research papers in gender studies

Gender Studies: Foundations and Key Concepts

Gender studies developed alongside and emerged out of Women’s Studies. This non-exhaustive list introduces readers to scholarship in the field.

Gender studies asks what it means to make gender salient, bringing a critical eye to everything from labor conditions to healthcare access to popular culture. Gender is never isolated from other factors that determine someone’s position in the world, such as sexuality, race, class, ability, religion, region of origin, citizenship status, life experiences, and access to resources. Beyond studying gender as an identity category, the field is invested in illuminating the structures that naturalize, normalize, and discipline gender across historical and cultural contexts.

At a college or university, you’d be hard pressed to find a department that brands itself as simply Gender Studies. You’d be more likely to find different arrangements of the letters G, W, S, and perhaps Q and F, signifying gender, women, sexuality, queer, and feminist studies. These various letter configurations aren’t just semantic idiosyncrasies. They illustrate the ways the field has grown and expanded since its institutionalization in the 1970s.

This non-exhaustive list aims to introduce readers to gender studies in a broad sense. It shows how the field has developed over the last several decades, as well as how its interdisciplinary nature offers a range of tools for understanding and critiquing our world.

Catharine R. Stimpson, Joan N. Burstyn, Domna C. Stanton, and Sandra M. Whisler, “Editorial.” Signs , 1975; “Editorial,” off our backs , 1970

The editorial from the inaugural issue of Signs , founded in 1975 by Catharine Stimpson, explains that the founders hoped that the journal’s title captured what women’s studies is capable of doing: to “represent or point to something.” Women’s studies was conceptualized as an interdisciplinary field that could represent issues of gender and sexuality in new ways, with the possibility of shaping “scholarship, thought, and policy.”

The editorial in the first issue of off our backs , a feminist periodical founded in 1970, explains how their collective wanted to explore the “dual nature of the women’s movement:” that “women need to be free of men’s domination” and “must strive to get off our backs.” The content that follows includes reports on the Equal Rights Amendment, protests, birth control, and International Women’s Day.

Robyn Wiegman, “Academic Feminism against Itself.” NWSA Journal , 2002

Gender studies developed alongside and emerged out of Women’s Studies, which consolidated as an academic field of inquiry in the 1970s. Wiegman tracks some of the anxieties that emerged with the shift from women’s to gender studies, such as concerns it would decenter women and erase the feminist activism that gave rise to the field. She considers these anxieties as part of a larger concern over the future of the field, as well as fear that academic work on gender and sexuality has become too divorced from its activist roots.

Jack Halberstam, “Gender.” Keywords for American Cultural Studies, Second Edition (2014)

Halberstam’s entry in this volume provides a useful overview for debates and concepts that have dominated the field of gender studies: Is gender purely a social construct? What is the relationship between sex and gender? How does the gendering of bodies shift across disciplinary and cultural contexts? How did the theorizing of gender performativity in the 1990s by Judith Butler open up intellectual trajectories for queer and transgender studies? What is the future of gender as an organizing rubric for social life and as a mode of intellectual inquiry? Halberstam’s synthesis of the field makes a compelling case for why the study of gender persists and remains relevant for humanists, social scientists, and scientists alike.

Miqqi Alicia Gilbert, “Defeating Bigenderism: Changing Gender Assumptions in the Twenty-First Century.” Hypatia , 2009

Scholar and transgender activist Miqqi Alicia Gilbert considers the production and maintenance of the gender binary—that is, the idea that there are only two genders and that gender is a natural fact that remains stable across the course of one’s life. Gilbert’s view extends across institutional, legal, and cultural contexts, imagining what a frameworks that gets one out of the gender binary and gender valuation would have to look like to eliminate sexism, transphobia, and discrimination.

Judith Lorber, “Shifting Paradigms and Challenging Categories.” Social Problems , 2006

Judith Lorber identifies the key paradigm shifts in sociology around the question of gender: 1) acknowledging gender as an “organizing principle of the overall social order in modern societies;” 2) stipulating that gender is socially constructed, meaning that while gender is assigned at birth based on visible genitalia, it isn’t a natural, immutable category but one that is socially determined; 3) analyzing power in modern western societies reveals the dominance of men and promotion of a limited version of heterosexual masculinity; 4) emerging methods in sociology are helping disrupt the production of ostensibly universal knowledge from a narrow perspective of privileged subjects. Lorber concludes that feminist sociologists’ work on gender has provided the tools for sociology to reconsider how it analyzes structures of power and produces knowledge.

bell hooks, “Sisterhood: Political Solidarity between Women.” Feminist Review , 1986

bell hooks argues that the feminist movement has privileged the voices, experiences, and concerns of white women at the expense of women of color. Instead of acknowledging who the movement has centered, white women have continually invoked the “common oppression” of all women, a move they think demonstrates solidarity but actually erases and marginalizes women who fall outside of the categories of white, straight, educated, and middle-class. Instead of appealing to “common oppression,” meaningful solidarity requires that women acknowledge their differences, committing to a feminism that “aims to end sexist oppression.” For hooks, this necessitates a feminism that is anti-racist. Solidarity doesn’t have to mean sameness; collective action can emerge from difference.

Jennifer C. Nash, “re-thinking intersectionality.” Feminist Review , 2008

Chances are you’ve come across the phrase “intersectional feminism.” For many, this term is redundant: If feminism isn’t attentive to issues impacting a range of women, then it’s not actually feminism. While the term “intersectional” now circulates colloquially to signify a feminism that is inclusive, its usage has become divorced from its academic origins. The legal scholar Kimberlé Crenshaw created the term “intersectionality” in the 1980s based on Black women’s experiences with the law in cases of discrimination and violence. Intersectionality is not an adjective or a way to describe identity, but a tool for analyzing structures of power. It aims to disrupt universal categories of and claims about identity. Jennifer Nash provides an overview of intersectionality’s power, including guidance on how to deploy it in the service of coalition-building and collective action.

Treva B. Lindsey, “Post-Ferguson: A ‘Herstorical’ Approach to Black Violability.” Feminist Studies , 2015

Treva Lindsey considers the erasure of Black women’s labor in anti-racist activism , as well as the erasure of their experiences with violence and harm. From the Civil Rights Movement to #BlackLivesMatter, Black women’s contributions and leadership have not been acknowledged to the same extent as their male counterparts. Furthermore, their experiences with state-sanctioned racial violence don’t garner as much attention. Lindsey argues that we must make visible the experiences and labor of Black women and queer persons of color in activist settings in order to strengthen activist struggles for racial justice.

Renya Ramirez, “Race, Tribal Nation, and Gender: A Native Feminist Approach to Belonging.” Meridians , 2007

Renya Ramirez (Winnebago) argues that indigenous activist struggles for sovereignty, liberation, and survival must account for gender. A range of issues impact Native American women, such as domestic abuse, forced sterilization , and sexual violence. Furthermore, the settler state has been invested in disciplining indigenous concepts and practices of gender, sexuality, and kinship, reorienting them to fit into white settler understandings of property and inheritance. A Native American feminist consciousness centers gender and envisions decolonization without sexism.

Hester Eisenstein, “A Dangerous Liaison? Feminism and Corporate Globalization.” Science & Society , 2005

Hester Eisenstein argues that some of contemporary U.S. feminism’s work in a global context has been informed by and strengthened capitalism in a way that ultimately increases harms against marginalized women. For example, some have suggested offering poor rural women in non-U.S. contexts microcredit as a path to economic liberation. In reality, these debt transactions hinder economic development and “continue the policies that have created the poverty in the first place.” Eisenstein acknowledges that feminism has the power to challenge capitalist interests in a global context, but she cautions us to consider how aspects of the feminist movement have been coopted by corporations.

Afsaneh Najmabadi, “Transing and Transpassing Across Sex-Gender Walls in Iran.” Women’s Studies Quarterly , 2008

Afsaneh Najmabadi remarks on the existence of sex-reassignment surgeries in Iran since the 1970s and the increase in these surgeries in the twenty-first century. She explains that these surgeries are a response to perceived sexual deviance; they’re offered to cure persons who express same-sex desire. Sex-reassignment surgeries ostensibly “heteronormaliz[e]” people who are pressured to pursue this medical intervention for legal and religious reasons. While a repressive practice, Najmabadi also argues that this practice has paradoxically provided “ relatively safer semipublic gay and lesbian social space” in Iran. Najmabadi’s scholarship illustrates how gender and sexual categories, practices, and understandings are influenced by geographical and cultural contexts.

Susan Stryker, Paisley Currah, and Lisa Jean Moore’s “Introduction: Trans-, Trans, or Transgender?” Women’s Studies Quarterly , 2008

Susan Stryker, Paisley Currah, and Lisa Jean Moore map the ways that transgender studies can expand feminist and gender studies. “Transgender” does not need to exclusively signify individuals and communities, but can provide a lens for interrogating all bodies’ relationships to gendered spaces, disrupting the bounds of seemingly strict identity categories, and redefining gender. The “trans-” in transgender is a conceptual tool for interrogating the relationship between bodies and the institutions that discipline them.

David A. Rubin, “‘An Unnamed Blank That Craved a Name’: A Genealogy of Intersex as Gender.” Signs , 2012

David Rubin considers the fact that intersex persons have been subject to medicalization, pathologization, and “regulation of embodied difference through biopolitical discourses, practices, and technologies” that rely on normative cultural understandings of gender and sexuality. Rubin considers the impact intersexuality had on conceptualizations of gender in mid-twentieth century sexology studies, and how the very concept of gender that emerged in that moment has been used to regulate the lives of intersex individuals.

Rosemarie Garland-Thomson, “Feminist Disability Studies.” Signs , 2005

Rosemarie Garland-Thomson provides a thorough overview of the field of feminist disability studies. Both feminist and disability studies contend that those things which seem most natural to bodies are actually produced by a range of political, legal, medical, and social institutions. Gendered and disabled bodies are marked by these institutions. Feminist disability studies asks: How are meaning and value assigned to disabled bodies? How is this meaning and value determined by other social markers, such as gender, sexuality, race, class, religion, national origin, and citizenship status?

The field asks under what conditions disabled bodies are denied or granted sexual, reproductive, and bodily autonomy and how disability impacts the exploration of gender and sexual expression in childhood, adolescence, and adulthood historical and contemporary pathologization of genders and sexualities. It explores how disabled activists, artists, and writers respond to social, cultural, medical, and political forces that deny them access, equity, and representation

Karin A. Martin, “William Wants a Doll. Can He Have One? Feminists, Child Care Advisors, and Gender-Neutral Child Rearing.” Gender and Society , 2005

Karin Martin examines the gender socialization of children through an analysis of a range of parenting materials. Materials that claim to be (or have been claimed as) gender-neutral actually have a deep investment in training children in gender and sexual norms. Martin invites us to think about how adult reactions to children’s gender nonconformity pivots on a fear that gender expression in childhood is indicative of present or future non-normative sexuality. In other words, U.S. culture is unable to separate gender from sexuality. We imagine gender identity and expression maps predictably onto sexual desire. When children’s gender identity and expression exceeds culturally-determined permissible bounds in a family or community, adults project onto the child and discipline accordingly.

Sarah Pemberton, “Enforcing Gender: The Constitution of Sex and Gender in Prison Regimes.” Signs , 2013

Sarah Pemberton’s considers how sex-segregated prisons in the U.S. and England discipline their populations differently according to gender and sexual norms. This contributes to the policing, punishment, and vulnerability of incarcerated gender-nonconforming, transgender, and intersex persons. Issues ranging from healthcare access to increased rates of violence and harassment suggest that policies impacting incarcerated persons should center gender.

Dean Spade, “Some Very Basic Tips for Making High Education More Accessible to Trans Students and Rethinking How We Talk about Gendered Bodies.” The Radical Teacher , 2011

Lawyer and trans activist Dean Spade offers a pedagogical perspective on how to make classrooms accessible and inclusive for students. Spade also offers guidance on how to have classroom conversations about gender and bodies that don’t reassert a biological understanding of gender or equate certain body parts and functions with particular genders. While the discourse around these issues is constantly shifting, Spade provides useful ways to think about small changes in language that can have a powerful impact on students.

Sarah S. Richardson, “Feminist Philosophy of Science: History, Contributions, and Challenges.” Synthese , 2010

Feminist philosophy of science is a field comprised of scholars studying gender and science that has its origins in the work of feminist scientists in the 1960s. Richardson considers the contributions made by these scholars, such as increased opportunities for and representation of women in STEM fields , pointing out biases in seemingly neutral fields of scientific inquiry. Richardson also considers the role of gender in knowledge production, looking at the difficulties women have faced in institutional and professional contexts. The field of feminist philosophy of science and its practitioners are marginalized and delegitimized because of the ways they challenge dominant modes of knowledge production and disciplinary inquiry.

Bryce Traister’s “Academic Viagra: The Rise of American Masculinity Studies.” American Quarterly , 2000

Bryce Traister considers the emergence of masculinity studies out of gender studies and its development in American cultural studies. He argues that the field has remained largely invested in centering heterosexuality, asserting the centrality and dominance of men in critical thought. He offers ways for thinking about how to study masculinity without reinstituting gendered hierarchies or erasing the contributions of feminist and queer scholarship.

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• 18 May 2022

Nature journals raise the bar on sex and gender reporting in research

You have full access to this article via your institution.

Many research studies don’t account for sex and gender. Credit: Getty

In late 2020, the European Commission announced that its research-grant recipients would need to incorporate analyses of sex and gender in their study design. This could include disaggregating data by sex when examining cells, or considering how a technology might perpetuate gender stereotypes. Back then, Nature wrote that this was a significant step and urged other funders to follow suit (see Nature 588 , 196; 2020 ). At the same time, we said that publishers, too, have a role in encouraging sex and gender reporting. The responsibility does not lie only with funders.

Some journals have encouraged reporting of sex and gender analyses for years, and the number of research studies that include such data has increased substantially in the past decade. But gaps remain — especially insufficient reporting of data disaggregated by sex and gender 1 – 3 .

To remedy this, from now on, researchers who submit papers to a subset of Nature Portfolio journals (see list at go.nature.com/3mcu0zj ) will be prompted to state whether and how sex and gender were considered in their study design, or to indicate that no sex and gender analyses were carried out, and clarify why. They should note in the title and/or abstract if findings apply to only one sex or gender.

Accounting for sex and gender makes for better science

They will also be asked to provide data disaggregated by sex and gender where this information has been collected, and informed consent for reporting and sharing individual-level data has been obtained. The changes apply to studies with human participants, on other vertebrates or on cell lines, in which sex and gender is an appropriate consideration.

At the same time, we’re urging care and caution in communicating findings about sex and gender, to avoid research findings having inadvertent and harmful effects, especially where there is the potential for societal and public-policy impact. More details about these changes can be found at go.nature.com/3mcu0zj . They are part of the SAGER (Sex and Gender Equity in Research) guidelines 4 .

In addition, from 1 June, four journals — Nature Cancer , Nature Communications , Nature Medicine and Nature Metabolism — will be raising awareness of the updated recommendations in letters to authors and reviewers during peer review. The aim here is to improve understanding of the degree to which sex and gender reporting is already part of study design, data collection and analysis in the research these journals publish. The journals will also evaluate author and reviewer reception of the changes so that we can iterate on them as we learn through experience.

The new measures are needed because research is still mostly failing to account for sex and gender in study design, sometimes with catastrophic results. Between 1997 and 2001, ten prescription drugs were withdrawn from use in the United States; eight of these were reported to have worse side effects in women than in men (we recognize that not everyone fits into these categories). These differences had probably been missed, in part, because of insufficient or inappropriate analysis of data on sex differences during clinical trials.

By introducing these changes, we aim to promote transparency in study design and, ultimately, make findings more accurate. Over time, we hope to see integration of sex and gender analysis in study design by default.

Nature 605 , 396 (2022)

doi: https://doi.org/10.1038/d41586-022-01218-9

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Rechlin, R. K., Splinter, T. F. L., Hodges, T. E., Albert, A. Y. & Galea, L. A. M. Nature Commun. 13 , 2137 (2021).

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Research Article

Twenty years of gender equality research: A scoping review based on a new semantic indicator

Contributed equally to this work with: Paola Belingheri, Filippo Chiarello, Andrea Fronzetti Colladon, Paola Rovelli

Roles Conceptualization, Formal analysis, Funding acquisition, Visualization, Writing – original draft, Writing – review & editing

Affiliation Dipartimento di Ingegneria dell’Energia, dei Sistemi, del Territorio e delle Costruzioni, Università degli Studi di Pisa, Largo L. Lazzarino, Pisa, Italy

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Visualization, Writing – original draft, Writing – review & editing

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Engineering, University of Perugia, Perugia, Italy, Department of Management, Kozminski University, Warsaw, Poland

Roles Conceptualization, Formal analysis, Funding acquisition, Writing – original draft, Writing – review & editing

Affiliation Faculty of Economics and Management, Centre for Family Business Management, Free University of Bozen-Bolzano, Bozen-Bolzano, Italy

• Paola Belingheri, 
• Filippo Chiarello, 
• Andrea Fronzetti Colladon, 
• Paola Rovelli

• Published: September 21, 2021
• https://doi.org/10.1371/journal.pone.0256474
• Reader Comments

9 Nov 2021: The PLOS ONE Staff (2021) Correction: Twenty years of gender equality research: A scoping review based on a new semantic indicator. PLOS ONE 16(11): e0259930. https://doi.org/10.1371/journal.pone.0259930 View correction

Gender equality is a major problem that places women at a disadvantage thereby stymieing economic growth and societal advancement. In the last two decades, extensive research has been conducted on gender related issues, studying both their antecedents and consequences. However, existing literature reviews fail to provide a comprehensive and clear picture of what has been studied so far, which could guide scholars in their future research. Our paper offers a scoping review of a large portion of the research that has been published over the last 22 years, on gender equality and related issues, with a specific focus on business and economics studies. Combining innovative methods drawn from both network analysis and text mining, we provide a synthesis of 15,465 scientific articles. We identify 27 main research topics, we measure their relevance from a semantic point of view and the relationships among them, highlighting the importance of each topic in the overall gender discourse. We find that prominent research topics mostly relate to women in the workforce–e.g., concerning compensation, role, education, decision-making and career progression. However, some of them are losing momentum, and some other research trends–for example related to female entrepreneurship, leadership and participation in the board of directors–are on the rise. Besides introducing a novel methodology to review broad literature streams, our paper offers a map of the main gender-research trends and presents the most popular and the emerging themes, as well as their intersections, outlining important avenues for future research.

Citation: Belingheri P, Chiarello F, Fronzetti Colladon A, Rovelli P (2021) Twenty years of gender equality research: A scoping review based on a new semantic indicator. PLoS ONE 16(9): e0256474. https://doi.org/10.1371/journal.pone.0256474

Editor: Elisa Ughetto, Politecnico di Torino, ITALY

Received: June 25, 2021; Accepted: August 6, 2021; Published: September 21, 2021

Copyright: © 2021 Belingheri et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its supporting information files. The only exception is the text of the abstracts (over 15,000) that we have downloaded from Scopus. These abstracts can be retrieved from Scopus, but we do not have permission to redistribute them.

Funding: P.B and F.C.: Grant of the Department of Energy, Systems, Territory and Construction of the University of Pisa (DESTEC) for the project “Measuring Gender Bias with Semantic Analysis: The Development of an Assessment Tool and its Application in the European Space Industry. P.B., F.C., A.F.C., P.R.: Grant of the Italian Association of Management Engineering (AiIG), “Misure di sostegno ai soci giovani AiIG” 2020, for the project “Gender Equality Through Data Intelligence (GEDI)”. F.C.: EU project ASSETs+ Project (Alliance for Strategic Skills addressing Emerging Technologies in Defence) EAC/A03/2018 - Erasmus+ programme, Sector Skills Alliances, Lot 3: Sector Skills Alliance for implementing a new strategic approach (Blueprint) to sectoral cooperation on skills G.A. NUMBER: 612678-EPP-1-2019-1-IT-EPPKA2-SSA-B.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The persistent gender inequalities that currently exist across the developed and developing world are receiving increasing attention from economists, policymakers, and the general public [e.g., 1 – 3 ]. Economic studies have indicated that women’s education and entry into the workforce contributes to social and economic well-being [e.g., 4 , 5 ], while their exclusion from the labor market and from managerial positions has an impact on overall labor productivity and income per capita [ 6 , 7 ]. The United Nations selected gender equality, with an emphasis on female education, as part of the Millennium Development Goals [ 8 ], and gender equality at-large as one of the 17 Sustainable Development Goals (SDGs) to be achieved by 2030 [ 9 ]. These latter objectives involve not only developing nations, but rather all countries, to achieve economic, social and environmental well-being.

As is the case with many SDGs, gender equality is still far from being achieved and persists across education, access to opportunities, or presence in decision-making positions [ 7 , 10 , 11 ]. As we enter the last decade for the SDGs’ implementation, and while we are battling a global health pandemic, effective and efficient action becomes paramount to reach this ambitious goal.

Scholars have dedicated a massive effort towards understanding gender equality, its determinants, its consequences for women and society, and the appropriate actions and policies to advance women’s equality. Many topics have been covered, ranging from women’s education and human capital [ 12 , 13 ] and their role in society [e.g., 14 , 15 ], to their appointment in firms’ top ranked positions [e.g., 16 , 17 ] and performance implications [e.g., 18 , 19 ]. Despite some attempts, extant literature reviews provide a narrow view on these issues, restricted to specific topics–e.g., female students’ presence in STEM fields [ 20 ], educational gender inequality [ 5 ], the gender pay gap [ 21 ], the glass ceiling effect [ 22 ], leadership [ 23 ], entrepreneurship [ 24 ], women’s presence on the board of directors [ 25 , 26 ], diversity management [ 27 ], gender stereotypes in advertisement [ 28 ], or specific professions [ 29 ]. A comprehensive view on gender-related research, taking stock of key findings and under-studied topics is thus lacking.

Extant literature has also highlighted that gender issues, and their economic and social ramifications, are complex topics that involve a large number of possible antecedents and outcomes [ 7 ]. Indeed, gender equality actions are most effective when implemented in unison with other SDGs (e.g., with SDG 8, see [ 30 ]) in a synergetic perspective [ 10 ]. Many bodies of literature (e.g., business, economics, development studies, sociology and psychology) approach the problem of achieving gender equality from different perspectives–often addressing specific and narrow aspects. This sometimes leads to a lack of clarity about how different issues, circumstances, and solutions may be related in precipitating or mitigating gender inequality or its effects. As the number of papers grows at an increasing pace, this issue is exacerbated and there is a need to step back and survey the body of gender equality literature as a whole. There is also a need to examine synergies between different topics and approaches, as well as gaps in our understanding of how different problems and solutions work together. Considering the important topic of women’s economic and social empowerment, this paper aims to fill this gap by answering the following research question: what are the most relevant findings in the literature on gender equality and how do they relate to each other ?

To do so, we conduct a scoping review [ 31 ], providing a synthesis of 15,465 articles dealing with gender equity related issues published in the last twenty-two years, covering both the periods of the MDGs and the SDGs (i.e., 2000 to mid 2021) in all the journals indexed in the Academic Journal Guide’s 2018 ranking of business and economics journals. Given the huge amount of research conducted on the topic, we adopt an innovative methodology, which relies on social network analysis and text mining. These techniques are increasingly adopted when surveying large bodies of text. Recently, they were applied to perform analysis of online gender communication differences [ 32 ] and gender behaviors in online technology communities [ 33 ], to identify and classify sexual harassment instances in academia [ 34 ], and to evaluate the gender inclusivity of disaster management policies [ 35 ].

Applied to the title, abstracts and keywords of the articles in our sample, this methodology allows us to identify a set of 27 recurrent topics within which we automatically classify the papers. Introducing additional novelty, by means of the Semantic Brand Score (SBS) indicator [ 36 ] and the SBS BI app [ 37 ], we assess the importance of each topic in the overall gender equality discourse and its relationships with the other topics, as well as trends over time, with a more accurate description than that offered by traditional literature reviews relying solely on the number of papers presented in each topic.

This methodology, applied to gender equality research spanning the past twenty-two years, enables two key contributions. First, we extract the main message that each document is conveying and how this is connected to other themes in literature, providing a rich picture of the topics that are at the center of the discourse, as well as of the emerging topics. Second, by examining the semantic relationship between topics and how tightly their discourses are linked, we can identify the key relationships and connections between different topics. This semi-automatic methodology is also highly reproducible with minimum effort.

