In May 2019, we released our Lancet Series on Gender Equality, Norms, and Health and launched the Series at Women Deliver in June. Our goal was to communicate a Call to Action for greater attention and inclusion of gender as a social determinant of health in the United Nations Sustainable Development Goals (SDGs) including Universal Health Coverage. This Lancet Series comprises five papers containing new analyses and insights into the impact of gender inequalities and restrictive gender norms on health, and the opportunities that exist within health systems, programmes, policies, and research to transform restrictive gender norms and inequalities. The inadequate attention to gender across programme and policy design, implementation, monitoring, and evaluation undermines the health of everyone—girls and women, boys and men, and gender minorities. Gender inequalities also interact with other social inequalities— associated, for example, with age, race, ethnicity, caste, tribe, religion, and socioeconomic status— to leave behind the most socially marginalised. We can and must do better!
Gender inequality is a social determinant of health that systematically devalues women and girls relative to men and boys, and gender and sexual minorities relative to cis-gender individuals (whose sense of personal identity and gender corresponds with their birth sex) and heterosexual individuals. Using a life course approach, multi-methods analyses, and cross-national data we demonstrate how restrictive gender norms compromise health and health systems functioning, and how we can alter norms to improve health and development at scale. We describe the structural power inequalities between women and men that evolve from and reinforce the disadvantage and discrimination that women and girls experience. We find that restrictive definitions of acceptable gender expression – or what it means to be a woman or a man or a gender minority in a given society – harms the health of everyone in society. The greater the gender inequalities and the more restrictive the gender norms, the worse the health conditions and health systems functioning for nations. To achieve National Health Goals (e.g., declines in maternal and child mortality), Universal Health Coverage under SDG 3, and gender equality and empowerment under SDG 5 and SDG 3 and 5 intersections, we must understand and address the ways gender inequalities and restrictive gender norms impact health and well-being.
Gender interacts with the socio-structural system that apportions power, resources, roles, and social status based on whether something or someone is perceived as male/masculine or female/feminine and appropriately adheres to the “guard rails” of their gender group. Gender systems are held in place by social norms that prescribe acceptable gender-related expression and behavior. Gender norms thus act upon individuals and shape their standing and options in the world, and their functioning within the institutions and communities in which they exist. It is in this sense that gender functions as a social determinant of health.
Making this structural argument, however, is complicated by the shifting use of the term “gender” in today’s world. Sometimes gender is synonymous with women and girls. There is also growing usage of the concept of gender as a key aspect of identity, i.e., a deeply-held personal sense of one’s self as either male, female, transgender, non-binary, fluid, genderqueer or any of many other gender identities. At other times it may be conflated with sex, blurring distinctions between sex differences in health based on biology and gender disparities in health due to social inequalities and the interactions between these. Responding appropriately to these differences and disparities requires different actions.
Our aim is that the findings and recommendations from this Series will help equip global health and development leaders, organisations, and policy makers and advocates to recognise and address the gender inequalities embedded in our health systems, with the goal of prioritising human rights to health at the community level. Our ultimate goal is to leave no one behind, to enable all people to achieve their full human potential by upholding human rights and improving health and well-being for all. Hence, we must go beyond seeing gender inequality as an ‘add-on’ to health but rather as a condition that fundamentally shapes and determines health systems and health outcomes. We must be aspirational rather than responsive in our approach, in the vein of the 1995 Beijing Declaration and Platform for Action and the 1994 International Conference on Population and Development in Cairo. As we approach the 25th anniversaries of these landmark efforts, we must broaden the scope of our work on gender equality to prioritise work in the health arena, engaging health systems, and recognising norms and normative change opportunities as invaluable toward accelerating achievement of the SDGs.
We call on leaders in national governments, global health institutions, civil society organisations, academic settings, and the corporate sector to focus on health outcomes and engage actors across sectors to achieve them; reform the workplace and workforce to be more gender-equitable; fill gaps in data and eliminate gender bias in research; fund civil-society actors and social movements; and strengthen accountability mechanisms. Partnership for revolutionary change on these issues is required now, and we offer this Series as a means of building this partnership between the scientists, policy advocates and change makers that are Women Deliver.
Gary L Darmstadt, Anita Raj, Margaret E Greene, Lori Heise, Geeta Rao Gupta, Sarah Henry, Beniamino Cislaghi, Sarah Hawkes, Katherine Hay, Jody Heymann, Jeni Klugman, Jessica K Levy, Ann M Weber.
Department of Pediatrics and the Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA (GLD, SHe, AMW); Department of Medicine, Center on Gender Equity and Health University of California San Diego, La Jolla, CA, USA (AR); ); GreeneWorks, Washington, DC, USA (MEG); Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Nursing, Baltimore, MD, USA (LH); United Nations Foundation, Washington, DC, USA (GRG); London School of Hygiene & Tropical Medicine, London, UK (BCUniversity College London, Centre for Gender and Global Health, London, UK (SHa); Bill & Melinda Gates Foundation, Seattle, WA, USA (KH); Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA (JH); Women and Public Policy Program, Harvard Kennedy School, Cambridge, MA, USA (JK); and Brown School at Washington University in St Louis, St Louis, MO, USA (JKL)