This blog accompanies the Lancet Commission on Gender and Global Health seminar series. The series accompanies the development of the Commission, inviting Commissioners and Co-Chairs to discuss a key topic, question, or challenge that the Commission hopes to tackle. The series aims to involve a range of stakeholders and voices in its work and to promote discussion and debate on gender and health.
In the seventh seminar of the Lancet Commission on Gender and Global Health series, Commissioner Gary Darmstadt presented the findings from the Lancet Series ‘Gender Equality, Norms, and Health’ , a collection of five papers that he led. An esteemed researcher, educator, and advocate for reproductive and maternal health, Darmstadt currently serves as the Associate Dean for Maternal and Child Health and Professor of Neonatal and Developmental Medicine in the Department of Pediatrics at the Stanford University School of Medicine. Joined by the Commission Co-Chair Sarah Hawkes, fellow Commissioners, and a YouTube live stream audience, Darmstadt’s presentation on the five Lancet papers provided insight into the impacts of gender inequalities on health and explored opportunities to transform gender norms within health systems, research, and policies (The Lancet, 2019).
The vision of the Lancet Series on Gender Norms
Darmstadt began his presentation by introducing the three-pronged vision of the ‘Gender Equality, Norms, and Health’ Lancet series:
- To develop rigorous evidence for the impact of gender inequalities and restrictive gender norms on health;
- To identify opportunities within health systems, programs, policies, and research to transform gender norms and inequalities;
- To inspire new conversations, partnerships, and methods of analysis to change practices and catalyze action across health and development sectors.
Summarizing this vision, Darmstadt stated, “We were looking for opportunities that exist to be disruptive in systems that hold up [the gender] norms that perpetuate gender inequalities.”.
Gender and Gender Norms
Before diving into the findings of the five papers, Darmstadt took a moment to describe the terms ‘gender’ and ‘gender norms’ (Darmstadt et al., 2019). In this Lancet series, ‘gender’ is viewed in the context of socio-structural systems that allocate power, resources, and social status based on one’s proximity to male/masculine, or female/feminine characteristics. Such a gender-based system is upheld by social norms which dictate acceptable gender-related behaviour.
‘Gender norms’, a complementary but separate term, refers to the explicit and implicit rules that govern the acceptable expression and behaviours for males and females within the family, community, workplaces, and wider society. Gender norms are impressed upon individuals, thus shaping and modelling people’s value and options in the world.
Paper 1: Gender inequality and restrictive gender norms: framing the challenges to health
Paper 1 examines the relationships between restrictive gender norms, gender inequity, and health and offers a conceptual framework that illustrates how biological males and females develop into gendered individuals (Heise, et al., 2019). It also discusses how various forms of discrimination such as sexism, racism, classism, and homophobia interact to create pathways that lead to poor health.
Darmstadt highlighted three key findings:
- Gender norms sustain hierarchies of power and privilege that favour males and masculinity, a preference that reinforces systemic inequalities which undermine the rights of women and restricts opportunities for women, men, and gender minorities to express themselves authentically.
- Health-related consequences of gender fall predominantly on women, especially poor women, due to the historical legacy of gender injustice. Contrastingly, restrictive gender norms undermine the health of everyone, unrelated to age, sex, gender, and income.
- The use of binary sex indicators for gender in sex-disaggregated data eliminates the opportunity to study the diverse experiences of gender and health.
Darmstadt concluded the discussion of paper 1 by iterating that “When we look at [gender] through a normative frame, we find that restrictive gender norms impact all of us, and undermine the health and the well-being of all people”.
Paper 2: Gender norms and health: insights from global survey data
Darmstadt briefly highlighted an examination of six case studies involving secondary analyses of global, national, and subnational gender-related datasets lead to the following findings (Weber, et al., 2019):
- Gender norms are multifaceted and complex, intersecting with other social factors that impact health;
- Gender-normative influences by parents and peers early in life lead to various health consequences;
- Non-conformity with gender norms can be harmful to health, especially in cases where negative sanctions are triggered;
- The impact of gender norms on health are often context-specific and thus demand consideration in the design of gender-transformative policies and programs.
Paper 3: Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms
The third paper of the Lancet ‘Gender Equality, Norms, and Health’ series presents a comprehensive review of literature evaluating programs that aim to reduce restrictive gender norms and gender inequality to improve health (Heymann, et al., 2019). In his discussion on this paper, Darmstadt described two elements in detail: a systematic review on the impacts of adolescent-focused gender-transformative programs on health and a policy analysis of countries that have instituted free primary education and paid parental leave policies.
Among the programs aiming to transform adolescent gender norms and health-related outcomes, 90% of the studies included measured outcomes related to family planning/sexual and reproductive health, violence, and/or HIV. Three-fourths of programs showed significant improvements in indicators of health as well as gender-related measures (though measures of gender norms were absent). Common features of high-quality, effective programs include: multisectoral action; multilevel, multi-stakeholder involvement; diversified programming, and social participation and empowerment.
An investigation into the policies that promoted free primary school education found that a 10% increase in gender parity in education is associated with an increased female life expectancy of 2.06 years and an increased male life expectancy of 0.88 years. Findings that Darmstadt asserted illustrate “the notion that addressing norms, while those norms affect all of us, ... also improve the opportunities, the health, and in this case, the life expectancy of everyone.”
Paper 4: Disrupting gender norms in health systems: making the case for change
Paper 4 considers how gender inequalities and restrictive gender norms are reinforced in health systems and seeks to explore how they can be recognized and addressed with disruptive solutions (Hay, et al., 2019). Using intersectional feminist theory to guide systematic reviews, this paper examines how and why health systems reinforce traditional gender roles, neglect gender inequalities, and devalue female health workers.
