Sex-Specific Medical Research - Brigham And Women's Hospital
�t WaitA Report of theMary Horrigan Connors Centerfor Women’s Health& Gender Biologyat Brigham and Women’s Hospital
The Connors Center for Women’s Health and Gender Biology and theDivision of Women’s Health at Brigham and Women’s Hospital, ledby Paula A. Johnson, MD, MPH, are committed to improving the healthof women and transforming their medical care through the discovery,dissemination and integration of knowledge of women’s health and sexand gender-based differences and the application of this knowledgeto the delivery of care. We are committed to building awareness ofissues related to women’s health and gender biology among clinicians,patients and the general public, advocating for changes in public policyto improve the health of women, and advancing the field of women’shealth globally by developing leaders with the experience and skills tohave a major impact on improving the health of women. For more information, please see www.brighamandwomens.org/connorscenter. 2014, Brigham and Women’s Hospital
Sex-SpecificMedical ResearchWhy Women’s HealthCan’t WaitA Report of theMary Horrigan Connors Centerfor Women’s Health & Gender Biologyat Brigham and Women’s HospitalAUTHORSPaula A. Johnson, MD, MPHChief, Division of Women’s Health and Executive Director, Connors Centerfor Women’s Health and Gender Biology, Brigham and Women’s Hospital;Professor of Medicine, Harvard Medical SchoolTherese Fitzgerald, PhD, MSWDirector, Women’s Health Policy and Advocacy Program, Connors Centerfor Women’s Health and Gender Biology, Brigham and Women’s HospitalAlina Salganicoff, PhDVice President and Director, Women’s Health Policy, Kaiser Family FoundationSusan F. Wood, PhDDirector, Jacobs Institute of Women’s Health, Associate Professor of Health Policy,George Washington University, School of Public Health and Health ServicesJill M. Goldstein, PhD, MPHDirector of Research, Connors Center for Women’s Health and Gender Biology,Brigham and Women’s Hospital;Professor of Psychiatry and Medicine, Harvard Medical School
CONTRIBUTING AUTHORSYolonda L. Colson, MD, PhDProfessor of Surgery, Harvard Medical School;Director, Women’s Lung Cancer Program, Brigham and Women’s HospitalLaura Cohen, JDSenior Health Policy Analyst, Women’s Health Policy and Advocacy Program, Connors Centerfor Women’s Health and Gender Biology, Brigham and Women’s HospitalUsha Ranji, MSAssociate Director, Women’s Health Policy, Kaiser Family FoundationAndrea CampSenior Policy Advisor, Communications Consortium Media CenterCarolyn LukResearch Assistant, Women’s Health Policy and Advocacy Program, Connors Centerfor Women’s Health and Gender Biology, Brigham and Women’s HospitalD. Richard Mauery, MS, MPHManaging Director, Jacobs Institute of Women’s Health, George Washington University2Janet Rich-Edwards, ScDAssociate Professor, Harvard Medical School (Department of Medicine) andHarvard School of Public Health (Department of Epidemiology);Director of Developmental Epidemiology, Connors Center for Women’s Healthand Gender Biology, Brigham and Women’s HospitalACKNOWLEDGMENTSWe would like to acknowledge the generous contribution of the Boston Foundation in publishing and disseminatingthe report and for editing and designing the final product. In particular, we would like to thank Mary Jo Meisner,Barbara Hindley, and Kathleen Clute of the Boston Foundation and Katherine Canfield of Canfield Design.Special thanks are due to our reviewers, particularly Ruth J. Katz, Director of the Health, Medicine and SocietyProgram at the Aspen Institute and Chloe E. Bird, PhD, senior sociologist at RAND and professor of sociology andpolicy analysis at the Pardee RAND Graduate School, for their valuable comments, suggestions and ongoing support.We would also like to thank Nisha Kurani, Program Associate at the Kaiser Family Foundation for her invaluableassistance.Finally, we want to express our deep appreciation to the members of Congress, pioneers and advocates whose tirelessdedication and force of action made the historic NIH Revitalization Act a reality. They are true champions whoushered in a new era of federal policy focused on gender equity in medical research.