This literature review is organized as follows. In the next section, we present how we selected relevant papers and how we analyzed them through text mining and social network analysis. We then illustrate the importance of 27 selected research topics, measured by means of the SBS indicator. In the results section, we present an overview of the literature based on the SBS results–followed by an in-depth narrative analysis of the top 10 topics (i.e., those with the highest SBS) and their connections. Subsequently, we highlight a series of under-studied connections between the topics where there is potential for future research. Through this analysis, we build a map of the main gender-research trends in the last twenty-two years–presenting the most popular themes. We conclude by highlighting key areas on which research should focused in the future.

Our aim is to map a broad topic, gender equality research, that has been approached through a host of different angles and through different disciplines. Scoping reviews are the most appropriate as they provide the freedom to map different themes and identify literature gaps, thereby guiding the recommendation of new research agendas [ 38 ].

Several practical approaches have been proposed to identify and assess the underlying topics of a specific field using big data [ 39 – 41 ], but many of them fail without proper paper retrieval and text preprocessing. This is specifically true for a research field such as the gender-related one, which comprises the work of scholars from different backgrounds. In this section, we illustrate a novel approach for the analysis of scientific (gender-related) papers that relies on methods and tools of social network analysis and text mining. Our procedure has four main steps: (1) data collection, (2) text preprocessing, (3) keywords extraction and classification, and (4) evaluation of semantic importance and image.

Data collection

In this study, we analyze 22 years of literature on gender-related research. Following established practice for scoping reviews [ 42 ], our data collection consisted of two main steps, which we summarize here below.

Firstly, we retrieved from the Scopus database all the articles written in English that contained the term “gender” in their title, abstract or keywords and were published in a journal listed in the Academic Journal Guide 2018 ranking of the Chartered Association of Business Schools (CABS) ( https://charteredabs.org/wp-content/uploads/2018/03/AJG2018-Methodology.pdf ), considering the time period from Jan 2000 to May 2021. We used this information considering that abstracts, titles and keywords represent the most informative part of a paper, while using the full-text would increase the signal-to-noise ratio for information extraction. Indeed, these textual elements already demonstrated to be reliable sources of information for the task of domain lexicon extraction [ 43 , 44 ]. We chose Scopus as source of literature because of its popularity, its update rate, and because it offers an API to ease the querying process. Indeed, while it does not allow to retrieve the full text of scientific articles, the Scopus API offers access to titles, abstracts, citation information and metadata for all its indexed scholarly journals. Moreover, we decided to focus on the journals listed in the AJG 2018 ranking because we were interested in reviewing business and economics related gender studies only. The AJG is indeed widely used by universities and business schools as a reference point for journal and research rigor and quality. This first step, executed in June 2021, returned more than 55,000 papers.

In the second step–because a look at the papers showed very sparse results, many of which were not in line with the topic of this literature review (e.g., papers dealing with health care or medical issues, where the word gender indicates the gender of the patients)–we applied further inclusion criteria to make the sample more focused on the topic of this literature review (i.e., women’s gender equality issues). Specifically, we only retained those papers mentioning, in their title and/or abstract, both gender-related keywords (e.g., daughter, female, mother) and keywords referring to bias and equality issues (e.g., equality, bias, diversity, inclusion). After text pre-processing (see next section), keywords were first identified from a frequency-weighted list of words found in the titles, abstracts and keywords in the initial list of papers, extracted through text mining (following the same approach as [ 43 ]). They were selected by two of the co-authors independently, following respectively a bottom up and a top-down approach. The bottom-up approach consisted of examining the words found in the frequency-weighted list and classifying those related to gender and equality. The top-down approach consisted in searching in the word list for notable gender and equality-related words. Table 1 reports the sets of keywords we considered, together with some examples of words that were used to search for their presence in the dataset (a full list is provided in the S1 Text ). At end of this second step, we obtained a final sample of 15,465 relevant papers.

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https://doi.org/10.1371/journal.pone.0256474.t001

Text processing and keyword extraction

Text preprocessing aims at structuring text into a form that can be analyzed by statistical models. In the present section, we describe the preprocessing steps we applied to paper titles and abstracts, which, as explained below, partially follow a standard text preprocessing pipeline [ 45 ]. These activities have been performed using the R package udpipe [ 46 ].

The first step is n-gram extraction (i.e., a sequence of words from a given text sample) to identify which n-grams are important in the analysis, since domain-specific lexicons are often composed by bi-grams and tri-grams [ 47 ]. Multi-word extraction is usually implemented with statistics and linguistic rules, thus using the statistical properties of n-grams or machine learning approaches [ 48 ]. However, for the present paper, we used Scopus metadata in order to have a more effective and efficient n-grams collection approach [ 49 ]. We used the keywords of each paper in order to tag n-grams with their associated keywords automatically. Using this greedy approach, it was possible to collect all the keywords listed by the authors of the papers. From this list, we extracted only keywords composed by two, three and four words, we removed all the acronyms and rare keywords (i.e., appearing in less than 1% of papers), and we clustered keywords showing a high orthographic similarity–measured using a Levenshtein distance [ 50 ] lower than 2, considering these groups of keywords as representing same concepts, but expressed with different spelling. After tagging the n-grams in the abstracts, we followed a common data preparation pipeline that consists of the following steps: (i) tokenization, that splits the text into tokens (i.e., single words and previously tagged multi-words); (ii) removal of stop-words (i.e. those words that add little meaning to the text, usually being very common and short functional words–such as “and”, “or”, or “of”); (iii) parts-of-speech tagging, that is providing information concerning the morphological role of a word and its morphosyntactic context (e.g., if the token is a determiner, the next token is a noun or an adjective with very high confidence, [ 51 ]); and (iv) lemmatization, which consists in substituting each word with its dictionary form (or lemma). The output of the latter step allows grouping together the inflected forms of a word. For example, the verbs “am”, “are”, and “is” have the shared lemma “be”, or the nouns “cat” and “cats” both share the lemma “cat”. We preferred lemmatization over stemming [ 52 ] in order to obtain more interpretable results.

In addition, we identified a further set of keywords (with respect to those listed in the “keywords” field) by applying a series of automatic words unification and removal steps, as suggested in past research [ 53 , 54 ]. We removed: sparse terms (i.e., occurring in less than 0.1% of all documents), common terms (i.e., occurring in more than 10% of all documents) and retained only nouns and adjectives. It is relevant to notice that no document was lost due to these steps. We then used the TF-IDF function [ 55 ] to produce a new list of keywords. We additionally tested other approaches for the identification and clustering of keywords–such as TextRank [ 56 ] or Latent Dirichlet Allocation [ 57 ]–without obtaining more informative results.

Classification of research topics

To guide the literature analysis, two experts met regularly to examine the sample of collected papers and to identify the main topics and trends in gender research. Initially, they conducted brainstorming sessions on the topics they expected to find, due to their knowledge of the literature. This led to an initial list of topics. Subsequently, the experts worked independently, also supported by the keywords in paper titles and abstracts extracted with the procedure described above.

Considering all this information, each expert identified and clustered relevant keywords into topics. At the end of the process, the two assignments were compared and exhibited a 92% agreement. Another meeting was held to discuss discordant cases and reach a consensus. This resulted in a list of 27 topics, briefly introduced in Table 2 and subsequently detailed in the following sections.

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Evaluation of semantic importance

Working on the lemmatized corpus of the 15,465 papers included in our sample, we proceeded with the evaluation of semantic importance trends for each topic and with the analysis of their connections and prevalent textual associations. To this aim, we used the Semantic Brand Score indicator [ 36 ], calculated through the SBS BI webapp [ 37 ] that also produced a brand image report for each topic. For this study we relied on the computing resources of the ENEA/CRESCO infrastructure [ 58 ].

The Semantic Brand Score (SBS) is a measure of semantic importance that combines methods of social network analysis and text mining. It is usually applied for the analysis of (big) textual data to evaluate the importance of one or more brands, names, words, or sets of keywords [ 36 ]. Indeed, the concept of “brand” is intended in a flexible way and goes beyond products or commercial brands. In this study, we evaluate the SBS time-trends of the keywords defining the research topics discussed in the previous section. Semantic importance comprises the three dimensions of topic prevalence, diversity and connectivity. Prevalence measures how frequently a research topic is used in the discourse. The more a topic is mentioned by scientific articles, the more the research community will be aware of it, with possible increase of future studies; this construct is partly related to that of brand awareness [ 59 ]. This effect is even stronger, considering that we are analyzing the title, abstract and keywords of the papers, i.e. the parts that have the highest visibility. A very important characteristic of the SBS is that it considers the relationships among words in a text. Topic importance is not just a matter of how frequently a topic is mentioned, but also of the associations a topic has in the text. Specifically, texts are transformed into networks of co-occurring words, and relationships are studied through social network analysis [ 60 ]. This step is necessary to calculate the other two dimensions of our semantic importance indicator. Accordingly, a social network of words is generated for each time period considered in the analysis–i.e., a graph made of n nodes (words) and E edges weighted by co-occurrence frequency, with W being the set of edge weights. The keywords representing each topic were clustered into single nodes.

The construct of diversity relates to that of brand image [ 59 ], in the sense that it considers the richness and distinctiveness of textual (topic) associations. Considering the above-mentioned networks, we calculated diversity using the distinctiveness centrality metric–as in the formula presented by Fronzetti Colladon and Naldi [ 61 ].

Lastly, connectivity was measured as the weighted betweenness centrality [ 62 , 63 ] of each research topic node. We used the formula presented by Wasserman and Faust [ 60 ]. The dimension of connectivity represents the “brokerage power” of each research topic–i.e., how much it can serve as a bridge to connect other terms (and ultimately topics) in the discourse [ 36 ].

The SBS is the final composite indicator obtained by summing the standardized scores of prevalence, diversity and connectivity. Standardization was carried out considering all the words in the corpus, for each specific timeframe.

This methodology, applied to a large and heterogeneous body of text, enables to automatically identify two important sets of information that add value to the literature review. Firstly, the relevance of each topic in literature is measured through a composite indicator of semantic importance, rather than simply looking at word frequencies. This provides a much richer picture of the topics that are at the center of the discourse, as well as of the topics that are emerging in the literature. Secondly, it enables to examine the extent of the semantic relationship between topics, looking at how tightly their discourses are linked. In a field such as gender equality, where many topics are closely linked to each other and present overlaps in issues and solutions, this methodology offers a novel perspective with respect to traditional literature reviews. In addition, it ensures reproducibility over time and the possibility to semi-automatically update the analysis, as new papers become available.

Overview of main topics

In terms of descriptive textual statistics, our corpus is made of 15,465 text documents, consisting of a total of 2,685,893 lemmatized tokens (words) and 32,279 types. As a result, the type-token ratio is 1.2%. The number of hapaxes is 12,141, with a hapax-token ratio of 37.61%.

Fig 1 shows the list of 27 topics by decreasing SBS. The most researched topic is compensation , exceeding all others in prevalence, diversity, and connectivity. This means it is not only mentioned more often than other topics, but it is also connected to a greater number of other topics and is central to the discourse on gender equality. The next four topics are, in order of SBS, role , education , decision-making , and career progression . These topics, except for education , all concern women in the workforce. Between these first five topics and the following ones there is a clear drop in SBS scores. In particular, the topics that follow have a lower connectivity than the first five. They are hiring , performance , behavior , organization , and human capital . Again, except for behavior and human capital , the other three topics are purely related to women in the workforce. After another drop-off, the following topics deal prevalently with women in society. This trend highlights that research on gender in business journals has so far mainly paid attention to the conditions that women experience in business contexts, while also devoting some attention to women in society.

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Fig 2 shows the SBS time series of the top 10 topics. While there has been a general increase in the number of Scopus-indexed publications in the last decade, we notice that some SBS trends remain steady, or even decrease. In particular, we observe that the main topic of the last twenty-two years, compensation , is losing momentum. Since 2016, it has been surpassed by decision-making , education and role , which may indicate that literature is increasingly attempting to identify root causes of compensation inequalities. Moreover, in the last two years, the topics of hiring , performance , and organization are experiencing the largest importance increase.

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Fig 3 shows the SBS time trends of the remaining 17 topics (i.e., those not in the top 10). As we can see from the graph, there are some that maintain a steady trend–such as reputation , management , networks and governance , which also seem to have little importance. More relevant topics with average stationary trends (except for the last two years) are culture , family , and parenting . The feminine topic is among the most important here, and one of those that exhibit the larger variations over time (similarly to leadership ). On the other hand, the are some topics that, even if not among the most important, show increasing SBS trends; therefore, they could be considered as emerging topics and could become popular in the near future. These are entrepreneurship , leadership , board of directors , and sustainability . These emerging topics are also interesting to anticipate future trends in gender equality research that are conducive to overall equality in society.

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In addition to the SBS score of the different topics, the network of terms they are associated to enables to gauge the extent to which their images (textual associations) overlap or differ ( Fig 4 ).

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There is a central cluster of topics with high similarity, which are all connected with women in the workforce. The cluster includes topics such as organization , decision-making , performance , hiring , human capital , education and compensation . In addition, the topic of well-being is found within this cluster, suggesting that women’s equality in the workforce is associated to well-being considerations. The emerging topics of entrepreneurship and leadership are also closely connected with each other, possibly implying that leadership is a much-researched quality in female entrepreneurship. Topics that are relatively more distant include personality , politics , feminine , empowerment , management , board of directors , reputation , governance , parenting , masculine and network .

The following sections describe the top 10 topics and their main associations in literature (see Table 3 ), while providing a brief overview of the emerging topics.

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Compensation.

The topic of compensation is related to the topics of role , hiring , education and career progression , however, also sees a very high association with the words gap and inequality . Indeed, a well-known debate in degrowth economics centers around whether and how to adequately compensate women for their childbearing, childrearing, caregiver and household work [e.g., 30 ].

Even in paid work, women continue being offered lower compensations than their male counterparts who have the same job or cover the same role [ 64 – 67 ]. This severe inequality has been widely studied by scholars over the last twenty-two years. Dealing with this topic, some specific roles have been addressed. Specifically, research highlighted differences in compensation between female and male CEOs [e.g., 68 ], top executives [e.g., 69 ], and boards’ directors [e.g., 70 ]. Scholars investigated the determinants of these gaps, such as the gender composition of the board [e.g., 71 – 73 ] or women’s individual characteristics [e.g., 71 , 74 ].

Among these individual characteristics, education plays a relevant role [ 75 ]. Education is indeed presented as the solution for women, not only to achieve top executive roles, but also to reduce wage inequality [e.g., 76 , 77 ]. Past research has highlighted education influences on gender wage gaps, specifically referring to gender differences in skills [e.g., 78 ], college majors [e.g., 79 ], and college selectivity [e.g., 80 ].

Finally, the wage gap issue is strictly interrelated with hiring –e.g., looking at whether being a mother affects hiring and compensation [e.g., 65 , 81 ] or relating compensation to unemployment [e.g., 82 ]–and career progression –for instance looking at meritocracy [ 83 , 84 ] or the characteristics of the boss for whom women work [e.g., 85 ].

The roles covered by women have been deeply investigated. Scholars have focused on the role of women in their families and the society as a whole [e.g., 14 , 15 ], and, more widely, in business contexts [e.g., 18 , 81 ]. Indeed, despite still lagging behind their male counterparts [e.g., 86 , 87 ], in the last decade there has been an increase in top ranked positions achieved by women [e.g., 88 , 89 ]. Following this phenomenon, scholars have posed greater attention towards the presence of women in the board of directors [e.g., 16 , 18 , 90 , 91 ], given the increasing pressure to appoint female directors that firms, especially listed ones, have experienced. Other scholars have focused on the presence of women covering the role of CEO [e.g., 17 , 92 ] or being part of the top management team [e.g., 93 ]. Irrespectively of the level of analysis, all these studies tried to uncover the antecedents of women’s presence among top managers [e.g., 92 , 94 ] and the consequences of having a them involved in the firm’s decision-making –e.g., on performance [e.g., 19 , 95 , 96 ], risk [e.g., 97 , 98 ], and corporate social responsibility [e.g., 99 , 100 ].

Besides studying the difficulties and discriminations faced by women in getting a job [ 81 , 101 ], and, more specifically in the hiring , appointment, or career progression to these apical roles [e.g., 70 , 83 ], the majority of research of women’s roles dealt with compensation issues. Specifically, scholars highlight the pay-gap that still exists between women and men, both in general [e.g., 64 , 65 ], as well as referring to boards’ directors [e.g., 70 , 102 ], CEOs and executives [e.g., 69 , 103 , 104 ].

Finally, other scholars focused on the behavior of women when dealing with business. In this sense, particular attention has been paid to leadership and entrepreneurial behaviors. The former quite overlaps with dealing with the roles mentioned above, but also includes aspects such as leaders being stereotyped as masculine [e.g., 105 ], the need for greater exposure to female leaders to reduce biases [e.g., 106 ], or female leaders acting as queen bees [e.g., 107 ]. Regarding entrepreneurship , scholars mainly investigated women’s entrepreneurial entry [e.g., 108 , 109 ], differences between female and male entrepreneurs in the evaluations and funding received from investors [e.g., 110 , 111 ], and their performance gap [e.g., 112 , 113 ].

Education has long been recognized as key to social advancement and economic stability [ 114 ], for job progression and also a barrier to gender equality, especially in STEM-related fields. Research on education and gender equality is mostly linked with the topics of compensation , human capital , career progression , hiring , parenting and decision-making .

Education contributes to a higher human capital [ 115 ] and constitutes an investment on the part of women towards their future. In this context, literature points to the gender gap in educational attainment, and the consequences for women from a social, economic, personal and professional standpoint. Women are found to have less access to formal education and information, especially in emerging countries, which in turn may cause them to lose social and economic opportunities [e.g., 12 , 116 – 119 ]. Education in local and rural communities is also paramount to communicate the benefits of female empowerment , contributing to overall societal well-being [e.g., 120 ].

Once women access education, the image they have of the world and their place in society (i.e., habitus) affects their education performance [ 13 ] and is passed on to their children. These situations reinforce gender stereotypes, which become self-fulfilling prophecies that may negatively affect female students’ performance by lowering their confidence and heightening their anxiety [ 121 , 122 ]. Besides formal education, also the information that women are exposed to on a daily basis contributes to their human capital . Digital inequalities, for instance, stems from men spending more time online and acquiring higher digital skills than women [ 123 ].

Education is also a factor that should boost employability of candidates and thus hiring , career progression and compensation , however the relationship between these factors is not straightforward [ 115 ]. First, educational choices ( decision-making ) are influenced by variables such as self-efficacy and the presence of barriers, irrespectively of the career opportunities they offer, especially in STEM [ 124 ]. This brings additional difficulties to women’s enrollment and persistence in scientific and technical fields of study due to stereotypes and biases [ 125 , 126 ]. Moreover, access to education does not automatically translate into job opportunities for women and minority groups [ 127 , 128 ] or into female access to managerial positions [ 129 ].

Finally, parenting is reported as an antecedent of education [e.g., 130 ], with much of the literature focusing on the role of parents’ education on the opportunities afforded to children to enroll in education [ 131 – 134 ] and the role of parenting in their offspring’s perception of study fields and attitudes towards learning [ 135 – 138 ]. Parental education is also a predictor of the other related topics, namely human capital and compensation [ 139 ].

Decision-making.

This literature mainly points to the fact that women are thought to make decisions differently than men. Women have indeed different priorities, such as they care more about people’s well-being, working with people or helping others, rather than maximizing their personal (or their firm’s) gain [ 140 ]. In other words, women typically present more communal than agentic behaviors, which are instead more frequent among men [ 141 ]. These different attitude, behavior and preferences in turn affect the decisions they make [e.g., 142 ] and the decision-making of the firm in which they work [e.g., 143 ].

At the individual level, gender affects, for instance, career aspirations [e.g., 144 ] and choices [e.g., 142 , 145 ], or the decision of creating a venture [e.g., 108 , 109 , 146 ]. Moreover, in everyday life, women and men make different decisions regarding partners [e.g., 147 ], childcare [e.g., 148 ], education [e.g., 149 ], attention to the environment [e.g., 150 ] and politics [e.g., 151 ].

At the firm level, scholars highlighted, for example, how the presence of women in the board affects corporate decisions [e.g., 152 , 153 ], that female CEOs are more conservative in accounting decisions [e.g., 154 ], or that female CFOs tend to make more conservative decisions regarding the firm’s financial reporting [e.g., 155 ]. Nevertheless, firm level research also investigated decisions that, influenced by gender bias, affect women, such as those pertaining hiring [e.g., 156 , 157 ], compensation [e.g., 73 , 158 ], or the empowerment of women once appointed [ 159 ].

Career progression.

Once women have entered the workforce, the key aspect to achieve gender equality becomes career progression , including efforts toward overcoming the glass ceiling. Indeed, according to the SBS analysis, career progression is highly related to words such as work, social issues and equality. The topic with which it has the highest semantic overlap is role , followed by decision-making , hiring , education , compensation , leadership , human capital , and family .

Career progression implies an advancement in the hierarchical ladder of the firm, assigning managerial roles to women. Coherently, much of the literature has focused on identifying rationales for a greater female participation in the top management team and board of directors [e.g., 95 ] as well as the best criteria to ensure that the decision-makers promote the most valuable employees irrespectively of their individual characteristics, such as gender [e.g., 84 ]. The link between career progression , role and compensation is often provided in practice by performance appraisal exercises, frequently rooted in a culture of meritocracy that guides bonuses, salary increases and promotions. However, performance appraisals can actually mask gender-biased decisions where women are held to higher standards than their male colleagues [e.g., 83 , 84 , 95 , 160 , 161 ]. Women often have less opportunities to gain leadership experience and are less visible than their male colleagues, which constitute barriers to career advancement [e.g., 162 ]. Therefore, transparency and accountability, together with procedures that discourage discretionary choices, are paramount to achieve a fair career progression [e.g., 84 ], together with the relaxation of strict job boundaries in favor of cross-functional and self-directed tasks [e.g., 163 ].

In addition, a series of stereotypes about the type of leadership characteristics that are required for top management positions, which fit better with typical male and agentic attributes, are another key barrier to career advancement for women [e.g., 92 , 160 ].

Hiring is the entrance gateway for women into the workforce. Therefore, it is related to other workforce topics such as compensation , role , career progression , decision-making , human capital , performance , organization and education .

A first stream of literature focuses on the process leading up to candidates’ job applications, demonstrating that bias exists before positions are even opened, and it is perpetuated both by men and women through networking and gatekeeping practices [e.g., 164 , 165 ].

The hiring process itself is also subject to biases [ 166 ], for example gender-congruity bias that leads to men being preferred candidates in male-dominated sectors [e.g., 167 ], women being hired in positions with higher risk of failure [e.g., 168 ] and limited transparency and accountability afforded by written processes and procedures [e.g., 164 ] that all contribute to ascriptive inequality. In addition, providing incentives for evaluators to hire women may actually work to this end; however, this is not the case when supporting female candidates endangers higher-ranking male ones [ 169 ].

Another interesting perspective, instead, looks at top management teams’ composition and the effects on hiring practices, indicating that firms with more women in top management are less likely to lay off staff [e.g., 152 ].

Performance.

Several scholars posed their attention towards women’s performance, its consequences [e.g., 170 , 171 ] and the implications of having women in decision-making positions [e.g., 18 , 19 ].

At the individual level, research focused on differences in educational and academic performance between women and men, especially referring to the gender gap in STEM fields [e.g., 171 ]. The presence of stereotype threats–that is the expectation that the members of a social group (e.g., women) “must deal with the possibility of being judged or treated stereotypically, or of doing something that would confirm the stereotype” [ 172 ]–affects women’s interested in STEM [e.g., 173 ], as well as their cognitive ability tests, penalizing them [e.g., 174 ]. A stronger gender identification enhances this gap [e.g., 175 ], whereas mentoring and role models can be used as solutions to this problem [e.g., 121 ]. Despite the negative effect of stereotype threats on girls’ performance [ 176 ], female and male students perform equally in mathematics and related subjects [e.g., 177 ]. Moreover, while individuals’ performance at school and university generally affects their achievements and the field in which they end up working, evidence reveals that performance in math or other scientific subjects does not explain why fewer women enter STEM working fields; rather this gap depends on other aspects, such as culture, past working experiences, or self-efficacy [e.g., 170 ]. Finally, scholars have highlighted the penalization that women face for their positive performance, for instance when they succeed in traditionally male areas [e.g., 178 ]. This penalization is explained by the violation of gender-stereotypic prescriptions [e.g., 179 , 180 ], that is having women well performing in agentic areas, which are typical associated to men. Performance penalization can thus be overcome by clearly conveying communal characteristics and behaviors [ 178 ].

