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Designing clinical practice guidelines for equitable, inclusive, and contextualised care. Sabine Oertelt-Prigione and colleagues argue that European clinical practice guidelines need standardised, inclusive, sex and gender sensitive development to not only guide healthcare but also drive innovation and research agendas

Women and gender diverse individuals are under-represented and underserved in clinical research and care. Although sex and gender sensitive medicine is expanding and knowledge gaps are being filled as a result of structural interventions such as funding mandates, policy reforms, and publishing prerequisites,3 implementation into clinical practice is lagging behind. Previous reviews from Canada, the US, and Australia have shown the limited attention to sex/gender in national guidelines.4 5 6 Sex and gender were either not systematically mentioned in recommendations or used interchangeably—for example, by using “gender” when considering biological sex. Incorrect use of terminology can reduce the target specificity of healthcare interventions, ultimately disadvantaging already underserved populations.7 Furthermore, a lack of adequate inclusion of female participants at the clinical trial level also contributes to the inability to formulate sex specific recommendations owing to limited strength of evidence.8 However, we suggest that this lack of data does not exonerate CPG development committees from focusing on sex and gender. Rather, they could explicitly point out these shortcomings and define relevant areas for future research agendas. This reflects a broader research and innovation failure, one that CPGs are well placed to expose and correct.

this lack of data does not exonerate CPG development committees from focusing on sex and gender. Rather, they could explicitly point out these shortcomings and define relevant areas for future research agendas. This reflects a broader research and innovation failure, one that CPGs are well placed to expose and correct. The analysis reported in this article, part of the BMJ Collection on Women’s Health Innovation (bmj.com/collections/womens-health-innovation), draws on our empirical research to show how CPGs can be reimagined as levers for inclusive innovation. We hypothesised that the greater diversity of European guideline committees might lead to more consistent attention to sex and gender related aspects than is observed in national guidelines. To test this, we analysed more than a decade (January 2012 to December 2022) of European CPGs in 10 subspecialties of internal medicine, on the basis of their inclusion in national internal medicine specialty training. We evaluated whether sex/gender aspects were explicitly mentioned throughout the body of the CPG, in the suggested actions, and in the evidence based graded clinical recommendations.9 Using a machine assisted process and pre-specified list of sex/gender related keywords, we identified guidelines reporting on sex/gender. We then categorised these into three groups focusing on fertility/reproduction, gynaecological/urological diseases, or sex/gender aspects beyond gynaecology/urology and reproduction.

Using a machine assisted process and pre-specified list of sex/gender related keywords, we identified guidelines reporting on sex/gender. We then categorised these into three groups focusing on fertility/reproduction, gynaecological/urological diseases, or sex/gender aspects beyond gynaecology/urology and reproduction. Of the 325 EU-wide CPGs reviewed, 74% (240) contained sex/gender related keywords and a total of 14 109 individual recommendations. In gastroenterology, for example, 87 CPGs included sex and gender sensitive terminology in their text and offered a total of 4326 individual recommendations. However, only 18 (0.4%) of these recommendations covered sex/gender aspects beyond reproductive/gynaecological/urological care, in a total of 11 CPGs. At the overarching level, only 660 (4.7%) of all recommendations covered sex/gender related topics. Of these 660, 83% (545) focused on fertility/reproduction, gynaecology/urology related aspects, and gonosomal variations, whereas only 17% (115) centred sex/gender beyond these categories (box 1). Of the 325 EU-wide CPGs reviewed, 74% (n=240) contained sex/gender related keywords and a total of 14 109 individual recommendations 660 (4.7%) of all recommendations covered sex/gender related topics Of these 660, 83% (n=545) focused on fertility/reproduction, gynaecology/urology related aspects, and gonosomal variations, whereas only 17% (n=115) centred sex/gender beyond these categories