FOREWORDTwenty years ago, a bipartisan group of legislators worked with patients, providers, policy makers, andadvocates to create and pass the 1993 National Institutes of Health Revitalization Act, a law mandating thatwomen and minorities be included in clinical trials funded by the NIH. In many ways the law has been a success.Women are now routinely included in clinical trials, and we have learned how certain diseases present differentlyin men and women.Yet, despite some progress, medical research is too often flawed by its failure to examine sex differences. It is nowclear that men and women experience illness differently and this report looks closely at four diseases where thisis especially true: cardiovascular disease, lung cancer, depression and Alzheimer’s disease. The past two decadeshave shown not only that sex differences exist, but have produced scientific advancements that enhance our abilityto discover why they occur and how we might adapt prevention, detection and treatment strategies for the benefitof women and men alike. Therefore, to ignore these differences challenges the quality and integrity of science andmedicine.While this report focuses on women, understanding health differences is valuable to all who want to understandthe impact of different conditions and treatments on men and communities of color as well. Our hope is that thisdocument will fill a void in our collective conscience by highlighting the challenges ahead and inspiring men andwomen alike to care about the inequities that now exist. Researchers around the world have worked tirelessly on theseissues, and many of their studies are cited in these pages. We gratefully acknowledge their important contributions.In addition to documenting the problem, this report also offers a realistic, concrete action plan for a path forward.We hope this plan will inspire all stakeholders to work together to gain a recommitment to research in which the studyof sex differences is the norm, not the exception.Now is the time for us to act so that we can realize the promise of the NIH Revitalization Act. Embracing the study ofsex differences can improve the lives of women and men in the United States and around the globe, for this generationand for generations to come.3
TABLE of CONTENTS5Executive Summary7Introduction812Routes and Roadblocks on the Way to Health EquityCardiovascular Disease12 Progress13 Roadblocks16Lung Cancer16 Progress17 Roadblocks18Depression18 Progress419 Roadblocks20Alzheimer’s Disease20 Progress20 Roadblocks22Women’s Health Equity Action Plan22 Don’t Leave Women’s Health to Chance22 Hold Federal Agencies Accountable23 Promote Transparency23 Expand Sex-based Research Requirements24 Adopt New Clinical Practices and Training Curricula24 Make Your Voice Heard24 It’s Time to Act25Notes
EXECUTIVE SUMMARYThe historic 1993 NIH Revitalization Act, bornfrom a vision of healthcare based on evidencethat incorporates the best knowledge about sex/genderand race/ethnicity differences and similarities, madeinclusion of women in health research a national priority.Yet, despite progress during the past 20 years, womenstill have not achieved equity in biomedical and healthoutcomes investigations. The science that informs medicine—including the prevention, diagnosis, and treatmentof disease—routinely fails to consider the crucial impactof sex and gender. This happens in the earliest stages ofresearch, when females are excluded from animal andhuman studies or the sex of the animals isn’t stated in thepublished results.1 Once clinical trials begin, researchersfrequently do not enroll adequate numbers of women2or, when they do, fail to analyze or report data separatelyby sex.3-6 This hampers our ability to identify importantdifferences that could benefit the health of all. Researchon these differences must become the norm if we are toachieve equity and, most important, to improve the healthand well-being of women and men.When we fail to routinely consider the impact of sex andgender in research, we are leaving women’s health tochance. The evidence on sex differences in major causesof disease and disability in women is mounting, as arethe gaps in research.cancer never smoked, nonsmoking women are three timesmore likely than nonsmoking men to get it.11-13While the number of women participating in lung cancerclinical trials has risen, women—particularly those fromracial and ethnic minorities—are still less likely to enrollin these trials than men.12-14 Even when studies