Evidence has been provided on how the involvement of women in boards of directors and decision-making positions affects firms’ performance. Nevertheless, results are mixed, with some studies showing positive effects on financial [ 19 , 181 , 182 ] and corporate social performance [ 99 , 182 , 183 ]. Other studies maintain a negative association [e.g., 18 ], and other again mixed [e.g., 184 ] or non-significant association [e.g., 185 ]. Also with respect to the presence of a female CEO, mixed results emerged so far, with some researches demonstrating a positive effect on firm’s performance [e.g., 96 , 186 ], while other obtaining only a limited evidence of this relationship [e.g., 103 ] or a negative one [e.g., 187 ].

Finally, some studies have investigated whether and how women’s performance affects their hiring [e.g., 101 ] and career progression [e.g., 83 , 160 ]. For instance, academic performance leads to different returns in hiring for women and men. Specifically, high-achieving men are called back significantly more often than high-achieving women, which are penalized when they have a major in mathematics; this result depends on employers’ gendered standards for applicants [e.g., 101 ]. Once appointed, performance ratings are more strongly related to promotions for women than men, and promoted women typically show higher past performance ratings than those of promoted men. This suggesting that women are subject to stricter standards for promotion [e.g., 160 ].

Behavioral aspects related to gender follow two main streams of literature. The first examines female personality and behavior in the workplace, and their alignment with cultural expectations or stereotypes [e.g., 188 ] as well as their impacts on equality. There is a common bias that depicts women as less agentic than males. Certain characteristics, such as those more congruent with male behaviors–e.g., self-promotion [e.g., 189 ], negotiation skills [e.g., 190 ] and general agentic behavior [e.g., 191 ]–, are less accepted in women. However, characteristics such as individualism in women have been found to promote greater gender equality in society [ 192 ]. In addition, behaviors such as display of emotions [e.g., 193 ], which are stereotypically female, work against women’s acceptance in the workplace, requiring women to carefully moderate their behavior to avoid exclusion. A counter-intuitive result is that women and minorities, which are more marginalized in the workplace, tend to be better problem-solvers in innovation competitions due to their different knowledge bases [ 194 ].

The other side of the coin is examined in a parallel literature stream on behavior towards women in the workplace. As a result of biases, prejudices and stereotypes, women may experience adverse behavior from their colleagues, such as incivility and harassment, which undermine their well-being [e.g., 195 , 196 ]. Biases that go beyond gender, such as for overweight people, are also more strongly applied to women [ 197 ].

Organization.

The role of women and gender bias in organizations has been studied from different perspectives, which mirror those presented in detail in the following sections. Specifically, most research highlighted the stereotypical view of leaders [e.g., 105 ] and the roles played by women within firms, for instance referring to presence in the board of directors [e.g., 18 , 90 , 91 ], appointment as CEOs [e.g., 16 ], or top executives [e.g., 93 ].

Scholars have investigated antecedents and consequences of the presence of women in these apical roles. On the one side they looked at hiring and career progression [e.g., 83 , 92 , 160 , 168 , 198 ], finding women typically disadvantaged with respect to their male counterparts. On the other side, they studied women’s leadership styles and influence on the firm’s decision-making [e.g., 152 , 154 , 155 , 199 ], with implications for performance [e.g., 18 , 19 , 96 ].

Human capital.

Human capital is a transverse topic that touches upon many different aspects of female gender equality. As such, it has the most associations with other topics, starting with education as mentioned above, with career-related topics such as role , decision-making , hiring , career progression , performance , compensation , leadership and organization . Another topic with which there is a close connection is behavior . In general, human capital is approached both from the education standpoint but also from the perspective of social capital.

The behavioral aspect in human capital comprises research related to gender differences for example in cultural and religious beliefs that influence women’s attitudes and perceptions towards STEM subjects [ 142 , 200 – 202 ], towards employment [ 203 ] or towards environmental issues [ 150 , 204 ]. These cultural differences also emerge in the context of globalization which may accelerate gender equality in the workforce [ 205 , 206 ]. Gender differences also appear in behaviors such as motivation [ 207 ], and in negotiation [ 190 ], and have repercussions on women’s decision-making related to their careers. The so-called gender equality paradox sees women in countries with lower gender equality more likely to pursue studies and careers in STEM fields, whereas the gap in STEM enrollment widens as countries achieve greater equality in society [ 171 ].

Career progression is modeled by literature as a choice-process where personal preferences, culture and decision-making affect the chosen path and the outcomes. Some literature highlights how women tend to self-select into different professions than men, often due to stereotypes rather than actual ability to perform in these professions [ 142 , 144 ]. These stereotypes also affect the perceptions of female performance or the amount of human capital required to equal male performance [ 110 , 193 , 208 ], particularly for mothers [ 81 ]. It is therefore often assumed that women are better suited to less visible and less leadership -oriented roles [ 209 ]. Women also express differing preferences towards work-family balance, which affect whether and how they pursue human capital gains [ 210 ], and ultimately their career progression and salary .

On the other hand, men are often unaware of gendered processes and behaviors that they carry forward in their interactions and decision-making [ 211 , 212 ]. Therefore, initiatives aimed at increasing managers’ human capital –by raising awareness of gender disparities in their organizations and engaging them in diversity promotion–are essential steps to counter gender bias and segregation [ 213 ].

Emerging topics: Leadership and entrepreneurship

Among the emerging topics, the most pervasive one is women reaching leadership positions in the workforce and in society. This is still a rare occurrence for two main types of factors, on the one hand, bias and discrimination make it harder for women to access leadership positions [e.g., 214 – 216 ], on the other hand, the competitive nature and high pressure associated with leadership positions, coupled with the lack of women currently represented, reduce women’s desire to achieve them [e.g., 209 , 217 ]. Women are more effective leaders when they have access to education, resources and a diverse environment with representation [e.g., 218 , 219 ].

One sector where there is potential for women to carve out a leadership role is entrepreneurship . Although at the start of the millennium the discourse on entrepreneurship was found to be “discriminatory, gender-biased, ethnocentrically determined and ideologically controlled” [ 220 ], an increasing body of literature is studying how to stimulate female entrepreneurship as an alternative pathway to wealth, leadership and empowerment [e.g., 221 ]. Many barriers exist for women to access entrepreneurship, including the institutional and legal environment, social and cultural factors, access to knowledge and resources, and individual behavior [e.g., 222 , 223 ]. Education has been found to raise women’s entrepreneurial intentions [e.g., 224 ], although this effect is smaller than for men [e.g., 109 ]. In addition, increasing self-efficacy and risk-taking behavior constitute important success factors [e.g., 225 ].

Finally, the topic of sustainability is worth mentioning, as it is the primary objective of the SDGs and is closely associated with societal well-being. As society grapples with the effects of climate change and increasing depletion of natural resources, a narrative has emerged on women and their greater link to the environment [ 226 ]. Studies in developed countries have found some support for women leaders’ attention to sustainability issues in firms [e.g., 227 – 229 ], and smaller resource consumption by women [ 230 ]. At the same time, women will likely be more affected by the consequences of climate change [e.g., 230 ] but often lack the decision-making power to influence local decision-making on resource management and environmental policies [e.g., 231 ].

Research gaps and conclusions

Research on gender equality has advanced rapidly in the past decades, with a steady increase in publications, both in mainstream topics related to women in education and the workforce, and in emerging topics. Through a novel approach combining methods of text mining and social network analysis, we examined a comprehensive body of literature comprising 15,465 papers published between 2000 and mid 2021 on topics related to gender equality. We identified a set of 27 topics addressed by the literature and examined their connections.

At the highest level of abstraction, it is worth noting that papers abound on the identification of issues related to gender inequalities and imbalances in the workforce and in society. Literature has thoroughly examined the (unconscious) biases, barriers, stereotypes, and discriminatory behaviors that women are facing as a result of their gender. Instead, there are much fewer papers that discuss or demonstrate effective solutions to overcome gender bias [e.g., 121 , 143 , 145 , 163 , 194 , 213 , 232 ]. This is partly due to the relative ease in studying the status quo, as opposed to studying changes in the status quo. However, we observed a shift in the more recent years towards solution seeking in this domain, which we strongly encourage future researchers to focus on. In the future, we may focus on collecting and mapping pro-active contributions to gender studies, using additional Natural Language Processing techniques, able to measure the sentiment of scientific papers [ 43 ].

All of the mainstream topics identified in our literature review are closely related, and there is a wealth of insights looking at the intersection between issues such as education and career progression or human capital and role . However, emerging topics are worthy of being furtherly explored. It would be interesting to see more work on the topic of female entrepreneurship , exploring aspects such as education , personality , governance , management and leadership . For instance, how can education support female entrepreneurship? How can self-efficacy and risk-taking behaviors be taught or enhanced? What are the differences in managerial and governance styles of female entrepreneurs? Which personality traits are associated with successful entrepreneurs? Which traits are preferred by venture capitalists and funding bodies?

The emerging topic of sustainability also deserves further attention, as our society struggles with climate change and its consequences. It would be interesting to see more research on the intersection between sustainability and entrepreneurship , looking at how female entrepreneurs are tackling sustainability issues, examining both their business models and their company governance . In addition, scholars are suggested to dig deeper into the relationship between family values and behaviors.

Moreover, it would be relevant to understand how women’s networks (social capital), or the composition and structure of social networks involving both women and men, enable them to increase their remuneration and reach top corporate positions, participate in key decision-making bodies, and have a voice in communities. Furthermore, the achievement of gender equality might significantly change firm networks and ecosystems, with important implications for their performance and survival.

Similarly, research at the nexus of (corporate) governance , career progression , compensation and female empowerment could yield useful insights–for example discussing how enterprises, institutions and countries are managed and the impact for women and other minorities. Are there specific governance structures that favor diversity and inclusion?

Lastly, we foresee an emerging stream of research pertaining how the spread of the COVID-19 pandemic challenged women, especially in the workforce, by making gender biases more evident.

For our analysis, we considered a set of 15,465 articles downloaded from the Scopus database (which is the largest abstract and citation database of peer-reviewed literature). As we were interested in reviewing business and economics related gender studies, we only considered those papers published in journals listed in the Academic Journal Guide (AJG) 2018 ranking of the Chartered Association of Business Schools (CABS). All the journals listed in this ranking are also indexed by Scopus. Therefore, looking at a single database (i.e., Scopus) should not be considered a limitation of our study. However, future research could consider different databases and inclusion criteria.

With our literature review, we offer researchers a comprehensive map of major gender-related research trends over the past twenty-two years. This can serve as a lens to look to the future, contributing to the achievement of SDG5. Researchers may use our study as a starting point to identify key themes addressed in the literature. In addition, our methodological approach–based on the use of the Semantic Brand Score and its webapp–could support scholars interested in reviewing other areas of research.

Supporting information

S1 text. keywords used for paper selection..

https://doi.org/10.1371/journal.pone.0256474.s001

Acknowledgments

The computing resources and the related technical support used for this work have been provided by CRESCO/ENEAGRID High Performance Computing infrastructure and its staff. CRESCO/ENEAGRID High Performance Computing infrastructure is funded by ENEA, the Italian National Agency for New Technologies, Energy and Sustainable Economic Development and by Italian and European research programmes (see http://www.cresco.enea.it/english for information).

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Gender and Migration: An Introduction

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• First Online: 08 March 2022

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• Anastasia Christou 3 &
• Eleonore Kofman 4  

Part of the book series: IMISCOE Research Series ((IMIS))

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Why has it been important to incorporate gender relations into our understanding of migration processes and to engender migration research? The need to do so does not only stem from the fact that women globally make up just under half of international migrants. Gender is one of the key forms of differentiation within societies which interacts with other social divisions such as age, class, ethnicity, nationality, race, disability and sexual orientation. The drivers of migration impact on women and men differently. Women and men circulate distinctively, whether it be between rural and urban areas, intra-regionally or globally. Labour markets are often highly segregated and the possibility of women and men crossing borders may also be restricted or opened up through gendered discourses, practices, and regulations governing the right to move and under what conditions. Migration may in turn change gender relations within households and in the community and impact on gendered and sexual identities.

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1.1 Introduction

Gendered understandings of international migration emerged slowly in the 1970s and 1980s (Morokvasic, 1975 , 1984 ; Phizacklea, 1983 ; Simon & Brettell, 1986 ). The special issue of International Migration Review in 1984 was titled ‘Women and Migration’ and highlighted historical and contemporary dimensions of a neglected issue, namely that of rural-urban and international migration and the incorporation of women into wage labour through labour migrations. Until then, women had been largely ignored in writings on international migration; they had been largely relegated to the home and seen as relatively insignificant economically and politically. As migrants, they were depicted as following men rather than as initiators of migration or moving as independent beings. However the gender blindness of migration studies began to be challenged through the writings of feminist scholars in the 1980s and then some mainstream authors in the 1990s (e.g. Castles & Miller, 1993 ; Cohen, 1995 ).

Initial studies had focussed on women and migration but by the 1990s there had been a paradigm shift to migration as a gendered process , where gender reflected the practices and representations of femininity and masculinity and relationships between women and men (see Chap. 2 ). Nonetheless, gender continued for many writers to connote women’s experiences and lives. In a review of the field, the first handbook on this topic (Willis & Yeoh, 2000 ) noted that a gender perspective has drawn attention to the significance of the household and its reproductive activities (Truong, 1996 ), in particular of domestic and sex work. Labour migration, as the focus of much gender and migration, demanded an explanation and highlighted the complexities of migratory movements, their temporalities and circularities.

Poised at the cusp of new developments, the review identified emerging trends such as the diversity among women and men in which gender cut across class, ethnicity, sexuality, age and other social variables, an approach would become more evident with the development of the concept of intersectionality , the buzzword of feminist scholarship (Nash, 2008 and Chap. 2 ). Absence of men and masculinity would not be rectified until males were studied as gendered subjects (Charsley & Wray, 2015 ; Gallo & Scrinzi, 2016 ; Pasura & Christou, 2018 ) (Chap. 2 ).

Though transnationalism questioned the focus on the bounded nation-state in the 1990s, it remained masculinist until a decade later (Mahler & Pessar, 2001 ; Pessar & Mahler, 2003 ). The gender and migration literature also increasingly engaged with theoretical analyses of global inequalities and the counter geographies of globalisation that create new circuits linking the Global South and the Global North, and in which women significantly contribute to household survival in economies destabilised by economic restructuring and withdrawal of public welfare (Sassen, 2000 ). Concepts such as the global chains of care (Hochschild, 2000 ) reflected the growing global demand for reproductive labour (domestic, care and sex work). Though family migration had received relatively little attention (Kofman, 2004 ), with increasing labour migration more families were forced to live apart and stretched across space, as the study of transnational families in Europe (Bryceson & Vuorela, 2002 ), Asia (Yeoh et al., 2005 ) and North America (Hondagneu-Sotelo & Avila, 1997 ) revealed.

Three socio-economic and political changes have also oriented the development of gender and migration. They are firstly the enlargement of the EU and the growth of mobilities and migrations from Eastern to Western and Southern Europe where research has focused on domestic and care labour exemplifying the global chains of care (Lutz, 2011 ; Marchetti, 2013 ) as well as family networks (Ryan et al., 2008 ). The second is the financial crisis, especially severe in Southern European countries which had less impact on migrant women’s employment, though it often put additional pressure on them as breadwinners. The loss of employment brought about new mobilities between sending and receiving countries (Herrera, 2012 ). It also led to emigration from Southern to Northern European countries, but here we know less about its gendered outcomes (Bartolini et al., 2017 ; Lafleur & Stanek, 2017 ). Thirdly conflicts in the Middle East and Africa generated large flows of asylum seekers and a renewed interest in gendered aspects of refugee flows and settlement in Europe in academic and policy studies (Freedman et al., 2017 ; Williams et al., 2020 ).

Throughout this period in the growth of studies of gender and migration, it has become common to speak of the feminization of migration , noted as one of the four key trends in the age of migration (Castles & Miller, 1993 ). Yet in the last few years, the notion of the recent feminization of migration has been challenged (Donato & Gabaccia, 2015 ; Schrover, 2013 ). Donato and Gabaccia ( 2015 ) note that globally the percentage of female migrants has only increased by a small amount from 46.7% in 1960 to 49.6% in 2005. They argued that migrations had already begun to feminise in the early twentieth century in settler societies and Europe. In the United States the share of women in immigrant flows increased sharply between the 1830s and 1860s, and again in the first half of the twentieth century, to attain 50% in 1930. In many European countries it was gender balanced before World War II, leading Schrover ( 2013 : 123) to comment that ‘if there was ever a period of feminization, it was in this interwar period’.

During the twentieth century, the composition of flows tended to change according to immigration policies, recruitment practices and the nature of the labour market. In the 1920s, a number of countries restricted male migration but allowed female migration. Many German women migrated as domestic workers to the Netherlands and Scandinavian countries (Schrover, 2013 : 112). After the war labour shortages emerged by the end of the 1940s. States with colonies, such as France and the UK, had largely free movement within the colonial system, often recruiting women for low level service and welfare work as with Caribbean women in France and Britain (Byron & Condon, 2008 ). Other sources of labour in the UK came from displaced persons camps and the Baltic (McDowell, 2016 ). The liberalization of labour flows in Western Europe following the establishment of the European Coal and Steel Community initially favoured men but from the mid-1960s, the growth of the electronics industry and the search for so-called nimble fingers led to the recruitment of female labour in Germany beyond Southern Europe to countries such as Turkey (Erdem & Mattes, 2003 ). Sectors such as domestic work and concierges were largely filled by Southern European women, as Laura Oso ( 2005 ) highlighted for France. It is estimated that until the economic crisis of 1973 that the ‘guest worker’ recruitment comprised about 70% men.

However, the global average masks substantial differences between regions due in large part to types of migration (Fig. 1.1 ).

Proportion of female migrants of all international migrants 1990–2017

Regions such as Europe and North America, Australia and New Zealand, and Latin America and the Caribbean have a gender balance with a very slight increase since 1990. These regions offer permanent settlement as well as the right to family reunification and the possibility for family members to accompany labour migrants. This tends to push up the gender balance due to the feminised nature of family migration. In contrast, in other regions, male predominance has risen slightly since 1990. In Western Asia, which includes the Gulf States, demand for less skilled and skilled male labour has been strong even though female domestic workers are also in demand (Malhotra et al., 2016 ). Thus, the number of female migrants may have increased in absolute terms while relatively declining, a distinction which should be taken into account in the discussion on the feminization of migration (Vause & Toma, 2015 ). The evidence does not substantiate the view that feminization has been linear nor always a new development, but rather that it is dynamic and complex. We need to distinguish between the feminization of migration and the feminization of the ‘migratory discourse’ in which women are conceptualised as actors of migration (Schrover, 2013 ; Vause & Toma, 2015 ).

Lastly, a different critique of the view that migration has become feminised draws upon the increasingly higher levels of education of migrant women to contend that what we have been witnessing in the past few years is the feminization of skilled migration (Dumitru, 2017 ). Highly educated women in particular are migrating to a much greater extent than men with a similar educational level with the number of tertiary educated migrants increasing by 79% between 2000/01 and 2010/11, 17% greater than for male migrants to OECD countries (OECD, 2016 ). In the countries of the South, among women aged over 25 years, highly educated women are the most mobile groups, especially from poorer countries, such as sub-Saharan Africa, where almost 20% of the highly educated in 2010 had emigrated compared to 0.4% of the least educated (Dumitru & Marfouk, 2015 ). Women have thus formed an increasing percentage of skilled migrants (defined by their level of education rather than the occupation they take up after they have migrated). As we shall see in Chap. 3 , there has been relatively little research on highly educated women or those undertaking highly skilled jobs post-migration.

It should also be noted that the discussion about feminization focuses on labour migration, yet in 2015 the largest source of permanent migration in OECD countries was family migration, ahead of labour and humanitarian migration, with 38% of migrants entering through this route. Over 50% of this type of flow are women, with 60% in European OECD countries, 57% of sponsored family in Canada and two-thirds in Australia. In some countries with a large number of family permits, such as Canada, the UK and the US, the proportion of accompanying family of other admissions streams, such as the economic, pushes up the proportion of family-related reasons for migration. Most family migrants are spouses, followed by children and parents (OECD, 2017 : 125). In some countries where family reunification is not permitted for less skilled migrants, one of the most significant forms of family migration is marriage migration as in Asia (Chung et al., 2016 ; Constable, 2005 ). In general, the number of family migrants may fluctuate according to the general level of migration, as in Southern Europe, or due to shifts in immigration policy where governments seek to control this form of migration, often in favour of skilled labour migration, as in Australia in the 1990s (Boucher, 2016 ).

The focus on labour migration framed the migration of women within a general push-pull model, even if a social dimension was added. Only more recently has a more comprehensive reflection on how female migration to a much greater extent than male might be driven by a desire to escape socially discriminatory institutions and social control. Evidence from the Social Institutions and Gender Index (SIGI), which measures discrimination against women in social institutions, indicates that gender inequalities serve as both a motivating factor and barrier for women’s migration (Ferrant & Tuccio, 2015 ; Ruyssen & Salomone, 2018 ). On the one hand, women who face discrimination in their country of origin may want to migrate abroad, and may chose destinations where levels of gender discrimination in social institutions are lower than at home. On the other hand, gender discrimination in countries of origin can also prevent women from being able to migrate, when they have onerous family responsibilities, limited access to resources and social networks, little bargaining power or the right to initiate migration themselves. Qualitative research further supports the finding that discrimination is a driver of women’s migration. Studies show, for example, that women migrate internally to larger cities, or across country borders, to avoid child, early and forced marriage and other forms of violence against women in the family (Parish, 2017 ).

And lastly, we should take into account that migration has become complex in its directions and orientations. It is varied in its duration with migrants not necessarily starting out with fixed intentions or what Engbersen et al. ( 2013 ) have called ‘liquid mobility’. In Europe the opening up of free movement in 2004 in the context of increasingly liberalized and deregulated labour markets has generated large-scale movements from East to West with such migrants often replacing racialized migrants beyond Europe (Favell, 2008 ). Subsequently the severity of the economic crisis in Southern Europe, loss of employment, especially among youth and the austerity measures drove many highly educated young people to seek employment and opportunities in Northern Europe (Lafleur & Stanek, 2017 ).

And whilst, as we shall see in Chap. 3 , many young Europeans experienced dequalification and deskilling, especially in the initial period of movement, those with recognized cultural capital, and often from a solidly middle class background, are able to enter more smoothly into skilled occupations, for example, as with Spanish migrants in France (Oso, 2020 ). In this way gender, racialization, class and age have stratified the outcomes of their migratory projects. The ability for European citizens to move with relatively few barriers has also initiated onward migration of new EU citizens of migrant and refugee background (Ahrens et al., 2016 ; King & Karamoschou, 2019 ) which breaks down a straightforward relationship between origin and destination country. Gender plays a part in whether the family moves and in the severity of the often precarious experiences of such onward migrants (McIlwaine, 2020 ).

1.2 Scope and Aims of the Book

There are a number of ways in which one may structure the field of gender and migration which has in the past two decades begun to crystallise into an epistemic community (Kofman, 2020 ; Levy et al., 2020 ) as a production of knowledge amongst a network of scholars around certain topics and approaches. Some scholars have focussed on threading an analysis around key perspectives such as intersectionality and transnationalism (Amelina & Lutz, 2019 ) or integration (Anthias et al., 2013 ). In this book we trace the emergence of knowledge production of the field in general followed by the key drivers or motives for migration – labour family and asylum/refugees. These are the building blocks of contemporary migration governance, and as categories implemented by states and international organisations, they shape and control the modes of entry open to migrant women and men and also structure the nature of academic outputs. This is not to say that these categories determine migrant lives or that the categories themselves are fixed; they are in fact entangled, articulated and dynamic.

In the past few years, reflections on the construction of categories in migration research and policy have come to the fore (Crawley & Skleparis, 2018 ; Dahinden et al., 2021 ; de Haas et al., 2019 ; Schrover & Moloney, 2013 ). Throughout the book we acknowledge the fact that the categories we are dealing with have been determined by states and international organisations, and often disseminated by the media. Classifications and categories emerge in a particular social and political context and period; they may evolve in certain instances, whilst in others they remain largely unchanged in a reality that has changed. Within the broader categories, there are numerous issues which demand critical attention. Especially pertinent are definitions of skills and their gendered implications, the notion of the family, usually nuclear and heterosexist for the purpose of entry, and of the refugee more likely to have been displaced through mass movements arising from conflicts rather than the individual (male) figure envisaged by the 1951 Refugee Convention. Our three prevailing categories are those used to classify modes of entry but the bearers of these classifications assume a range of identities in societies post entry. The labour migrant may form a family, the family migrant is increasingly likely to work, and the asylum seeker/refugee seeks to work and reunite with their family or to form a new one. Thus the gendered division of labour draws upon migrants entering through the entire range of categories i.e. those entering through family channels or asylum also participate in the labour market. So too are the categories and the ways they are applied challenged by activists and researchers. Examples are the heterosexist nature of the family in immigration policy which has, in a large number of European countries, recognised same sex and cohabiting couples as constituting families; equally there has been an attempt to inject gender and sexuality-related persecution grounds into the Refugee Convention (see Chap. 5 ). In terms of participation in a society, the concept of integration too has been subjected to considerable critique (Anthias & Pajnik, 2014 ) at a time when many states are imposing greater demands on migrants (see Chap. 6 ).