Of the 325 EU-wide CPGs reviewed, 74% (n=240) contained sex/gender related keywords and a total of 14 109 individual recommendations 660 (4.7%) of all recommendations covered sex/gender related topics Of these 660, 83% (n=545) focused on fertility/reproduction, gynaecology/urology related aspects, and gonosomal variations, whereas only 17% (n=115) centred sex/gender beyond these categories The specialties contributing the most guidelines with sex/gender sensitive recommendations were gastroenterology (26/111; 30% of all CPGs including any sex/gender terminology), cardiology (19/25; 76%), and oncology (16/75; 29%) However, the numbers of recommendations focusing on sex/gender beyond reproduction were very few in these specialties: cardiology (55/3430; 1.6% of all recommendations in the included CPGs), gastroenterology (18/4326; 0.4%), oncology (9/2390; 0.4%) A total of 3314 individual authors from 59 different countries contributed to the CPGs containing sex/gender related keywords (fig 1 and fig 2) Authorship distribution did not differ significantly between CPGs without any reference to sex/gender (996 authorships; 726 (73.2%) men, 264 (26.5%) women, and 6 (0.6%) of unknown gender) and CPGs with reference to sex/gender (4053 authorships; 2887 (71.5%) men, 1149 (28.3%) women, and 17 (0.4%) of unknown gender) A comparison of the gender distribution between absolute number of authors and total number of authorships highlights how men are more likely to participate in multiple CPG committees (women 999 (30.1%) v 1149 (28.3%); men 2298 (69.3%) v 2887 (71.5%))

Authorship distribution did not differ significantly between CPGs without any reference to sex/gender (996 authorships; 726 (73.2%) men, 264 (26.5%) women, and 6 (0.6%) of unknown gender) and CPGs with reference to sex/gender (4053 authorships; 2887 (71.5%) men, 1149 (28.3%) women, and 17 (0.4%) of unknown gender) A comparison of the gender distribution between absolute number of authors and total number of authorships highlights how men are more likely to participate in multiple CPG committees (women 999 (30.1%) v 1149 (28.3%); men 2298 (69.3%) v 2887 (71.5%)) Notable examples such as sex specific diagnostic thresholds (for example, markers for cardiac pump function or electrical conduction: B-type natriuretic peptide, QT intervals), sex/gender informed risk scores (for example, the stroke risk score CHA2DS2-VASc and the liver failure risk score GRACE), and differentiated management strategies (for example, for Turner’s syndrome, a genetic condition in which somatic cells harbour only one X chromosome instead of XX or XY) show that integrating sex and gender into clinical guidance is feasible and already happening in some areas. These cases expose a critical gap: sex/gender sensitive care is not only possible but should be systematically expected across specialties. Their rarity underscores missed opportunities for innovation in how evidence is translated into inclusive, precise, and equitable clinical practice.

Of the 325 EU-wide CPGs reviewed, 74% (n=240) contained sex/gender related keywords and a total of 14 109 individual recommendations 660 (4.7%) of all recommendations covered sex/gender related topics Of these 660, 83% (n=545) focused on fertility/reproduction, gynaecology/urology related aspects, and gonosomal variations, whereas only 17% (n=115) centred sex/gender beyond these categories

The specialties contributing the most guidelines with sex/gender sensitive recommendations were gastroenterology (26/111; 30% of all CPGs including any sex/gender terminology), cardiology (19/25; 76%), and oncology (16/75; 29%) However, the numbers of recommendations focusing on sex/gender beyond reproduction were very few in these specialties: cardiology (55/3430; 1.6% of all recommendations in the included CPGs), gastroenterology (18/4326; 0.4%), oncology (9/2390; 0.4%)

A total of 3314 individual authors from 59 different countries contributed to the CPGs containing sex/gender related keywords (fig 1 and fig 2) Authorship distribution did not differ significantly between CPGs without any reference to sex/gender (996 authorships; 726 (73.2%) men, 264 (26.5%) women, and 6 (0.6%) of unknown gender) and CPGs with reference to sex/gender (4053 authorships; 2887 (71.5%) men, 1149 (28.3%) women, and 17 (0.4%) of unknown gender) A comparison of the gender distribution between absolute number of authors and total number of authorships highlights how men are more likely to participate in multiple CPG committees (women 999 (30.1%) v 1149 (28.3%); men 2298 (69.3%) v 2887 (71.5%))