includewomen, researchers often fail to analyze data by sex orinclude hormone status or other gender-specific factors,making it difficult to uncover differences in incidence,prevalence, and survivability between men and womenand to replicate the studies.15Depression: Depression is the leading cause of diseaseburden worldwide. In the United States, twice as manywomen than men suffer from depression,16,17 with directcosts exceeding 20 billion annually.18 We know thatmajor endocrine changes throughout a woman’s life,including puberty, pregnancy, and menopause, havebeen directly linked to increased risk for this disease.Furthermore, basic research into drug development hasshown that women metabolize drugs differently thanmen. Yet fewer than 45 percent of animal studies onanxiety and depression use female lab animals.Alzheimer’s Disease: Two-thirds of the 5.1 millionpeople currently suffering from Alzheimer’s diseaseare women.19, 20 Women are also the primary caregiversof adult loved ones with Alzheimer’s disease, meaningthey shoulder both the risks and the burdens of theillness. Even though a woman’s overall lifetime risk ofdeveloping Alzheimer’s disease is almost twice that ofa man, the prevailing thinking in the field is that this issimply because women live longer. However, the impactof hormonal changes at menopause and sex differencesin gene expression have begun to emerge as potentialexplanations.Cardiovascular Disease: We now know that cardiovascular disease, the number one killer of women in the UnitedStates, affects women and men differently at every level,including prevalence, underlying physiology, risk factors,presenting symptoms, and outcomes. Racial and ethnicdisparities also exist, with black women more likely thantheir white peers to experience the disease and to diefrom it.7 Yet only one-third of cardiovascular clinical trialsubjects are female and fewer than one-third (31 percent)of cardiovascular clinical trials that include women reportoutcomes by sex.8Equity in Research Is Essential for QualityOutcomes and ValueLung Cancer: More women die of lung cancer each yearthan from breast, ovarian, and uterine cancers combined.9It is the leading cause of cancer death in women.10 Whileabout one in five people who are diagnosed with lungAs the investment in healthcare has skyrocketed, ashealthcare reform extends care to more Americans, andas the healthcare system evolves to meet shifting needs,research on sex and gender differences must become the5
norm, not the exception. While we celebrate 20 years ofthe NIH Revitalization Act’s important contributions, wemust recommit to its intention and authority. The law wasenacted to remedy sex/gender and race/ethnicity biasin biomedical research, but we have a long way to go tofulfill its possibilities. Sex and gender equity in researchis an essential component of quality research. Withoutequity in research, we are not getting the full value ofour massive public investment.A Call to Action6Don’t leave women’s health to chance. Research on sexand gender differences must become the norm, not theexception, for the United States to achieve health equityand, most important, to improve the health and well-being of all. Our leaders, in government and in the field ofresearch, must ensure that all health agencies are activelyengaged in women’s health research and the evaluation ofsex differences across the lifespan. Health agency leaders must prioritize the design, analysis, and reporting ofhealth research by sex. And in this new era of personalized medicine, a multi-stakeholder approach is the bestway to ensure quality, safety, value, and efficacy in themethods we use to address disease. All stakeholdersmust exercise influence in their spheres.Act Hold federal agencies accountable. Government andand other funding agencies, including the NationalInstitutes of Health (NIH), the Agency for HealthcareResearch and Quality (AHRQ), the Centers for DiseaseControl and Prevention (CDC) and the Food and DrugAdministration (FDA) should ensure that the designof clinical studies includes a consideration of the sex ofthe subject, adequate participation of women, and thereporting of sex-stratified findings. Promote transparency and disclosure regardingthe absence of sex- and gender-based evidence inresearch, drugs and devices. Medical device and pharmaceutical labeling should carry a disclaimer if clinicaltesting did not include adequate numbers of femalesubjects. Researchers should be required to disclose