Gender inequality and restrictive gender norms: framing the challenges to health

Functional limitation among middle age and older adults: Exploring cross-national gender disparities

OBJECTIVE

Functional limitations are prevalent among aging demographics, especially women. Structural and health factors, which vary worldwide, influence rates of functional limitations. Yet, gender disparities in functional limitation remain unclear in a global context.

METHODS

We use 2018 data from the Health and Retirement Study (HRS) international family of studies with respondents ages 50-64 and (n = 87,479) and 65-89 (n = 92,145) to investigate gender disparities in large muscle functional limitation (LMFL) across 10 countries/regions using mixed effects logistic regression, with special attention to structural indicators of inequality and health.

RESULTS

Among both women and men, LMFL was generally higher in China, India, Mexico, United States, and Baltic States than in England, Scandinavia, Southern Europe, Eastern Europe, and Western Europe. The gender disparity in LMFL gradually declined at older ages in India, China, Mexico, and United States, while this disparity gradually increased at older ages throughout Europe. Among middle age respondents, the greater risk of LMFL for women in countries/regions with a high GII was no longer observed after accounting for comorbidities. Among older respondents, a lower risk of LMFL for women in countries/regions with a high GII was not observed until accounting for comorbidities.

DISCUSSION

Our findings suggest that rates of LMFL are higher in middle-income countries than high-income countries, especially among women, and in countries with a higher GII. In addition, consideration of comorbidities was integral to these relationships. Thus, national/regional contexts inform differential rates of functional limitation, particularly as it relates to gender.

Sexual and Reproductive Health Among Cisgender Women With HIV Aged 18-44 Years

INTRODUCTION

The sexual and reproductive health of cisgender women with HIV is essential for overall health and well-being. Nationally representative estimates of sexual and reproductive health outcomes among women with HIV were assessed in this study.

METHODS

Data from the Centers for Disease Control and Prevention's Medical Monitoring Project-including data on sexual and reproductive health-were collected during June 2018-May 2021 through interviews and medical record abstraction among women with HIV and analyzed in 2023. Among women with HIV aged 18-44 years (n=855), weighted percentages were reported, and absolute differences were assessed between groups, highlighting differences ≥|5%| with CIs that did not cross the null.

RESULTS

Overall, 86.4% of women with HIV reported receiving a cervical Pap smear in the past 3 years; 38.5% of sexually active women with HIV had documented gonorrhea, chlamydia, and syphilis testing in the past year; 88.9% of women with HIV who had vaginal sex used ≥1 form of contraception in the past year; and 53.4% had ≥1 pregnancy since their HIV diagnosis-of whom 81.5% had ≥1 unintended pregnancy, 24.6% had ≥1 miscarriage or stillbirth, and 9.8% had ≥1 induced abortion. Some sexual and reproductive health outcomes were worse among women with certain social determinants of health, including women with HIV living in households <100% of the federal poverty level compared with women with HIV in households ≥139% of the federal poverty level.

CONCLUSIONS

Many women with HIV did not receive important sexual and reproductive health services, and many experienced unintended pregnancies, miscarriages/stillbirths, or induced abortions. Disparities in some sexual and reproductive health outcomes were observed by certain social determinants of health. Improving sexual and reproductive health outcomes and reducing disparities among women with HIV could be addressed through a multipronged approach that includes expansion of safety net programs that provide sexual and reproductive health service coverage.

Intersectionality, gender norms, and young adolescents in context: a review of longitudinal multicountry research programmes to shape future action

Discriminatory gender norms can intersect and interact with other dimensions of discrimination-such as age, race, ethnicity, disability, education status, and sexual orientation-to shape individuals' experiences and impact their health and wellbeing. This interaction is referred to as intersectionality. Although the theory has been in circulation since the late 1980s, only recently has it gained traction in low-income and middle-income settings, and it has yet to fully penetrate global research on adolescence. The social and structural intersectional drivers of adolescent health and wellbeing, particularly during early adolescence (age 10-14 years), are poorly understood. The evidence base for designing effective interventions for this formative period of life is therefore relatively small. In this Review, we examine how gender intersects with other forms of disadvantage in the early stages of adolescence. Analysing data from hybrid observation-intervention longitudinal studies with young adolescents in 16 countries, our aim is to inform the health and wellbeing of girls and boys from a range of social contexts, including in conflict settings. Adolescents' perceptions about gender norms vary by context, depend on individual opinion, and are shaped by socioecological drivers of gender inequalities in health. Shifting those perceptions is therefore challenging. We argue for the importance of applying an intersectionality lens to improve health and wellbeing outcomes for young adolescents and conclude with five practical recommendations for programme design and research.

Sex and gender differences in adverse events following influenza and COVID-19 vaccination

INTRODUCTION

Active and passive surveillance studies have found that a greater proportion of females report adverse events (AE) following receipt of either the COVID-19 or seasonal influenza vaccine compared to males. In a predominately young adult female population of healthcare workers, we sought to determine the intersection of biological sex and sociocultural gender differences in prospective active reporting of vaccine outcomes, which remains poorly characterized.

METHODS

This cohort study enrolled Johns Hopkins Health System healthcare workers (HCWs) who were recruited from the mandatory annual fall 2019-2022 influenza vaccine and the fall 2022 COVID-19 bivalent vaccine campaigns. Vaccine recipients were enrolled the day of vaccination and AE surveys were administered two days post-vaccination for bivalent COVID-19 and influenza vaccine recipients. Data were collected regarding the presence of a series of solicited local and systemic AEs. Open-ended answers about participants' experiences with AEs also were collected for the COVID-19 vaccine recipients.

RESULTS

Females were more likely to report local AEs after either influenza (OR = 2.28, p = 0.001) or COVID-19 (OR = 2.57, p = 0.008) vaccination compared to males, regardless of age or race. Males and females had comparable probabilities of reporting systemic AEs after either influenza (OR = 1.18, p = 0.552) or COVID-19 (OR = 0.96, p = 0.907) vaccination. Hormonal birth control use did not impact the rates of reported AEs following influenza vaccination among reproductive-aged female HCWs. Women reported more interruptions in their daily routine following COVID-19 vaccination than men and were more likely to seek out self-treatment. More women than men scheduled their COVID-19 vaccination before their days off in anticipation of AEs.

CONCLUSIONS

Our findings highlight the need for sex- and gender-inclusive policies to inform more effective mandatory occupational health vaccination strategies. Further research is needed to evaluate the potential disruption of AEs on occupational responsibilities following mandated vaccination for healthcare workers, a predominately female population, and to more fully characterize the post-vaccination behavioral differences between men and women.

Active listening, shared decision-making and participation in care among older women and primary care nurses: a critical discourse analysis approach from a gender perspective

BACKGROUND

Nursing care for older women represent a challenge worldwide due to its characteristics. When communication is impaired between primary care nurses and older women living alone, an imbalance in power relations occurs. The main objective of this study is to analyse the power relations between older women and primary care nurses in situations of active listening, shared decision-making and participation in care.

METHODS

We developed a qualitative study in southern Spain using a discursive and gender approach. We used purposeful sampling to interview older women who lived alone and received home nursing care. Simultaneously, we conducted focus groups with primary care nurses who provided home care to older women. A linguistic analysis of the transcripts was carried out.

RESULTS

Nine semi-structured face-to-face interviews were conducted with older women who lived alone and two face-to-face focus groups with four primary care nurses in each. The discourse of the participants demonstrated an imbalance in power relations. Influenced by work overload, active listening was considered a privilege in primary care nurses´ discourse. Regarding shared decision-making, older women´s discourses revealed "mirages" of real situations where they thought they were deciding. Participation in care was difficult since older women saw themselves as a nuisance in nurses´ presence, and primary care nurses did not facilitate older women's engagement. Older women weren´t considered when organising home visits and had interiorised a subordinated feeling. Similarly, a strict sense of identity made primary care nurses feel powerful in their relationships with older women.