Our recent work showed that the evidence base underpinning European CPGs remains skewed by the under-representation of women in clinical trials, limiting the development of sex and gender sensitive recommendations.8 This lack of inclusive data continues to constrain the type and quality of analyses that can be conducted and hinders robust, equitable guideline development.10 Yet CPGs are well positioned to flag these data gaps and help to set upstream research priorities that strengthen future evidence generation. Progress in some areas, such as the expanded attention to sex/gender in the 2021 CPG for cardiovascular disease prevention, showcases that methodological innovation is possible.11

et CPGs are well positioned to flag these data gaps and help to set upstream research priorities that strengthen future evidence generation. Progress in some areas, such as the expanded attention to sex/gender in the 2021 CPG for cardiovascular disease prevention, showcases that methodological innovation is possible.11 Whereas the 2012 version of the guideline included only one general section on “gender and age,” in 2021 this section was expanded to four full sections, including explicit and nuanced definitions of sex and gender and highlighting persisting knowledge gaps. Recent guidelines published after the timeframe of our study illustrate both progress and persistent challenges. The 2024 ESC guideline for arterial hypertension comprehensively focuses on sex, gender, and several diversity aspects in text and imagery; however, sex and gender are still operationalised in a strictly binary manner. Similarly, the 2024 ESC guideline on atrial fibrillation builds on the current debates about the appropriateness of the CHA2DS2-VASc score or the advantage of the proposed alternative, CHA2DS2-VA, which removes biological sex as a risk factor owing to declining sex based stroke disparities in Nordic countries.12 Although this shift is important, the applicability beyond a limited geographical region is yet to be demonstrated. Notably, the CPG development committee was, however, quick in declaring that “the inclusion of gender complicates clinical practice both for healthcare professionals and patients” and in advising the use of the CHA2DS2-VA score that does not include female sex as risk factor, highlighting how implementation considerations may constrain the incorporation of sex and gender even where evidence exists.13

Our analysis found European CPGs to be predominantly written by men and that men were also more likely than women to participate in multiple guideline committees (fig 1; fig 2; box 1). This gender distribution remains consistent whether or not the guidelines covered sex/gender. Research shows women authors to be more likely to include sex/gender specific analyses in their work and gender and intersectional factors to affect the type of research investigators engage in.14 15 This suggests that under-representation of women and gender diverse individuals in these committees might reduce their focus on sex/gender and diversity related aspects. Committee diversity can influence what is counted, who is considered, and whether sex/gender gaps are even recognised as noteworthy. Gender distribution within EU clinical practice guideline (CPG) committees. Gender of participants was inferred by name and/or internet searches. Every bubble represents a CPG development committee. Bubble sizes reflect total number of participating authors. Colour coding reflects different tears of relative participation of women and men Gender distribution of EU clinical practice guideline (CPG) committee members at national level. Gender of participants was inferred by name and/or internet searches. Colour coding represents relative participation of women and men in identified EU CPG committees according to their country of origin

The European CPG development process highlights the potential advantages of an international co-creative enterprise, such as diversity of representation and perspectives. However, it only marginally delivers, as the inadequate consideration of sex/gender specific content demonstrates. One key challenge at the European level is the lack of centralised standardisation. Variations in CPG development strategies and inconsistent approaches to grading recommendations hinder comparability across societies, specialties, and regions.16 Although internationally recognised tools such as AGREE II17 (for assessing guideline quality) and GRADE18 (for evaluating the strength of evidence and recommendations) are available, many professional societies continue to rely on their own processes and criteria. The inconsistent use of standards limits the ability to ensure relevance to sex, gender, or specific contexts.

A transnational, structured, inclusive, and innovation oriented reform of CPG development processes could help to overcome some of the illustrated limitations, enabling a more comprehensive role for CPGs as systemic levers towards inclusive sex and gender sensitive care (fig 3). Reference framework for context sensitive clinical practice guideline (CPG) development processes. AI=artificial intelligence; FAIR=findable, accessible, interoperable, and reusable data; ML=machine learning

A transnational, structured, inclusive, and innovation oriented reform of CPG development processes could help to overcome some of the illustrated limitations, enabling a more comprehensive role for CPGs as systemic levers towards inclusive sex and gender sensitive care (fig 3). Reference framework for context sensitive clinical practice guideline (CPG) development processes. AI=artificial intelligence; FAIR=findable, accessible, interoperable, and reusable data; ML=machine learning CPG development processes are time and labour intensive as well as resource intensive. This affects the ability of many low and middle income countries to fully support these processes and has led to the widespread use of a number of European CPGs beyond their original target geography.19 This can lead to a potential mismatch between the recommendations and the applicability, as EU CPGs are developed by high income countries for specialist, resource rich settings. Several adaptation frameworks, such as “adolopment” (combining adoption, adaptation, and development) have been proposed over the past decades.20 21 22 Examples from low and middle income countries in Africa (for example, oncological care in Nigeria and CPG implementation in Ghana)23 and globally,24 highlight how national and international guidelines from high income countries are predominantly being used in practice, albeit with structural limitations in their implementation, and emphasise how contextualised knowledge by partners in low and middle income countries must be embedded early in the development process.25 However, this valuable “adolopment”22 process of adjustment to individual national realities is resource intensive in itself, even in high income countries.26 For globally highly prevalent diseases, rethinking CPG development as an inclusive innovation pathway with early integration of sex/gender, intersectional, and socioeconomic dimensions could enhance resource efficiency, reduce the need for costly adaptation, and support equitable global health collaboration.