ina standardized format (similar to a nutritional label)how their study addresses sex and whether the data areanalyzed by sex. An annual review of peer-reviewedjournals should be conducted to assess how well andoften they present sex- and gender-based research.An online gateway should be developed to providepublic access to sex-stratified data from governmentsponsored research. Expand sex-based research requirements. Institutional Review Boards can require that research plansinclude adequate numbers of female and male humansubjects and lab animals. Journals can require authorsto report the sex of lab animals and human subjects andencourage the publication of sex-specific results. Adopt clinical care practices and training curriculathat incorporate a sex- and gender-based lens in careand research. Medical education and research on alllevels should include differences based on sex andgender.Make Your Voice HeardAll women and men can play a role in making sex- andgender-based research the norm. They can demand thattheir policymakers ensure that women are included in allphases of medical research and that sex differences arestudied and evaluated at all levels as is currently requiredby law. They can demand that the findings be translatedfrom bench to bedside for the benefit of all. And whenthey seek care, they can ask their doctors if the recommended prevention strategies, diagnostic tests, and medical treatments are based on research that included women.Two decades after the landmark NIH Revitalization Actwas signed into law, we still have much work to do tomake certain that its promise is realized. The passageof the law was a critical milestone. Now is the time torecommit to its vision and ensure that research at alllevels is performed with a sex- or gender-specific lens.The crucial impact that these factors may have on healthoutcomes and ultimately on our care still is not routinelyor adequately assessed. Without sex- and gender-specificapproaches to research and healthcare, our research investments will not provide us with the value so crucial tobettering the health of our nation, improving the qualityof care, and controlling the growth in health costs. It istime to act. Future generations are counting on us.
INTRODUCTION“The historical lack of research focuson women’s health concerns hascompromised the quality of health informationavailable to women as well asthe healthcare they receive.”Just over 20 years have come and gone since thepassage in 1993 of the federal NIH RevitalizationAct, which had its roots in the report quoted above.Heralded as a landmark in science and public health,this groundbreaking law required for the first time thatall “NIH-supported biomedical and behavioral researchinvolving human subjects” include and analyze theimpact on women and racial/ethnic minorities.1, 2 Thegoal was that, after years of neglect, federal investmentwould bring equity to health research, thus paving theway for new advances in health. Indeed, today’s progressin understanding the role of sex and gender in health,in identifying who is at risk for health conditions, andin recognizing that symptoms and treatment may differbetween men and women, is attributable largely toresearch stemming from that law.The nation now has offices of women’s health in severalstates and most U.S. Department of Health and HumanServices (HHS) agencies, 21 centers of excellence inwomen’s health, and more than 3.8 billion allotted by theNational Institutes of Health (NIH) for women’s healthresearch. Notable advances have been made in maternalhealth: the focus on preconception health has increasedWomen’s Health: Report of thePublic Health Service Task Forceon Women’s Health Issues, 1985while infant mortality has decreased. The NIH Women’sHealth Initiative produced major findings on the connection between hormone replacement therapy and breastcancer. Great strides have been made, according to theInstitute of Medicine’s (IOM) thorough review, Women’sHealth Research: Progress, Pitfalls, and Promise, in reducingthe burdens on women of breast cancer, cervical cancer,and heart disease. Given the combined toll of thosediseases on millions of women, these important accomplishments are cause for celebration.Yet the same IOM report identified other conditionswhere progress has slowed or, in some cases, stalled.These include epidemics that disproportionately affectwomen’s health and well-being at all stages of their lives,including depression, lung cancer, and Alzheimer’sdisease. Unintended pregnancy, estimated at half of allpregnancies, is another area where little progress has beenmade, showing that much remains to be learned in reproductive health as well.The idea that women’s health requires its own focushas not yet been universally embraced by basic science,clinical, and health services researchers. This is unfor-1985U.S. Public Health Service’s Task Forceon Women’s Health issues report.7
