The Lancet Series on Gender Equality, Norms, and Health finds better global healthcare outcomes and reducing gender inequality are dependent on changing gender norms
Today, The Lancet published a new Series that finds that restrictive gender norms impact the health of all people — women and girls, men and boys, and gender minorities — across multiple dimensions of health, all along the life course, around the world. The Lancet Series on Gender Equality, Norms, and Health has determined that health systems are structured in ways that perpetuate bias, and much health research and data are similarly biased.
"The health consequences of gender inequality undoubtedly fall most heavily on women and girls, especially poor, marginalised women, yet restrictive gender norms undermine the health and well-being of all people," said Gary L. Darmstadt, MD, Associate Dean for Maternal and Child Health and Professor of Pediatrics at the Stanford University School of Medicine. "Gender norms are complex and can intersect with other social factors to impact health over the life course. Non-conformity with, and transgression of, gender norms can be harmful to health, particularly when it causes a person to be mistreated or abused by family, peers, and community members."
The five-part Series was first conceptualised to marshal evidence demonstrating whether and how gender inequality and restrictive gender norms — defined as social roles encompassing a range of behaviours and attitudes that are generally considered acceptable, appropriate, or desirable for people based on their actual or perceived sex — affect health systems and people's health. Additionally, the Series aims to identity opportunities to improve health and strengthen health systems through programmes and policies aimed at transforming gender norms and addressing inequalities.
Key findings of the five papers include:
- Gender norms and gender-related inequalities are powerful determinants of health and health disparities between men and women, distinct from health differences based on sex.
- Due to the historical legacy of gender-based injustice, the health consequences of gender inequality fall most heavily on women, especially poor women, but restrictive gender norms undermine the health and wellbeing of women, men, and gender minorities.
- Existing data provide limited information on the intersection of gender norms and health; however, insights can be gained through innovative analytic approaches.
- Policy approaches that increase gender equality can also improve health, with evidence demonstrating the health impact of tuition-free primary education and paid parental leave.
- High-quality gender-transformative programmes that impacted multiple health outcomes and were sustainable and scalable shared several features: multisectoral action, multilevel and multistakeholder involvement, diversified programming, and social participation and empowerment.
- There is a need to address the role of restrictive gender norms and gender inequalities to reach the collective goal of universal health coverage.
- We must take steps immediately — at the societal and political level — to transform the way gender is reflected in our health systems.
"The hope is this work will inspire action where we know what works, and new partnerships and methods of analysis where there's still more to learn," said Jody Heymann, PhD, Founding Director of the WORLD Policy Analysis Center at UCLA Fielding School of Public Health. "By implementing laws and policies that address gender inequality and support more egalitarian gender norms, we can improve global health outcomes. Making education tuition free and providing paid parental leave are two examples of national policies that support greater gender equality in education and at work, and — as a result — substantially improve health outcomes."
Additional findings from the Series include:
- Gender-normative influences by parents and peers start early and may have multiple short- and long-term health consequences that differ for girls and boys. What's more, non-conformity and transgression of gender norms — including hyper-masculinity and hyper-femininity — can be harmful to health, especially when they trigger negative sanctions, including bullying or ostracism by peers, scolding or punishment by caretakers and teachers, and violence from spouses.
- Existing survey research relies on sex-disaggregated data that can result in misclassification of gender and ignores transgender and non-binary experiences. Currently, datasets often include rich gender-related attitude data or health-related data, but rarely both.
- Questions are often unbalanced by sex of the respondent (e.g., only women are asked about child health and care) and phrasing of questions frequently reveal underlying gender biases in research.
Studies conducted as part of the Series show how these disparities play out in societies throughout the world. In one study, the Series authors examined the influence of normative pressure from parents in Pelotas, Brazil, finding that 7 percent of normal-BMI girls compared to 5.6 percent of boys reported that their parents thought they were fat at age 11. Girls who thought they were fatter than ideal at age 15 had significantly poorer mental health at age 18 compared to those who were satisfied with their bodies — but only if, at age 11, they had reported that their parents thought they were fat.
In another study, the authors examined the impact of community expectations of appropriate sexual behaviour on youth in Zambia. They found that because of sexual double standards, young women may especially avoid seeking information, negotiating condom use, or seeking care to minimise risks of premarital sex, resulting in a higher risk of HIV infection with potentially fatal consequences.
As Drs. Jocalyn Clark and Richard Horton of The Lancet write in an opening commentary, "Gender runs the risk of being everyone's problem, yet no one's responsibility. On the one hand, it's everywhere — #MeToo, pay gap reporting, campaigns to advance women in science — and is ubiquitous in the UN system. On the other hand, it's nowhere. It's not in the universal healthcare coverage plans, it's not tied to the accountability of organisational and government leaders, and it's not routinely reported in research.
An uncomfortable truth is that the shift in global health thinking from women and girls to gender has depoliticised the agenda intended to transform lives. The gender equality aspiration has not translated into meaningful action or accountability; men do not sufficiently exercise their political prominence and power to drive equity; and we haven't sufficiently overcome a brutal reality for millions of women and gender minorities in the world who suffer sexual and domestic violence, are denied basic human rights, or lack control over their own bodies.
The intent of this Series is to go beyond gender analyses that simply recount the value placed on traditional masculinity over femininity and link gender to broader relations of economic and political power. Ultimately, the Series concludes that the transformation of gender inequality and norms is a political act. But, is the world ready to act?"
Despite the adoption by all United Nations Member States of Sustainable Development Goal 5 (SDG5), which aims to achieve gender equality and empower all women and girls by 2030, the links between restrictive gender norms, gender inequality, and poor health outcomes continues to receive insufficient attention in global health.
To promote gender equality and shift gender norms for improved health outcomes, health systems must:
- Focus on health outcomes and engagement across sectors.
- Reform the workplace/workforce to be more gender equitable.
- Fill data gaps and eliminate gender bias in research.
- Fund civil society actors and social movements.
- Strengthen accountability mechanisms.
To read the full series, please visit http://www.thelancet.com/series/gender-equality-norms-health.