: “fair (white), family (positive family history), fat (BMI > 30), woman, fertile, forty (age ⩾ 40 years)”	Epidemiology: risk factors for cholesterol stones include female gender, pregnancy, oral contraceptives, and hormone replacement therapy	New sex and gender sensitive facts are missing
Chronic pancreatitis		Epidemiology: it is common in middle-aged male alcoholics	Clinical presentation: men have a 40% higher risk of developing diabetes (associated with diseases of the exocrine pancreas) than women.[36]
Hereditary nonpolyposis colorectal cancer (HNPCC)	Clinical presentation: increased risk of cancer at other sites: endometrial cancer (40%-60% of affected women) and ovarian cancer (10% of affected women)	Clinical presentation: it is associated with an increased risk of cancer at other sites, including the endometrium and the ovary	New sex and gender sensitive facts are missing
	Prevention: annual gynecological exams including transvaginal sonography for affected women aged 25 years and older; annual endometrial biopsies for affected women aged 35 years and older
Immunology/rheumatology
Scleroderma (progressive systemic sclerosis)	Epidemiology: F > M (3:1)	Epidemiology: it affects women more than men	Sex ratio of women to men with SSc prior to menopause is estimated at 15:1, while it lowers to 2.4:1 after menopause.[37]
	Prognosis: Men have a poorer prognosis than women
Sjögren syndrome (sicca syndrome)	Epidemiology: F > M (10:1), especially women during menopause	Epidemiology: women are affected more often than men	New sex and gender sensitive facts are missing
Systemic lupus erythematosus (SLE)	Epidemiology: F > M (10:1)	Epidemiology: women are affected much more often than men (F:M = 9:1)	Alopecia, photosensitivity, oral ulcers, arthritis, malar rash, lupus anticoagulant level, and low level of C3 were significantly higher in female lupus patients, whereas renal involvement, serositis and pleurisies, thrombocytopenia, and anti-double-stranded deoxyribonucleic acid level were predominant in male patients with SLE.[25] The primary cause of mortality in female patients with SLE is cardiovascular disease.[24] Hypertension, thrombosis, and embolism have high prevalence rates in these women.[23]
Nephrology
IgA nephropathy (Berger disease)	Epidemiology: risk factors for an unfavorable course include “men under the age of 30 years”	Epidemiology: it affects children and young adults, mostly men	New sex and gender sensitive facts are missing
Pyelonephritis	Epidemiology: F > M	Epidemiology: it affects women much more than men, but the incidence increases in older men with prostatic hyperplasia	New sex and gender sensitive facts are missing
Urinary tract infection (UTI)	Epidemiology: predisposing factors include female sex; a UTI in men always requires further investigation	Epidemiology: clinically, it affects women far more than men; predisposing factors include benign prostatic hypertrophy and cystocele	New sex and gender sensitive facts are missing
	Diagnostics: every suspicion of an UTI is indication for a urine culture, except in women with uncomplicated UTIs
Urolithiasis	Epidemiology: M > F	Epidemiology: men are affected more often than women	New sex and gender sensitive facts are missing
Neurology
Meningioma	Epidemiology: F > M (3:2)	Epidemiology: it is common in adults, F > M	New sex and gender sensitive facts are missing
Multiple sclerosis (MS)	Epidemiology: F > M (2:1), typically young women	Epidemiology: women have two times the risk of men	Gender differences include earlier disease onset and more frequent relapses in women and faster progression and worse outcomes in men.Hormone-related physiological conditions in women such as puberty, pregnancy, puerperium, and menopause also exert significant influence both on disease prevalence and on outcomes.[27] Knowledge gap:To date, however, due to a lack of systematic studies on treatment responses in males versus females, evidence in this area is still sparse. We argue that studies taking sex differences into account could pave the way for sex-specific and therefore personalized treatment.[26]
Myasthenia gravis	Epidemiology: F > M (3:2); two peaks in frequency between age 30 and 40 years (more women) and age 60 and 80 years (more men)	Epidemiology: women are affected more frequently than men	New sex and gender sensitive facts are missing
	Clinical presentation: symptoms often increase during menstruation
Pneumology
Lung cancer	Epidemiology: M > F (3:1); leading cause of death among both men and women; second most common carcinoma in men and third most common carcinoma in women	Epidemiology: lung cancer is the leading cause of death among both men and women; it has been increasing in women (increased smoking) in the past few decades	New sex and gender sensitive facts are missing
	Epidemiology: squamous cell carcinoma is the most common non-small-cell lung carcinoma (NSCLC) in men (45%); adenocarcinoma is the most common NSCLC in women (40%)	Epidemiology: adenocarcinoma is more commonly seen in women; squamous cell carcinoma and small-cell carcinoma affect men more than women
Sarcoidosis	Epidemiology: over all F = M; especially young women are affected by Löfgren syndrome	Epidemiology: the disease affects women more than men	New sex and gender sensitive facts are missing
Tuberculosis	Epidemiology: M > F		New sex and gender sensitive facts are missing
	Clinical presentation: urogenital tuberculosis in men (e.g. prostatitis) and women (eg, adnexitis)	Clinical presentation: sites that may become involved include fallopian tubes and epididymis

