Fifth anniversary of the Sex And Gender Equity in Research (SAGER) guidelines: taking stock and looking ahead

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PetersSAE, etal. BMJ Global Health 2021;6:e007853. doi:10.1136/bmjgh-2021-007853
Fifth anniversary of the Sex And
Gender Equity in Research (SAGER)
guidelines: taking stock and
looking ahead
Sanne A E Peters,1,2,3 Thomas F Babor,4 Robyn N Norton,1,3 Janine A Clayton,5
Pavel V Ovseiko ,6 Cara Tannenbaum,7 Shirin Heidari8,9
Editorial
To cite: PetersSAE,
BaborTF, NortonRN, etal.
Fifth anniversary of the
Sex And Gender Equity in
Research (SAGER) guidelines:
taking stock and looking
ahead. BMJ Global Health
2021;6:e007853. doi:10.1136/
bmjgh-2021-007853
Received 1 November 2021
Accepted 8 November 2021
For numbered afliations see
end of article.
Correspondence to
Dr Sanne A E Peters;
speters@ georgeinstitute. org. uk
© Author(s) (or their
employer(s)) 2021. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
This year marks the fifth anniversary of the
publication of the Sex And Gender Equity
in Research (SAGER) guidelines,1 which
provide recommendations to authors, journal
editors, peer- reviewers and publishers for
ensuring that sex and gender considerations
are appropriately reported in the scholarly
literature. The guidelines were developed in
recognition of the persistent sex and gender
gaps in research across disciplines, especially
in health and biomedical research. At the
time of development, there was notable resis-
tance to implement sex and gender policies,
reflecting a lack of awareness of the impor-
tance of sex and gender as critical determi-
nants of health and well- being.2
The guidelines have now been trans-
lated into six languages, adopted by a
growing number of journals, encouraged
by major publishers, and extensively used
by researchers.3 Despite these successes and
growing awareness, there remain critical
barriers to systematic implementation of sex-
based and gender- based analyses in research
and reporting. For example, many COVID- 19
trials continue to include fewer women than
men,4 and there is a persistent lack of sex-
based and gender- based analyses in several
medical disciplines,5 6 often without justifica-
tion. Here, we reflect on the barriers to the
uptake and implementation of the SAGER
guidelines and offer recommendations to
overcome them.
CONCERNS ABOUT MANDATING
There are concerns about the additional time
and costs associated with the larger sample
sizes or different statistical analyses required
for sex- based and gender- based analyses.
However, several national funding agencies
have made these analyses a funding require-
ment, with success,7 and budgets are available
to factor in additional costs. Furthermore,
there is value in presenting data by sex or
gender to indicate trends and enable future
meta- analyses.
There are also concerns about the burden
on reviewers imposed by enforcing the
SAGER guidelines. Although checking for
sex and gender reporting does take time, the
perceived burden on reviewers can be mini-
mised if submitted manuscripts are screened
prior to peer- review. Screening manuscripts
for adherence to editorial policies is already
common practice in most journals.
LACK OF TIME, CAPACITY AND RESOURCES
Journal editors may lack the time, capacity
and resources to introduce the SAGER guide-
lines as a formal policy or to enforce adher-
ence. Journals with relatively few issues per
year may find it particularly challenging
considering infrequent board meetings and
competing priorities. Nevertheless, jour-
nals should consider implementation of the
SAGER guidelines, as with other mandatory
reporting guidelines, as way to improve scien-
tific quality. Support from publishers could
facilitate introduction of the SAGER guide-
lines across all journals.8
RESISTANCE OR LACK OF AWARENESS
Some journals are resistant to include the
SAGER guidelines or consider them not
applicable to their field. Journals may choose
to implement more tailored policies by
adapting SAGER to specific disciplines. Some
editors have expressed a lack of knowledge
of sex and gender (and their differences)
among reviewers. Online trainings, such as
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2PetersSAE, etal. BMJ Global Health 2021;6:e007853. doi:10.1136/bmjgh-2021-007853
BMJ Global Health
those developed by the Canadian Institutes of Health
Research,9 could be offered to reviewers to improve their
knowledge about integrating sex and gender in health
research. Editors may also benefit from diversity training,
as implicit bias is often a persistent problem in the reme-
diation of sex and gender disparities.10
TECHNICAL CHALLENGES
Individual journals might not be able to change the
instructions to authors (ITA) or electronic submis-
sion systems to align with the SAGER guidelines. Large
publishers often have standard ITA for all journals and
rarely offer flexibility to modify the ITA. Pressure from
journal editors can encourage publishers to incorporate
the SAGER guidelines alongside other reporting guide-
lines across all journals. Moreover, submission systems
can be tailored to incorporate a tick box for authors to
claim adherence and add questions to the evaluation
form for peer- reviewers.
LOOKING AHEAD
The SAGER guidelines offer an opportunity to improve
research and reporting practices. While they have stim-
ulated discussion and have been incorporated into the
ITA of an increasing number of journals, more needs to
be done to ensure wider uptake and implementation.
Efforts to embed relevant intersectional dimensions,
such as age, race, ethnicity, social identity and geograph-
ical diversity into research and reporting practices should
also continue intersection with sex and gender to influ-
ence on health and societal outcomes can be addressed
appropriately. Although the implementation of the
SAGER guidelines by journal editors is an important step,
this should not be the responsibility of researchers and
journal editors alone. If we are to improve research for
the benefit of everyone, structural and systemic changes
across the entire research and innovation cycle are
required, involving engagement with universities, profes-
sional societies, ethics committees, funders, industry and
policy- makers.
Author afliations
1The George Institute for Global Health, Imperial College London, London, UK
2Julius Center for Health Sciences and Primary Care, University Medical Center
Utrecht, Utrecht, The Netherlands
3The George Institute for Global Health, University of New South Wales, Sydney,
New South Wales, Australia
4Department of Public Health Sciences, University of Connecticut School of
Medicine, Farmington, Connecticut, USA
5Ofce of Research on Women's Health, National Institutes of Health, Bethesda,
Maryland, USA
6Radcliffe Department of Medicine, University of Oxford, Oxford, UK
7Canadian Institutes of Health Research, Institute of Gender and Health, Universite
de Montreal, Montreal, Quebec, Canada
8GENDRO, Geneva, Switzerland
9Global Health Center, Graduate Institute of International and Development Studies,
Geneva, Switzerland
Twitter Sanne A E Peters @saepeters
Contributors SP wrote the rst draft. All authors provided intellectual input and
approved the nal manuscript.
Funding SP is supported by a UK Medical Research Council Skills Development
Fellowship (MR/P014550/1).
Competing interests None declared.
Patient consent for publication Not applicable.
Ethics approval This study did not receive nor require ethics approval, as it does
not involve human and animal participants.
Provenance and peer review Not commissioned; internally peer reviewed.
Data availability statement No data are available.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non- commercial. See:http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
ORCID iD
Pavel VOvseiko http:// orcid. org/ 0000- 0002- 3504- 2177
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