CONCLUSIONS

The discourse of older women represented them as victims of a hostile panorama whilst they were sometimes satisfied with the deficient care received. The discourse of primary care nurses used more discursive strategies to represent themselves as professionals committed to caring. However, it also revealed deficiencies in care, discriminatory elements, and feelings of being limited by their working conditions. Active listening to older women and engagement in decision-making readjust empower the older women. Attending to the needs and concerns of primary care nurses could recalibrate the power imbalance between them and healthcare organisations.

World Psychiatric Association-Asian Journal of Psychiatry Commission on Public Mental Health

Although there is considerable evidence showing that the prevention of mental illnesses and adverse outcomes and mental health promotion can help people lead better and more functional lives, public mental health remains overlooked in the broader contexts of psychiatry and public health. Likewise, in undergraduate and postgraduate medical curricula, prevention and mental health promotion have often been ignored. However, there has been a recent increase in interest in public mental health, including an emphasis on the prevention of psychiatric disorders and improving individual and community wellbeing to support life trajectories, from childhood through to adulthood and into older age. These lifespan approaches have significant potential to reduce the onset of mental illnesses and the related burdens for the individual and communities, as well as mitigating social, economic, and political costs. Informed by principles of social justice and respect for human rights, this may be especially important for addressing salient problems in communities with distinct vulnerabilities, where prominent disadvantages and barriers for care delivery exist. Therefore, this Commission aims to address these topics, providing a narrative overview of relevant literature and suggesting ways forward. Additionally, proposals for improving mental health and preventing mental illnesses and adverse outcomes are presented, particularly amongst at-risk populations.

Family Factors and Gender Norms as Protective Factors Against Sexual Risk-Taking Behaviors Among Adolescent Girls in Southern Uganda

Adolescent girls and young women are at a higher risk for HIV infection stemming from barriers to accessing comprehensive sexual health education, unequal cultural, social, and economic statuses, limited access to education and health care services, and gender-based violence. This makes adolescent girls susceptible to high-risk sexual behaviors. This study examines the protective role of family, social support factors and gender norms against sexual risk-taking behaviors among secondary school adolescent girls in Uganda. Baseline data from the National Institute of Mental Health-funded Suubi4Her study were analyzed. A total of 1260 girls aged 14-17 years and enrolled in the first or second year of secondary school were recruited across 47 secondary schools. Hierarchical linear regression models were conducted to determine the role of family, social support factors and gender norms on sexual risk-taking behaviors. Results indicate that traditional gender norms, family care and relationships, and social support were all associated with lower levels of sexual risk-taking intentions-a proxy for engaging in sexual risk behaviors. Findings point to the need to develop family level support interventions to equip adolescent girls with adequate sexual health-related knowledge and skills to facilitate safer sexual practices and reduce high-risk sexual-taking behaviors, as they develop and transition into young adulthood.

Gender(ed) science: How the institutionalization of gender continues to shape the conduct and content of women's health research

Gender refers to the socially constructed roles, behaviors, and attributes that a particular society considers appropriate for men and women based on assumptions about biological sex. It also operates as a major social organizing principle that confers unequal power, status, and resources to men and women, with direct consequences for health. Historic patriarchal and misogynistic beliefs and values are reinforced through social institutions, including health science, which reify gender inequities. This commentary examines two key domains in which the social organization and institutionalization of gender in scientific research affect the conduct of women's health research and, by extension, women's health outcomes. These domains are: 1) decisions about which topics are prioritized, researched, and funded and 2) the dissemination of research findings. Using the National Institutes of Health (NIH) as a case study to illustrate broader patterns in scientific research, we present evidence of gender-based inequities in what is prioritized, deemed fundable, and disseminated, and how this affects knowledge production and attention to women's health. We highlight efforts and progress made by the NIH and call for additional attention to further address gender-based inequities and their impact on women's health research. We conclude with a call for critical social science analyses-ideally supported by the NIH-of the social organization of health science research to identify points of intervention for redressing deep-seated obstacles to advancing research on women's health.

Stigma, social support, and spirituality: associations with symptoms among Black, Latina, and Chinese American cervical cancer survivors

PURPOSE

Few studies have examined experiences of stigma and factors associated with symptoms among cervical cancer survivors from diverse racial and ethnic backgrounds. We investigated survivorship experiences and patient-reported outcomes in the SPADE symptom cluster (sleep disturbance, pain interference, anxiety, depression, and energy/fatigue) among Black, Latina, and Chinese American women diagnosed with cervical cancer.

METHODS

In two phases of research with cervical cancer survivors, we collected qualitative data through individual interviews (N=12; recruited through community referrals) and quantitative data from an observational cohort study (N=91; recruited through 4 national cancer registries). We coded interview transcripts to describe the survivors' experiences. We then evaluated associations between social support, spirituality, and SPADE symptom cluster domains using linear regression models.

RESULTS

Qualitative analysis yielded four themes: perceptions of stigma, empowerment, physical and psychological effects, and social support. These concepts revolved around internal and external stigmas, emotional responses, strengthened faith, and different social support types. Quantitative analyses indicated that greater spirituality was associated with lower symptom burden on all five SPADE domains (p<0.01). We observed nuanced associations between specific types of social support and SPADE domains.

CONCLUSIONS

The survivorship experiences of Black, Latina, and Chinese American women with cervical cancer are negatively influenced by perceptions of stigma. Higher scores on spirituality and varied types of social support were significantly associated with fewer symptoms in the SPADE symptom cluster.

IMPLICATIONS FOR CANCER SURVIVORS

Results suggest targets for future interventions to reduce symptom burden among women diagnosed with cervical cancer by leveraging spirituality and social support.

Workshop summary: National Institutes of Health (NIH) 2022 scientific workshop on gender and health

In this manuscript, we summarize the goals, content, and impact of the Gender and Health: Impacts of Structural Sexism, Gender Norms, Relational Power Dynamics, and Gender Inequities workshop held by the National Institutes of Health (NIH) Office of Research on Women's Health (ORWH) in collaboration with 10 NIH Institutes, Centers, and Offices. Specifically, we outline the key points emerging from the workshop presentations, which are the focus of the collection of articles in this supplement. The overarching goals of the workshop were to convene NIH staff, the external scientific community, and the public to discuss methods, measurement, modifiable factors, interventions, and best practices in health research on gender as a social and cultural variable and to identify opportunities to advance research and foster collaborations on these key topics. Themes emerging from the workshop include the need for intersectional measures in research on gender and health, the role of multilevel interventions and analyses, and the importance of considering gender as a social and structural determinant of health. Careful, nuanced, and rigorous integration of gender in health research can contribute to knowledge about and interventions to change the social and structural forces that lead to disparate health outcomes and perpetuate inequities.

"Women's work": Gender and the physician workforce

Historically, the physician professional identity and the organizational structure of Western medicine have been defined by masculine norms such as authority and assertiveness. The past five decades have seen a rapid shift in the demographics of attendees as medical schools, with equal numbers of women and men matriculants for nearly twenty years. Gender as a social, cultural, and structural variable continues to influence the physician workforce. The entry of women into medicine, has had far reaching effects on the expectations of patients, the interactions of physicians with other members of the healthcare team, and the delivery of care. Redefining the culture of medicine to accommodate the diversity of the modern workforce may benefit all physician and improve the delivery of healthcare.

Paediatric melioidosis

Melioidosis is a tropical infectious disease caused by the saprophytic gram-negative bacterium Burkholderia pseudomallei. Despite the infection being endemic in southeast Asia and northern Australia, the broad clinical presentations and diagnostic difficulties limit its early detection, particularly in children. Melioidosis more commonly affects the immunocompromised and adults. Melioidosis is increasingly being diagnosed around the world and whole-genome sequencing indicates that these cases are not linked with travel to endemic areas. Research has concentrated on the adult population with limited experience reported in the care of this uncommon, but potentially fatal condition in children presenting with bacteraemia and pneumonia.