Medical research that is either sex- or gender-neutralor skewed to male physiology puts women at risk formissed opportunities for prevention, incorrect diagnoses,misinformed treatments, sickness, and even death.8tunate, because sex and gender must be integrated intoand embraced in all aspects of research: basic sciencediscovery, clinical research, translation to clinical practice,and measurement and evaluation. Far too often, researchfails to illuminate important differences because sex orgender is excluded or inadequately addressed at one ofthese steps. Too often, important research fails to tease outsex differences at the cellular and animal levels, limitingits value. The lack of sex-based animal studies, typicallyan early stage in research, perpetuates the gap down theroad. Human studies may include women as subjects, butoften researchers do not analyze or report results by sex.More often, studies “control” for sex differences insteadof investigating them, but this approach is inadequatewhen the mechanisms underlying health may operatedifferently in men and women. The U.S. Food and DrugAdministration (FDA) does not require sex-specific analysis in the drug-approval process or even when makingdosing recommendations, and healthcare delivery systemsrarely investigate systems or interventions that may bemore or less effective for women.3Many factors lie behind this stalled progress, including alack of enforcement of the NIH policy, which specificallycalls for researchers to describe “plans to conduct analysesto detect significant differences in intervention effect bysex/gender, racial/ethnic groups, and relevant subpopulations, if applicable.” Researchers may be inexperiencedin conducting sex/gender-based research, and scientificjournal editors do not consistently consider sex/genderanalysis when reviewing submissions.In truth, the expectation that one of humanity’s most basicdistinguishing characteristics be integrated into healthresearch is not new. However, in the two decades sincethe NIH Revitalization Act, the urgency has heightened.As expense and inequity in services have increased, ashealthcare reform extends care to more Americans, andas the healthcare system evolves to meet shifting needs,research on sex and gender differences must become thenorm, not the exception. Only then can we continue tomake medical breakthroughs worthy of each preciousresearch dollar invested.While we celebrate 20 years of the Revitalization Act’simportant contributions, we must recommit to its intention and authority. This recommitment is required fromthe public and private sectors, scientists and researchers,advocates, policymakers, funders, the pharmaceutical andbiotech industries, medical device companies, professionalsocieties, clinicians, journal editors and reviewers, andthe public. Several HHS agencies, such as the NIH, FDA,CDC, and the Agency for Healthcare Research and Quality (AHRQ) play a particularly important role as leadersand primary sponsors of biomedical and health servicesresearch. Together we must ask how to get back on theroad to equity.ROUTES AND ROADBLOCKS ONTHE WAY TO HEALTH EQUITY:THE FOUR STAGES OF RESEARCHThe entire research process—from discovery at the molecular and cellular levels, to pre-clinical research in animalsand humans, to clinical trials, ending in translation intopractice and measurement of outcomes—is inequitablebecause sex and gender differences are so often notembedded within it.