untries.26 For globally highly prevalent diseases, rethinking CPG development as an inclusive innovation pathway with early integration of sex/gender, intersectional, and socioeconomic dimensions could enhance resource efficiency, reduce the need for costly adaptation, and support equitable global health collaboration. Structural influences on the CPG development process include the diversity and representativeness of the committee and the socioeconomic possibilities of the adopting healthcare system. To enable more innovative, inclusive, and foreseeing guidance, these factors should be explicitly included early in the planning process. We recommend that guideline developers begin with a context specific definition of the target population and then build on implementation frameworks such as the PIPOH instrument (defining patient population (P), intervention (I), professional (P), outcomes (O), and healthcare setting (H)).20 This could include instruments to cover sex/gender and intersectional dimensions,27 28 socioeconomic contexts of the healthcare system, and potential limitations in access unrelated to resources. Procedurally, this entails deliberately focusing on the patient/user population, rather than solely centring the healthcare providers offering the service.

to cover sex/gender and intersectional dimensions,27 28 socioeconomic contexts of the healthcare system, and potential limitations in access unrelated to resources. Procedurally, this entails deliberately focusing on the patient/user population, rather than solely centring the healthcare providers offering the service. A key innovation opportunity lies in using this early contextual analysis not only to guide recommendations but also to shape the composition of the CPG development committee. On the basis of this assessment, committees should include a broad range of experts, such as experts in care provision, sex/gender experts,29 health economists with a special focus on low and middle income countries, and stakeholders with lived experience,30 as well as a balanced representation of target countries. Socioeconomic aspects affecting the target healthcare systems should be explicitly defined to inform cascading recommendations based on national resources.31

mists with a special focus on low and middle income countries, and stakeholders with lived experience,30 as well as a balanced representation of target countries. Socioeconomic aspects affecting the target healthcare systems should be explicitly defined to inform cascading recommendations based on national resources.31 Current European CPGs include few sex/gender specific recommendations, and their applicability beyond high income country settings is limited. To prevent these limitations, CPG processes must build on resource awareness and contextual relevance from the outset. Target groups and implementation settings should be interwoven into the development process (fig 3) in alignment with approaches from the public health field —for example, the World Health Organization’s INTEGRATE framework, which integrates human rights and equity considerations into decision making.32 Checklists for under-represented aspects should be adopted throughout the process to ensure attention to under-represented groups and settings.29 33

the public health field —for example, the World Health Organization’s INTEGRATE framework, which integrates human rights and equity considerations into decision making.32 Checklists for under-represented aspects should be adopted throughout the process to ensure attention to under-represented groups and settings.29 33 Importantly, CPGs must not only inform clinical care but also guide future research and retrospectively evaluate which relevant aspects have been ignored. If clinical trials under-represent, for example, women, CPGs cannot incorporate this information even though it might be essential for tailored care. CPGs should clearly flag these gaps as limitations and signal them as priority research needs, in line with AGREE II’s domain 3 (rigour of development). These research gaps could then be transformed into funding calls through partnerships between guideline developers, national research councils, and innovation funders. Resource intensive recommendations could be stratified according to relevant economic, logistic, and practical aspects, offering a stepwise process tailored to opportunity and priority. Aspects to take into account could be national gross income and available global and human resources for healthcare delivery and logistics, as well as gender budgeting considerations in line with AGREE II domain 5 (applicability).34 Exploratory approaches to develop “context tailored” recommendations are under way and could inform these developments.33