Advancing gender transformative intersectional science for health justice: An ecosocial analysis

At a time when health-oriented institutions both globally and nationally are increasingly recognizing the need to support research, interventions and training that engage with analysis of how gendered social systems shape population health, independent of and in conjunction with sex-linked biology, it is essential that this work reject biological essentialism and instead embrace embodied integration. In this essay, guided by the ecosocial theory of disease distribution, I clarify connections and distinctions between biological versus social reproduction and inheritance, underscore the non-equivalence of the categories "sex" and "race," and offer a set of examples analyzing the production of gendered health inequities and who needs to do what to address them. The examples concern the worlds of work (sexual harassment; breastfeeding; sex work), ecologic environments (water access; fracking, sexually transmitted infections, & sexual violence); sexual reproduction and reproductive justice (gender stereotyping of reproductive biology; sterilization abuse and abortion bans); and (4) gender transformative initiatives (violence; health interventions). To advance gender transformative intersectional science for health justice, I offer recommendations regarding requirements for justifying data conceptualization, analysis and governance that can be implemented by institutions with the power to shape the funding, translation, and publication of science involving gender, sex-linked biology, and the people's health.

Stigmatizing deferrals disproportionally reduce donor return rates: Evidence from Brazil

BACKGROUND AND OBJECTIVES

Prior research has shown that temporary deferrals negatively influence donor return rates, but it remains unknown the extent to which these effects vary across reasons for deferral. We investigate whether deferrals differ in their degree of perceived stigmatization and, if so, how being deferred for stigmatizing (vs. non-stigmatizing) reasons affects subsequent donation behaviour.

MATERIALS AND METHODS

We examined whether reasons for deferral vary on their perceived level of stigmatization through an online survey (n = 400). Furthermore, we used a dataset encompassing 25 years of donation records from the state-run blood collection agency (BCA) from Rio de Janeiro, Brazil, to investigate how stigmatizing (vs. non-stigmatizing) reasons for deferral affected return rates of 82,648 donors over a 60-month follow-up period.

RESULTS

Being deferred for sex- and drug-related reasons was perceived as much more stigmatizing than other reasons for deferral (odds ratio = 3.14, 95% confidence interval [CI]: 2.33-4.25). Controlling for multiple observables, prospective donors were less likely to return to the BCA when deferred for stigmatizing (vs. non-stigmatizing) reasons (adjusted hazard ratio = 0.87, 95% CI: 0.83-0.93).

CONCLUSION

Donors perceive deferrals motivated by sex- and drug-related reasons as particularly stigmatizing, which is negatively associated with donor return rates. BCAs may want to pay special attention when communicating stigmatizing reasons for deferral to prospective donors.

The EMERGE framework to measure empowerment for health and development

RATIONALE

Women's empowerment is a UN Sustainable Development Goal and a focus of global health and development but survey measures and data on gender empowerment remain weak. Existing indicators are often disconnected from theory; stronger operationalization is needed.

OBJECTIVE

We present the EMERGE Framework to Measure Empowerment, a framework to strengthen empowerment measures for global health and development.

METHOD

We initiated development of this framework in 2016 as part of EMERGE - an initiative designed to build the science of survey research and availability of high-quality survey measures and data on gender empowerment. The framework is guided by existing theories of empowerment, evidence, and expert input. We apply this framework to understand women's empowerment in family planning (FP) via review of state of the field measures.

RESULTS

Our framework offers concrete measurable constructs to assess critical consciousness and choice, agency and backlash, and goal achievement as the empowerment process, recognizing its operation at multiple levels-from the individual to the collective. Internal attributes, social norms, and external contexts and resources create facilitators or barriers to the empowerment process. Review of best evidence FP measures assessing empowerment constructs, social norms, and key influencers (e.g., partners and providers) show a strong landscape of measures, including those with women, partners, and providers, but they are limited in assessing translation of choice to agency to achievement of women's self-determined fertility or contraceptive goals, instead relying on assumption of contraceptive use as the goal. We see no measures on collective empowerment toward women's reproductive choice and rights.

CONCLUSION

The EMERGE Framework can guide development and analysis of survey measures on empowerment and is needed as the current state of the field shows limited coverage of empowerment constructs even in areas which have received more study, such as family planning.

Trend in prevalence, associated risk factors, and longitudinal outcomes of sarcopenia in China: A national cohort study

AIMS

To estimate the contemporary trend in the prevalence of sarcopenia and evaluate its risk factors and the longitudinal associations with multiple chronic conditions and mortality among Chinese middle-aged and older adults.

METHODS

This was a nationwide, prospective cohort study using data from the China Health and Retirement Longitudinal Study. The definition of sarcopenia was based on the Asian Working Group for Sarcopenia 2019 algorithm. In the cross-sectional analysis, we estimated the trend in the weighted prevalence of sarcopenia from 2011 to 2015 and examined the associated risk factors for sarcopenia severity in 2011. In the longitudinal analysis, we assessed the longitudinal associations between sarcopenia and 14 chronic conditions and mortality during a 9-year follow-up.

RESULTS

The weighted prevalence of sarcopenia remained consistently high in the overall population from 2011 (15.9%, 95% confidence intervals [CI]: 15.1, 16.6) to 2015 (15.0%, 95% CI: 14.3, 15.6; p for trend = 0.075). A range of risk factors were independently associated with the severity of sarcopenia, including older age, female sex, lower socioeconomic status, smoking status, malnutrition, and several chronic conditions. Possible sarcopenic and sarcopenic individuals had higher odds of several chronic conditions (i.e., heart disease, chronic lung disease, and memory-related disease) and increased risks of mortality (possible sarcopenia: odds ratios (OR): 1.66, 95% CI: 1.37, 2.00; sarcopenia: OR: 1.69, 95% CI: 1.36, 2.11) in 9 years of follow-up.

CONCLUSIONS

The prevalence of sarcopenia remained consistently high in the investigated population. Various risk factors were significantly associated with a higher prevalence of sarcopenia. Sarcopenic individuals had higher odds of several chronic conditions and increased risks of mortality, highlighting that the urgent need for dedicated efforts to improve the management of sarcopenic patients.

Gender/Sex Disparities in the COVID-19 Cascade From Testing to Mortality: An Intersectional Analysis of Swiss Surveillance Data

Objectives

This study investigates gender and sex disparities in COVID-19 epidemiology in the Canton of Vaud, Switzerland, focusing on the interplay with socioeconomic position (SEP) and age.

Methods

We analyzed COVID-19 surveillance data from March 2020 to June 2021, using an intersectional approach. Negative binomial regression models assessed disparities between women and men, across SEP quintiles and age groups, in testing, positivity, hospitalizations, ICU admissions, and mortality (Incidence Rate Ratios [IRR], with 95% Confidence Intervals [CI]).

Results

Women had higher testing and positivity rates than men, while men experienced more hospitalizations, ICU admissions, and deaths. The higher positivity in women under 50 was mitigated when accounting for their higher testing rates. Within SEP quintiles, gender/sex differences in testing and positivity were not significant. In the lowest quintile, women's mortality risk was 68% lower (Q1: IRR 0.32, CI 0.20-0.52), with decreasing disparities with increasing SEP quintiles (Q5: IRR 0.66, CI 0.41-1.06).

Conclusion

Our findings underscore the complex epidemiological patterns of COVID-19, shaped by the interactions of gender/sex, SEP, and age, highlighting the need for intersectional perspectives in both epidemiological research and public health strategy development.