Thus this book seeks to cover the general development of the field of gender and migration in the past 30 or so years, both in relation to different forms of immigration and post entry insertion into societies. In doing so, we seek to raise debates and explore different and emerging approaches. Intersectionality has become a major concept in gender and migration studies though it struggles to encompass the full range of the interplay of different social divisions (see Chap. 2 ). Moving on from women to gender, there remains nonetheless a tendency to focus on women, although the need to recognise men and masculinity is being addressed in general and across a range of topics. So too is the relevance of sexuality in migration patterns and outcomes. Most of the literature referred to in the Reader is in English but we acknowledge the large bodies of academic and policy writing in other languages, and in particular French, German and Spanish. Whilst both authors subscribe to looking beyond the global North as the source of theoretical insights as part of the decolonisation of gender and migration and the uneven circulation of knowledge (Fiddian-Qasmiyeh, 2020 ; Grosfoguel et al., 2015 ; Kofman, 2020 ), the restrictions of a short reader have meant the book is largely limited to a European focus unlike in a longer volume (Mora & Piper, 2021 ). Nonetheless, wherever possible, we have incorporated wider theoretical insights. The limitations imposed by length have also meant we have been unable, except to some extent through the discussion of transnational families, to connect up origin and destination, though here too we do not assume migration is in any way a linear or permanent journey.

1.3 Organisation of the Book

In this Chap. 1 we have briefly traced the development of gender and development from the 1980s and then in the 1990s the adoption of the idea of feminization of migration propounded by mainstream scholars as well. However others have questioned the simplicity of the analysis and suggested gendered patterns as more complex geographically and over time.

In Chap. 2 , we turn to the major theoretical perspectives and the shifting analytical parameters from women to gender and the introduction of intersectionalities, said by some scholars to be the key contribution of feminist scholarship. We then examine some of the recent conceptual developments and methodological shifts and their implications for gendered understandings of migration. We end Chap. 2 with a discussion of research and ethics in undertaking migration studies.

In Chap. 3 , we turn to one of the major empirical areas of study in gender and migration, that of gendered labour. This title reflects the fact that labour may be derived from a number of sources, ranging from labour migration, family migration, asylum seekers and refugees as well as students, and that it may have regular or irregular status. We argue that the labour market for migrants is heavily gendered both among the lesser and more highly skilled sectors. There has been a tendency to focus on what we have called the emblematic figure of the female migrant , that of domestic and care work especially supporting the social reproduction of the household, but as we indicate there are other sectors both in the lesser skilled sectors, such as hospitality, and in the skilled, such as health professionals as well as academia which deserve more attention. There are also a few studies of women in predominantly male sectors such as IT and engineering. We also recognise that migrants are distributed across the labour market but there are few studies to draw upon. Indeed focussing on the sectoral division may mean one loses sight of the trajectories of individual migrants both in relation to deskilling as well as social mobility.

Chapter 4 explores family migration, for a long time understudied and treated as a secondary form of migration in which women followed men. As from the beginning of this century it captured more attention and is the main reason for permanent migration. Furthermore familial reasons generate more moves than labour in intra-European mobility. The interest in the family and familyhood has spawned a growing literature on diverse aspects of transnational families and how migrants have engaged with borders and split lives and separated families. Thus transnational parenting and children have become significant topics as have considerations of cross-border intimacies and sexualities.

In Chap. 5 we discuss another form of mobility and displacement in which women traditionally did not manage to get to European shores to the same degree as men who had greater resources to make often difficult and dangerous journeys. We show how gendered representations played a part in maintaining the binary between the ‘there’ beyond Europe and ‘here’ in Europe. Gender-related persecution had difficulty in fitting into the male political figure of the refugee enshrined in the 1951 Refugee Convention and the attempts to incorporate such concerns as well as sexual orientation and gender identity in asylum determination. The second part examines the contemporary ‘Migrant/Refugee Crisis’ generated by recent and protracted conflicts in South Asia, sub-Saharan Africa, North Africa and Middle East, especially Syria (Freedman, 2016 ). Although initial flows were male dominated and gave rise to representations of male refugees as cowardly and threatening to European societies, after the summer of 2015 the gender balance shifted towards women. In particular, we engage with the critique of the prioritising of certain asylum categories through the application of the concept of vulnerability by states, the European Union and international organisations.

In Chap. 6 we move to academic critiques and debates about integration and the application of the concept to target certain categories of migrants. It has been recognised that integration fails to take into account class and race (Schinkel, 2018 ) but we argue that gender considerations have also been absent, yet integration measures and policies have targeted migrant women, too often assumed to have come from backward and patriarchal societies in the Global South and are either reluctant or held back by men from integrating. The second section examines the different gendered discourses applied to integration of women and men in the past 20 years, especially targeting Muslims as disrupters of a modern society. The third section seeks to go beyond integration and how migrants have sought to contest discrimination and lack of rights, especially in the workplace, as well as claims to political subjectivities seeking to recognise them as fully participating members of society.

In the Conclusion we suggest that that it is important to understand the history of gender and migration and the way in which particular issues, such as feminization and intersectionality, have evolved. We end by highlighting the emergence of significant events – the COVID-19 pandemic, Brexit and Black Lives Matter – which have implications for the scholarship of gender and migration and our engagement with broader societal developments.

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Christou, A., Kofman, E. (2022). Gender and Migration: An Introduction. In: Gender and Migration. IMISCOE Research Series. Springer, Cham. https://doi.org/10.1007/978-3-030-91971-9_1

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The Cass review: an opportunity to unite behind evidence informed care in gender medicine

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At the heart of Hilary Cass’s review of gender identity services in the NHS is a concern for the welfare of “children and young people” (doi: 10.1136/bmj.q820 ). 1 Her stated ambition is to ensure that those experiencing gender dysphoria receive a high standard of care. This will be disputed, of course, by people and lobbying groups angered by her recommendations, but it is a theme running through the review. Cass, a past president of the UK’s Royal College of Paediatrics and Child Health, seeks to provide better care for children and adolescents on one of the defining issues of our age. Her conclusion is alarming for anybody who genuinely cares for child welfare: gender medicine is “built on shaky foundations” (doi: 10.1136/bmj.q814 ). 2

That verdict is supported by a series of review papers published in Archives of Disease in Childhood , a journal published by BMJ and the Royal College of Paediatrics and Child Health (doi: 10.1136/archdischild-2023-326669 doi: 10.1136/archdischild-2023-326670 doi: 10.1136/archdischild-2023-326499 doi: 10.1136/archdischild-2023-326500 ). 3 4 5 6 The evidence base for interventions in gender medicine is threadbare, whichever research question you wish to consider—from social transition to hormone treatment.

For example, of more than 100 studies examining the role of puberty blockers and hormone treatment for gender transition only two were of passable quality. To be clear, intervention studies—particularly of drug and surgical interventions—should include an appropriate control group, ideally be randomised, ensure concealment of treatment allocation (although open label studies are sometimes acceptable), and be designed to evaluate relevant outcomes with adequate follow-up.

One emerging criticism of the Cass review is that it set the methodological bar too high for research to be included in its analysis and discarded too many studies on the basis of quality. In fact, the reality is different: studies in gender medicine fall woefully short in terms of methodological rigour; the methodological bar for gender medicine studies was set too low, generating research findings that are therefore hard to interpret. The methodological quality of research matters because a drug efficacy study in humans with an inappropriate or no control group is a potential breach of research ethics. Offering treatments without an adequate understanding of benefits and harms is unethical. All of this matters even more when the treatments are not trivial; puberty blockers and hormone therapies are major, life altering interventions. Yet this inconclusive and unacceptable evidence base was used to inform influential clinical guidelines, such as those of the World Professional Association for Transgender Health (WPATH), which themselves were cascaded into the development of subsequent guidelines internationally (doi: 10.1136/bmj.q794 ). 7

The Cass review attempted to work with the Gender Identity Development Service (GIDS) and the NHS adult gender services to “fill some of the gaps in follow-up data for the approximately 9000 young people who have been through GIDS to develop a stronger evidence base.” However, despite encouragement from NHS England, “the necessary cooperation was not forthcoming.” Professionals withholding data from a national inquiry seems hard to imagine, but it is what happened.

A spiralling interventionist approach, in the context of an evidence void, amounted to overmedicalising care for vulnerable young people. A too narrow focus on gender dysphoria, says Cass, neglected other presenting features and failed to provide a holistic model of care. Gender care became superspecialised when a more general, multidisciplinary approach was required. In a broader sense, this failure is indicative of a societal failure in child and adolescent health (doi: 10.1136/bmj.q802 doi: 10.1136/bmj-2022-073448 ). 8 9 The review’s recommendations, which include confining prescription of puberty blockers and hormonal treatments to a research setting (doi: 10.1136/bmj.q660 ), now place the NHS firmly in line with emerging practice internationally, such as in Scandinavia (doi: 10.1136/bmj.p553 ). 10 11

Cass proposes a future model of regional multidisciplinary centres that provide better access and, importantly, standardised care for gender dysphoria, including a smoother transition between adolescent and adult services. Staff will need training. All children and young people embarking on a care pathway will be included in research to begin to rectify the problems with the evidence base, with long term outcomes being an important area of focus. An already stretched workforce will need to extend itself further (doi: 10.1136/bmj.q795 doi: 10.1136/bmj-2024-079474 ). 12 13 In the meantime, some children and young people will turn to the private sector or online providers to meet their needs. The dangers in this moment of service transition are apparent.

But it’s also a moment of opportunity. Families, carers, advocates, and clinicians—acting in the best interests of children and adolescents—face a clear choice whether to allow the Cass review to deepen division or use it as a driver of better care. The message from the evidence reviews in Archives of Disease in Childhood is as unequivocal as it could be. Cass’s review is independent and listened to people with lived experience. Without doubt, the advocacy and clinical practice for medical treatment of gender dysphoria had moved ahead of the evidence—a recipe for harm.

People who are gender non-conforming experience stigmatisation, marginalisation, and harassment in every society. They are vulnerable, particularly during childhood and adolescence. The best way to support them, however, is not with advocacy and activism based on substandard evidence. The Cass review is an opportunity to pause, recalibrate, and place evidence informed care at the heart of gender medicine. It is an opportunity not to be missed for the sake of the health of children and young people. It is an opportunity for unity.

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Documenting Research with Transgender, Nonbinary, and Other Gender Diverse (Trans) Individuals and Communities: Introducing the Global Trans Research Evidence Map

Zack marshall.

1 School of Social Work, Faculty of Arts, McGill University, Montreal, Canada.

2 Division of Community Health and Humanities, Faculty of Medicine, Memorial University, St. John's, Canada.

Vivian Welch

3 Bruyère Research Institute, Ottawa, Canada.

4 School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada.

Michelle Swab

5 Health Sciences Library, Faculty of Medicine, Memorial University, St. John's, Canada.

Fern Brunger

Chris kaposy, associated data.

There is limited information about how transgender, nonbinary, and other gender diverse (trans) people have been studied and represented by researchers. The objectives of this study were to: (1) increase access to trans research; (2) map and describe trans research across subject fields; and (3) identify evidence gaps and opportunities for more responsible research. Eligibility criteria were established to include empirical research of any design, which included trans participants or their personal information and that was published in English in peer-reviewed journals. A search of 15 academic databases resulted in 25,230 references; data presented include 690 trans-focused articles that met the screening criteria and were published between 2010 and 2014. The 10 topics studied most frequently were: (1) therapeutics and surgeries; (2) gender identity and expression; (3) mental health; (4) biology and physiology; (5) discrimination and marginalization; (6) physical health; (7) sexual health, HIV, and sexually transmitted infections; (8) health and mental health services; (9) social support, relationships, and families; and (10) resilience, well-being, and quality of life. This map also highlights the relatively minor attention that has been paid to a number of study topics, including ethnicity, culture, race, and racialization; housing; income; employment; and space and place. Results of this review have the potential to increase awareness of existing trans research, to characterize evidence gaps, and to inform strategic research prioritization. With this information, it is more likely that trans communities and allies will be in a position to benefit from existing research and to hold researchers accountable.

Introduction

Systematic review methodologies, including scoping reviews and evidence maps, provide an opportunity to study detailed aspects of knowledge production, including what topics are researched, who tends to be studied, what types of methods are used, and how people interact with the products of research. In this way, reviews turn the focus of attention toward the research process and researchers themselves, uncovering new information and increasing the visibility of diverse fields of study.

The aim of this review is to map and describe how transgender, nonbinary, and other gender diverse (trans) people have been studied and represented within and across research in the fields of social sciences, humanities, health, sciences, business, and education. The term “trans” refers to people who “do not conform to prevailing expectations about gender” (Terminology section, para. 1) 1 and includes transgender, transsexual, and other gender diverse people of all ages. In contrast, the term cisgender refers to people who identify with the gender they were labeled at birth. 2 While trans is a self-identification, it also relates to a psychiatric diagnosis. 3 Transsexual and transgender people diagnosed with gender identity disorder or gender dysphoria have been the subjects of medical and psychiatric research and are described in clinical and social science literature. In this review of trans research, we have opted for a broad trans conceptualization 4 that incorporates diverse gender identities and expressions across global contexts. This includes transgender and transsexual people as well as drag queens, butch femmes, Two-Spirit people, hijra, travesti, cross-dressers, and additional nonbinary and gender diverse identities and expressions.

Knowledge about the scope of research focusing on trans individuals and communities is incomplete. Because many people are unaware of the extent of research that has been carried out, this leads to miscommunication and misinterpretations. Such misunderstandings may be particularly troublesome if trans community members are not aware of existing research evidence related to the questions they have about their lives. Systematic research detailing the nature of studies that have been conducted provides new insights into the evidence that does exist and can aid in identifying opportunities for more responsible research 5 with trans individuals and communities.

Multiple challenges constrain our ability to conduct reviews in the field of trans research. The first relates to the language used to describe transgender and nonbinary people and the ways this impacts search strategies. Terminology to describe gender diverse people differs across stakeholder communities, including language used within communities, medical diagnoses, and phrases distinct to linguistic or cross-cultural groups. As this language develops over time, 6 it adds to the diversity of terms that should be incorporated into effective search strategies. A second barrier relates to indexed subject headings, both in terms of their inability to remain up to date, and the ways these headings reflect the spectrum of trans experience. 7 These complications require searches that go beyond subject headings, a process that is made more convoluted because it is difficult to search terms such as “trans” or “gender identity” by themselves due to the lack of specificity of these terms and the consequent number of extraneous results this produces. Search strategies also need to include database-specific headings and independent search terms such as vaginoplasty or mastectomy that may be germane to both cisgender and transgender experiences. Once searches are complete, screening is impacted by problems identifying whether the study includes any trans participants, or whether the research is trans focused, due to incomplete and/or unclear information in the title and abstract. For example, these difficulties arise when reviewing references that include trans participants within larger studies with lesbian, gay, bisexual, trans, Two-Spirit, and queer (LGBT2Q) communities, and surgery-related case reports. In their recent systematic review of gaps and opportunities in primary care preventative health services for trans people, Edmiston et al. 8 reported similar challenges.

Despite these circumstances, some researchers have attempted to increase awareness of the types of trans research available. One of the earliest examples was published by Denny as an annotated bibliography in 1994, 9 including a classification of books, articles, and community reports. Since then, the number of systematic reviews has slowly increased. Primarily health focused, 10 researchers have conducted trans-focused reviews related to mental health, 11 gender dysphoria, 12 learning disabilities, 13 aging, 14 cancer care, 15 and HIV. 16 More commonly, trans research is included as part of larger reviews centering men who have sex with men (MSM), LGBT2Q communities, or other marginalized populations. 17 , 18

Combining a comprehensive search strategy, text mining, and evidence map, this investigation has the potential to enhance knowledge in several fields. There are currently no evidence maps of trans research. By documenting this broad field of study, this review will enhance awareness of existing trans research, highlight evidence gaps, and inform strategic research prioritization. 19 Publishing the map online will also expand access to research for key stakeholders, including community members, policymakers, and health care providers.

Materials and Methods

Evidence maps are an emerging research method 20 to “collate, describe, and catalog” knowledge across a broad field of study. 21 This information can then be leveraged by stakeholders to inform policy and clinical decision-making. 21 This evidence map was developed using the four-step framework introduced by Hetrick et al. 22 : identify objectives, describe characteristics to be mapped and eligibility criteria, screen the literature, and chart the study within the map. The protocol for this evidence map was previously published 23 in agreement with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). 24

Aim and objectives

The aim of this study was to map and describe how trans people have been studied and represented within and across multiple fields of research. The objectives were to

• (1) increase access to research that includes trans people for community members, health care providers, and policymakers by establishing an online evidence map, including a searchable reference database;
• (2) document trans research in the fields of social sciences, health, sciences, education, humanities, and business, including information about sample demographics, study topic, and study design; and
• (3) characterize evidence gaps and opportunities for more responsible research with trans individuals and communities.

Eligibility criteria

It is suggested that researchers clarify concepts and engage key stakeholders as part of the process of developing evidence maps. 25 Accordingly, one-on-one consultations were held with members of trans and cisgender communities to discuss search scope, terminology, and possible uses of an evidence map. Based on the results of pilot searches and consultations, the eligibility criteria were established to include empirical research studies of any design with human participants, which identifiably included trans people or their personal information, and were reported in English in peer-reviewed journals.

Information sources

The identification of academic databases was informed by the larger goal of locating trans research from multiple fields. A secondary emphasis was to gather research on a global scale. For example, to appropriately identify research related to gender diverse Indigenous people, three databases focused on Indigenous and First Nations research were included.

Fifteen databases were selected to ensure diverse study design identification, 26 including Academic Search Premier, Anthropology Plus, Bibliography of Native North Americans, CINAHL, First Nations Periodical Index, Indigenous Studies Portal, LILACS, ProQuest Social Sciences Premium (contains ERIC, Social Services Abstracts & Applied Social Sciences Index and Abstracts, and Sociological Abstracts,), PsycINFO, PubMed, SciELO, Scopus, Social Work Abstracts, Web of Science, and Women's Studies International.

Search strategy

Search terms concentrated on transgender, non-binary, and other gender diverse experiences and identities. Because there are multiple terms used for (and/or by) trans people, and this language continues to evolve over time, 6 the full list of search terms was wide-ranging and comprised terms linked to gender identity (e.g., “trans woman”), diagnoses (e.g., “gender dysphoria” and “gender identity disorder”), therapeutics and surgical procedures (e.g., facial feminization), language that was used historically (e.g., transvestite), and words used in a range of cultures and countries (e.g., waria, travesti, Two-Spirit, and hijra). A sample search strategy for one academic database is provided in Supplementary Data S1 .

Data management

A health sciences librarian reviewed the draft search. Pilot searches were conducted in January 2015 in all 15 databases for each search string to ensure that the search was specific, but not overly sensitive. Full searches were then carried out between January 25 and February 22, 2015. Searches resulted in a total of 63,004 references ( Table 1 ). After eliminating duplicates, the total number of references included in the review was 25,230 ( Fig. 1 ).

PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analysis.

Search Results

Selection process

Screening on title and abstract.

The first author developed the initial approach to screening and 2 reviewers conducted a pilot review of a random sample of 100 references. This was followed by a follow-up review of a random sample of ∼10% of the dataset (2,393 references). Differences were reconciled through discussion and clarification, leading to a refinement of the eligibility criteria. After this, references were randomly allocated into groups of 1,000. Two reviewers screened the first two groups, reconciling differences through dialogue and discussion.

Reference screening was conducted based on the content of the title and abstract (level 1). Studies were excluded if they were not written in English, if they were not empirical research, if they did not include humans, or if they included only cisgender heterosexual people or people diagnosed with disorders of sex development (DSD; sometimes referred to as intersex people). If a reference was not excluded at level 1, the article was uploaded so that the full text could be reviewed (level 2). Any reference with no abstract was automatically screened on full text.

Whether there were any trans participants included in studies was often not clear from the abstracts. For example, in research with a diversity of LGBT2Q participants, authors might have presented the total number of participants in the abstract, or the study may have included trans participants, but they were not necessarily mentioned at this level. Early in the screening process, it became clear that many disagreements between reviewers were linked to a lack of specificity about sample characteristics in the abstract. As a result, it was necessary to automatically include references with LGBT2Q or MSM samples for screening on full text. In addition, due to the connections between HIV, sex work, and trans populations, all references that mentioned sex workers or people living with HIV as participants were automatically screened on full text. Lack of specificity was also a challenge with some clinical case studies. As a result, any study that mentioned trans-specific surgeries or therapeutics was automatically included. Finally, due to diversity within the general population, any study with a sample size over 1,000 was included. The rationale for this was to verify in the full-text article whether surveys included demographic questions inclusive of trans identities, and whether any trans participant had self-identified.

Screening on full text

For full-text screening, two team members reviewed each reference, and any difference was reconciled through discussion. The goal of level 2 screening was to identify original research that included trans participants or their personal information. In addition, at this level, we identified three different types of studies: trans focused, LGBT2Q/MSM, and mixed. Trans-focused studies included those with only trans participants as well as those with a cisgender control group. LGBT2Q/MSM studies were studies that included trans people as part of larger studies with sexual and gender diverse participants. Mixed studies were those with both cisgender and trans participants. In addition, studies with photographs were also flagged at this level of screening. The purpose of identifying this information at level 2 was to support data extraction. The evidence map presented in this study included only trans-focused studies.

Data items for mapping

Data extraction focused on developing an evidence map that emphasized the distribution and extent 27 of trans research studies. The following information was collected for mapping: year of publication, study topic, study design, trans sample demographics, data sources, geographic location of data collection, and open access availability. This article focuses on data related to study topic and study design.

Data analysis

Study topics.

To develop a list of study topics for the map, the team started with the social determinants of health 28 and frameworks that incorporate both structural health perspectives and individual health behaviors. Models by Ansari et al. 29 and Brennan Ramirez et al. 30 inspired early conceptualizations of topic areas. After piloting, additional subjects were added to the map that helped to expand the coding framework beyond a health focus. New topics that were added included the following: arts and creativity; sex work; resilience, well-being and quality of life; and resistance and activism.

In the first phase of data extraction, one reviewer went through each reference to identify key study topics. In coding for study topic, we focused on the stated purpose as identified by the study author(s). While there was no set limit to the number of study topics that could be selected, we aimed for a range of two to four study topics per reference. In the next phase, a second team member reviewed groups of references by study topic. For example, all references within the study topic of aging or physical health were verified for consistency and topic cohesion. In this phase, some of the more traditional social determinant topics were also renamed to better communicate the subject matter included in that category. For example, natural built environments were reconceptualized as space and place.

In this phase, the second reviewer also conducted word searches within the set of included studies to verify that no relevant references had been excluded. For example, in searching for articles about aging, the dataset was searched for any reference that included relevant search terms such as “age,” “aging,” “elder,” “senior,” and “old” in the title and/or abstract. This not only produced larger sets of references for checking but also helped to ensure that studies relevant to each topic were captured within the map.

Study design

Because this review included a broad range of quantitative, qualitative, and clinical study types, it was not possible to use an existing evidence-based categorization scheme. As a result, two of the coauthors developed a coding framework, including the following options: (1) systematic review of randomized controlled trials; (2) randomized controlled trial; (3) nonrandomized controlled trial; (4) case–control study; (5) cohort study; (6) systematic review of descriptive or qualitative studies; (7) cross-sectional study; (8) qualitative study with interviews or focus groups; (9) ethnography or phenomenological qualitative study; (10) historical research; (11) case report, case study, or case series; (12) autoethnography; (13) basic science; and (14) community-based research or other forms of participatory research.

Clear definitions of each study design were identified using the following sources: systematic reviews, 31 case–control, cohort, and cross-sectional studies, 32–34 case studies, 35 and case reports and case series. 36 To be categorized as a systematic review, studies needed to include a clear search strategy or method to identify studies, and to explicitly state their methods of study selection. Because there are limited systematic reviews in the field of trans studies and this evidence map aimed for broad inclusion, we did not require the third criteria from the PRISMA-P definition of a systematic review (explicitly described methods of synthesis) 31 in order for studies to be included.

One reviewer extracted information about study design and data collection methods from all trans-focused studies. A second reviewer verified the first 10% of the data extraction. After clarifying any difference in coding, additional questions about how to code particular studies were discussed with a third member of the study team. Based on this information reviewer, two checked the references within each study design, grouping for accuracy and consistency.