be national gross income and available global and human resources for healthcare delivery and logistics, as well as gender budgeting considerations in line with AGREE II domain 5 (applicability).34 Exploratory approaches to develop “context tailored” recommendations are under way and could inform these developments.33 Digital innovation holds promise for assisting with some steps of the guideline development process. In a context of limited resources, artificial intelligence/machine learning (AI/ML) could support evidence selection, grading, synthesis, and contextualisation,35 provided these tools are used transparently and in line with clear procedural and ethical standards. Without safeguards, AI/ML tools risk reproducing historical biases and excluding marginalised populations from the evidence base and final recommendations.36 To prevent this, unsupervised generative models, which produce text on the basis of predictive algorithms conveying the illusion of scholarly reasoning, should be avoided, with preference instead for specialised, targeted digital support programmes for specific cross verified processes, such as summarising and assembling verified literature sources, accessory searches, preparation of meetings, and text refinement. Use of digital assistance should be clearly and transparently logged and equity based, or liberatory design principles could function as guidelines for a digitally assisted CPG development process.37 Digitalised feedback loops could also be implemented with healthcare professionals in different contexts to identify challenges with the scalability of recommendations of the CPG and continuously and transparently optimise the guideline over time in line with living guideline approaches.38 When used intentionally, digital tools could drive innovation by improving both efficiency and equity, enabling more context responsive and inclusive guideline development. The development and evaluation of these approaches is an area in which non-commercially driven research informed by ethical and equitable principles is imperative.

ionally, digital tools could drive innovation by improving both efficiency and equity, enabling more context responsive and inclusive guideline development. The development and evaluation of these approaches is an area in which non-commercially driven research informed by ethical and equitable principles is imperative. Governance of these processes could be facilitated by an overarching institution that could provide guidance, monitor the systematic introduction of standards, and coordinate post-implementation evaluations,30 possibly in coordination with WHO or as a specialised subdivision. However, independence of the participating professional societies would have to be guaranteed through bilateral agreements and procedural transparency. Benefits of an institutional anchor could also include the establishment of an archive for all developed guidelines under this new framework, fostering accessibility, transparency, and resource efficiency.

CPG development processes are time and labour intensive as well as resource intensive. This affects the ability of many low and middle income countries to fully support these processes and has led to the widespread use of a number of European CPGs beyond their original target geography.19 This can lead to a potential mismatch between the recommendations and the applicability, as EU CPGs are developed by high income countries for specialist, resource rich settings. Several adaptation frameworks, such as “adolopment” (combining adoption, adaptation, and development) have been proposed over the past decades.20 21 22 Examples from low and middle income countries in Africa (for example, oncological care in Nigeria and CPG implementation in Ghana)23 and globally,24 highlight how national and international guidelines from high income countries are predominantly being used in practice, albeit with structural limitations in their implementation, and emphasise how contextualised knowledge by partners in low and middle income countries must be embedded early in the development process.25 However, this valuable “adolopment”22 process of adjustment to individual national realities is resource intensive in itself, even in high income countries.26 For globally highly prevalent diseases, rethinking CPG development as an inclusive innovation pathway with early integration of sex/gender, intersectional, and socioeconomic dimensions could enhance resource efficiency, reduce the need for costly adaptation, and support equitable global health collaboration.

Structural influences on the CPG development process include the diversity and representativeness of the committee and the socioeconomic possibilities of the adopting healthcare system. To enable more innovative, inclusive, and foreseeing guidance, these factors should be explicitly included early in the planning process. We recommend that guideline developers begin with a context specific definition of the target population and then build on implementation frameworks such as the PIPOH instrument (defining patient population (P), intervention (I), professional (P), outcomes (O), and healthcare setting (H)).20 This could include instruments to cover sex/gender and intersectional dimensions,27 28 socioeconomic contexts of the healthcare system, and potential limitations in access unrelated to resources. Procedurally, this entails deliberately focusing on the patient/user population, rather than solely centring the healthcare providers offering the service.

Current European CPGs include few sex/gender specific recommendations, and their applicability beyond high income country settings is limited. To prevent these limitations, CPG processes must build on resource awareness and contextual relevance from the outset. Target groups and implementation settings should be interwoven into the development process (fig 3) in alignment with approaches from the public health field —for example, the World Health Organization’s INTEGRATE framework, which integrates human rights and equity considerations into decision making.32 Checklists for under-represented aspects should be adopted throughout the process to ensure attention to under-represented groups and settings.29 33 Importantly, CPGs must not only inform clinical care but also guide future research and retrospectively evaluate which relevant aspects have been ignored. If clinical trials under-represent, for example, women, CPGs cannot incorporate this information even though it might be essential for tailored care. CPGs should clearly flag these gaps as limitations and signal them as priority research needs, in line with AGREE II’s domain 3 (rigour of development). These research gaps could then be transformed into funding calls through partnerships between guideline developers, national research councils, and innovation funders.