Gender-transformative programmes: a framework for demonstrating evidence of social impact

Ample evidence has demonstrated that gender inequality and restrictive gender norms wield significant influence over health outcomes. While gender-transformative programmes have grown with the aim of challenging these norms and promoting gender equality, their effectiveness in driving sustainable norm change remains a subject of debate. This paper introduces a comprehensive analytical framework designed to assess the impact of these programmes.Drawing from extensive literature reviews of rigorously evaluated health programmes, this framework identifies four key dimensions that are instrumental in determining a programme's potential for transformative change. These dimensions are multiplicative effect, sustainability, spread and scalability. Multiplicative effect emphasises the interconnected nature of societal systems, positing that altering one element can trigger cascading effects throughout the entire system. Sustainability recognises that change within a system is less likely to revert once the structure has shifted. Programmes that facilitate norm change are more likely to sustain the changes brought about by their interventions. Spread acknowledges the importance of engaging entire networks that share the targeted norms. Successful programmes should demonstrate evidence of gender-related outcomes extending beyond the immediate beneficiaries, progressively diffusing through the broader population. Finally, scalability emphasises the need to bring gender-transformative initiatives to a larger scale to effect broader norm change.By aligning programme design and evaluation with these four dimensions, the proposed framework provides a standardised approach for assessing gender-transformative programmes. It shifts the focus from individual-level change to systemic transformation, bridging the gap between programmatic aspirations and the ability to measure genuine progress.

Differences across the lifespan between females and males in the top 20 causes of disease burden globally: a systematic analysis of the Global Burden of Disease Study 2021

BACKGROUND

Sex and gender shape health. There is a growing body of evidence focused on comprehensively and systematically examining the magnitude, persistence, and nature of differences in health between females and males. Here, we aimed to quantify differences in the leading causes of disease burden between females and males across ages and geographies.

METHODS

We used the Global Burden of Disease Study 2021 to compare disability-adjusted life-year (DALY) rates for females and males for the 20 leading causes of disease burden for individuals older than 10 years at the global level and across seven world regions, between 1990 and 2021. We present absolute and relative differences in the cause-specific DALY rates between females and males.

FINDINGS

Globally, females had a higher burden of morbidity-driven conditions with the largest differences in DALYs for low back pain (with 478·5 [95% uncertainty interval 346·3-632·8] more DALYs per 100 000 individuals among females than males), depressive disorders (348·3 [241·3-471·0]), and headache disorders (332·9 [48·3-731·9]), whereas males had higher DALY rates for mortality-driven conditions with the largest differences in DALYs for COVID-19 (with 1767·8 [1581·1-1943·5] more DALYs per 100 000 among males than females), road injuries (1012·2 [934·1-1092·9]), and ischaemic heart disease (1611·8 [1405·0-1856·3]). The differences between sexes became larger over age and remained consistent over time for all conditions except HIV/AIDS. The largest difference in HIV/AIDS was observed among those aged 25-49 years in sub-Saharan Africa with 1724·8 (918·8-2613·7) more DALYs per 100 000 among females than males.

INTERPRETATION

The notable health differences between females and males point to an urgent need for policies to be based on sex-specific and age-specific data. It is also important to continue promoting gender-sensitive research, and ultimately, implement interventions that not only reduce the burden of disease but also achieve greater health equity.

FUNDING

Bill & Melinda Gates Foundation.

Female Attendings in University Clinics of Surgery in Germany: A Scoping Analysis of an Ongoing Disparity

INTRODUCTION

 Gender-based discrimination, particularly in healthcare, affects women's roles and opportunities, including in surgery where they remain underrepresented in leadership positions. The extent to which such discrimination is prevalent in attending positions is unclear.

METHODS

 The publicly available records of 48 universities and university-associated hospitals in Germany were extracted to quantify gender ratios among attending surgeons and head surgeons in the fields of visceral, vascular, cardiac, thoracic, pediatric, orofacial, neuro-, trauma, and plastic surgery. Statistical analysis, including Chi-Square tests and Student's t-test, was used to analyze the data.

RESULTS

 Among the 367 department heads, 353 (96.2%) were male and 14 (3.8%) were female. Among the 2,366 attendings, 1,854 (78.4%) were men and 512 (21.6%) were women. These differences were significant (χ²=64.95, p<0.001, odds ratio=0.14, 95% confidence interval=0.08-0.25). Departments being led by a female department head were not more likely to employ female attendings (χ²=0.379, p=0.538, odds ratio=1.17, 95% confidence interval=0.70-1.96).

CONCLUSION

 German surgical departments in University Hospitals have significant gender disparities, with women underrepresented at higher levels. This may negatively affect patient outcomes. To tackle the problem, further research is needed to fully understand the issue.

Community gender norms, mental health, and suicide ideation and attempts among older Japanese adults: a cross-sectional study

OBJECTIVES

Gender norms embedded in communities may restrict opportunities and harm the mental health of older adults, yet this phenomenon has received little attention. This study investigates the connection between older adults' perceptions of community gender norms and mental health and suicide-related outcomes.

DESIGN

Cross-sectional.

SETTING

This study analyzed data from the 2019 wave of the Japan Gerontological Evaluation Study.

PARTICIPANTS

In total, 25,937 participants aged 65 years or older in 61 municipalities.

MEASUREMENTS

Perceptions of community gender norms were assessed by the respondents' perceptions of the gender-differentiating language used by those around them such as "You should/should not do XXX, because you are a man/woman."

RESULTS

The prevalence of all mental health outcomes was higher among both men and women who perceived community gender norms as restrictive. These associations remained in fully adjusted multivariable analyses. Prevalence ratios for men were 1.36 [95% confidence interval: 1.13, 1.65] for psychological resistance to obtaining help, 1.85 [1.54, 2.23] for depressive symptoms, 1.99 [1.34, 2.96] for suicidal ideation, and 2.15 [1.21, 3.80] for suicide attempts. The corresponding figures for women were 1.39 [1.17, 1.65], 1.80 [1.55, 2.10], 2.13 [1.65, 2.74], 2.62 [1.78, 3.87]. There was a more pronounced association between perceiving community gender norms as restrictive and depressive symptoms and suicidal behaviors among those with nonconventional gender role attitudes compared to those with conventional attitudes.

CONCLUSIONS

Considering the effects of community gender norms, in addition to individual gender role attitudes, may be critical in designing effective public health interventions for improving mental health.

Respectful maternity care interventions to address women mistreatment in childbirth: What has been done?

INTRODUCTION

Over the last decade, there has been an increasing number of studies regarding experiences of mistreatment, disrespect and abuse (D&A) during facility-based childbirth. These negative experiences during labour have been proven to create a barrier for seeking both facility-based childbirth and postnatal health care, as well as increasing severe postpartum depression among the women who experienced them. This constitutes a serious violation of human rights. However, few studies have carried out specifically designed interventions to reduce these practices. The aim of this scoping review is to synthetise available evidence on this subject, and to identify initiatives that have succeeded in reducing the mistreatment, D&A that women suffer during childbirth in health facilities.

METHODS

A PubMed search of the published literature was conducted, and all original studies evaluating the efficacy of any type of intervention specifically designed to reduce these negative experiences and promote RMC were selected.

RESULTS

Ten articles were included in this review. Eight studies were conducted in Africa, one in Mexico, and the other in the U.S. Five carried out a before-and-after study, three used mixed-methods, one was a comparative study between birth centres, and another was a quasi-experimental study. The most common feature was the inclusion of some sort of RMC training for providers at the intervention centre, which led to the conclusion that this training resulted in an improvement in the care received by the women in childbirth. Other strategies explored by a small number of articles were open maternity days, clinical checklists, wall posters and constant user feedback.

DISCUSSION

These results indicate that there are promising interventions to reduce D&A and promote RMC for women during childbirth in health facilities. RMC training for providers stands as the most proven strategy, and the results suggest that it improves the experiences of care received by women in labour.