A total of 25,230 references were screened based on title and abstract content (level 1). Around 14,579 references were excluded for the following reasons: 8,133 based on study design, 2,926 were not in English, 1,608 because they gave no indication that trans people had been participants, 794 did not include human participants (i.e., they were based on animal models or relied on documents for analysis), 723 were articles about surgery that did not suggest trans participation, and 395 focused on intersex or DSD experience. A total of 6,915 references met the inclusion criteria based on title and abstract, and an additional 3,736 were included based on no abstract being available ( Fig. 1 ).

A total of 10,651 references were eligible for screening on full text. Due to resource constraints, the decision was made to focus the first version of the evidence map on the most recent 5-year period. As a result, 3,533 references published between 2010 and 2014 were screened on full text.

A total of 1,667 articles met the inclusion criteria. Six hundred ninety articles were trans focused, 462 included LGBT2Q and/or MSM participants, and 515 included mixed samples. A total of 1,866 studies were excluded based on the following criteria: not empirical research (787 references); no trans participants (552 references); LGB or MSM, but explicitly no trans participants (273 references); no human participants (96 references); not written in English (62 references); book reviews (52 references); not journal articles (19 references); case summary or composite only (14 references); or focused on intersex participants or people diagnosed with DSD (11 references).

The 690 trans-focused articles form the basis of the remaining data analysis for this article (see Supplementary Data S2 for a full list of the trans-focused references). Data on study topics and study design are the focus of the next section, and are summarized in Supplementary Data S3 . Combining data about topic and study design provides additional insights into how researchers have chosen to explore trans research topics, including information about areas of overemphasis and underemphasis, topics that could benefit from knowledge synthesis, and areas that need further attention.

The map included a total of 37 study topics ( Table 2 ). The top 10 study topics were as follows: (1) therapeutics and surgeries; (2) gender identity and expression; (3) mental health; (4) biology and physiology; (5) discrimination and marginalization; (6) physical health; (7) sexual health, HIV, and sexually transmitted infections (STIs); (8) health and mental health services; (9) social support, relationships, and families; and, (10) resilience, well-being, and quality of life ( Fig. 2 ).

Top 10 study topics.

Summary Table of Study Topics and Frequencies

STIs, sexually transmitted infections.

Therapeutics and surgeries

The number one topic area was therapeutics and surgeries, with 224 references. This study topic included gender-affirming processes and procedures such as cross-gender hormone treatment, feminizing or masculinizing procedures such as facial feminization surgery, silicone injection, or electrolysis/laser hair removal, and studies focusing on gender-affirming surgeries such as orchiectomy and vaginoplasty, chest reconstruction, hysterectomy, and phalloplasty. Also included in this category were studies that detailed surgical procedures and outcomes, research and case reports describing side effects of therapeutics or surgeries, and studies exploring levels of satisfaction with gender-affirming medical therapeutics or procedures.

Gender identity and expression

Gender identity and expression was the second most common study topic with 203 references. While it was not surprising that a trans research evidence map would include a large number of studies focused on gender identity, efforts were made to clearly distinguish this topic area so that it did not include all studies in the review. Areas of focus included the following: the experience of gender identity, including trans gender identity development; nonbinary and other gender diverse identities; gender dysphoria; gender identity disclosure; medical and social transition; and gender identity assessment and diagnosis.

Mental health

Mental health was the third most common study topic with 124 references. This included diagnoses and/or experiences of depression, anxiety, suicide, and other co-occurring mental health diagnoses. This category also included studies documenting the interaction between discrimination, structural oppression, and mental health, and the medicalization and pathologization of gender identity.

Biology and physiology

Including 106 studies, the category of biology and physiology includes research at the cellular level, neurological research, bone density studies, and genetic and chromosomal research. In some cases, these studies explored the impacts of medical transition on the physical body. In others, researchers were attempting to identify the etiology of trans gender identity through twin studies, handedness, and measures of cortical thickness.

Discrimination and marginalization

There were a total of 99 articles on the topic of discrimination and marginalization. This included studies about different aspects of discrimination such as harassment, bullying, microaggressions, cisgenderism, transphobia, and other forms of oppression. In addition, this topic included research on the topic of social exclusion, stigma, and marginalization. This topic was distinct from violence and trauma, a subject area that included 47 studies. Verbal abuse, physical abuse, and any other form of violence or trauma were included in the latter category.

Physical health

The area of physical health had 97 studies, including research related to diabetes, cancer, eating disorders, granulomas, meningiomas, and cardiovascular disease. Some studies explored the link between trans-related therapeutics and longer term health, where others documented complications as a result of surgeries or other medical procedures. Physical health as a study topic was distinct from side effects and impacts of therapeutics and surgeries, and there was little overlap between these two areas of the map. Short-term impacts or complications from surgeries such as chest reconstruction or vaginoplasty were coded within the area of therapeutics and surgeries, whereas longer term health impacts that needed their own intervention were classified under the area of physical health.

Sexual health, HIV, and STIs

The category of sexual health, HIV, and STIs included 97 studies about sexual behaviors, and HIV and other STIs. The HIV and STI literature included articles linked to testing, treatment and treatment adherence, transmission, and co-infection, as well as literature that connected HIV and STIs to broader syndemic factors. Sexual health literature included studies about sexual behaviors, communication and negotiation of safer sex behavior, and research related to sexual risk factors. Sexual health was differentiated from the study topic of sexuality, which included 52 references and referred more specifically to sexual attraction and sexual identity.

Health and mental health services

Health and mental health services was a relatively large area of the map, including 89 references. These studies investigated barriers and access to health and/or mental health services, experiences with mental health services, discrimination in health care, patient satisfaction, studies of interactions between patients and providers from the trans person's perspective, waitlists, cost-effectiveness, and models of care. This research also explored the impact of barriers to health services on health and mental health.

Social support, relationships, and families

Social support, relationships, and families included 70 references. This element of the map included references related to social support and communities, relationships with friends and family, as well as romantic and/or sexual relationships. Social support has been measured and investigated as a factor in relation to health incorporating mental health, physical health, and sexual health. In addition, there were a number of articles related to family support, including family responses to trans children, siblings, or parents.

Resilience, well-being, and quality of life

The review included 61 articles on the topic of resilience, well-being, and quality of life. In these strength-based articles, researchers often explored alternate, nonpathologizing conceptualizations of trans lives, including experiences of hope, resilience, and community support.

Of the 37 study topics that we categorized, the top 10 most common (listed above), each included at least 50 references. In the mid-range (i.e., between the top 10 and the bottom 10), categories included the following: sexuality; ethnicity, culture, race, and racialization; violence and trauma; early life experiences; resistance and politicization; therapeutic process; intersectionalities * ; space and place; education; law and criminalization (crime, prisons, incarceration, and policing); research methods; employment; arts and creativity; sex work; substance use; and parenting, reproduction, and assisted reproduction. The bottom 10 topics in the map all included less than 15 references. These were as follows: disability; age and aging; historical perspectives; religion and spirituality; ethics; income; sports and physical activity; housing; Indigeneity; and migration and refugee experiences ( Fig. 3 ).

Bottom 10 study topics.

Exploring the intersections between study topic and study design

Of the 690 studies in the review, the emphasis was on observational research. Less than 2% were experimental. The frequency of study design across the trans-focused dataset was: (1) cross-sectional studies (250 references); (2) case reports, case studies, and case series (182 references); (3) qualitative study with interviews or focus groups (99 references); (4) cohort studies (56 references); (5) ethnographies or phenomenological studies (37 references); (6) basic science (23 references); (7) systematic reviews of descriptive or qualitative studies (20 references); (8) community-based research or other participatory research (15 references), (9) autoethnographies (8 references); (10) case–control studies (7 references); (11) nonrandomized controlled trials (7 references); (12) historical research (4 studies); and (13) randomized controlled trials (3 references) ( Fig. 4 ).

Frequency of study designs.

The most common research was cross-sectional, emphasizing information gathered at one point in time. Within the top 10 study topics, cross-sectional research was most common in the areas of (1) mental health; (2) gender identity and expression; (3) sexual health, HIV, and STIs; (4) biology and physiology; and (5) therapeutics and surgeries. Cross-sectional research most often involved survey research and clinical measures.

Case reports, case studies, and case series were also very common within the dataset, specifically within the areas of therapeutics and surgeries, and physical health. In these situations, case reports were often used to document novel procedures, surgical complications, or physical side effects related to therapeutics. We also saw the use of case reports and case studies in relation to mental health; gender identity and expression; therapeutic processes; health and mental health services; and sexual health, HIV, and STIs. In the case of health and mental health services, and therapeutic processes, some clinicians reported on client demographics within their clinic, or on the process with specific patients.

Ninety-nine studies included qualitative interviews or focus groups. These methods were particularly relevant when exploring gender identity and expression; discrimination and social exclusion; and social support, relationships, and families. While cross-sectional studies were more frequently used in each of these areas, qualitative interviews or focus groups were the second most common study design for all of these study topics.

Conclusions

Topics that received the most attention.

Study topics that received the most attention from researchers were as follows: (1) therapeutics and surgeries; (2) gender identity and expression; (3) mental health; (4) biology and physiology; (5) discrimination and marginalization; (6) physical health; (7) sexual health, HIV, and STIs; (8) health and mental health services; (9) social support, relationships, and families; and (10) resilience, well-being, and quality of life. Comparing these results to Reisner et al.'s 10 review of health-related outcome categories, there were similarities and differences. For example, both reviews share an emphasis on the following topics: (1) mental health; (2) sexual and reproductive health; (3) stigma and discrimination; and (4) general health. In contrast, two topics that were highlighted in Reisner et al.'s 10 review—substance use, and violence and victimization—did not include a large enough number of studies to be included in the top 10 topics of the evidence map. Some of these differences were linked to Reisner et al.'s 10 emphasis on quantitative health research. Having a broader subject and methodological focus in this study meant that it was possible to incorporate greater diversity into the evidence map, including research related to therapeutics and surgeries, health and mental health services, social support, and resilience.

Topics that received the least attention

Topics that have received the least attention include several factors linked to the social determinants of health such as ethnicity and culture, housing, income, employment, and space and place. This review highlights the relatively minor attention invested to date in these study topics and underscores the need to assess whether additional research focused in these areas would be beneficial. For example, given the challenges many trans people face in obtaining employment, research centering on poverty and employment in trans communities, including barriers and facilitators to employment, may be called for. These studies could provide insight into these topics beyond their consideration as risk factors in relation to health and/or mental health.

Areas that have been systematically reviewed and opportunities for knowledge synthesis

Examining the overlap between the study topics that have received the most attention and existing systematic reviews, there was some positive overlap. For example, gender identity and expression is one of the most researched subject areas and is the topic of five systematic reviews. Similarly, mental health received good attention from researchers and was the focus of five systematic reviews. Sexual health, HIV, and STIs has been the subject of three reviews.

As discussed, therapeutics and surgeries was the most commonly investigated study topic. On the one hand, the ability to conduct reviews in this area was complicated by study designs that tended to emphasize case reports. That said, researchers have taken several approaches to synthesizing knowledge in this area, including case series and analysis of outcomes linked to specific therapeutic interventions or surgeries (e.g., long-term impact of cross-gender hormone treatment, or complications from silicone injection). In addition, although they were not included in this study because they did not meet the criteria for systematic reviews, some authors who are also surgeons review their experiences with surgical procedures, including outcomes and advances in technique.

While 20 systematic reviews of descriptive and qualitative studies have been conducted, there are opportunities for additional knowledge synthesis related to the following: specific aspects of gender identity and expression such as disclosure, or social or medical transition; discrimination and marginalization; physical health; health and mental health services; social support, relationships, and families; and resilience, well-being, and quality of life. Other topics in the map that received less attention (although they each included at least 15 studies) were as follows: sexuality; ethnicity, culture, race, and racialization; violence and trauma; early life experiences; resistance and politicization; education; law and criminalization; employment; arts and creativity; and sex work. These are all relevant and important topics for future systematic or scoping reviews.

Limitations

The primary limitations of this study relate to resources and technology. Time and financial resources necessitated limiting the map to studies published between 2010 and 2014. To complete the full map, it will be necessary to screen an additional 7,118 references on full text, and references that meet the inclusion criteria will need further data extraction. In addition, to update the map to 2017 would require the searches to be updated and these references would then need to be screened on title and abstract, and where relevant on full text.

Resource constraints have also limited the type of research included in the evidence map. This project is focused on documenting research with trans people from the perspective of human subjects research ethics. As a result, all studies in the map include at least one trans participant. One drawback is that this also means studies about trans topics that do not include trans people are not currently a part of the evidence map. For example, a study to evaluate the knowledge and awareness of health care providers in relation to trans health would not be included, unless it explicitly also included one or more trans participants. While these types of studies form part of the larger field of trans research, this work is not visible in this dataset.

Similarly, the evidence map contains empirical research published in English in peer-reviewed journals. In stating this, it is also important to acknowledge that it does not include solely theoretical, conceptual, or historical work, unless that work is based on original or secondary data analysis with trans participants. There are also no community research reports (sometimes referred to as “gray” literature) or book chapters. In focusing on one aspect of research with trans participants, our intent was not to contribute to making this other work less visible or to imply that it does not constitute an important aspect of the broader field of trans studies.

That the map is already out of date before being published points to the critical need for different ways of working. In time, promising new developments in text mining, automation, and semiautomation will allow us to complete large, living reviews and share this information with key stakeholders in a more timely manner.

Hesitations: the implications of mapping

There is great potential for this evidence map and the accompanying database to be useful to community members, researchers, clinicians, and policymakers. There are also limitations to how useful it can be to community members if information is not presented in an accessible manner. In addition, research itself can be damaging. As noted by Ansara and Hegarty, 37 some research continues to perpetuate pathologizing beliefs and to misgender participants from multiple angles.

The selection of the term “evidence map” is informative. Building on the work of Ahmed, 38 and her approach to following multiple meanings of words and concepts, it is useful to be circumspect about the concept of evidence in relation to evidence-based practice, and about research as a form of evidence. One should be mindful of the implicit goals of empirical research, and question evidence as “evidence of what?,” and “evidence for what?.” In addition to providing data, the research articles in this review are themselves a form of evidence, documenting the actions and decisions of researchers and clinicians.

In speaking of evidence maps, we refer as well to evidence gaps. What do gaps mean in the context of research about trans people? The word gap suggests that something is absent. However, we should ask whether what is missing is something that should be there. What do these gaps hinder and what purpose might they also serve, and perhaps more importantly, whom do they serve? This analysis leads to larger questions about who and what gets studied, who makes these decisions, and what motivates researcher attention.

Critical Data Studies 39 highlights the connections between “the spatial nature of data” and “the processes of data production and accumulation” (p. 1). Data visualizations such as maps are built on templates of those that have come before. In some ways, this map is no different. It mirrors a tradition of evidence mapping and borrows from longer standing frameworks related to social determinants of health and medical framing of experiences. Where this project is different is in the ways we consider the potential of digital evidence maps as living documents 40 that can be leveraged to document previous ways of working and to “challenge the legacies of colonialism—to emphasize local knowledge and local control” (p. 422). 41

In identifying future directions for research and knowledge synthesis, it is critical to engage trans communities and other stakeholders in local and global contexts to determine research priorities. Engagement is about more than participation: rather we advocate for the centering of trans people, and more specifically trans women of color. 42 There are many excellent examples of these forms of engagement, including Marvellous Grounds: Queer of Colour Spaces in Toronto 43 and the work of Reisner et al. at the Fenway Institute. 44 These types of involvement will help to ensure that the knowledge that is produced is relevant to trans communities and to stakeholders such as policy-makers, health care providers, and educators. Within this study, we have taken the approach that it is better for people to be aware of the types of research that are being conducted. These insights make it clearer as to whose knowledge and perspectives are centered in this work, and it is more likely that trans communities and our allies will be in a position to benefit from existing research and hold researchers accountable as community awareness increases.

Supplementary Material

Acknowledgments.

The authors wish to acknowledge the generous contributions of community members who provided consultation on search terms and data extraction. In addition, we are grateful for the work of a large team of research assistants who supported this project at different stages of the review process. This work would also not have been possible without the librarians, library assistants, and library technicians at Memorial University, Dalhousie University, the University of Waterloo, and others who retrieved and processed 1,192 Interlibrary Loan requests. During this study, Z.M. was supported by a doctoral fellowship funded by the Canadian Institutes of Health Research and the Research and Development Corporation (RDC) of Newfoundland and Labrador, and by the Canadian Mental Health Association-Newfoundland and Labrador (CMHA-NL). V.W. holds an Ontario Early Researcher Award.

Abbreviations Used

* The articles that were categorized within the intersectionalities study topic explicitly explored the impact of interacting or interlocking identities. For example, if the article was about trans women with disabilities, or trans people of color, the authors needed to address the ways these experiences intersected to produce specific structural dynamics, rather than exploring these as stand-alone topics.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Data S1

Supplementary Data S2

Supplementary Data S3

Cite this article as: Marshall Z, Welch V, Minichiello A, Swab M, Brunger F, Kaposy C (2019) Documenting research with transgender, non-binary, and other gender diverse (trans) individuals and communities: introducing the global trans research evidence map, Transgender Health 4:1, 68–80, DOI: 10.1089/trgh.2018.0020.

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Gender medicine ‘built on shaky foundations’, Cass review finds

Analysis finds most research underpinning clinical guidelines, hormone treatments and puberty blockers to be low quality

• Review of gender services has major implications for mental health services

The head of the world’s largest review into children’s care has said that gender medicine is “built on shaky foundations”.

Dr Hilary Cass, the paediatrician commissioned to conduct a review of the services provided by the NHS to children and young people questioning their gender identity, said that while doctors tended to be cautious in implementing new findings in emerging areas of medicine, “quite the reverse happened in the field of gender care for children”.

Cass commissioned the University of York to conduct a series of analyses as part of her review.

Two papers examined the quality and development of current guidelines and recommendations for managing gender dysphoria in children and young people. Most of the 23 clinical guidelines reviewed were not independent or evidence based, the researchers found.

A third paper on puberty blockers found that of 50 studies, only one was of high quality.

Similarly, of 53 studies included in a fourth paper on the use of hormone treatment, only one was of sufficiently high quality, with little or only inconsistent evidence on key outcomes.

Here are the main findings of the reviews:

Clinical guidelines

Increasing numbers of children and young people experiencing gender dysphoria are being referred to specialist gender services. There are various guidelines outlining approaches to the clinical care of these children and adolescents.

In the first two papers, the York researchers examined the quality and development of published guidelines or clinical guidance containing recommendations for managing gender dysphoria in children and young people up to the age of 18.

They studied a total of 23 guidelines published in different countries between 1998 and 2022. All but two were published after 2010.

Most of them lacked “an independent and evidence-based approach and information about how recommendations were developed”, the researchers said.

Few guidelines were informed by a systematic review of empirical evidence and they lack transparency about how their recommendations were developed. Only two reported consulting directly with children and young people during their development, the York academics found.

“Healthcare services and professionals should take into account the poor quality and interrelated nature of published guidance to support the management of children and adolescents experiencing gender dysphoria/incongruence,” the researchers wrote.

Writing in the British Medical Journal (BMJ) , Cass said that while medicine was usually based on the pillars of integrating the best available research evidence with clinical expertise, and patient values and preferences, she “found that in gender medicine those pillars are built on shaky foundations”.

She said the World Professional Association of Transgender Healthcare (WPATH) had been “highly influential in directing international practice, although its guidelines were found by the University of York’s appraisal to lack developmental rigour and transparency”.

In the foreword to her report, Cass said while doctors tended to be cautious in implementing new findings “quite the reverse happened in the field of gender care for children”.

In one example, she said a single Dutch medical study, “suggesting puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence”, had formed the basis for their use to “spread at pace to other countries”. Subsequently, there was a “greater readiness to start masculinising/feminising hormones in mid-teens”.

She added: “Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised compared to other young people with similarly complex presentations. They deserve very much better.”

Both papers repeatedly pointed to a key problem in this area of medicine: a dearth of good data.

She said: “Filling this knowledge gap would be of great help to the young people wanting to make informed choices about their treatment.”

Cass said the NHS should put in place a “full programme of research” looking at the characteristics, interventions and outcomes of every young person presenting to gender services, with consent routinely sought for enrolment in a research study that followed them into adulthood.

Gender medicine was “an area of remarkably weak evidence”, her review found, with study results also “exaggerated or misrepresented by people on all sides of the debate to support their viewpoint”.

Alongside a puberty blocker trial, which could be in place by December, there should be research into psychosocial interventions and the use of the masculinising and feminising hormones testosterone and oestrogen, the review found.

Hormone treatment

Many trans people who seek medical intervention in their transition opt to take hormones to masculinise or feminise their body, an approach that has been used in transgender adults for decades.

“It is a well-established practice that has transformed the lives of many transgender people,” the Cass review notes, adding that while these drugs are not without long-term problems and side-effects, for many they are dramatically outweighed by the benefits.

For birth-registered females, the approach means taking testosterone, which brings about changes including the growth of facial hair and a deepening of the voice, while for birth-registered males, it involves taking hormones including oestrogen to promote changes including the growth of breasts and an increase in body fat. Some of these changes may be irreversible.

However, in recent years a growing proportion of adolescents have begun taking these cross-sex, or gender-affirming, hormones, with the vast majority who are prescribed puberty blockers subsequently moving on to such medication.

This growing take-up among young people has led to questions over the impact of these hormones in areas ranging from mental health to sexual functioning and fertility.

Now researchers at the University of York have carried out a review of the evidence, comprising an analysis of 53 previously published studies, in an attempt to set out what is known – and what is not – about the risks, benefits and possible side-effects of such hormones on young people.

All but one study, which looked at side-effects, were rated of moderate or low quality, with the researchers finding limited evidence for the impact of such hormones on trans adolescents with respect to outcomes, including gender dysphoria and body satisfaction.

The researchers noted inconsistent findings around the impact of such hormones on growth, height, bone health and cardiometabolic effects, such as BMI and cholesterol markers. In addition, they found no study assessed fertility in birth-registered females, and only one looked at fertility in birth-registered males.

“These findings add to other systematic reviews in concluding there is insufficient and/or inconsistent evidence about the risks and benefits of hormone interventions in this population,” the authors write.

However, the review did find some evidence that masculinising or feminising hormones might help with psychological health in young trans people. An analysis of five studies in the area suggested hormone treatment may improve depression, anxiety and other aspects of mental health in adolescents after 12 months of treatment, with three of four studies reporting an improvement around suicidality and/or self-harm (one reported no change).

But unpicking the precise role of such hormones is difficult. “Most studies included adolescents who received puberty suppression, making it difficult to determine the effects of hormones alone,” the authors write, adding that robust research on psychological health with long-term follow-up was needed.

The Cass review has recommended NHS England should review the current policy on masculinising or feminising hormones, advising that while there should be the option to provide such drugs from age 16, extreme caution was recommended, and there should be a clear clinical rationale for not waiting until an individual reached 18.

Puberty blockers

Treatments to suppress puberty in adolescents became available through routine clinical practice in the UK a decade ago.

While the drugs have long been used to treat precocious puberty – when children start puberty at an extremely young age – they have only been used off-label in children with gender dysphoria or incongruence since the late 1990s. The rationale for giving puberty blockers, which originated in the Netherlands, was to buy thinking time for young people and improve their ability to smooth their transition in later life.

Data from gender clinics reported in the Cass review showed the vast majority of people who started puberty suppression went on to have masculinising or feminising hormones, suggesting that puberty blockers did not buy people time to think.

To understand the broader effects of puberty blockers, researchers at the University of York identified 50 papers that reported on the effects of the drugs in adolescents with gender dysphoria or incongruence. According to their systematic review, only one of these studies was high quality, with a further 25 papers regarded as moderate quality. The remaining 24 were deemed too weak to be included in the analysis.

Many of the reports looked at how well puberty was suppressed and the treatment’s side-effects, but fewer looked at whether the drugs had their intended benefits.

Of two studies that investigated gender dysphoria and body satisfaction, neither found a change after receiving puberty blockers. The York team found “very limited” evidence that puberty blockers improved mental health.

Overall, the researchers said “no conclusions” could be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development, though there was some evidence bone health and height may be compromised during treatment.

Based on the York work, the Cass review finds that puberty blockers offer no obvious benefit in helping transgender males to help their transition in later life, particularly if the drugs do not lead to an increase in height in adult life. For transgender females, the benefits of stopping irreversible changes such as a deeper voice and facial hair have to be weighed up against the need for penile growth should the person opt for vaginoplasty, the creation of a vagina and vulva.

In March, NHS England announced that children with gender dysphoria would no longer receive puberty blockers as routine practice. Instead, their use will be confined to a trial that the Cass review says should form part of a broader research programme into the effects of masculinising and feminising hormones.