THE ROAD TO HEALTH INEQUITYDISCOVERThis failure to address sex and gender differences acrossthe full spectrum of research diminishes innovation inmedicine and decreases the value of our enormous investment in research and healthcare. Medical research that iseither sex- or gender-neutral or skewed to male physiologyputs women at risk for missed opportunities for prevention, incorrect diagnoses, misinformed treatments, sickness, and even death.Women and men have different risks for the onset, expression, course, and treatment response for disease. In thissection, we explain why, to improve medical research inwomen’s health and fulfill the promise of the NIH Revitalization Act, the paradigm must shift toward the systematicanalysis of sex and gender differences. After describing thestops along the research road, we then present examplesof four diseases that have a significant—and different—impact on the health of women and men: cardiovasculardisease, lung cancer, depression, and Alzheimer’s disease.STEP 1: SCIENTIFIC DISCOVERYHow Can We Ground Women’s Healthin Basic Science?Medical research begins with the discovery stage, whichincludes “bench research” such as work with stem cellsand cell lines, and experimental studies with animals andhumans. Sex differences must be explored even at themolecular and cellular levels, given that sex differences indisease pathophysiology and prevalence extend beyondthe hormonal influences, encompassing each cell andits sex and genotype.4 To put it simply (and to borrow aphrase from the Institute of Medicine), every cell has a sex.Basic research is usually not designedto study the impact of sex on disease.Animal and human studies typicallyuse males or do not identify sex whenfemales are included.TESTWomen are under-represented inclinical trials. Even when they areincluded, researchers often fail toanalyze and report results by sex.TRANSLATESex differences discovered in basicresearch or clinical trials are oftenignored as the findings are translatedinto clinical practice. Healthcareprofessionals are often slow toadopt evidence-based guidelinesthat address sex and gender.MEASUREOutcome measures are not routinelyanalyzed or reported by sex.1990General Accounting Office releases NIH: Problems in ImplementingPolicy on Women in Study Populations. National Institutes of Health(NIH) creates Office of Research on Women’s Health.9
Animal research, a cornerstone of biomedical investigation, has contributed to almost every medical advance ofthe last century. Without it, we would not have insulin fordiabetes, statins for cardiovascular risk, or chemotherapyfor leukemia. To lay a valid foundation for human studiesof women’s health, animal studies must include female animals and incorporate into the study’s design the analysisof differences in outcome by sex.4, 5 Furthermore, an essential component of scientific discovery is the replication ofstudies, which is virtually impossible without knowingwhether the animals involved were male, female, or both.10The discovery phase also includes clinical research in humans with the goal of discovering the pathophysiology ofdiseases. For instance, researchers may observe how bloodvessels react to different stimuli to better understand sexdifferences in cardiovascular disease, or conduct imagingstudies of the brain to identify differences between healthyindividuals and those with depression or Alzheimer’sdisease.Despite some progress, many basic science researchersdo not explore the impact of sex on disease. Their studies,whether of animals or humans, simply do not include females or enough females to analyze nor report on sex differences. There are many examples of discovery researchthat were not designed to study the impact of sex and thushave blocked progress in women’s health.STEP 2: CLINICAL TRIALSIs Our Discovery Effective and Safe forWomen?Promising new discoveries must be tested to ensure thatthey are both effective and safe for women. The testingphase includes clinical trials on human subjects. Adequatenumbers of women are critical at this phase of research.Designing studies to investigate the impact of sex is criticalfor understanding the underlying mechanisms of disease,but clinical trials often fail to analyze and report results bysex, significantly hampering their ability to test the safetyand efficacy of discoveries.STEP 3: TRANSLATING RESEARCH INTOPRACTICEHow Can We Use Our Research Safely andEffectively?The third step on the road to health equity for women isthe translation of research into clinical practice using a“sex- and gender-specific lens.” Translation includes usingdiscoveries to create new prevention, diagnostic, andtreatment protocols with the possibility of individualizedor personalized treatment. Yet sex and gender differences discovered through biomedical and clinical researchare often ignored at this stage and are not integrated intoclinical practice. Healthcare professionals have also beenslow to adopt evidence-based guidelines that address sexand gender.1991NIH launches Women’s Health Initiative, thelargest clinical study specifically on women.