CONCLUSION

The specific types of training and the different initiatives that complement them should be evaluated through further scientific research, and health institutions should implement RMC interventions that apply these strategies to ensure human rights-based maternity care for women giving birth in health facilities around the world.

Qualitative evaluation of an edutainment intervention to prevent age-disparate transactional sex in Tanzania: Changes in educational aspirations and gender equitable attitudes towards work

Age-disparate transactional sex is a major contributor to the disproportionate rates of HIV experienced by adolescent girls in sub-Saharan Africa, and a key driver of unintended adolescent pregnancy. This paper comprises one element of the impact evaluation of the Learning Initiative on Norms, Exploitation and Abuse (LINEA) radio drama intervention to prevent age-disparate transactional sex. It provides new insights into the radio drama's influence on distal drivers of age-disparate transactional sex identified in formative research: girls' own educational aspirations, and gendered attitudes towards work. The intervention, which targeted adolescent girls and their caregivers in the Shinyanga Region of Tanzania, uses an edutainment approach to prevent transactional sex between girls aged 12-16 years and men at least 5-10 years older. We distributed the 39-episode radio drama on USB flash drives to 331 households and conducted longitudinal in-depth interviews with 59 participants. We conducted a thematic analysis of endline (December 2021) transcripts from 23 girls, 18 women caregivers, and 18 men caregivers of girls (n = 59), and midline (November 2021) transcripts from a sub-sample of these participants: 16 girls, 16 women and 13 men (n = 45). Findings suggest the radio drama created an enabling environment for preventing age-disparate transactional sex by increasing girls' motivation to focus on their studies and remain in school. There was also strong evidence of increased gender-equitable attitudes about work among girls and women and men caregivers. These supported women joining the workforce in positions traditionally reserved for men and challenging the male provider role. Our findings suggest that the LINEA radio drama can supplement interventions that address structural drivers of age-disparate transactional sex. The radio drama may also have impacts beyond preventing age-disparate transactional sex, such as reducing girls' HIV morbidity and mortality, and challenging attitudes that promote sexual and gender-based violence to foster more gender-equitable communities across Tanzania.

Higher morning cortisol is associated with lower intuitive eating in midlife women

BACKGROUND

Stress is associated with negative health outcomes in adults, including increased adiposity. Eating behaviors to cope with stress can have a negative effect on adiposity. There is limited research on positive eating behaviors, such as intuitive eating (IE), and their relationship to stress and adiposity. Thus, this study aimed to examine the association between stress and adiposity and to assess whether IE is a mediator of that pathway.

METHODS

Data were analyzed from a cross-sectional study of 114 women between 40-64 years of age. Participants completed in-person visits and self-reported questionnaires, including the Intuitive Eating Scale and Perceived Stress Scale. Adiposity was assessed using dual energy x-ray absorptiometry. Measurements included total body fat percentage and android/gynoid (AG) ratio as a measure of abdominal adiposity. Participants provided ten salivary cortisol samples over two days, collected upon waking, 30-, 45-, and 60-minutes after waking, and prior to bed. Several methods were used to characterize cortisol secretion and exposure, including the diurnal cortisol slope and the cortisol area under the curve with respect to ground (AUCg). Linear regression was used to assess the associations between perceived stress and IE and between features of diurnal cortisol and IE. Mediation models were tested to examine the indirect effects of IE on the relationship between perceived stress and adiposity and to test the indirect effects of IE on the relationship between cortisol measures and adiposity.

RESULTS

Linear regression analyses indicated that higher cortisol AUCg was associated with lower scores on the eating for physical reasons subscale (β: -0.01, p = 0.008). After adjusting for covariates, neither higher perceived stress nor diurnal cortisol were associated with intuitive eating. There was no evidence of mediation of the association of stress on adiposity through IE.

CONCLUSION

Our findings demonstrate a relationship between higher overall morning cortisol and lower scores on the eating for physical reasons subscale of the Intuitive Eating Scale. Future research should seek to understand how intuitive eating may be used as a technique for individuals who engage in emotional eating to cope with stress, and to prevent excess adiposity resulting from stress in midlife women.

The role of resilience in the development of depression, anxiety, and post-traumatic stress disorder after trauma in children and adolescents

This investigation, conducted within the Texas Childhood Trauma Research Network, investigated the prospective relationships between resiliency and emergent internalizing symptoms among trauma-exposed youth. The cohort encompassed 1262 youth, aged 8-20, from twelve health-related institutions across Texas, who completed assessments at baseline and one- and six-month follow-ups for resiliency, symptoms of depression, generalized anxiety, posttraumatic stress disorder (PTSD), and other demographic and clinical characteristics. At baseline, greater resilience was positively associated with older age, male (vs female) sex assigned at birth, and history of mental health treatment. Unadjusted for covariates, higher baseline resilience was associated with greater prospective depression and PTSD symptoms but not anxiety symptoms. Upon adjusting for demographic and clinical factors, higher baseline resilience was no longer associated with depression, PTSD, or anxiety symptoms. Our analyses demonstrate that the predictive value of resilience on psychopathology is relatively small compared to more readily observable clinical and demographic factors. These data suggest a relatively minor prospective role of resilience in protecting against internalizing symptoms among trauma-exposed youth and highlight the importance of controlling for relevant youth characteristics when investigating a protective effect of resilience on internalizing symptoms.

Gender differences in midlife to later-life cumulative burden and variability of obesity measures and risk of all-cause and cause-specific mortality

BACKGROUND/OBJECTIVES

Previous studies have reported the gender-specific association between general and central obesity measures, using snapshot assessments, and mortality events. This study seeks to further explore this link by examining how the longitudinal cumulative burden and variability of obesity measures from midlife to later-life impact mortality events in the Atherosclerosis Risk in Communities (ARIC) study population, specifically in relation to gender differences.

SUBJECTS/METHODS

Using data from the ARIC study, a total of 7615 (4360 women) participants free of cardiovascular disease, cancer, and early mortality events were included in the data analysis. Longitudinal cumulative burden (estimated by the area under the curve (AUC) using a quadratic mixed-effects method) and variability (calculated according to average successive variability (ASV)) were considered as exposures, separately and all together. Cox proportional hazard regression models were used to estimate multivariable-adjusted standardized hazard ratios.

RESULTS

The mean age was 62.4 and the median follow-up was 16.9 years. In men, AUCs of waist-related obesity measures, and also ASVs of all obesity measures were associated with increased all-cause mortality risk. In women, waist circumference and waist-to-height ratio AUCs were associated with increased all-cause mortality risk. Regarding cardiovascular mortality, all adiposity measures ASVs in both genders and waist-related obesity measures AUCs in men were associated with increased risk. Significant gender differences were found for the associations between cumulative and variability of waist-to-hip ratio for all-cause mortality and all adiposity measures ASVs for cardiovascular mortality risk with higher impact among men.

CONCLUSIONS

Cumulative burden and variability in general and central obesity measures were associated with higher all-cause and cardiovascular mortalities among men. In women, general obesity measures variability, as well as cumulative and variability of central adiposity measure, increased all-cause mortality risk.

Perspectives From Students and Faculty on How Women Achieve Leadership Roles in Academic Medicine: An Exploratory Qualitative Study

INTRODUCTION

The glass ceiling in academic medicine has resulted in lower pay and fewer career advancement opportunities for women. Creating change relies on preparing early-career women for positions of leadership, but most leadership programs focus on faculty, not trainees. The present exploratory qualitative study investigates how to prepare women medical students to be leaders in academic medicine.

METHODS

Focus groups with medical students and faculty who identify as women were conducted at an academic medical center in the West. A total of 25 individuals (10 students and 15 faculty) participated. Recordings of focus groups were transcribed and coded using thematic analysis until saturation of themes was achieved.

