title: Sex disparities among persons receiving operative care during armed conflicts.
abstract: Armed conflict increasingly involves civilian populations, and health care needs may be immense. We hypothesized that sex disparities may exist among persons receiving operative care in conflict zones and sought to describe predictors of disparity.
  
  
  
  We performed a retrospective analysis of operative interventions performed between 2008 and 2014 at Médecins Sans Frontières Operation Center Brussels conflict projects. A Médecins Sans Frontières Operation Center Brussels conflict project was defined as a program established in response to human conflict, war, or social unrest. Intervention- and country-level variables were evaluated. For multivariate analysis, multilevel mixed-effects logistic regression was used with random-effect modeling to account for clustering and population differences in conflict zones.
  
  
  
  Between 2008 and 2014, 49,715 interventions were performed in conflict zones by Médecins Sans Frontières Operation Center Brussels. Median patient age was 24 years (range: 1-105 years), and 34,436 (69%) were men. Patient-level variables associated with decreased interventions on women included: American Society of Anesthesiologists score (P = .003), degree of urgency (P = .02), mechanism (P < .0001), and a country's predominant religion (P = .006). Men were 1.7 times more likely to have an operative intervention in a predominantly Muslim country (P = .006).
  
  
  
  Conflict is an unfortunate consequence of humanity in a world with limited resources. For most operative interventions performed in conflict zones, men were more commonly represented. Predominant religion was the greatest predictor of increased disparity between sexes, irrespective of the number of patients presenting as a result of traumatic injury. It is critical to understand what factors may underlie this disparity to ensure equitable and appropriate care for all patients in an already tragic situation.
authors.affiliation: Department of Surgery, Stanford University, Stanford, CA. Electronic address: JDForrester84@gmail.com.
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Forrester
authors.affiliation: Department of Surgery, Stanford University, Stanford, CA.
authors.forename: Jared A
authors.initials: JA
authors.lastname: Forrester
authors.affiliation: Médecins sans Frontières-Doctors Without Borders, Operational Centre Brussels (MSF-OCB), Brussels, Belgium; General Referral Hospital, MSF-OCB Democratic Republic of the Congo, Masisi, Democratic Republic of the Congo.
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Basimouneye
authors.affiliation: Médecins sans Frontières-Doctors Without Borders, Operational Centre Brussels (MSF-OCB), Brussels, Belgium; Ahmad-Shah-Baba General Hospital, MSF Afghanistan, Kabul, Afghanistan.
authors.forename: Mohammad-Zahir
authors.initials: MZ
authors.lastname: Tahir
authors.affiliation: Médecins sans Frontières-Doctors Without Borders, Operational Centre Brussels (MSF-OCB), Brussels, Belgium; Surgery, Anaesthesia, Gynaecology, and Emergency Medicine Unit, MSF-OCB, Brussels, Belgium.
authors.forename: Miguel
authors.initials: M
authors.lastname: Trelles
authors.affiliation: Surgeons OverSeas, New York, NY; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Surgery, Columbia University, New York, NY.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Kushner
authors.affiliation: Department of Surgery, Stanford University, Stanford, CA; Palo Alto Veterans Affairs Health Care System, Palo Alto, CA.
authors.forename: Sherry M
authors.initials: SM
authors.lastname: Wren
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000068337:Armed Conflicts; D002648:Child; D002675:Child, Preschool; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012189:Retrospective Studies; D012737:Sex Factors; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*; D055815:Young Adult