Darmstadt explained that women are disproportionately conditioned into “care” roles, while men are pushed into “cure” roles. In care roles, women are valued less, compensated less, and have less influence within the health system. Although 75% of the health workforce is female, most women are restricted to positions with very little power, contributing to work stress, tolerance of abuse, and burnout, especially among socially marginalized women. Male dominated cure roles, however, have greater opportunities for leadership, influence, and pay. The dichotomy between the two roles leads to more poorly performing health systems which can result in a decreased quality of care for patients.
Paper 5: Gender equality and gender norms: Framing the opportunities for health
Paper 5 draws on evidence to dispel major myths on gender and health and describes the most persistent barriers to progress in gender equality (Gupta, et al., 2019). This paper also proposes an actionable agenda for reducing gender inequality and transforming gender norms which includes calling on leaders across government, health, and civil society to focus on health outcomes, reform the workforce to be more gender-equitable, and strengthen accountability mechanisms.
To start, Darmstadt debunked three key myths on gender norms:
- Gender norms do not affect health outcomes
- Gender norms are entrenched and cannot be changed
- Gender norms are elusive and cannot be measured
He then went on to describe the major persistent barriers to progress, which include gender bias in health systems, inadequate response to gender inequity by national governments and health institutions, gaps and bias in gender data and health research, restricted funding for women’s movements and civil society action, and meager accountability mechanisms for corporations that manipulate gender norms and promote stereotypes for profit.
Darmstadt concluded his presentation with a final thought:
“Ultimately, it is all political… Ultimately this is not a matter of lack of evidence… its really the time for political action in holding people to account for the fundamental human right of gender equality.”
Implications for Commission
In the wake of the COVID-19 pandemic and the Lancet Commission on Gender and Global Health publications, we are left with a unique opportunity to leverage the benefits of addressing gender inequalities and global health targets together. As Darmstadt remarked near the end of his presentation, we are not powerless in the fact of gender inequality. We have tools to hypothesize where and how gender norms are having adverse impacts on health and the ability to gain insight into what programs and policies should be doing to increase gender equality.
New conversations are making their way to the centre stage of global health discourses. Global health has historically advocated for more data on women and girls, but the findings from the Lancet Series and other ongoing research has shown that gender research requires more data from all genders. The ways in which the field of global health approaches biases, absence of, and imbalance in gender data is paving the way for a more thorough and equitable understanding of the field. Moving forward, research that acquires balanced data on characteristics such as gender, age, and ethnicity will enable researchers to examine intersectionality and inequality in newfound quantitative approaches. More extensive and proportional data sets will lead to a more comprehensive understanding of the gendered dimensions of health and well-being.
The new era of gender research has highlighted the inherently political nature of gender and intersectional discrimination. The Lancet Commission joins others in advocating for the collection of data on all facets of gender, the mobilization of individuals and institutions in addressing the outcomes of gender-health relationships, and the use of an intersectional feminist strategy for the creation of structural change in global health.
“Now is the right time to unpick the complexity and identify solutions for gender-responsive change within systems and sectors.” (Hawkes, Allotey, Elhadj, Clark, & Horton, 2020)
You can watch the full online seminar here.
The views expressed in this post are those of the presenter and author and may not reflect those of UNU-IIGH or the UCL Centre for Gender and Global Health.
Darmstadt GL, Heise L, Gupta GR, Henry S, Cislaghi B, Greene ME, Hawkes S, Hay K, Heymann J, Klugman J, Levy JK, Raj A, Weber AM. Why now for a Series on gender equality, norms, and health? Lancet 2019;393(10189):2374-2377.
Gupta, G., Oomman, N., Grown, C., Conn, K., Hawkes, S., Shawar, Y. R., .Darmstadt, G. (2019, May 30). Gender equality and gender norms: framing the opportunities for health. The Lancet, 393(10190), 2550-2562. doi:10.1016/S0140-6736(19)30651-8
Hawkes, S., Allotey, P., Elhadj, A. S., Clark, J., & Horton, R. (2020, August 22). The Lancet Commission on Gender and Global Health. The Lancet, 396(10250), 521-522. doi:10.1016/S0140-6736(20)31547-6
Hay, C., McDougal, L., Percival, V., Henry, S., Klugman, J., Wurie, H., Raj, A. (2019, May 19). Disrupting gender norms in health systems: making the case for change. The Lancet, 393(10190), 2535-2549. doi:10.1016/S0140-6736(19)30648-8
Heise, L., Greene, M., Opper, N., Stavropoulou, M., Harper, C., Nascimento, M., & Zewdie, D. (2019, May 30). Gender inequality and restrictive gender norms: framing the challenges to health. The Lancet, 393(10189), 2440-2454. doi:10.1016/S0140-6736(19)30652-X
Heymann, J., Levy, J., Bose, B., Ríos-Salas, V., Mekonen, Y., Swaminathan, H., Darmstadt, G. (2019, May 30). Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms. The Lancet, 393(10190), 2522-2534. doi:10.1016/S0140-6736(19)30656-7
The Lancet. (2019, May 30). Gender Equality, Norms, and Health. Retrieved from The Lancet: https://www.thelancet.com/series/gender-equality-norms-health
Weber, A., Cislaghi, B., Meausoone, V., Abdalla, S., Mejía-Guevara, I., Loftus, P., Darmstadt, G. (2019, May 30). Gender norms and health: insights from global survey data. The Lancet, 393(10189), 2455-2468. doi:10.1016/S0140-6736(19)30765-2