FINDINGS

Codes were organized into three themes: obstacles, support systems, and self-presentation. Obstacles identified included the subthemes microaggressions, macroaggressions, a lack of female role models in leadership, and personal characteristics such as the ability to self-promote and remain resilient. Support systems included sponsorship, allyship, mentorship, networking, and gender-specific role modeling subthemes. Self-presentation involved learning behaviors for demonstrating leadership and exuding confidence, being strategic about career moves, resiliency, and navigating social norms.

CONCLUSIONS

The key themes of obstacles, support systems, and self-presentation are targets for systemic and individualistic improvement in leadership development.

Digital activism about gay fatherhood on Instagram: male homoparenting in the picture

In contemporary Brazil, the number of male fathers taking care of their sons and daughters and the initiatives to produce content about fatherhood on Instagram have been significant. This article aims to analyze the concepts that support the digital activism of homoparenting on Instagram, based on gender studies with men. To this end, a qualitative study was conducted using the life narrative method in a digital environment. The results were analyzed and divided into the following sections: parenting project, personal experience of fatherhood, articulation with LGBT political agenda when parenthood becomes a "business", and haters, criticism, and adverse reactions. It was concluded that the reflection on the experience of fatherhood/masculinity itself is crossed by the social marker of the difference in sexual orientation and the activism for rights that sustain content production. Thus, the uniqueness of each fatherhood is highlighted since the fact of being gay constructs the fatherhood experience for each man. Despite the initiatives brought forth in this study, changes are still in progress, as rights activism coexists with the advancement of conservative forces, which limit the expressions of sexual and gender otherness.

Social concordance and patient reported experiences in countries with different gender equality: a multinational survey

BACKGROUND

Patient reported experiences (PREMs) are important indices of quality of care. Similarities in demography between patient and doctor, known as social concordance, can facilitate patient-doctor interaction and may be associated with more positive patient experiences. The aim of this research is to study associations between gender concordance, age concordance and PREMs (doctor-patient communication, involvement in decision making, comprehensiveness of care and satisfaction) and to investigate whether these associations are dependent on a countries' Gender Equality Index (GEI).

METHODS

Secondary analysis on a multinational survey (62.478 patients, 7.438 GPs from 34 mostly European countries) containing information on general practices and the patient experiences regarding their consultation. Multi-level analysis is used to calculate associations of both gender and age concordance with four PREMs.

RESULTS

The female/female dyad was associated with better experienced doctor-patient communication and patient involvement in decision making but not with patient satisfaction and experienced comprehensiveness of care. The male/male dyad was not associated with more positive patient experiences. Age concordance was associated with more involvement in decision making, more experienced comprehensiveness, less satisfaction but not with communication. No association was found between a country's level of GEI and the effect of gender concordance.

CONCLUSION

Consultations in which both patient and GP are female are associated with higher ratings of communication and involvement in decision making, irrespective of the GEI of the countries concerned. Age concordance was associated with all PREMs except communication. Although effect sizes are small, social concordance could create a suggestion of shared identity, diminish professional uncertainty and changes communication patterns, thereby enhancing health care outcomes.

Nursing students' knowledge regarding sexuality, sex, and gender diversity in a multicenter study

Introduction

Sexuality is an integral part of development and personality, and is important in healthcare. Nurses are among the most representative healthcare professionals. For holistic and inclusive nursing care practice and to improve equality, human rights, well-being, and health of individuals, the curricula of nursing courses must integrate broad knowledge about sexuality and its diversity. This study aimed to identify and analyze nursing students' knowledge of sexuality, sex, and gender diversity. The present study was part of a multicenter study conducted in Europe.

Methods

Questionnaires were administered in three nursing schools to assess nursing students' knowledge (n = 75). Data processing was performed using Excel® software version 20 and IRaMuTeQ (R Interface pour les Analysis Multidimensionnelles de Textes et de Questionnaires) 0.7 alpha 2, allowing organization by category and subsequent thematic analysis using content analysis.

Results

The textual corpus "Nursing students' knowledge about sexuality in its diversity," was divided into two sub-corpus: "Students' perception of sexuality" and "Students' perception of gender identity," originating Class 6 "Eroticism" (14.23%) and Classes 4 "Sexual Orientation" (16.07%) and 3 "Heteronormative" (16.07%), the latter with greater proximity to each other and consequently to Class 6. Similarly, Classes 1 "Gender" (20.36%) and 5 "Cisgender" (12.14%) also presented a greater interrelationship between themselves and consecutively with Class 2 "Gender Identity" (15.36%).

Discussion

The analyses revealed that though nursing students possessed knowledge about sexuality and its diversity, this knowledge was elementary and did not reveal a sustained appropriation of concepts related to sexuality, sexual orientation, and gender diversity. For some questions, the absence of students' answers were noteworthy, and may be associated with their personal reservation in expressing themselves on this sensitive and intimate theme. To ensure diversity, inclusivity, and impartiality in nursing practice, it is imperative to change the curriculum plans of nursing courses to address the theme of sexuality during the training process of nurses in Europe.

Contraception Requirements in Clinical Research Consent Forms: Assessing and Supporting Gender Inclusive Practices

Gender-diverse individuals are underserved in clinical research settings. Reliance on gendered language throughout the consent process for clinical research contributes to the marginalization of these populations. The research objective was to assess use of gender-inclusive language used to describe the contraception requirement in consent forms. We categorized and analyzed contraception language in 289 clinical trial consent forms using a deductive and summative content analysis approach. We found that 79% (n = 227) of consent forms contained gender-inclusive language, 80% (n = 231) used terms that fell under the biological sex language, and 91% (n = 264) used gendered language. No consent forms used exclusively gender-inclusive language and the majority 63% (n = 182) featuring a combination of all three language types. There were many consent forms which would have been entirely gender-inclusive language if section headings with references to biological-sex-specific contraceptives were excluded, suggesting that gender-inclusive language may be attainable with minor revisions.

Perception of gender norms and its association with bullying behavior among adolescent students

BACKGROUND

Inequitable gender norms are increasingly seen as a risk to health and well-being. Although adolescence represents a critical phase of development before adulthood, there is limited understanding about adolescents' perception of gender norms in Egypt. Adolescents' nonconformity with stereotypical gender norms is suspected to increase their exposure to bullying behavior. This study aimed to explore the adolescents' perception of gender norms - especially towards romantic relations and stereotypical gender traits and roles - and its association with bullying behavior among school children.

METHODS

A cross-sectional study of a sample of 400 students 11-17 years from 10 public schools in Aswan city, Egypt was conducted. Data were collected via interviewer-administered questionnaires using the Gender Norms Scales and School Life Survey tool for bullying.

RESULTS

School adolescents of both sexes showed no significant difference with respect to their attitudes towards romantic relationships engagement, but boys were slightly more permissive about romantic relationships than girls (54.4%, 46.1%, respectively). On the other hand, girls were significantly more likely to indicate agreement with a sexual double standard regarding boy/girl relationships than boys (75% vs. 46.4%, P < 0.001). Regarding gender stereotypical traits, girls' and boys' perception showed no significant difference, but boys had more endorsement, and 64.3% of boys perceived more agreement with gender stereotypical traits compared to 57.4% of girls. Also, boys were more likely to express more agreement with stereotypical gender roles than girls (74% vs. 52.9%, P < 0.001). However, 51% of students agreed that it was okay to tease a boy who acted like a girl, and 27.5% agreed that it was okay to tease a girl who acted like a boy. Students' status of bullying and victimization was not significantly associated with any studied gender norms concept.

