Gender as a determinant of health: a narrative review from a public health perspective

INTRODUCTION

Distinct concepts exist when it comes to sex and gender, even though these terms are sometimes used interchangeably. Sex refers to an individual's biological attributes (e.g., male or female), while gender refers to the roles, behaviours, expectations, and power relations associated with being a man or a woman in society.¹ Gender norms are developed by family, religion, education, peer groups, and the mass media; therefore, they influence an individual's health behaviours and ability to access certain resources. For example, in many cultures, being aggressive is often accepted as a manifestation of masculinity; conversely, being submissive, obedient, and responsible or caring for the domestic environment is expected from women. A person's diet, physical activity level and patterns of sexual behaviour are very important determinants of health for both infectious and chronic illnesses.² Also, the accessibility of healthcare can have both a positive and negative effect on the overall success of an individual's response to illness. An individual, or community, who has little access to healthcare, generally manifests worse health outcomes than communities or individuals who have adequate access to healthcare. Transgender individuals also have special healthcare needs that are often not addressed by the healthcare system. These needs should be included within the provision of integrated and community-based care. All females experience a number of unique health concerns due to being female and yet have a longer life expectancy than males who share similar socioeconomic status. This study shows that the interaction between social disadvantage, biological protection, and inequity in healthcare systems is complex.

METHODS

The review of the literature and global reports, including those published by the World Health Organization (WHO), United Nations Development Programme (UNDP), Government of India (GoI), and peer-reviewed journals, provided the basis for the narrative review provided in this paper. The review utilized a thematic synthesis approach and explored multiple dimensions related to gender in public health, including the conceptual, epidemiological, and programmatic.

CONCEPTUAL FRAMEWORK: GENDER AND HEALTH

The lack of discrimination due to sex illustrates gender equality, while buying into the fairness associated with distributing benefits and responsibilities for both men and women is related to the principles of gender equity. The analyses associated with gender-related issues will be able to measure and determine health disparities based upon social and economic differences between gender roles that women face throughout their lives.

Each of these facets of gender-related discrimination stems from people's views on a gender's place in society or culture, and as such, create disparities that accrue to women disproportionately in the vast majority of nations, including India. Examples of these included statistically distorted ratios of women to men, unequal levels of educational and job opportunities, and the creation of limited political representation within government institutions.

The Gender Inequality Index (GII) is a statistical measure developed by the UNDP, which measures gender-related inequities in reproductive health, empowerment and labour-force participation.³ Similarly, as the GII illustrates, systemic factors and barriers continue to exist, creating and maintaining a gender-based gap that continues to be prevalent in our societies and cultures. Table 1 summarises key differences between the genders as they relate to major areas of public health.

GENDER DIFFERENCES IN DISEASE BURDEN

Cardiovascular diseases

Heart disease is one of the top ten risk factors for mortality among both genders.⁴ Prior to menopause, women benefit from the hormone, oestrogen, which slightly decreases their risk of developing heart disease by increasing their levels of HDL cholesterol, while simultaneously decreasing their levels of LDL cholesterol. After a woman goes through menopause, her risk for developing heart disease begins to increase rapidly. After the age 65, the risk of mortality from heart disease is greater in women than in men. Women with diabetes have a much higher risk of developing cardiovascular disease compared to men with diabetes.⁴ Other metabolic syndrome risk factors (obesity, hypertension, dyslipidemia) contribute significantly to a women’s increased risk of developing cardiovascular disease early in life, as indicated above.

Stroke

Risks of stroke differ by gender due to both biological and social factors. Women's risks of developing a fatal stroke increase with pregnancy, pre-eclampsia, gestational diabetes, combined use of oral contraceptives with smoking, and use of hormone replacement therapy after menopause. Stroke is associated with a significantly higher rate of mortality in women than in men on a global scale.

Blindness

Globally, approximately 40-45 million individuals suffer from blindness (the majority of whom are women—approximately two-thirds of the worldwide total).⁵ Additionally, there are many barriers’ women face to receiving quality eye care services—such as cost, inability to travel independently, limited access to information, and fear of an unfavourable outcome from surgery. Data from the National Health Profile indicate that women in India have a higher prevalence and incidence of blindness than men, which may suggest that they do not have adequate access to and/or do not use eye care services.⁶

Gender and communicable diseases

Malaria

Women and men are equal in terms of malarial infection exposures based on their job and home responsibilities. Women have a greater risk of being infected with falciparum malaria during pregnancy due to their decreased immunity, making pregnant women particularly susceptible to developing anaemia as a result of falciparum malaria.⁷

Adolescent girls are particularly at high risk of developing severe anaemia, leading to poor pregnancy outcomes. Men working in mines, fields or forests at peak biting times or those migrating to high endemicity areas for work and females who get up before dawn to perform household chores are at risk of a bite. Pregnant women are at high-risk areas should target malaria control programs.

Tuberculosis

Data suggests that men are more inclined to contract tuberculosis as compared to women, but the disease remains the third leading cause of death for women aged between 15 and 44 years.⁸ Whereas the rate of disease progression and case fatality tends to be greater among women because they face longer times to diagnosis and more severe stigma related to this serious illness, the Revised National Tuberculosis Control Programme (presently referred to as the National Tuberculosis Elimination Programme) adopted the DOTS method of treating tuberculosis as per established guidelines. The additional gender-specific issues of exposure to tuberculosis, health-seeking behaviour, stigma, and the economic impact of the disease must be addressed in the future planning for tuberculosis control programmes.^9-11

HIV/AIDS

India has the third highest number of individuals living with HIV in the world. Women represent approximately of two-fifths of the total number of individuals living with HIV.¹² Social factors (such as social norms and economic insecurity) combined with biological vulnerabilities increase women's exposure to HIV transmission via heterosexual sexual contact. Transmission from male to female occurs at a rate of between 2 and 20 times more efficiently than female-to-male transmissions.¹³ The gender inequities and power imbalances that exist in many developing countries prevent women from having adequate access to resources and services for preventative health care (including HIV testing, counselling, and treatment).The burden of caregiving for family members affected by HIV is borne disproportionately by women, thus placing additional physical, emotional, and financial strains on women living with HIV.