• Transgender
• Young people

More on this story

Scottish gender clinic pauses prescribing puberty blockers to under-18s

No case for closing Scotland’s only NHS gender services clinic, says first minister

Veteran trans campaigner: ‘Cass review has potential for positive change’

Cass review must be used as ‘watershed moment’ for NHS gender services, says Streeting

‘This isn’t how good scientific debate happens’: academics on culture of fear in gender medicine research

Five thousand children with gender-related distress awaiting NHS care in England

Ban on children’s puberty blockers to be enforced in private sector in England

What Cass review says about surge in children seeking gender services

Adult transgender clinics in England face inquiry into patient care

‘Children are being used as a football’: Hilary Cass on her review of gender identity services

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Spotlight: Assigning a Creative Short Story in a Gender & Sexuality Studies Course

The Communication Spotlight features innovative instructors who teach written, oral, digital/technological, kinetic, and visual communication modes.

Dr. Mahaliah A. Little is a proud alumna of Spelman College and the UNCF Mellon Mays Undergraduate Fellowship. In addition to her research interests, she is passionate about feminist pedagogy, media literacy, and the teaching of writing. 

Check out some of her work without a paywall: See “Being Toward Trauma: Theorizing Post-Violence Sexuality,” published in Rejoinder: An Online Journal Published by the Institute for Research on Women. Little is also a contributing author for the forthcoming Naylor in the Archives anthology (University of Mississippi Press). Learn more about Dr. Little’s work here .

What is the assignment? 

Creative Short Story

Students will submit a 4-5pg creative short story involving a character from course readings in lieu of an in-class final exam. This creative story is meant to be a fun way to incorporate a character or characters from stories in Lesley Nneka Arimah’s What It Means When a Man Falls from the Sky, Leone Ross’ Come, Let Us Sing Anyway, or Jesmyn Ward’s Sing Unburied, Sing. You are welcome to include elements or characters from Octavia Butler’s “The Evening, the Morning, and the Night,” as well as elements of magical realism that we’ve learned about in course readings and discussions. I understand that many or most students may not have experience writing creative fiction, but this will be an exercise in which you all can utilize your imagination. These short stories must involve at least one character, obvious element, or setting from one assigned class reading. 

How does it work?

I like this assignment because it gives students an opportunity be creative! It’s an approach to assessment that doesn’t rely on a purely formulaic academic essay, and I like designing assignments that deviate from standard forms of assessment. Unique assignments can sometimes be anxiety-producing for students, especially when they are more accustomed to routine or regimented assignments. To mitigate that worry, I include short story examples from previous students, a detailed rubric, and in-class writing time for students to get feedback in real-time from their classmates and from me.

What do students say?

“I really enjoyed the course content overall this maybe one of my favorite courses I’ve taken since starting college! However, if I had to choose one aspect it would be the opportunity to do our own creative writing!”  — Student A

“I usually only write/focus on research and analytical essays because of my major, so writing my own short story related to the material has helped me flex my creative writing muscles.” — Student B

Student Artifact: 

This student is deeply curious about the world around her, and I’ve had the pleasure of having her in two of my classes in the past two years. SaMiah’s assignment is a strong example of the creative short story assignment in my section of Gender and Sexuality Studies 170: Race and Magical Realism course for its detail, underlying social commentary, and its immersive quality. She successfully references themes and elements of three short stories we read during Winter quarter, and she innovates her own original protagonist, settings, and conflicts to flesh out the glimpse in time her story represents. One of the short stories she cites as inspiration, Lesley Nneka Arimah’s “What Is A Volcano?” is written in the style of a oral origin myth. The way that SaMiah incorporates the feel of an ancient story or legend that’s been passed down through generations is a sight to behold!

Excerpt from SaMiah’s Creative Short Story:

“Luckily for you I have been graced with a life long enough to have seen the manifestation of one other Secret Keeper prior to you unfortunately though,” the old woman pauses for a moment then let out a deep sigh continuing “unfortunately, Secret Keepers don’t tend to have very long lifespans. The one before you died when she was around your age, possibly younger.” “How did she die?” The girl asked, feeling a deep and unexplainable sorrow in the pit of her stomach. “Killed.” the old woman says simply.

Click here to read the rest of SaMiah’s story and see Dr. Little’s Rubric.

Why does this work?

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Zulfiya Tursunova Presents at the 12th Annual London Research Workshop on Gender inequalities and women’s rights in Central Asia

Chairperson of the Department of Peace and Conflict Studies and an Associate Professor, Zulfiya Tursunova, gave a talk on “Precarity amid COVID -19 in Uzbekistan” at the London Central Asia Research Network held on January 27th, 2024. Feminist scholars examined the impact of precarity on women’s empowerment and bargaining power, and how their agency affects outcomes such as health and domestic violence. In the Asia Pacific, while the job losses and the decline of working hours impacted both genders’ mental health, women who experienced an increase in unpaid domestic and care work were more likely to report a decline in mental and emotional well-being than men who experienced such an increase. According to the United Nations studies, essential frontline health workers, 82% of whom are female, have experienced extreme stress during the pandemic in Uzbekistan. Half of female healthcare workers reported suffering from anxiety, burnout, and depression. The studies revealed that the pandemic has been disrupting main health services and reduced women’s economic, social, and psychological well-being disproportionately in Uzbekistan.

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Tim Kircher Advises Virginia Tech Inaugural Leadership in Technology Fellows

Timothy kircher presents talks on renaissance letters, zulfiya tursunova presents at the roundtable “decentering russian history through central asia” at the 2024 southern conference on slavic studies, we’ve saved your selection..

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DEVELOPING: Israel carries out strike in Iran

Prestigious cancer research institute has retracted 7 studies amid controversy over errors

Seven studies from researchers at the prestigious Dana-Farber Cancer Institute have been retracted over the last two months after a scientist blogger alleged that images used in them had been manipulated or duplicated.

The retractions are the latest development in a monthslong controversy around research at the Boston-based institute, which is a teaching affiliate of Harvard Medical School. 

The issue came to light after Sholto David, a microbiologist and volunteer science sleuth based in Wales, published a scathing post on his blog in January, alleging errors and manipulations of images across dozens of papers produced primarily by Dana-Farber researchers . The institute acknowledged errors and subsequently announced that it had requested six studies to be retracted and asked for corrections in 31 more papers. Dana-Farber also said, however, that a review process for errors had been underway before David’s post. 

Now, at least one more study has been retracted than Dana-Farber initially indicated, and David said he has discovered an additional 30 studies from authors affiliated with the institute that he believes contain errors or image manipulations and therefore deserve scrutiny.

The episode has imperiled the reputation of a major cancer research institute and raised questions about one high-profile researcher there, Kenneth Anderson, who is a senior author on six of the seven retracted studies. 

Anderson is a professor of medicine at Harvard Medical School and the director of the Jerome Lipper Multiple Myeloma Center at Dana-Farber. He did not respond to multiple emails or voicemails requesting comment. 

The retractions and new allegations add to a larger, ongoing debate in science about how to protect scientific integrity and reduce the incentives that could lead to misconduct or unintentional mistakes in research. 

The Dana-Farber Cancer Institute has moved relatively swiftly to seek retractions and corrections. 

“Dana-Farber is deeply committed to a culture of accountability and integrity, and as an academic research and clinical care organization we also prioritize transparency,” Dr. Barrett Rollins, the institute’s integrity research officer, said in a statement. “However, we are bound by federal regulations that apply to all academic medical centers funded by the National Institutes of Health among other federal agencies. Therefore, we cannot share details of internal review processes and will not comment on personnel issues.”

The retracted studies were originally published in two journals: One in the Journal of Immunology and six in Cancer Research. Six of the seven focused on multiple myeloma, a form of cancer that develops in plasma cells. Retraction notices indicate that Anderson agreed to the retractions of the papers he authored.

Elisabeth Bik, a microbiologist and longtime image sleuth, reviewed several of the papers’ retraction statements and scientific images for NBC News and said the errors were serious. 

“The ones I’m looking at all have duplicated elements in the photos, where the photo itself has been manipulated,” she said, adding that these elements were “signs of misconduct.” 

Dr.  John Chute, who directs the division of hematology and cellular therapy at Cedars-Sinai Medical Center and has contributed to studies about multiple myeloma, said the papers were produced by pioneers in the field, including Anderson. 

“These are people I admire and respect,” he said. “Those were all high-impact papers, meaning they’re highly read and highly cited. By definition, they have had a broad impact on the field.” 

Chute said he did not know the authors personally but had followed their work for a long time.

“Those investigators are some of the leading people in the field of myeloma research and they have paved the way in terms of understanding our biology of the disease,” he said. “The papers they publish lead to all kinds of additional work in that direction. People follow those leads and industry pays attention to that stuff and drug development follows.”

The retractions offer additional evidence for what some science sleuths have been saying for years: The more you look for errors or image manipulation, the more you might find, even at the top levels of science. 

Scientific images in papers are typically used to present evidence of an experiment’s results. Commonly, they show cells or mice; other types of images show key findings like western blots — a laboratory method that identifies proteins — or bands of separated DNA molecules in gels. 

Science sleuths sometimes examine these images for irregular patterns that could indicate errors, duplications or manipulations. Some artificial intelligence companies are training computers to spot these kinds of problems, as well. 

Duplicated images could be a sign of sloppy lab work or data practices. Manipulated images — in which a researcher has modified an image heavily with photo editing tools — could indicate that images have been exaggerated, enhanced or altered in an unethical way that could change how other scientists interpret a study’s findings or scientific meaning. 

Top scientists at big research institutions often run sprawling laboratories with lots of junior scientists. Critics of science research and publishing systems allege that a lack of opportunities for young scientists, limited oversight and pressure to publish splashy papers that can advance careers could incentivize misconduct. 

These critics, along with many science sleuths, allege that errors or sloppiness are too common , that research organizations and authors often ignore concerns when they’re identified, and that the path from complaint to correction is sluggish. 

“When you look at the amount of retractions and poor peer review in research today, the question is, what has happened to the quality standards we used to think existed in research?” said Nick Steneck, an emeritus professor at the University of Michigan and an expert on science integrity.

David told NBC News that he had shared some, but not all, of his concerns about additional image issues with Dana-Farber. He added that he had not identified any problems in four of the seven studies that have been retracted. 

“It’s good they’ve picked up stuff that wasn’t in the list,” he said. 

NBC News requested an updated tally of retractions and corrections, but Ellen Berlin, a spokeswoman for Dana-Farber, declined to provide a new list. She said that the numbers could shift and that the institute did not have control over the form, format or timing of corrections. 

“Any tally we give you today might be different tomorrow and will likely be different a week from now or a month from now,” Berlin said. “The point of sharing numbers with the public weeks ago was to make clear to the public that Dana-Farber had taken swift and decisive action with regard to the articles for which a Dana-Farber faculty member was primary author.” 

She added that Dana-Farber was encouraging journals to correct the scientific record as promptly as possible. 

Bik said it was unusual to see a highly regarded U.S. institution have multiple papers retracted. 

“I don’t think I’ve seen many of those,” she said. “In this case, there was a lot of public attention to it and it seems like they’re responding very quickly. It’s unusual, but how it should be.”

Evan Bush is a science reporter for NBC News. He can be reached at [email protected].

Institute of Advanced Studies (IAS)

• Think Pieces
• Calls & Funding
• Early Career Network

Call for Papers 'Precarity in Urban China: Surviving in Capitalist Ruins'

17 April 2024

We are inviting research papers for 15-minute presentations as part of an in-person only workshop at the Institute of Advanced Studies on 21st June, 2024. Deadline for submissions: 15th May, 2024

Keynote speakers

Prof Margaret Hillenbrand, University of Oxford Dr Carwyn Morris, University of Leiden

The Chinese city now exists in a time and space where the economy slows, work intensifies, and Xi Jinping’s “Chinese Dream” of social mobility seems to dim. In this context, surviving and thriving in the city has become increasingly resource intensive and experiences of precarity have diversified. As Margaret Hillenbrand (2023) has recently demonstrated, states of precarity in China’s urban spaces have been largely underexplored by scholars. Yet exploring precarity in Chinese cities can help us scrutinise the “global city” (Saskia Sassen, 1991) with a local eye: international capitalism under state-managed conditions has created particular pressures and responses which call for academic investigation. 

Funded by the IAS Critical Area Studies Fund , this half-day workshop uses Anna Tsing’s (2015) The Mushroom at the End of the World as a gateway to invite participants from the humanities and social sciences to explore these local conditions, particularly in connection to the idea that meaningful lives and meaning are pieced together in the “ruins” of capitalism. The concept of capitalist ruins invokes images of what is left behind in the wake of capitalist advancement and reminds us that capitalism has boundaries and externality, domains of non-capitalist experience from which capitalism itself scavenges. Using Tsing’s work as an entry point, this workshop invites researchers to think of their work in China’s cities in connection to these notions of “salvage accumulation,” and to explore the “landscapes of unintentional design” that rapid development leaves behind, while also drawing attention to the global pull of supply chains and markets. Ranging from lived experiences of precarity and informal work, the gig economy and social media livelihoods, to urban exploration, to urban design and planning policy, through to play and rebellion in the city, this workshop aims to highlight the Chinese city as both a space of precarity and a space made out of the creative response to that precarity. 

We warmly welcome contributors from researchers at all career stages to participate in two panels of 3-4 papers and discussions. To apply, please submit the following information:

• Presentation title and 300-word abstract
• 100-word bio
• Email to the organisers, Dr Alison Lamont (IOE, UCL) and Dr Annabella Massey (IOE, UCL) at  [email protected] by 5pm BST on Wednesday 15th May, 2024

Please note this workshop will take place in-person at UCL, London. Refreshments will be provided during the day, and a speaker’s dinner will be provided after the event at a local restaurant.

This paper is in the following e-collection/theme issue:

Published on 17.4.2024 in Vol 26 (2024)

Digital Interventions for Recreational Cannabis Use Among Young Adults: Systematic Review, Meta-Analysis, and Behavior Change Technique Analysis of Randomized Controlled Studies

Authors of this article:

• José Côté 1, 2, 3 , RN, PhD   ; 
• Gabrielle Chicoine 3, 4 , RN, PhD   ; 
• Billy Vinette 1, 3 , RN, MSN   ; 
• Patricia Auger 2, 3 , MSc   ; 
• Geneviève Rouleau 3, 5, 6 , RN, PhD   ; 
• Guillaume Fontaine 7, 8, 9 , RN, PhD   ; 
• Didier Jutras-Aswad 2, 10 , MSc, MD  

1 Faculty of Nursing, Université de Montréal, Montreal, QC, Canada

2 Research Centre of the Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada

3 Research Chair in Innovative Nursing Practices, Montreal, QC, Canada

4 Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada

5 Department of Nursing, Université du Québec en Outaouais, Saint-Jérôme, QC, Canada

6 Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada

7 Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada

8 Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada

9 Kirby Institute, University of New South Wales, Sydney, Australia

10 Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada

Corresponding Author:

José Côté, RN, PhD

Research Centre of the Centre Hospitalier de l’Université de Montréal

850 Saint-Denis

Montreal, QC, H2X 0A9

Phone: 1 514 890 8000

Email: [email protected]

Background: The high prevalence of cannabis use among young adults poses substantial global health concerns due to the associated acute and long-term health and psychosocial risks. Digital modalities, including websites, digital platforms, and mobile apps, have emerged as promising tools to enhance the accessibility and availability of evidence-based interventions for young adults for cannabis use. However, existing reviews do not consider young adults specifically, combine cannabis-related outcomes with those of many other substances in their meta-analytical results, and do not solely target interventions for cannabis use.

Objective: We aimed to evaluate the effectiveness and active ingredients of digital interventions designed specifically for cannabis use among young adults living in the community.

Methods: We conducted a systematic search of 7 databases for empirical studies published between database inception and February 13, 2023, assessing the following outcomes: cannabis use (frequency, quantity, or both) and cannabis-related negative consequences. The reference lists of included studies were consulted, and forward citation searching was also conducted. We included randomized studies assessing web- or mobile-based interventions that included a comparator or control group. Studies were excluded if they targeted other substance use (eg, alcohol), did not report cannabis use separately as an outcome, did not include young adults (aged 16-35 y), had unpublished data, were delivered via teleconference through mobile phones and computers or in a hospital-based setting, or involved people with mental health disorders or substance use disorders or dependence. Data were independently extracted by 2 reviewers using a pilot-tested extraction form. Authors were contacted to clarify study details and obtain additional data. The characteristics of the included studies, study participants, digital interventions, and their comparators were summarized. Meta-analysis results were combined using a random-effects model and pooled as standardized mean differences.

Results: Of 6606 unique records, 19 (0.29%) were included (n=6710 participants). Half (9/19, 47%) of these articles reported an intervention effect on cannabis use frequency. The digital interventions included in the review were mostly web-based. A total of 184 behavior change techniques were identified across the interventions (range 5-19), and feedback on behavior was the most frequently used (17/19, 89%). Digital interventions for young adults reduced cannabis use frequency at the 3-month follow-up compared to control conditions (including passive and active controls) by −6.79 days of use in the previous month (95% CI −9.59 to −4.00; P <.001).

Conclusions: Our results indicate the potential of digital interventions to reduce cannabis use in young adults but raise important questions about what optimal exposure dose could be more effective, both in terms of intervention duration and frequency. Further high-quality research is still needed to investigate the effects of digital interventions on cannabis use among young adults.

Trial Registration: PROSPERO CRD42020196959; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=196959

Introduction

Cannabis use among young adults is recognized as a public health concern.

Young adulthood (typically the ages of 18-30 y) is a critical developmental stage characterized by a peak prevalence of substance use [ 1 , 2 ]. Worldwide, cannabis is a substance frequently used for nonmedical purposes due in part to its high availability in some regions and enhanced product variety and potency [ 3 , 4 ]. The prevalence of cannabis use (CU) among young adults is high [ 5 , 6 ], and its rates have risen in recent decades [ 7 ]. In North America and Oceania, the estimated past-year prevalence of CU is ≥25% among young adults [ 8 , 9 ].

While the vast majority of cannabis users do not experience severe problems from their use [ 4 ], the high prevalence of CU among young adults poses substantial global health concerns due to the associated acute and long-term health and psychosocial risks [ 10 , 11 ]. These include impairment of cognitive function, memory, and psychomotor skills during acute intoxication; increased engagement in behaviors with a potential for injury and fatality (eg, driving under the influence); socioeconomic problems; and diminished social functioning [ 4 , 12 - 14 ]. Importantly, an extensive body of literature reveals that subgroups engaging in higher-risk use, such as intensive or repeated use, are more prone to severe and chronic consequences, including physical ailments (eg, respiratory illness and reproductive dysfunction), mental health disorders (eg, psychosis, depression, and suicidal ideation or attempts), and the potential development of CU disorder [ 4 , 15 - 17 ].

Interventions to Reduce Public Health Impact of Young Adult CU

Given the increased prevalence of lifetime and daily CU among young adults and the potential negative impact of higher-risk CU, various prevention and intervention programs have been implemented to help users reduce or cease their CU. These programs primarily target young adults regardless of their CU status [ 2 , 18 ]. In this context, many health care organizations and international expert panels have developed evidence-based lower-risk CU guidelines to promote safer CU and intervention options to help reduce risks of adverse health outcomes from nonmedical CU [ 4 , 16 , 17 , 19 ]. Lower-risk guidance-oriented interventions for CU are based on concepts of health promotion [ 20 - 22 ] and health behavior change [ 23 - 26 ] and on other similar harm reduction interventions implemented in other areas of population health (eg, lower-risk drinking guidelines, supervised consumption sites and services, and sexual health) [ 27 , 28 ]. These interventions primarily aim to raise awareness of negative mental, physical, and social cannabis-related consequences to modify individual-level behavior-related risk factors.

Meta-analyses have shown that face-to-face prevention and treatment interventions are generally effective in reducing CU in young adults [ 18 , 29 - 32 ]. However, as the proportion of professional help seeking for CU concerns among young adults remains low (approximately 15%) [ 33 , 34 ], alternative strategies that consider the limited capacities and access-related barriers of traditional face-to-face prevention and treatment facilities are needed. Digital interventions, including websites, digital platforms, and mobile apps, have emerged as promising tools to enhance the accessibility and availability of evidence-based programs for young adult cannabis users. These interventions address barriers such as long-distance travel, concerns about confidentiality, stigma associated with seeking treatment, and the cost of traditional treatments [ 35 - 37 ]. By overcoming these barriers, digital interventions have the potential to have a stronger public health impact [ 18 , 38 ].

State of Knowledge of Digital Interventions for CU and Young Adults

The literature regarding digital interventions for substance use has grown rapidly in the past decade, as evidenced by several systematic reviews and meta-analyses of randomized controlled trial (RCT) studies on the efficacy or effectiveness of these interventions in preventing or reducing harmful substance use [ 2 , 39 - 41 ]. However, these reviews do not focus on young adults specifically. In addition, they combine CU-related outcomes with those of many other substances in their meta-analytical results. Finally, they do not target CU interventions exclusively.

In total, 4 systematic reviews and meta-analyses of digital interventions for CU among young people have reported mixed results [ 42 - 45 ]. In their systematic review (10 studies of 5 prevention and 5 treatment interventions up to 2012), Tait et al [ 44 ] concluded that digital interventions effectively reduced CU among adolescents and adults at the posttreatment time point. Olmos et al [ 43 ] reached a similar conclusion in their meta-analysis of 9 RCT studies (2 prevention and 7 treatment interventions). In their review, Hoch et al [ 42 ] reported evidence of small effects at the 3-month follow-up based on 4 RCTs of brief motivational interventions and cognitive behavioral therapy (CBT) delivered on the web. In another systematic review and meta-analysis, Beneria et al [ 45 ] found that web-based CU interventions did not significantly reduce consumption. However, these authors indicated that the programs tested varied significantly across the studies considered and that statistical heterogeneity was attributable to the inclusion of studies of programs targeting more than one substance (eg, alcohol and cannabis) and both adolescents and young adults. Beneria et al [ 45 ] recommend that future work “establish the effectiveness of the newer generation of interventions as well as the key ingredients” of effective digital interventions addressing CU by young people. This is of particular importance because behavior change interventions tend to be complex as they consist of multiple interactive components [ 46 ].

Behavior change interventions refer to “coordinated sets of activities designed to change specified behavior patterns” [ 47 ]. Their interacting active ingredients can be conceptualized as behavior change techniques (BCTs) [ 48 ]. BCTs are specific and irreducible. Each BCT has its own individual label and definition, which can be used when designing and reporting complex interventions and as a nomenclature system when coding interventions for their content [ 47 ]. The Behavior Change Technique Taxonomy version 1 (BCTTv1) [ 48 , 49 ] was developed to provide a shared, standardized terminology for characterizing complex behavior change interventions and their active ingredients. Several systematic reviews with meta-regressions that used the BCTTv1 have found interventions with certain BCTs to be more effective than those without [ 50 - 53 ]. A better understanding of the BCTs used in digital interventions for young adult cannabis users would help not only to establish the key ingredients of such interventions but also develop and evaluate effective interventions.

In the absence of any systematic review of the effectiveness and active ingredients of digital interventions designed specifically for CU among community-living young adults, we set out to achieve the following:

• conduct a comprehensive review of digital interventions for preventing, reducing, or ceasing CU among community-living young adults,
• describe the active ingredients (ie, BCTs) in these interventions from the perspective of behavior change science, and
• analyze the effectiveness of these interventions on CU outcomes.

Protocol Registration

We followed the Cochrane Handbook for Systematic Reviews of Interventions [ 54 ] in designing this systematic review and meta-analysis and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines in reporting our findings (see Multimedia Appendix 1 [ 55 ] for the complete PRISMA checklist). This review was registered in PROSPERO (CRD42020196959).

Search Strategy

The search strategy was designed by a health information specialist together with the research team and peer reviewed by another senior information specialist before execution using Peer Review of Electronic Search Strategies for systematic reviews [ 56 ]. The search strategy revolved around three concepts:

• CU (eg, “cannabis,” “marijuana,” and “hashish”)
• Digital interventions (eg, “telehealth,” “website,” “mobile applications,” and “computer”)
• Young adults (eg, “emerging adults” and “students”)

The strategy was initially implemented on March 18, 2020, and again on October 13, 2021, and February 13, 2023. The full, detailed search strategies for each database are presented in Multimedia Appendix 2 .

Information Sources

We searched 7 electronic databases of published literature: CINAHL Complete, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, PubMed, and PsycINFO. No publication date filters or language restrictions were applied. A combination of free-text keywords and Medical Subject Headings was tailored to the conventions of each database for optimal electronic searching. The research team also manually screened the reference lists of the included articles and the bibliographies of existing systematic reviews [ 18 , 31 , 42 - 45 ] to identify additional relevant studies (snowballing). Finally, a forward citation tracking procedure (ie, searching for articles that cited the included studies) was carried out in Google Scholar.