Outcome measures are not routinely analyzedor reported by sex.STEP 4: MEASURING EFFECTIVENESSWhat is the Most Effective Way to Prevent,Diagnose, or Treat Disease in Women? Whatis the Value of this Investment for Women’sHealth?The final step on the road to health equity in research ismeasuring and understanding how sex and gender impacthealth outcomes, from individual practice to entire healthcare delivery systems. Today, this is especially importantas it relates to healthcare reform. Outcome measures, suchas quality, are not routinely analyzed or reported by sex,in spite of our understanding that sex differences occurin health and disease and in access to and use of healthcare.6 For example, HEDIS, the Healthcare EffectivenessData and Information Set, a tool used by the vast majorityof health plans in the United States to measure quality ofcare and service, does not report results by sex or gender,hindering any evaluation of whether women’s outcomesare as good as men’s and slowing progress towardimproving women’s health.We also cannot measure the value of our investments inbiomedical research when we lack sex- and gender-specificresearch at the discovery, testing, and translation stages.Similarly, we cannot measure the value of the enormousinvestment in healthcare in the United States withoutevaluating outcomes in women, who comprise 51 percentof the population. Healthcare reform law requires thecollection of certain data—including sex, race and ethnicity—but requires the reporting of health data and outcomedata only “to the extent practicable.” Yet, without outcomesreported in this way, we risk not achieving the full benefitof healthcare and health system reform.The IOM notes that there has been little progress inwomen’s health research in the areas of lung cancer andAlzheimer’s disease. There has been some progress indepression and major progress for cardiovascular disease(CVD).4 We need to ensure that the resources allocated toprevent, diagnose, and treat disease are being used effectively and that we are achieving value for our investment.In the following sections, we look at each of these fourdiseases and discuss both the progress that has been madeand the roadblocks that still stand in the way along theroad to health equity for women.Sex vs. GenderThis report uses the terms “sex,” “gender,” and “sex/gender” when discussing the inclusion and implicationof biomedical research on women. According tothe World Health Organization (WHO), sex “refersto the biological and physiological characteristicsthat define men and women.” Thus, this report usesthe term “sex” when discussing the implications ofscientific research and clinical trials on women as basicscience, discovery and testing most often impact the“biological and physiological characteristics” of women.Gender, according to the WHO, “refers to the sociallyconstructed roles, behaviors, activities and attributesthat a given society considers appropriate for men andwomen.” Thus, this report will use the term “gender”when discussing the impact of health systems research(access to care, affordability, utilization, etc.) on womenbecause gender is most often the m
The Connors Center for Women’s Health and Gender Biology and the Division of Women’s Health at Brigham and Women’s Hospital, led by Paula A. Johnson, MD, MPH, are committed to improving the health of women and transforming their medical care through the discovery, dissemination and integration
SEX LINKED INHERITANCE The characters for which genes are located on sex or ‘X’ chromosomes which occurs in different numbers in two sexes and the absence of its allele in the ‘Y’ chromosome are known as sex linked traits. Such genes are called sex linked genes and linkage of such genes is referred to as sex linkage.
the classroom are responsible for contributing to this complete educational vision. A BYU education should be spiritually strengthening, intellectually enlarging, and character building, leading to lifelong learning and service. (The Mission of Brigham Young University and The Aims of a BYU Education, Brigham Young University. Brigham Young .
Recessive, Dominant, and Sex-Linked Trait Sex-linked traits ·some traits and disorders are located on the sex chromosomes (23rd pair) ·genes located on the sex chromosomes (X, Y) are said to be "sex-linked" ·the probability of inheriting a particular trait depends on if your are a boy or girl ·must use XX and XY in your Punnett squares
We recommend that this toolkit is used alongside the University of Leicester’s Student Sex Work policy and Leicester Students’ Union and Standing Together student sex work campaign. The aims of this toolkit are to outline: 1. The picture of student sex work within the UK 2. The legal context of the UK Sex Industry/Adult Entertainment .
Australian Human Rights Commission’s sex and gender diversity project – Sex Files: the legal recognition of sex in documents and government records (Sex Files). As Australia’s Human Rights Commissioner, I am responsible for monitoring, protecting and promoting human rights in Australia. People who
Table 6.5: Unemployment rate for youth aged 15 to 34 years by region and sex 68 Table 6.6: NEET by age group and sex 69 Table 6.7: NEET by region and sex 69 Table 6.8: NEET by educational level and sex 70 Table A 1: Labour Force Participation Rates (LFPR) by sex and region (strict) 72
The title Behind Closed Doors refers to the hidden nature of the indoor sex industry (in which solicitation and the sexual exchange occur off the street), and the isolation felt by its sex workers. For the purposes of this study, indoor sex work was defined as any kind of sex work that goes on be
IN THE COURT OF LD CMM, PATIALA HOUSE COURTS, NEW DELHI Complaint Case No. of 2021 In the matter of: ARG Outlier Media Pvt. Ltd. [Through Sh.