Gender and cancer

Men and women develop different types of cancer and have different causes for these cancers.¹⁴ Men have a greater incidence of lung cancer and mouth cancer, while women are more commonly diagnosed with breast cancer and cervical cancer. In addition to the many hormonal and lifestyle factors that put women at higher risk for developing breast cancer and cervical cancer. The National Cancer Control Program has developed a strategy directed toward significantly decreasing the incidence of breast and cervical cancer.¹⁵ It focuses on primary prevention and early detection. Routine screening and gender-sensitive health education are vital components of a successful cancer control program.

Gender and mental health

Mental health disorders comprise a significant component of the global disease burden. The incidence of conduct disorders is higher among boys than girls during childhood. However, adolescent girls have a much higher incidence of depression, eating disorders and suicidal ideation than boys.

In adult women, the rate of depression and anxiety are both considerably higher than in men; however, men have a significantly higher rate of substance abuse and antisocial behaviour. Older women have a greater incidence of depression and Alzheimer's disease than older men and frequently receive inferior care and fewer resources due to negligence and a delay in seeking treatment.¹⁶ It is critical to address gender-related barriers to the receipt of appropriate mental healthcare and incorporate gender analysis into the provision of mental health services.

Malnutrition, gender and nutrition, and reproductive health

A woman is generally the last person to eat in her family, and this has a negative impact on women's nutrition throughout all stages of their lives. Reproductive health services and nutrition programs must include and consider the role of women in these programs in order for them to be effective on a population level, as these women will also have children who will be affected by the improper nutrition (i.e. malnutrition as adults) for generations.^18,19

Gender-based violence and injury

Violence against women (VAW) is a major public health concern; approximately 30% (one-third of) of all women in the world have been physically and/or sexually abused in their lifetime (Estimated Range of VAW).²⁰

The health consequences associated with VAW include unintended pregnancies, unsafe abortions, sexually transmitted infections including HIV, mental health disorders, and increased mortality rates for all women who experience VAW.²¹

Women's injuries from domestic violence and VAW, as well as men's injuries resulting from domestic violence and VAW are underreported and poorly studied. Other forms of domestic violence affect both genders; Indian legislation (Section 498-A of the IPC) has focused primarily on protecting women from domestic violence, through protective mechanisms such as increase in women's civil rights.^22-24

Males are more prone to road accidents. On a global level, men are more than three times more likely to encounter from road traffic accidents than women.¹⁷ The higher risk of men from road traffic accidents results from their greater propensity for risk taking, alcohol use, and conformity to social norms concerning masculinity.

Gender, work, and occupational health

Women comprise about 42% of the workforce and experience occupational hazards ranging from work-related stress to sexual harassment, violence and reproductive health hazards.²⁷

Men experience higher levels of exposure to physical, chemical, noise and radiation hazards, as well as greater risks of dying from work-related injuries. Occupational health policies should take into account the unique vulnerabilities created by gender.

Gender and health in disasters

During disasters, women suffer disproportionate impacts due to their social vulnerability, limited ability to move and be involved in decision making to create plans for preparedness and response that are sensitive to the unique needs of women and reduce their inequitable impact.²⁵

Gender bias in health research

Traditionally, the vast majority of subjects represented in health research have been male, while women receive the majority of prescriptions in the U.S.²⁶

Therefore, clinical guidelines that are developed using research undertaken with men are not necessarily going to be applicable to women and other gender groups.

Health disparities among transgender populations

Transgender populations experience higher levels of health disparities than others. These disparities include higher rates of HIV, depression, substance abuse and barriers to quality health care, and hormone therapy can increase the likelihood of them experiencing higher levels of cardiovascular disease, thromboembolism, liver dysfunction and hormone-related cancers.

Factors that contribute to these disparities include social stigma, discrimination, and limited access to inclusive health care.²⁹

Gender mainstreaming in health systems

Incorporating gender perspectives into health system planning and policy development is called gender mainstreaming. The WHO is implementing a gender mainstreaming strategy that focuses on the development of capacity, and gender disaggregated data and monitoring and evaluation of gender-related activities.²⁸

The strategy is to develop a two-tiered approach that consists of six programmatic and three institutional gender mainstreaming strategies in all developing nations.

WAY FORWARD AND POLICY IMPLICATIONS

The goal for achieving gender equity in health is through the systematic inclusion of gender perspectives in healthcare policies and programs.

Although there has been some success in achieving more equitable maternal and child health through programmes like the National Rural Health Mission (NRHM) and Janani Suraksha Yojana (JSY), continued efforts are needed to address the continuing inequities that exist among the most vulnerable populations within and outside of India.^30-33

Figure 1 illustrates how biological sex and socially constructed gender norms interact to influence health behaviours, access to healthcare, exposure to risk factors, and health outcomes across the life course.

Health systems and policies, through gender mainstreaming and use of sex-disaggregated data, can modify these pathways.

CONCLUSION

Gender greatly impacts health outcomes through biological, social and structural pathways. Continued gender inequity limits access to, and negatively impacts health and outcomes of, public health systems and reduces the effectiveness of universal health coverage. Therefore, gender analysis and inclusive research, as well as gender mainstreaming in all healthcare systems, are essential for achieving and maintaining health equity.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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