Inclusion Criteria

The population, intervention, comparison, outcome, and study design process is presented in Multimedia Appendix 3 . The inclusion criteria were as follows: (1) original research articles published in peer-reviewed journals; (2) use of an experimental study design (eg, RCT, cluster RCT, or pilot RCT); (3) studies evaluating the effectiveness (or efficacy) of digital interventions designed specifically to prevent, reduce, or cease CU as well as promote CU self-management or address cannabis-related harm and having CU as an outcome measure; (4) studies targeting young adults, including active and nonactive cannabis users; (5) cannabis users and nonusers not under substance use treatment used as controls in comparator, waitlist, or delayed-treatment groups offered another type of intervention (eg, pharmacotherapy or psychosocial) different from the one being investigated or participants assessed only for CU; and (6) quantitative CU outcomes (frequency and quantity) or cannabis abstinence. Given the availability of numerous CU screening and assessment tools with adequate psychometric properties and the absence of a gold standard in this regard [ 57 ], any instrument capturing aspects of CU was considered. CU outcome measures could be subjective (eg, self-reported number of CU days or joints in the previous 3 months) or objective (eg, drug screening test). CU had to be measured before the intervention (baseline) and at least once after.

Digital CU interventions were defined as web- or mobile-based interventions that included one or more activities (eg, self-directed or interactive psychoeducation or therapy, personalized feedback, peer-to-peer contact, and patient-to-expert communication) aimed at changing CU [ 58 ]. Mobile-based interventions were defined as interventions delivered via mobile phone through SMS text message, multimedia messaging service (ie, SMS text messages that include　multimedia content, such as pictures, videos, or emojis), or mobile apps, whereas web-based interventions (eg, websites and digital platforms) were defined as interventions designed to be accessed on the web (ie, the internet), mainly via computers. Interventions could include self-directed and web-based interventions with human support. We defined young adults as aged 16 to 35 years and included students and nonstudents. While young adulthood is typically defined as covering the ages of 18 to 30 years [ 59 ], we broadened the range given that the age of majority and legal age to purchase cannabis differs across countries and jurisdictions. This was also in line with the age range targeted by several digital CU interventions (college or university students or emerging adults aged 15-24 years) [ 31 , 45 ]. Given the language expertise of the research team members and the available resources, only English- and French-language articles were retained.

Exclusion Criteria

Knowledge synthesis articles, study protocols, and discussion papers or editorials were excluded, as were articles with cross-sectional, cohort, case study or report, pretest-posttest, quasi-experimental, or qualitative designs. Mixed methods designs were included only if the quantitative component was an RCT. We excluded studies if (1) use of substances other than cannabis (eg, alcohol, opioids, or stimulants) was the focus of the digital intervention (though studies that included polysubstance users were retained if CU was assessed and reported separately); (2) CU was not reported separately as an outcome or only attitudes or beliefs regarding, knowledge of, intention to reduce, or readiness or motivation to change CU was measured; and (3) the data reported were unpublished (eg, conferences and dissertations). Studies of traditional face-to-face therapy delivered via teleconference on mobile phones and computers or in a hospital-based setting and informational campaigns (eg, web-based poster presentations or pamphlets) were excluded as well. Studies with samples with a maximum age of <15 years and a minimum age of >35 years were also excluded. Finally, we excluded studies that focused exclusively on people with a mental health disorder or substance use disorder or dependence or on adolescents owing to the particular health care needs of these populations, which may differ from those of young adults [ 1 ].

Data Collection

Selection of studies.

Duplicates were removed from the literature search results in EndNote (version X9.3.3; Clarivate Analytics) using the Bramer method for deduplication of database search results for systematic reviews [ 60 ]. The remaining records were uploaded to Covidence (Veritas Health Innovation), a web-based systematic review management system. A reviewer guide was developed that included screening questions and a detailed description of each inclusion and exclusion criterion based on PICO (population, intervention, comparator, and outcome), and a calibration exercise was performed before each stage of the selection process to maximize consistency between reviewers. Titles and abstracts of studies flagged for possible inclusion were screened first by 2 independent reviewers (GC, BV, PA, and GR; 2 per article) against the eligibility criteria (stage 1). Articles deemed eligible for full-text review were then retrieved and screened for inclusion (stage 2). Full texts were assessed in detail against the eligibility criteria again by 2 reviewers independently. Disagreements between reviewers were resolved through consensus or by consulting a third reviewer.

Data Extraction Process

In total, 2 reviewers (GC, BV, PA, GR, and GF; 2 per article) independently extracted relevant data (or informal evidence) using a data extraction form developed specifically for this review and integrated into Covidence. The form was pilot-tested on 2 randomly selected studies and refined accordingly. Data pertaining to the following domains were extracted from the included studies: (1) Study characteristics included information on the first and corresponding authors, publication year, country of origin, aims and hypotheses, study period, design (including details on randomization and blinding), follow-up times, data collection methods, and types of statistical analysis. (2) Participant characteristics included study target population, participant inclusion and exclusion criteria, sex or gender, mean age, and sample sizes at each data collection time point. (3) Intervention characteristics, for which the research team developed a matrix inspired by the template for intervention description and replication 12-item checklist [ 61 ] to extract informal evidence (ie, intervention descriptions) from the included studies under the headings name of intervention, purpose, underpinning theory of design elements, treatment approach, type of technology (ie, web or mobile) and software used, delivery format (ie, self-directed, human involvement, or both), provider characteristics (if applicable), intervention duration (ie, length of treatment and number of sessions or modules), material and procedures (ie, tools or activities offered, resources provided, and psychoeducational content), tailoring, and unplanned modifications. (4) Comparator characteristics were details of the control or comparison group or groups, including nature (passive vs active), number of groups or clusters (if applicable), type and length of the intervention (if applicable), and number of participants at each data collection time point. (5) Outcome variables, including the primary outcome variable examined in this systematic review, that is, the mean difference in CU frequency before and after the intervention and between the experimental and control or comparison groups. When possible, we examined continuous variables, including CU frequency means and SDs at the baseline and follow-up time points, and standardized regression coefficients (ie, β coefficients and associated 95% CIs). The secondary outcomes examined included other CU outcome variables (eg, quantity of cannabis used and abstinence) and cannabis-related negative consequences (or problems). Details on outcome variables (ie, definition, data time points, and missing data) and measurements (ie, instruments, measurement units, and scales) were also extracted.

In addition, data on user engagement and use of the digital intervention and study attrition rates (ie, dropouts and loss to follow-up) were extracted. When articles had missing data, we contacted the corresponding authors via email (2 attempts were made over a 2-month period) to obtain missing information. Disagreements over the extracted data were limited and resolved through discussion.

Data Synthesis Methods

Descriptive synthesis.

The characteristics of the included studies, study participants, interventions, and comparators were summarized in narrative and table formats. The template for intervention description and replication 12-item checklist [ 61 ] was used to summarize and organize intervention characteristics and assess to what extent the interventions were appropriately described in the included articles. As not all studies had usable data for meta-analysis purposes and because of heterogeneity, we summarized the main findings (ie, intervention effects) of the included studies in narrative and table formats for each outcome of interest in this review.

The BCTs used in the digital interventions were identified from the descriptions of the interventions (ie, experimental groups) provided in the articles as well as any supplementary material and previously published research protocols. A BCT was defined as “an observable, replicable, and irreducible component of an intervention designed to alter or redirect causal processes that regulate behavior” [ 48 ]. The target behavior in this review was the cessation or reduction of CU by young adults. BCTs were identified and coded using the BCTTv1 [ 48 , 49 ], a taxonomy of 93 BCTs organized into 16 hierarchical thematic clusters or categories. Applying the BCTTv1 in a systematic review allows for the comparison and synthesis of evidence across studies in a structured manner. This analysis allows for the identification of the explicit mechanisms underlying the reported behavior change induced by interventions, successful or not, and, thus, avoids making implicit assumptions about what works [ 62 ].

BCT coding was performed by 2 reviewers independently—BV coded all studies, and GC and GF coded a subset of the studies. All reviewers completed web-based training on the BCTTv1, and GF is an experienced implementation scientist who had used the BCTTv1 in prior work [ 63 - 65 ]. The descriptions of the interventions in the articles were read line by line and analyzed for the clear presence of BCTs using the guidelines developed by Michie et al [ 48 ]. For each article, the BCTs identified were documented and categorized using supporting textual evidence. They were coded only once per article regardless of how many times they came up in the text. Disagreements about including a BCT were resolved through discussion. If there was uncertainty about whether a BCT was present, it was coded as absent. Excel (Microsoft Corp) was used to compare the reviewers’ independent BCT coding and generate an overall descriptive synthesis of the BCTs identified. The BCTs were summarized by study and BCT cluster.

Statistical Analysis

Meta-analyses were conducted to estimate the size of the effect of the digital interventions for young adult CU on outcomes of interest at the posttreatment and follow-up assessments compared with control or alternative intervention conditions. The outcome variables considered were (1) CU frequency and other CU outcome variables (eg, quantity of cannabis used and abstinence) at baseline and the posttreatment time point or follow-up measured using standardized instruments of self-reported CU (eg, the timeline followback [TLFB] method) [ 66 ] and (2) cannabis-related negative consequences measured using standardized instruments (eg, the Marijuana Problems Scale) [ 67 ].

Under our systematic review protocol, ≥2 studies were needed for a meta-analysis. On the basis of previous systematic reviews and meta-analyses in the field of digital CU interventions [ 31 , 42 - 45 ], we expected between-study heterogeneity regarding outcome assessment. To minimize heterogeneity, we chose to pool studies with similar outcomes of interest based on four criteria: (1) definition of outcome (eg, CU frequency, quantity consumed, and abstinence), (2) type of outcome variable (eg, days of CU in the previous 90 days, days high per week in the previous 30 days, and number of CU events in the previous month) and measure (ie, instruments or scales), (3) use of validated instruments, and (4) posttreatment or follow-up time points (eg, 2 weeks or 1 month after the baseline or 3, 6, and 12 months after the baseline).

Only articles that reported sufficient statistics to compute a valid effect size with 95% CIs were included in the meta-analyses. In the case of articles that were not independent (ie, more than one published article reporting data from the same clinical trial), only 1 was included, and it was represented only once in the meta-analysis for a given outcome variable regardless of whether the data used to compute the effect size were extracted from the original paper or a secondary analysis paper. We made sure that the independence of the studies included in the meta-analysis of each outcome was respected. In the case of studies that had more than one comparator, we used the effect size for each comparison between the intervention and control groups.

Meta-analyses were conducted only for mean differences based on the change from baseline in CU frequency at 3 months after the baseline as measured using the number of self-reported days of use in the previous month. As the true value of the estimated effect size for outcome variables might vary across different trials and samples, we used a random-effects model given that the studies retained did not have identical target populations. The random-effects model incorporates between-study variation in the study weights and estimated effect size [ 68 ]. In addition, statistical heterogeneity across studies was assessed using I 2 , which measures the proportion of heterogeneity to the total observed dispersion; 25% was considered low, 50% was considered moderate, and 75% was considered high [ 69 ]. Because only 3 studies were included in the meta-analysis [ 70 - 72 ], publication bias could not be assessed. All analyses were completed using Stata (version 18; StataCorp) [ 73 ].

Risk-of-Bias Assessment

The risk of bias (RoB) of the included RCTs was assessed using the Cochrane RoB 2 tool at the outcome level [ 74 ]. Each distinct risk domain (ie, randomization process, deviations from the intended intervention, missing outcome data, measurement of the outcome, and selection of the reported results) was assessed as “low,” “some concerns,” or “high” based on the RoB 2 criteria. In total, 2 reviewers (GC and BV) conducted the assessments independently. Disagreements were discussed, and if not resolved consensually by the 2, the matter was left for a third reviewer (GF) to settle. The assessments were summarized by risk domain and outcome and converted into figures using the RoB visualization tool robvis [ 75 ].

Search Results

The database search generated a total of 13,232 citations, of which 7822 (59.11%) were from the initial search on March 18, 2020, and 2805 (21.2%) and 2605 (19.69%) were from the updates on October 13, 2021, and February 13, 2023, respectively. Figure 1 presents the PRISMA study flow diagram [ 76 ]. Of the 6606 unique records, 6484 (98.15%) were excluded based on title and abstract screening. Full texts of the remaining 1.85% (122/6606) of the records were examined, as were those of 25 more reports found through hand searching. Of these 147 records, 128 (87.1%) were excluded after 3 rounds of full-text screening. Of these 128 records, 39 (30.5%) were excluded for not being empirical research articles (eg, research protocols). Another 28.1% (36/128) were excluded for not meeting our definition of digital CU intervention. The remaining records were excluded for reasons that occurred with a frequency of ≤14%, including young adults not being the target population and the study not meeting our study design criteria (ie, RCT, cluster RCT, or pilot RCT). Excluded studies and reasons for exclusion are listed in Multimedia Appendix 4 . Finally, 19 articles detailing the results of 19 original studies were included.

Description of Studies

Study characteristics.

Multimedia Appendix 5 [ 70 - 72 , 77 - 92 ] describes the general characteristics of the 19 included studies. The studies were published between 2010 and 2023, with 58% (11/19) published in 2018 or later. A total of 53% (10/19) of the studies were conducted in the United States [ 77 - 86 ], 11% (2/19) were conducted in Canada [ 87 , 88 ], 11% (2/19) were conducted in Australia [ 71 , 89 ], 11% (2/19) were conducted in Germany [ 72 , 90 ], 11% (2/19) were conducted in Switzerland [ 70 , 91 ], and 5% (1/19) were conducted in Sweden [ 92 ]. A total of 79% (15/19) were RCTs [ 70 - 72 , 77 , 79 , 81 - 83 , 86 - 92 ], and 21% (4/19) were pilot RCTs [ 78 , 80 , 84 , 85 ].

Participant Characteristics

The studies enrolled a total of 6710 participants—3229 (48.1%) in the experimental groups, 3358 (50%) in the control groups, and the remaining 123 (1.8%) from 1 study [ 82 ] where participant allocation to the intervention condition was not reported. Baseline sample sizes ranged from 49 [ 81 ] to 1292 [ 72 ] (mean 352.89, SD 289.50), as shown in Multimedia Appendix 5 . Participant mean ages ranged from 18.03 (SD 0.31) [ 79 ] to 35.3 (SD 12.6) years [ 88 ], and the proportion of participants who identified as female ranged from 24.7% [ 91 ] to 84.1% [ 80 ].

Of the 19 included studies, 10 (53%) targeted adults aged ≥18 years, of which 7 (70%) studies focused on adults who had engaged in past-month CU [ 70 , 71 , 80 , 84 , 85 , 90 , 91 ], 2 (20%) studies included adults who wished to reduce or cease CU [ 72 , 89 ], and 1 (10%) study focused on noncollege adults with a moderate risk associated with CU [ 88 ]. Sinadinovic et al [ 92 ] targeted young adults aged ≥16 years who had used cannabis at least once a week in the previous 6 months. The remaining 8 studies targeted college or university students (aged ≥17 y) specifically, of which 7 (88%) studies focused solely on students who reported using cannabis [ 78 , 79 , 81 - 83 , 86 , 87 ] and 1 (12%) study focused solely on students who did not report past-month CU (ie, abstainers) [ 77 ].

Intervention Characteristics

The 19 included studies assessed nine different digital interventions: (1) 5 (26%) evaluated Marijuana eCHECKUP TO GO (e-TOKE), a commercially available electronic intervention used at colleges throughout the United States and Canada [ 77 , 78 , 81 - 83 ]; (2) 2 (11%) examined the internationally known CANreduce program [ 70 , 91 ]; (3) 2 (11%) evaluated the German Quit the Shit program [ 72 , 90 ]; (4) 2 (11%) assessed a social media–delivered, physical activity–focused cannabis intervention [ 84 , 85 ]; (5) 1 (5%) investigated the Swedish Cannabishjälpen intervention [ 92 ]; (6) 1 (5%) evaluated the Australian Grassessment: Evaluate Your Use of Cannabis website program [ 89 ]; (7) 1 (5%) assessed the Canadian Ma réussite, mon choix intervention [ 87 ]; (8) 1 (5%) examined the Australian Reduce Your Use: How to Break the Cannabis Habit program [ 71 ]; and (9) 4 (21%) each evaluated a unique no-name intervention described as a personalized feedback intervention (PFI) [ 79 , 80 , 86 , 88 ]. Detailed information regarding the characteristics of all interventions as reported in each included study is provided in Multimedia Appendix 6 [ 70 - 72 , 77 - 113 ] and summarized in the following paragraphs.

In several studies (8/19, 42%), the interventions were designed to support cannabis users in reducing or ceasing their consumption [ 70 , 72 , 80 , 87 , 89 - 92 ]. In 37% (7/19) of the studies, the interventions aimed at reducing both CU and cannabis-related consequences [ 79 , 81 - 85 , 88 ]. Other interventions focused on helping college students think carefully about the decision to use cannabis [ 77 , 78 ] and on reducing either cannabis-related problems among undergraduate students [ 86 ] or symptoms associated with CU disorder in young adults [ 71 ].

In 26% (5/19) of the studies, theory was used to inform intervention design along with a clear rationale for theory use. Of these 5 articles, only 1 (20%) [ 87 ] reported using a single theory of behavior change, the theory of planned behavior [ 114 ]. A total of 21% (4/19) of the studies selected only constructs of theories (or models) for their intervention design. Of these 4 studies, 2 (50%) evaluated the same intervention [ 72 , 90 ], which focused on principles of self-regulation and self-control theory [ 93 ]; 1 (25%) [ 70 ] used the concept of adherence-focused guidance enhancement based on the supportive accountability model of guidance [ 94 ]; and 1 (25%) [ 71 ] reported that intervention design was guided by the concept of self-behavioral management.

The strategies (or approaches) used in the delivery of the digital interventions were discussed in greater detail in 84% (16/19) of the articles [ 70 - 72 , 79 - 81 , 83 - 92 ]. Many of these articles (9/19, 47%) reported using a combination of approaches based on CBT or motivational interviewing (MI) [ 70 , 71 , 79 , 83 - 85 , 90 - 92 ]. PFIs were also often mentioned as an approach to inform intervention delivery [ 7 , 71 , 79 , 86 - 88 ].

More than half (13/19, 68%) of all the digital interventions were asynchronous and based on a self-guided approach without support from a counselor or therapist. The study by Côté et al [ 87 ] evaluated the efficacy of a web-based tailored intervention focused on reinforcing a positive attitude toward and a sense of control over cannabis abstinence through psychoeducational messages delivered by a credible character in short video clips and personalized reinforcement messages. Lee et al [ 79 ] evaluated a brief, web-based personalized feedback selective intervention based on the PFI approach pioneered by Marlatt et al [ 95 ] for alcohol use prevention and on the MI approach described by Miller and Rollnick [ 96 ]. Similarly, Rooke et al [ 71 ] combined principles of MI and CBT to develop a web-based intervention delivered via web modules, which were informed by previous automated feedback interventions targeting substance use. The study by Copeland et al [ 89 ] assessed the short-term effectiveness of Grassessment: Evaluate Your Use of Cannabis, a brief web-based, self-complete intervention based on motivational enhancement therapy that included personalized feedback messages and psychoeducational material. In the studies by Buckner et al [ 80 ], Cunningham et al [ 88 ], and Walukevich-Dienst et al [ 86 ], experimental groups received a brief web-based PFI available via a computer. A total of 16% (3/19) of the studies [ 77 , 78 , 82 ] applied a program called the Marijuana eCHECKUP TO GO (e-TOKE) for Universities and Colleges, which was presented as a web-based, norm-correcting, brief preventive and intervention education program designed to prompt self-reflection on consequences and consideration of decreasing CU among students. Riggs et al [ 83 ] developed and evaluated an adapted version of e-TOKE that provided participants with university-specific personalized feedback and normative information based on protective behavioral strategies for CU [ 97 ]. Similarly, Goodness and Palfai [ 81 ] tested the efficacy of eCHECKUP TO GO-cannabis, a modified version of e-TOKE combining personalized feedback, norm correction, and a harm and frequency reduction strategy where a “booster” session was provided at 3 months to allow participants to receive repeated exposure to the intervention.

In the remaining 32% (6/19) of the studies, which examined 4 different interventions, the presence of a therapist guide was reported. The intervention evaluated by Sinadinovic et al [ 92 ] combined principles of psychoeducation, MI, and CBT organized into 13 web-based modules and a calendar involving therapist guidance, recommendations, and personal feedback. In total, 33% (2/6) of these studies evaluated a social media–delivered intervention with e-coaches that combined principles of MI and CBT and a harm reduction approach for risky CU [ 84 , 85 ]. Schaub et al [ 91 ] evaluated the efficacy of CANreduce, a web-based self-help intervention based on both MI and CBT approaches, using automated motivational and feedback emails, chat with a counselor, and web-based psychoeducational modules. Similarly, Baumgartner et al [ 70 ] investigated the effectiveness of CANreduce 2.0, a modified version of CANreduce, using semiautomated motivational and adherence-focused guidance-based email feedback with or without a personal online coach. The studies by Tossman et al [ 72 ] and Jonas et al [ 90 ] used a solution-focused approach and MI to evaluate the effectiveness of the German Quit the Shit web-based program that involves weekly feedback provided by counselors.

In addition to using different intervention strategies or approaches, the interventions were diverse in terms of the duration and frequency of the program (eg, web-based activities, sessions, or modules). Of the 12 articles that provided details in this regard, 2 (17%) on the same intervention described it as a brief 20- to 45-minute web-based program [ 77 , 78 ], 2 (17%) on 2 different interventions reported including 1 or 2 modules per week for a duration of 6 weeks [ 71 , 92 ], and 7 (58%) on 4 different interventions described them as being available over a longer period ranging from 6 weeks to 3 months [ 70 , 72 , 79 , 84 , 85 , 87 , 90 , 91 ].

Comparator Types

A total of 42% (8/19) of the studies [ 72 , 77 - 80 , 85 , 87 , 92 ] used a passive comparator only, namely, a waitlist control group ( Multimedia Appendix 5 ). A total of 26% (5/19) of the studies used an active comparator only where participants were provided with minimal general health feedback regarding recommended guidelines for sleep, exercise, and nutrition [ 81 , 82 ]; strategies for healthy stress management [ 83 ]; educational materials about risky CU [ 88 ]; or access to a website containing information about cannabis [ 71 ]. In another 21% (4/19) of the studies, which used an active comparator, participants received the same digital intervention minus a specific component: a personal web-based coach [ 70 ], extended personalized feedback [ 89 ], web-based chat counseling [ 91 ], or information on risks associated with CU [ 86 ]. A total of 21% (4/19) of the studies had more than one control group [ 70 , 84 , 90 , 91 ].

Outcome Variable Assessment and Summary of Main Findings of the Studies

The methodological characteristics and major findings of the included studies (N=19) are presented in Multimedia Appendix 7 [ 67 , 70 - 72 , 77 - 92 , 115 - 120 ] and summarized in the following sections for each outcome of interest in this review (ie, CU and cannabis-related consequences). Of the 19 studies, 11 (58%) were reported as efficacy trials [ 7 , 77 , 79 , 81 - 83 , 86 - 88 , 91 , 92 ], and 8 (42%) were reported as effectiveness trials [ 70 - 72 , 78 , 84 , 85 , 89 , 90 ].

Across all the included studies (19/19, 100%), participant attrition rates ranged from 1.6% at 1 month after the baseline [ 77 , 78 ] to 75.1% at the 3-month follow-up [ 70 ]. A total of 37% (7/19) of the studies assessed and reported results regarding user engagement [ 71 , 78 , 84 , 85 , 90 - 92 ] using different types of metrics. In one article on the Marijuana eCHECKUP TO GO (e-TOKE) web-based program [ 78 ], the authors briefly reported that participation was confirmed for 98.1% (158/161) of participants in the intervention group. In 11% (2/19) of the studies, which were on a similar social media–delivered intervention [ 84 , 85 ], user engagement was quantified by tallying the number of comments or posts and reactions (eg, likes and hearts) left by participants. In both studies [ 84 , 85 ], the intervention group, which involved a CU-related Facebook page, displayed greater interactions than the control groups, which involved a Facebook page unrelated to CU. One article [ 84 ] reported that 80% of participants in the intervention group posted at least once (range 0-60) and 50% posted at least weekly. In the other study [ 85 ], the results showed that intervention participants engaged (ie, posting or commenting or clicking reactions) on average 47.9 times each over 8 weeks. In total, 11% (2/19) of the studies [ 90 , 91 ] on 2 different web-based intervention programs, both consisting of web documentation accompanied by chat-based counseling, measured user engagement either by average duration or average number of chat sessions. Finally, 16% (3/19) of the studies [ 71 , 91 , 92 ], which involved 3 different web-based intervention programs, characterized user engagement by the mean number of web modules completed per participant. Overall, the mean number of web modules completed reported in these articles was quite similar: 3.9 out of 13 [ 92 ] and 3.2 [ 91 ] and 3.5 [ 71 ] out of 6.