CPGs should clearly flag these gaps as limitations and signal them as priority research needs, in line with AGREE II’s domain 3 (rigour of development). These research gaps could then be transformed into funding calls through partnerships between guideline developers, national research councils, and innovation funders. Resource intensive recommendations could be stratified according to relevant economic, logistic, and practical aspects, offering a stepwise process tailored to opportunity and priority. Aspects to take into account could be national gross income and available global and human resources for healthcare delivery and logistics, as well as gender budgeting considerations in line with AGREE II domain 5 (applicability).34 Exploratory approaches to develop “context tailored” recommendations are under way and could inform these developments.33

Digital innovation holds promise for assisting with some steps of the guideline development process. In a context of limited resources, artificial intelligence/machine learning (AI/ML) could support evidence selection, grading, synthesis, and contextualisation,35 provided these tools are used transparently and in line with clear procedural and ethical standards. Without safeguards, AI/ML tools risk reproducing historical biases and excluding marginalised populations from the evidence base and final recommendations.36 To prevent this, unsupervised generative models, which produce text on the basis of predictive algorithms conveying the illusion of scholarly reasoning, should be avoided, with preference instead for specialised, targeted digital support programmes for specific cross verified processes, such as summarising and assembling verified literature sources, accessory searches, preparation of meetings, and text refinement. Use of digital assistance should be clearly and transparently logged and equity based, or liberatory design principles could function as guidelines for a digitally assisted CPG development process.37 Digitalised feedback loops could also be implemented with healthcare professionals in different contexts to identify challenges with the scalability of recommendations of the CPG and continuously and transparently optimise the guideline over time in line with living guideline approaches.38 When used intentionally, digital tools could drive innovation by improving both efficiency and equity, enabling more context responsive and inclusive guideline development. The development and evaluation of these approaches is an area in which non-commercially driven research informed by ethical and equitable principles is imperative.

Governance of these processes could be facilitated by an overarching institution that could provide guidance, monitor the systematic introduction of standards, and coordinate post-implementation evaluations,30 possibly in coordination with WHO or as a specialised subdivision. However, independence of the participating professional societies would have to be guaranteed through bilateral agreements and procedural transparency. Benefits of an institutional anchor could also include the establishment of an archive for all developed guidelines under this new framework, fostering accessibility, transparency, and resource efficiency.

European CPGs focus only marginally on sex/gender related aspects, guideline committees lack gender balance and context sensitivity, and the applicability of the CPGs beyond high income country settings is challenging. CPGs fall short of identifying potential health inequalities, shaping future research priorities, and driving inclusive innovation. To harness their potential for systemic change, CPG development strategies need to elevate the current procedural rigour to include inclusivity, sex and gender awareness, and socioeconomic contextualisation. Expanding the available multinational expertise in a representative manner could spearhead the development of more inclusive and context sensitive CPGs in the future. Context sensitive CPGs, developed in a coordinated, standardised, inclusive, multi-stakeholder process, could promote progress in inclusive, sex and gender sensitive health research and innovation, care, and provision of services. Clinical practice guidelines (CPGs) are trusted instruments for evidence based clinical care. This function entails a responsibility and an opportunity to identify, highlight, and challenge inequities in current research and care practice The lack of sex/gender sensitive recommendations in European CPGs reflects shortcomings in research and innovation and ultimately hinders equitable healthcare provision A lack of gender balance and socio-cultural and geographical diversity in the composition of guideline committees can limit awareness of the impact of sex, gender, and diversity on clinical care and outcomes in the developed CPGs

The lack of sex/gender sensitive recommendations in European CPGs reflects shortcomings in research and innovation and ultimately hinders equitable healthcare provision A lack of gender balance and socio-cultural and geographical diversity in the composition of guideline committees can limit awareness of the impact of sex, gender, and diversity on clinical care and outcomes in the developed CPGs CPG development should be standardised across professional societies and explicitly cover sex, gender, context, and data gaps to advance inclusivity This strategy could be expanded towards inclusive globally applicable, context sensitive CPGs for specific diseases and help to advance innovative, inclusive, sex/gender sensitive and diversity informed healthcare