CONCLUSIONS

Perception of unequal gender norms starts early in adolescence. Boys are more accepting of heteronormative relations among adolescents and more likely to endorse stereotypical gender roles than girls, while girls are more conservative and more likely to perceive a sexual double standard regarding boy/girl relationships. Moreover, adolescents of both genders perceived more agreement with deserving sanctions for atypical gender behaviors in boys with higher perception in boys compared to girls. However, both boys' and girls' perception of gender is not related to their status of bullying and victimization. This has important implications for understanding the development of gender norms and their impact on adolescent behavior and social interactions.

Towards a Feminist Global Health Policy: Power, intersectionality, and transformation

In the realm of global health policy, the intricacies of power dynamics and intersectionality have become increasingly evident. Structurally embedded power hierarchies constitute a significant concern in achieving health for all and demand transformational change. Adopting intersectional feminist approaches potentially mitigates health inequities through more inclusive and responsive health policies. While feminist approaches to foreign and development policies are receiving increasing attention, they are not accorded the importance they deserve in global health policy. This article presents a framework for a Feminist Global Health Policy (FGHP), outlines the objectives and underlying principles and identifies the actors responsible for its meaningful implementation. Recognising that power hierarchies and societal contexts inherently shape research, the proposed framework was developed via a participatory research approach that aligns with feminist principles. Three independent online focus groups were conducted between August and September 2022 with 11 participants affiliated to the global-academic or local-activist level and covering all WHO regions. The qualitative content analysis revealed that a FGHP must be centred on considerations of intersectionality, power and knowledge paradigms to present meaningful alternatives to the current structures. By balancing guiding principles with sensitivity for context-specific adaptations, the framework is designed to be applicable locally and globally, whilst its adoption is intended to advance health equity and reproductive justice, with communities and policymakers identified as the main actors. This study underscores the importance of dismantling power structures by fostering intersectional and participatory approaches for a more equitable global health landscape. The FGHP framework is intended to initiate debate among global health practitioners, policymakers, researchers and communities. Whilst an undeniably intricate and time-consuming process, continuous and collaborative work towards health equity is imperative to translate this vision into practice.

Sex- and Gender-Based Reporting in Antihypertensive Medication Literature Informing Hypertension Guidelines

BACKGROUND

Hypertension is the leading modifiable cardiovascular risk factor with recognized sex- and gender-based differences. We assessed the incorporation of sex and gender reporting in the antihypertensive medication literature informing hypertension guidelines.

METHODS AND RESULTS

Literature cited in the International Society of Hypertension (2020), European Society of Cardiology/European Society of Hypertension (2018), American College of Cardiology/American Heart Association (2017), Latin American Society of Hypertension (2017), Pan-African Society of Cardiology (2020), and Hypertension Canada (2020) guidelines was systematically reviewed. Observational studies, randomized controlled trials, and systematic reviews involving antihypertensive medications were included. Studies with participants of a single sex, guidelines, and commentaries were excluded. Data on study participation-to-prevalence ratio by sex, analysis of baseline demographics and study outcomes by sex, and stratification of adverse events by sex were extracted. Of 1659 unique citations, 331 studies met inclusion criteria. Of those, 81% reported the sex of participants, and 22% reported a male-to-female participation-to-prevalence ratio of 0.8 to 1.2. Three percent of studies stratified baseline characteristics by sex, and 20% considered sex during analysis through statistical adjustment or stratification. Although 32% of studies reported adverse events, only 0.6% stratified adverse events by sex. Most (58%) studies reporting sex/gender used sex and gender terms interchangeably.

CONCLUSIONS

Incorporation of sex- and gender-based considerations in study population, analysis, or reporting of results and adverse events is not common in the antihypertensive medication literature informing international hypertension guidelines. Greater attention to sex- and gender-based factors in research is required to optimally inform management of hypertension.

A developmental framework for understanding the influence of sex and gender on health: Pediatric pain as an exemplar

Sex differences are a robust finding in many areas of adult health, including cardiovascular disease, psychiatric disorders, and chronic pain. However, many sex differences are not consistently observed until after the onset of puberty. This has led to the hypothesis that hormones are primary contributors to sex differences in health outcomes, largely ignoring the relative contributions of early developmental influences, emerging psychosocial factors, gender, and the interaction between these variables. In this paper, we argue that a comprehensive understanding of sex and gender contributions to health outcomes should start as early as conception and take an iterative biopsychosocial-developmental perspective that considers intersecting social positions. We present a conceptual framework, informed by a review of the literature in basic, clinical, and social science that captures how critical developmental stages for both sex and gender can affect children's health and longer-term outcomes. The literature on pediatric chronic pain is used as a worked example of how the framework can be applied to understanding different chronic conditions.

Recommendations for a Better Understanding of Sex and Gender in the Neuroscience of Mental Health

There are prominent sex/gender differences in the prevalence, expression, and life span course of mental health and neurodiverse conditions. However, the underlying sex- and gender-related mechanisms and their interactions are still not fully understood. This lack of knowledge has harmful consequences for those with mental health problems. Therefore, we set up a cocreation session in a 1-week workshop with a multidisciplinary team of 25 researchers, clinicians, and policy makers to identify the main barriers in sex and gender research in the neuroscience of mental health. Based on this work, here we provide recommendations for methodologies, translational research, and stakeholder involvement. These include guidelines for recording, reporting, analysis beyond binary groups, and open science. Improved understanding of sex- and gender-related mechanisms in neuroscience may benefit public health because this is an important step toward precision medicine and may function as an archetype for studying diversity.

'My doctor just called me a good girl and I died a bit inside': From everyday misogyny to obstetric violence in UK fertility and maternity services

This paper begins with the common phrase 'good girl' as a lens through which to explore the insidious nature of patronising and paternalistic language on women's agency in obstetric care. Here we see how misogynistic language is both violence against women in its own right, and serves to create a context in which more extreme obstetric violence can be precipitated. Based on thematic analysis of discussion on Mumsnet, and on contributions to a research-focused Facebook group, this paper illustrates the complexity of recognising and refuting misogyny as a female patient as well as the damage that can occur from a cultural context in which this language is normalised. Here, words both boast a materiality through the environments they reify, and become transient and slippery, with semiotic uncertainty.

Parental gender attitudes and children's mental health: Evidence from the UK household longitudinal study

Gender role attitudes have been found to be associated with the mental health of adults and adolescents, but little is known about whether parents' gender attitudes are associated with their children's mental health. Using data from Understanding Society, the UK Household Longitudinal Study (UKHLS), a large-population representative sample, we examine the links between parental gender role attitudes and child mental health outcomes as measured by the total and five components of the strengths and difficulties questionnaire (SDQ). We construct structural equation models, separately for mothers and for fathers and for children aged 5 and 8, and adjust for key sociodemographic variables. We find that children aged 5 years exhibit fewer emotional and peer relationship problems and are more prosocial when their mothers have more egalitarian (compared to traditionalist) gender role attitudes. We also find that children are more prosocial at age 8 when their mothers have more egalitarian gender role attitudes. No statistically significant mediation effect is observed via maternal parenting behaviour. Fathers' more egalitarian gender role attitudes were associated with higher hyperactivity at age 5 and more prosocial behaviour at age 8. Further, engaging in less negative parenting behaviour completely mediates the association of fathers' more egalitarian gender attitudes with children's mental health across the majority of the SDQ scales. This suggests that parental gender attitudes may be a possible target for the prevention of mental health difficulties among children; however, future research will be required to examine the extent to which the associations we identified reflect causality.

"I always felt like I wasn't supposed to be there". An international qualitative study of fathers' engagement in family healthcare during transition to fatherhood

OBJECTIVE

Engagement of fathers in family health services confers benefits for the health and wellbeing of the whole family. The childbirth continuum is traditionally considered a feminine event, however, commensurate with the changing paradigm of gender equity in family healthcare worldwide, the role of fathers is in transformation. The aim of the study is to explore father's perceptions and experiences of healthcare engagement during pregnancy and early infant care.

