General Medicine · Medical Literature
Inclusion of sex and gender in clinical practice guidelines: an umbrella review.
Abstract
Clinical practice guidelines (CPGs) are key to standardised, evidence-based and equitable healthcare, and the inclusion of sex and gender considerations in CPGs is increasingly recognised as essential for quality care and health equity. This umbrella review synthesised evidence from reviews examining the extent and quality of sex and gender considerations in CPGs and identified barriers and best practice strategies to support their inclusion. Literature searches were conducted across eight databases, identifying systematic reviews and other reviews published between 2000 and 2025 that focused on sex and gender considerations in CPGs. Data extraction and quality appraisal followed Joanna Briggs Institute guidelines. After descriptively summarising the reviews, narrative synthesis was used to summarise how sex and gender considerations were integrated across the included reviews, identifying common issues and recommendations for improving their incorporation into CPGs. Analysis of the seven included reviews (appraising a total of 784 CPGs) found that despite mention of sex or gender in 69% of CPGs, only 15% incorporated these factors into diagnostic or management recommendations, reflecting inconsistent, conceptually unclear and often superficial application. Major barriers included under-representation of women, limited sex and gender expertise on guideline committees, incomplete translation of sex-specific and gender-specific evidence into recommendations, inconsistent terminology and methodological limitations in guideline development. To address these gaps, the included reviews identified several strategies that could be implemented before, during and after the guideline development process. Sex and gender inclusion in CPGs remains inconsistent and superficial, with significant implications for health equity. Addressing this requires strengthening sex-informed and gender-informed evidence, ensuring diverse and expert representation in guideline development and adopting systematic approaches that translate evidence into equitable, population-responsive recommendations.
Clinical relevance
Clinical practice guidelines (CPGs) are the cornerstone of standardised, evidence-based care, yet their failure to meaningfully incorporate sex and gender considerations creates a structural equity gap affecting all patient populations across virtually every specialty. This umbrella review synthesises evidence from seven reviews appraising 784 CPGs, providing the most comprehensive current estimate of how superficially sex and gender are addressed in the guidelines clinicians rely on daily. The findings are immediately relevant because guideline-driven decisions on diagnosis and management that ignore sex- and gender-specific evidence risk systematically suboptimal or inequitable care, particularly for women and gender-diverse patients.
Key findings
1. Of 784 CPGs appraised across seven included systematic and other reviews, 69% mentioned sex or gender in some form, yet only 15% actually incorporated these factors into diagnostic or management recommendations — a gap of 54 percentage points between mention and meaningful application. 2. The integration of sex and gender considerations was characterised as inconsistent, conceptually unclear, and often superficial across the totality of reviewed CPGs, indicating a systemic rather than specialty-specific failure. 3. Under-representation of women on guideline development committees was identified as a major structural barrier to sex- and gender-informed guideline production. 4. Limited sex and gender methodological expertise among guideline committee members was identified as a distinct and compounding barrier, separate from representational diversity alone. 5. Incomplete translation of available sex-specific and gender-specific evidence into actionable recommendations was a recurrent finding, suggesting that evidence generation deficits are compounded by evidence application failures at the guideline level. 6. Inconsistent and conflated terminology (sex vs. gender) and methodological limitations in the guideline development process itself were identified as additional systemic barriers; the review identified strategies implementable at pre-development, development, and post-development stages to address these gaps. NOTE: No individual effect sizes, confidence intervals, p-values, or NNT/NNH were reported in the abstract, as this is a descriptive umbrella review using narrative synthesis.
Practice implications
Clinicians should critically appraise the CPGs they apply by proactively asking whether diagnostic thresholds, treatment algorithms, and monitoring parameters have been validated in — or specifically account for — their patient's sex and gender identity, rather than assuming guideline recommendations are universally applicable. Specialty societies and institutional guideline committees should audit existing CPGs for sex and gender content using validated appraisal frameworks (e.g., Joanna Briggs Institute methodology) and mandate diverse, gender-expert representation and explicit sex-stratified evidence synthesis in all future guideline development cycles. Until CPGs are updated to reflect sex- and gender-informed evidence, attending physicians should supplement guideline-driven decisions with primary sex-disaggregated literature, particularly in domains such as cardiovascular disease, pharmacology, and autoimmune conditions where sex-based differences in presentation, drug metabolism, and outcomes are well-established.