Assessment of CU

As presented in Multimedia Appendix 7 , the included studies differed in terms of how they assessed CU, although all used at least one self-reported measure of frequency. Most studies (16/19, 84%) measured frequency by days of use, including days of use in the preceding week [ 91 ] or 2 [ 80 ], days of use in the previous 30 [ 70 - 72 , 78 , 84 - 86 , 88 - 90 ] or 90 days [ 79 , 81 , 82 ], and days high per week [ 83 ]. Other self-reported measures of CU frequency included (1) number of CU events in the previous month [ 87 , 90 ], (2) cannabis initiation or use in the previous month (ie, yes or no) [ 77 ], and (3) days without CU in the previous 7 days [ 92 ]. In addition to measuring CU frequency, 42% (8/19) of the studies also assessed CU via self-reported measures of quantity used, including estimated grams consumed in the previous week [ 92 ] or 30 days [ 72 , 85 , 90 ] and the number of standard-sized joints consumed in the previous 7 days [ 91 ] or the previous month [ 70 , 71 , 89 ].

Of the 19 articles included, 10 (53%) [ 70 - 72 , 80 , 84 - 86 , 89 , 90 , 92 ] reported using a validated instrument to measure CU frequency or quantity, including the TLFB instrument [ 66 ] (n=9, 90% of the studies) and the Marijuana Use Form (n=1, 10% of the studies); 1 (10%) [ 79 ] reported using CU-related questions from an adaptation of the Global Appraisal of Individual Needs–Initial instrument [ 115 ]; and 30% (3/10) [ 81 , 82 , 91 ] reported using a questionnaire accompanied by a calendar or a diary of consumption. The 19 studies also differed with regard to their follow-up time measurements for assessing CU, ranging from 2 weeks after the baseline [ 80 ] to 12 months after randomization [ 90 ], although 12 (63%) of the studies included a 3-month follow-up assessment [ 70 - 72 , 79 , 81 , 82 , 84 , 85 , 88 , 90 - 92 ].

Of all studies assessing and reporting change in CU frequency from baseline to follow-up assessments (19/19, 100%), 47% (9/19) found statistically significant differences between the experimental and control groups [ 70 - 72 , 80 , 81 , 83 , 85 , 87 , 91 ]. Importantly, 67% (6/9) of these studies showed that participants in the experimental groups exhibited greater decreases in CU frequency 3 months following the baseline assessment compared with participants in the control groups [ 70 - 72 , 81 , 85 , 91 ], 22% (2/9) of the studies showed greater decreases in CU frequency at 6 weeks after the baseline assessment [ 71 , 83 ], 22% (2/9) of the studies showed greater decreases in CU frequency at 6 months following the baseline assessment [ 81 , 85 ], 11% (1/9) of the studies showed greater decreases in CU frequency at 2 weeks after the baseline [ 80 ], and 11% (1/9) of the studies showed greater decreases in CU frequency at 2 months after treatment [ 87 ].

In the study by Baumgartner et al [ 70 ], a reduction in CU days was observed in all groups, but the authors reported that the difference was statistically significant only between the intervention group with the service team and the control group (the reduction in the intervention group with social presence was not significant). In the study by Bonar et al [ 85 ], the only statistically significant difference between the intervention and control groups at the 3- and 6-month follow-ups involved total days of cannabis vaping in the previous 30 days. Finally, in the study by Buckner et al [ 80 ], the intervention group had less CU than the control group 2 weeks after the baseline; however, this was statistically significant only for participants with moderate or high levels of social anxiety.

Assessment of Cannabis-Related Negative Consequences

A total of 53% (10/19) of the studies also assessed cannabis-related negative consequences [ 78 - 84 , 86 , 88 , 92 ]. Of these 10 articles, 8 (80%) reported using a validated self-report instrument: 4 (50%) [ 81 , 82 , 86 , 88 ] used the 19-item Marijuana Problems Scale [ 67 ], 2 (25%) [ 78 , 79 ] used the 18-item Rutgers Marijuana Problem Index [ 121 , 122 ], and 2 (25%) [ 80 , 84 ] used the Brief Marijuana Consequences Questionnaire [ 116 ]. Only 10% (1/10) of the studies [ 92 ] used a screening tool, the Cannabis Abuse Screening Test [ 117 , 118 ]. None of these 10 studies demonstrated a statistically significant difference between the intervention and control groups. Of note, Walukevich-Dienst et al [ 86 ] found that women (but not men) who received an web-based PFI with additional information on CU risks reported significantly fewer cannabis-related problems than did women in the control group at 1 month after the intervention ( B =−1.941; P =.01).

Descriptive Summary of BCTs Used in Intervention Groups

After the 19 studies included in this review were coded, a total of 184 individual BCTs targeting CU in young adults were identified. Of these 184 BCTs, 133 (72.3% ) were deemed to be present beyond a reasonable doubt, and 51 (27.7%) were deemed to be present in all probability. Multimedia Appendix 8 [ 48 , 70 - 72 , 77 - 92 ] presents all the BCTs coded for each included study summarized by individual BCT and BCT cluster.

The 184 individual BCTs coded covered 38% (35/93) of the BCTs listed in the BCTTv1 [ 48 ]. The number of individual BCTs identified per study ranged from 5 to 19, with two-thirds of the 19 studies (12/19, 63%) using ≤9 BCTs (mean 9.68). As Multimedia Appendix 8 shows, at least one BCT fell into 13 of the 16 possible BCT clusters. The most frequent clusters were feedback monitoring , natural consequences , goal planning , and comparison of outcomes .

The most frequently coded BCTs were (1) feedback on behavior (BCT 2.2; 17/19, 89% of the studies; eg, “Once a week, participants receive detailed feedback by their counselor on their entries in diary and exercises. Depending on the involvement of each participant, up to seven feedbacks are given” [ 90 ]), (2) social support (unspecified) (BCT 3.1; 15/19, 79% of the studies; eg, “The website also features [...] blogs from former cannabis users, quick assist links, and weekly automatically generated encouragement emails” [ 71 ]), and (3) pros and cons (BCT 9.2; 14/19, 74% of the studies; eg, “participants are encouraged to state their personal reasons for and against their cannabis consumption, which they can review at any time, so they may reflect on what they could gain by successfully completing the program” [ 70 ]). Other commonly identified BCTs included social comparison (BCT 6.2; 12/19, 63% of the studies) and information about social and environmental consequences (BCT 5.3; 11/19, 58% of the studies), followed by problem solving (BCT 2.1; 10/19, 53% of the studies) and information about health consequences (BCT 5.1; 10/19, 53% of the studies).

RoB Assessment

Figure 2 presents the overall assessment of risk in each domain for all the included studies, whereas Figure 3 [ 70 - 72 , 77 - 92 ] summarizes the assessment of each study at the outcome level for each domain in the Cochrane RoB 2 [ 74 ].

Figure 2 shows that, of the included studies, 93% (27/29) were rated as having a “low” RoB arising from the randomization process (ie, selection bias) and 83% (24/29) were rated as having a “low” RoB due to missing data (ie, attrition bias). For bias due to deviations from the intended intervention (ie, performance bias), 72% (21/29) were rated as having a “low” risk, and for selective reporting of results, 59% (17/29) were rated as having a “low” risk. In the remaining domain regarding bias in measurement of the outcome (ie, detection bias), 48% (14/29) of the studies were deemed to present “some concerns,” mainly owing to the outcome assessment not being blinded (eg, self-reported outcome measure of CU). Finally, 79% (15/19) of the included studies were deemed to present “some concerns” or were rated as having a “high” RoB at the outcome level ( Figure 3 [ 70 - 72 , 77 - 92 ]). The RoB assessment for CU and cannabis consequences of each included study is presented in Multimedia Appendix 9 [ 70 - 72 , 77 - 92 ].

Meta-Analysis Results

Due to several missing data points and despite contacting the authors, we were able to carry out only 1 meta-analysis of our primary outcome, CU frequency. Usable data were retrieved from only 16% (3/19) [ 70 - 72 ] of the studies included in this review. These 3 studies provided sufficient information to calculate an effect size, including mean differences based on change-from-baseline measurements and associated 95% CIs (or SE of the mean difference) and sample sizes per intervention and comparison conditions. The reasons for excluding the other 84% (16/19) of the studies included heterogeneity in outcome variables or measurements, inconsistent results, and missing data ( Multimedia Appendix 10 [ 77 - 92 ]).

Figure 4 [ 70 - 72 ] illustrates the mean differences and associated 95% CIs of 3 unique RCTs [ 70 - 72 ] that provided sufficient information to allow for the measurement of CU frequency at 3 months after the baseline relative to a comparison condition in terms of the number of self-reported days of use in the previous month using the TLFB method. Overall, the synthesized effect of digital interventions for young adult cannabis users on CU frequency, as measured using days of use in the previous month, was −6.79 (95% CI −9.59 to −4.00). This suggests that digital CU interventions had a statistically significant effect ( P <.001) on reducing CU frequency at the 3-month follow-up compared with the control conditions (both passive and active controls). The results of the meta-analysis also showed low between-study heterogeneity ( I 2 =48.3%; P =.12) across the 3 included studies.

The samples of the 3 studies included in the meta-analysis varied in size from 225 to 1292 participants (mean 697.33, SD 444.11), and the mean age ranged from 24.7 to 31.88 years (mean 26.38, SD 3.58 years). These studies involved 3 different digital interventions and used different design approaches to assess intervention effectiveness. One study assessed the effectiveness of a web-based counseling program (ie, Quit the Shit) against a waitlist control [ 72 ], another examined the effectiveness of a fully self-guided web-based treatment program for CU and related problems (ie, Reduce Your Use: How to Break the Cannabis Habit) against a control condition website consisting of basic educational information on cannabis [ 71 ], and the third used a 3-arm RCT design to investigate whether the effectiveness of a minimally guided internet-based self-help intervention (ie, CANreduce 2.0) might be enhanced by implementing adherence-focused guidance and emphasizing the social presence factor of a personal e-coach [ 70 ].

Summary of Principal Findings

The primary aim of this systematic review was to evaluate the effectiveness of digital interventions in addressing CU among community-living young adults. We included 19 randomized controlled studies representing 9 unique digital interventions aimed at preventing, reducing, or ceasing CU and evaluated the effects of 3 different digital interventions on CU. In summary, the 3 digital interventions included in the meta-analysis proved superior to control conditions in reducing the number of days of CU in the previous month at the 3-month follow-up.

Our findings are consistent with those of 2 previous meta-analyses by Olmos et al [ 43 ] and Tait et al [ 44 ] and with the findings of a recently published umbrella review of systematic reviews and meta-analyses of RCTs [ 123 ], all of which revealed a positive effect of internet- and computer-based interventions on CU. However, a recent systematic review and meta-analysis by Beneria et al [ 45 ] found that web-based CU interventions did not significantly reduce CU. Beneria et al [ 45 ] included studies with different intervention programs that targeted diverse population groups (both adolescents and young adults) and use of more than one substance (eg, alcohol and cannabis). In our systematic review, a more conservative approach was taken—we focused specifically on young adults and considered interventions targeting CU only. Although our results indicate that digital interventions hold great promise in terms of effectiveness, an important question that remains unresolved is whether there is an optimal exposure dose in terms of both duration and frequency that might be more effective. Among the studies included in this systematic review, interventions varied considerably in terms of the number of psychoeducational modules offered (from 2 to 13), time spent reviewing the material, and duration (from a single session to a 12-week spread period). Our results suggest that an intervention duration of at least 6 weeks yields better results.

Another important finding of this review is that, although almost half (9/19, 47%) of the included studies observed an intervention effect on CU frequency, none reported a statistically significant improvement in cannabis-related negative consequences, which may be considered a more distal indicator. More than half (10/19, 53%) of the included studies investigated this outcome. It seems normal to expect to find an effect on CU frequency given that reducing CU is often the primary objective of interventions and because the motivation of users’ is generally focused on changing consumption behavior. It is plausible to think that the change in behavior at the consumption level must be maintained over time before an effect on cannabis-related negative consequences can be observed. However, our results showed that, in all the included studies, cannabis-related negative consequences and change in behavior (CU frequency) were measured at the same time point, namely, 3 months after the baseline. Moreover, Grigsby et al [ 124 ] conducted a scoping review of risk and protective factors for CU and suggested that interventions to reduce negative CU consequences should prioritize multilevel methods or strategies “to attenuate the cumulative risk from a combination of psychological, contextual, and social influences.”

A secondary objective of this systematic review was to describe the active ingredients used in digital interventions for CU among young adults. The vast majority of the interventions were based on either a theory or an intervention approach derived from theories such as CBT, MI, and personalized feedback. From these theories and approaches stem behavior change strategies or techniques, commonly known as BCTs. Feedback on behavior , included in the feedback monitoring BCT cluster, was the most common BCT used in the included studies. This specific BCT appears to be a core strategy in behavior change interventions [ 125 , 126 ]. In their systematic review of remotely delivered alcohol or substance misuse interventions for adults, Howlett et al [ 53 ] found that feedback on behavior , problem solving , and goal setting were the most frequently used BCTs in the included studies. In addition, this research group noted that the most promising BCTs for alcohol misuse were avoidance/reducing exposure to cues for behavior , pros and cons , and self-monitoring of behavior, whereas 2 very promising strategies for substance misuse in general were problem solving and self-monitoring of behavior . In our systematic review, in addition to feedback on behavior , the 6 most frequently used BCTs in the included studies were social support , pros and cons , social comparison , problem solving , information about social and environmental consequences , and information about health consequences . Although pros and cons and problem solving were present in all 3 studies of digital interventions included in our meta-analysis, avoidance/reducing exposure to cues for behavior was reported in only 5% (1/19) of the articles, and feedback on behavior was more frequently used than self-monitoring of behavior. However, it should be noted that the review by Howlett et al [ 53 ] examined digital interventions for participants with alcohol or substance misuse problems, whereas in this review, we focused on interventions that targeted CU from a harm reduction perspective. In this light, avoidance/reducing exposure to cues for behavior may be a BCT better suited to populations with substance misuse problems. Lending support to this, a meta-regression by Garnett et al [ 127 ] and a Cochrane systematic review by Kaner et al [ 128 ] both found interventions that used behavior substitution and credible source to be associated with greater reduction in excessive alcohol consumption compared with interventions that used other BCTs.

Beyond the number and types of BCTs used, reflecting on the extent to which each BCT in a given intervention suits (or does not suit) the targeted determinants (ie, behavioral and environmental causes) is crucial for planning intervention programs [ 26 ]. It is important when designing digital CU interventions not merely to pick a combination of BCTs that have been associated with effectiveness. Rather, the active ingredients must fit the determinants that the interventionists seek to influence. For example, action planning would be more relevant as a BCT for young adults highly motivated and ready to take action on their CU than would pros and cons , which aims instead to bolster motivation. Given that more than half of all digital interventions are asynchronous and based on a self-guided approach and do not offer counselor or therapist support, a great deal of motivation is required to engage in intervention and behavior change. Therefore, it is essential that developers consider the needs and characteristics of the targeted population to tailor intervention strategies (ie, BCTs) for successful behavior change (eg, tailored to the participant’s stage of change). In most of the digital interventions included in this systematic review, personalization was achieved through feedback messages about CU regarding descriptive norms, motives, risks and consequences, and costs, among other things.

Despite the high number of recent studies conducted in the field of digital CU interventions, most of the included articles in our review (17/19, 89%) reported on the development and evaluation of web-based intervention programs. A new generation of health intervention modalities such as mobile apps and social media has drawn the attention of researchers in the past decade and is currently being evaluated. In this regard, the results from a recently published scoping review [ 129 ], which included 5 studies of mobile apps for nonmedical CU, suggested that these novel modes of intervention delivery demonstrated adequate feasibility and acceptability. Nevertheless, the internet remains a powerful and convenient medium for reaching young adults with digital interventions intended to support safe CU behaviors [ 123 , 130 ].

Quality of Evidence

The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach [ 131 - 133 ] was used to assess the quality of the evidence reviewed. It was deemed to be moderate for the primary outcome of this review, that is, CU frequency in terms of days of use in the previous month (see the summary of evidence in Multimedia Appendix 11 [ 70 , 72 ]). The direction of evidence was broadly consistent—in all 3 RCT studies [ 70 - 72 ] included in the meta-analysis, participants who received digital CU interventions reduced their consumption compared with those who received no or minimal interventions. The 3 RCTs were similar in that they all involved a web-based, multicomponent intervention program aimed at reducing or ceasing CU. However, the interventions did differ or vary in terms of several characteristics, including the strategies used, content, frequency, and duration. Given the small number of studies included in the meta-analysis, we could not conclude with certainty which intervention components, if any, contributed to the effect estimate observed.

Although inconsistency, indirectness, and imprecision were not major issues in the body of evidence, we downgraded the evidence from high to moderate quality on account of RoB assessments at the outcome level. The 3 RCT studies included in the meta-analysis were rated as having “some concerns” of RoB, mainly due to lack of blinding, which significantly reduced our certainty relative to subjective outcomes (ie, self-reported measures of CU frequency). A positive feature of these digital intervention trials is that most procedures are fully automated, and so there was typically a low RoB regarding randomization procedures, allocation to different conditions, and intervention delivery. It is impossible to blind participants to these types of behavior change interventions, and although some researchers have made attempts to counter the impact of this risk, performance bias is an inescapable issue in RCT studies of this kind. Blinding of intervention providers was not an issue in the 3 RCTs included in the meta-analysis because outcome data collection was automated. However, this same automated procedure made it very difficult to ensure follow‐up. Consequently, attrition was another source of bias in these RCT studies [ 70 - 72 ]. The participants lost to follow-up likely stopped using the intervention. However, there is no way of determining whether these people would have benefited more or less than the completers if they had seen the trial through.

The 3 RCTs included in the meta-analysis relied on subjective self-reported measures of CU at baseline and follow‐up, which are subject to recall and social desirability bias. However, all 3 studies used a well-validated instrument of measurement to determine frequency of CU, the TLFB [ 66 ]. This is a widely used, subjective self-report tool for measuring frequency (or quantity) of substance use (or abstinence). It is considered a reliable measure of CU [ 134 , 135 ]. Finally, it should be pointed out that any potential bias related to self‐reported CU frequency would have affected both the intervention and control groups (particularly in cases in which control groups received cannabis‐related information), and thus, it was unlikely to account for differential intervention effects. Moreover, we found RoB due to selective reporting in some studies owing mainly to the absence of any reference to a protocol. Ultimately, these limitations may have biased the results of the meta-analysis. Consequently, future research is likely to further undermine our confidence in the effect estimate we observed and report considerably different estimates.

Strengths and Limitations

Our systematic review and meta-analysis has a number of strengths: (1) we included only randomized controlled studies to ensure that the included studies possessed a rigorous research design, (2) we focused specifically on cannabis (rather than combining multiple substances), (3) we assessed the effectiveness of 3 different digital interventions on CU frequency among community-living young adults, and (4) we performed an exhaustive synthesis and comparison of the BCTs used in the 9 digital interventions examined in the 19 studies included in our review based on the BCTTv1.

Admittedly, this systematic review and meta-analysis has limitations that should be recognized. First, although we searched a range of bibliographic databases, the review was limited to articles published in peer-reviewed journals in English or French. This may have introduced publication bias given that articles reporting positive effects are more likely to be published than those with negative or equivocal results. Consequently, the studies included in this review may have overrepresented the statistically significant effects of digital CU interventions.

Second, only a small number of studies were included in the meta-analyses because many studies did not provide adequate statistical information for calculating and synthesizing effect sizes, although significant efforts were made to contact the authors in case of missing data. Because of the small sample size used in the meta-analysis, the effect size estimates may not be highly reflective of the true effects of digital interventions on CU frequency among young adults. Furthermore, synthesizing findings across studies that evaluated different modalities of web-based intervention programs (eg, fully self-guided vs with therapist guidance) and types of intervention approaches (eg, CBT, MI, and personalized feedback) may have introduced bias in the meta-analytical results due to the heterogeneity of the included studies, although heterogeneity was controlled for using a random-effects model and our results indicated low between-study heterogeneity.

Third, we took various measures to ensure that BCT coding was carried out rigorously throughout the data extraction and analysis procedures: (1) all coders received training on how to use the BCTTv1; (2) all the included articles were read line by line so that coders became familiar with intervention descriptions before initiating BCT coding; (3) the intervention description of each included article was double coded after a pilot calibration exercise with all coders, and any disagreements regarding the presence or absence of a BCT were discussed and resolved with a third party; and (4) we contacted the article authors when necessary and possible for further details on the BCTs they used. However, incomplete reporting of intervention content is a recognized issue [ 136 ], which may have resulted in our coding BCTs incorrectly as present or absent. Reliably specifying the BCTs used in interventions allows their active ingredients to be identified, their evidence to be synthesized, and interventions to be replicated, thereby providing tangible guidance to programmers and researchers to develop more effective interventions.

Finally, although this review identified the BCTs used in digital interventions, our approach did not allow us to draw conclusions regarding their effectiveness. Coding BCTs simply as present or absent does not consider the frequency, intensity, and quality with which they were delivered. For example, it is unclear how many individuals should self‐monitor their CU. In addition, the quality of BCT implementation may be critical in digital interventions where different graphics and interface designs and the usability of the BCTs used can have considerable influence on the level of user engagement [ 137 ]. In the future, it may be necessary to develop new methods to evaluate the dosage of individual BCTs in digital health interventions and characterize their implementation quality to assess their effectiveness [ 128 , 138 ]. Despite its limitations, this review suggests that digital interventions represent a promising avenue for preventing, reducing, or ceasing CU among community-living young adults.

Conclusions

The results of this systematic review and meta-analysis lend support to the promise of digital interventions as an effective means of reducing recreational CU frequency among young adults. Despite the advent and popularity of smartphones, web-based interventions remain the most common mode of delivery for digital interventions. The active ingredients of digital interventions are varied and encompass a number of clusters of the BCTTv1, but a significant number of BCTs remain underused. Additional research is needed to further investigate the effectiveness of these interventions on CU and key outcomes at later time points. Finally, a detailed assessment of user engagement with digital interventions for CU and understanding which intervention components are the most effective remain important research gaps.

Acknowledgments

The authors would like to thank Bénédicte Nauche, Miguel Chagnon, and Paul Di Biase for their valuable support with the search strategy development, statistical analysis, and linguistic revision, respectively. This work was supported by the Ministère de la Santé et des Services sociaux du Québec as part of a broader study aimed at developing and evaluating a digital intervention for young adult cannabis users. Additional funding was provided by the Research Chair in Innovative Nursing Practices. The views and opinions expressed in this manuscript do not necessarily reflect those of these funding entities.

Data Availability

The data sets generated and analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

JC contributed to conceptualization, methodology, formal analysis, writing—original draft, supervision, and funding acquisition. GC contributed to conceptualization, methodology, formal analysis, investigation, data curation, writing—original draft, visualization, and project administration. BV contributed to conceptualization, methodology, formal analysis, investigation, data curation, writing—original draft, and visualization. PA contributed to conceptualization, methodology, formal analysis, investigation, data curation, writing—original draft, visualization, and project administration. GR contributed to conceptualization, methodology, formal analysis, investigation, data curation, and writing—review and editing. GF contributed to conceptualization, methodology, formal analysis, investigation, data curation, and writing—review and editing. DJA contributed to conceptualization, methodology, formal analysis, writing—review and editing, and funding acquisition.

Conflicts of Interest

None declared.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.

Detailed search strategies for each database.

Population, intervention, comparison, outcome, and study design strategy.

Excluded studies and reasons for exclusion.

Study and participant characteristics.

Description of intervention characteristics in the included articles.

Summary of methodological characteristics and major findings of the included studies categorized by intervention name.

Behavior change techniques (BCTs) coded in each included study summarized by individual BCT and BCT cluster.

Risk-of-bias assessment of each included study for cannabis use and cannabis consequences.

Excluded studies and reasons for exclusion from the meta-analysis.

Summary of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation tool.

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Abbreviations

Edited by T Leung, G Eysenbach; submitted 30.11.23; peer-reviewed by H Sedrati; comments to author 02.01.24; revised version received 09.01.24; accepted 08.03.24; published 17.04.24.

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