Abbreviations: BMI, body mass index; F, female; M, male; ml, milliliter; S&G, sex & gender; SSc, systemic sclerosis.

Epidemiological sex- and gender-based aspects accounted for a large number of the total amount of detected data. The predominant absence of pathophysiological explanations for sex and gender differences supports the conclusion that sex- and gender-related content only serves as additional information. This could be caused by a lack of scientific evidence in regard to the pathophysiological mechanisms underlying the influence of sex and gender on health and disease or a lack of prioritization of sex- and gender-related knowledge in the preparatory materials and the respective standardized examinations.

Medical curricula emphasize so-called “hot topics” (areas considered of special importance by the accrediting body for medical schools in the United States and Canada), defined by the Liaison Committee on Medical Education.[38] In Germany, medical curricula should be based on the National Competency–based Learning Objective Catalog Medicine (NKLM). It is a competence-based core curriculum with a recommendation character (https://review.nklm.de/zend/).

Hochleitner et al[39] observed a discrepancy between the amount of evidence provided by sex- and gender-based research and its integration into conventional learning resources, which still consider the male body and physiology as the norm. Lack of support and guidance on an institutional (ie, medical faculties) and a governmental level (ie, compulsory guidelines) were considered influencing factors on the failure of a systematic SGBM implementation in medical education.

In accordance with the predominantly epidemiological data findings in this study, Song et al[40] found most of the sex- and gender-related content in their analysis on sex and gender of the Texas Tech University Health Sciences Center™ School of Medicine’s curriculum to be either of epidemiological nature or anatomy- and physiology-related. They discovered only incomplete coverage of many of the sex- and gender-based topics, which correlates with our finding that the analyzed preparatory materials rarely offered pathophysiological explanations for sex- and gender-based aspects. In a national student survey conducted by Jenkins et al,[41] clinical subjects such as endocrinology, rheumatology, cardiology, and pulmonology were considered to be covered moderately to extensively in regard to SGBM. However, more than half of the participants did not feel well prepared for transferring this sex- and gender-related knowledge into clinical practice.

As long as the implementation of sex- and gender-based medicine knowledge is not systematically integrated into the training and is not sufficiently taken into account in the exam questions, the students could only turn to alternative resources such as eGender, a web-based interactive knowledge sharing platform for sex- and gender-based medical education.[42]

The comparison of the preparatory materials provided evidence to support the conclusion that KAPLAN had a significantly higher share of sex- and gender-related content in the main field behavioral and social science, probably due to the two countries’ differing approaches for addressing socioeconomic aspects within the medical curriculum. In the United States, behavioral and social science is considered an independent subject within medical education. In contrast, German medical curricula often integrate socioeconomical aspects of health and disease into a clinical subject’s syllabus, reflected in the lack of sex- and gender-related content in the main field behavioral and social science in AMBOSS.

Limitations

This study only investigated two distinct preparatory materials. While they are popular among medical students, there are also other commercial learning resources available. Nevertheless, AMBOSS and KAPLAN aim to offer a comprehensive preparation for the German state examination and the USMLE Step 1, respectively, and are both geared toward those standard examinations. Furthermore, we focused on a selection of subjects and did not include all subjects in our analysis to increase comparability between the two preparatory materials.

Conclusions

The sex- and gender-related content of the preparatory materials focuses almost exclusively on biological sex differences. Gender is an important influencing factor on health and disease that should be further integrated into the preparatory materials for national medical exams. The supplemental character of the gender-based content in learning resources fails to reflect the importance of SGBM as an integral component of patient-centered medicine.

Click here for additional data file.

Supplemental material, Supplementary_Table_1_xyz27983efeaabf5 for Quantitative and Qualitative Analysis on Sex and Gender in Preparatory Material for National Medical Examination in Germany and the United States by Helena Schluchter, Ahmad T Nauman, Sabine Ludwig, Vera Regitz-Zagrosek and Ute Seeland in Journal of Medical Education and Curricular Development