DESIGN

Qualitative free-text questions were embedded in a large multi-country, cross-sectional survey, to explored fathers' attendance, participation, and experience of health care during appointments with their pregnant partner and/or baby.

SETTING AND PARTICIPANTS

Expectant and new fathers were recruited through Prolific®, an international paid online survey platform.

FINDINGS

Qualitative responses (n=889) were provided by fathers from 28 countries, with experiences of a range of contexts and models of care; 46.8% of whose partners were pregnant and 53.2% had given birth since 2020. The findings suggest that although most fathers wanted to attend and participate in maternity and early parenting-related healthcare, multiple barriers were identified at the individual father, organisational context, and societal levels. Fathers reported negative social factors such as gender bias and restrictive gender norms as barriers to their healthcare engagement. In contrast, factors that enabled fathers to overcome barriers included the fathers' feelings of confidence in their partner's autonomy and decision-making skills, trusted professional relationships with clinicians, and clinicians with good interpersonal skills.

KEY CONCLUSIONS

Multiple barriers restrict the participation of fathers in healthcare for childbearing and early parenting. Knowledge of these barriers can inform healthcare redesign to include more successful engagement strategies for fathers, to benefit fathers, mothers, and infants alike.

IMPLICATIONS FOR PRACTICE

Health professionals consulting with the mother, father and infant triad are ideally placed to address the healthcare needs of both parents. Early engagement of fathers in family health care by use of inclusive interpersonal skills and the development of a trusted relationship has potential to improve paternal mental health, and may be associated with benefits for the health, wellbeing and safety of the whole family.

The homeless period: a qualitative evidence synthesis

Women experiencing homelessness are marginalized not only through their housing status but also through their access and ability to manage their menstrual health. Currently, there are no existing published reviews exploring this topic. This study aimed to begin closing that gap, by systematically reviewing the literature examining women's experiences of menstruation whilst being homeless. In June 2020 (and updated in December 2022), we conducted comprehensive and systematic searches of four electronic databases: Medline, Web of Science, CINAHL, and PsychINFO, from which nine studies were found. The findings were thematically analyzed, using the enhancing transparency in reporting the synthesis of qualitative research tools (ENTREQ) guidelines. Three themes related to menstrual experiences were found: (1) challenges in the logistics of managing menstruation while homeless, (2) feelings of embarrassment, shame, and dignity linked to maintaining menstrual health, and (3) making do: how people experiencing homelessness manage challenges related to menstruation. We discuss barriers women face in getting necessary products and in accessing private, safe, and clean facilities to manage menstrual health. The study found that women living with homelessness often abandon other basic needs in favor of managing menstruation (i.e. using unsuitable materials, stealing, etc.), which furthers their risk. The findings highlight the need for future research to investigate the experiences of women who are menstruating while being homeless and what support they would find helpful. Results show that it is high time for commissioners and policy-makers to address the provision of menstrual resources as a basic human right.

Consideration of sex as a biological variable in diabetes research across twenty years

BACKGROUND

Sex differences exist in the risk of developing type 1 and type 2 diabetes, and in the risk of developing diabetes-associated complications. Sex differences in glucose homeostasis, islet and β cell biology, and peripheral insulin sensitivity have also been reported. Yet, we lack detailed information on the mechanisms underlying these differences, preventing the development of sex-informed therapeutic strategies for persons living with diabetes. To chart a path toward greater inclusion of biological sex as a variable in diabetes research, we first need a detailed assessment of common practices in the field.

METHODS

We developed a scoring system to evaluate the inclusion of biological sex in manuscripts published in Diabetes, a journal published by the American Diabetes Association. We chose Diabetes as this journal focuses solely on diabetes and diabetes-related research, and includes manuscripts that use both clinical and biomedical approaches. We scored papers published across 3 years within a 20-year period (1999, 2009, 2019), a timeframe that spans the introduction of funding agency and journal policies designed to improve the consideration of biological sex as a variable.

RESULTS

Our analysis showed fewer than 15% of papers used sex-based analysis in even one figure across all study years, a trend that was reproduced across journal-defined categories of diabetes research (e.g., islet studies, signal transduction). Single-sex studies accounted for approximately 40% of all manuscripts, of which > 87% used male subjects only. While we observed a modest increase in the overall inclusion of sex as a biological variable during our study period, our data highlight significant opportunities for improvement in diabetes research practices. We also present data supporting a positive role for journal policies in promoting better consideration of biological sex in diabetes research.

CONCLUSIONS

Our analysis provides significant insight into common practices in diabetes research related to the consideration of biological sex as a variable. Based on our analysis we recommend ways that diabetes researchers can improve inclusion of biological sex as a variable. In the long term, improved practices will reveal sex-specific mechanisms underlying diabetes risk and complications, generating knowledge to enable the development of sex-informed prevention and treatment strategies.

Age-disparate and intergenerational sex partnerships and HIV: the role of gender norms among adolescent girls and young women in Malawi

BACKGROUND

Age-mixing (age-disparate [5-9 years difference] and intergenerational [≥ 10 years difference]) partnerships are hypothesized drivers of HIV in adolescent girls and young women (AGYW; 15-24 years). These partnerships are often associated with increased gender inequities which undermine women's agency and assertiveness. We assessed whether age-mixing partnerships were associated with HIV in Malawi and if endorsement of inequitable gender norms modifies this relationship.

METHODS

We analyzed data from the Malawi Population-based HIV Impact Assessment, a nationally representative household survey conducted in 2015-2016. Participants underwent HIV testing and completed questionnaires related to actively endorsed gender norms and sexual risk behavior. We used multivariate logistic regression and multiplicative interaction to assess associations among AGYW who reported the age of their primary sex partner from the last year.

RESULTS

The analysis included 1,958 AGYW (mean age = 19.9 years, SD = 0.1), 459 (23.4%) and 131 (6.7%) of whom reported age-disparate and intergenerational partnerships, respectively. AGYW in age-mixing partnerships accounted for 13% of all AGYW and were older, more likely to reside in urban areas, to be married or cohabitating with a partner, and to have engaged in riskier sexual behavior compared with AGYW in age-concordant partnerships (p < 0.05). HIV prevalence among AGYW in age-disparate and intergenerational partnerships was 6.1% and 11.9%, respectively, compared with 3.2% in age-concordant partnerships (p < 0.001). After adjusting for residence, age, education, employment, wealth quintile, and ever been married or cohabitated as married, AGYW in age-disparate and intergenerational partnerships had 1.9 (95% CI: 1.1-3.5) and 3.4 (95% CI: 1.6-7.2) greater odds of HIV, respectively, compared with AGYW in age-concordant partnerships. Among the 614 (31% of the study group) who endorsed inequitable gender norms, AGYW in age-disparate and intergenerational partnerships had 3.5 (95% CI: 1.1-11.8) and 6.4 (95% CI: 1.5-27.8) greater odds of HIV, respectively, compared with AGYW in age-concordant partnerships.

CONCLUSIONS

In this Malawi general population survey, age-mixing partnerships were associated with increased odds of HIV among AGYW. These findings highlight inequitable gender norms as a potential focus for HIV prevention and could inform interventions targeting structural, cultural, and social constraints of this key group.

Development and Validation of Technology-Facilitated Sexual Violence Perpetration and Victimization Scales Among Adults

Technology-facilitated sexual violence (TFSV) includes different forms of digital violence, such as online gender-based violence, online gender- and sexuality-based violence, digital sexual harassment, online sexual coercion, and nonconsensual pornography. The aim of this study was to design and validate a measure to assess the perpetration and victimization of each dimension of TFSV. The relationships between the different dimensions and differences by gender and sexual orientation were also analyzed. The participants were a sample of 2,486 adults (69% women) from Spain, aged between 16 and 79 (M = 25.95; DT = 9.809) years. The Technology-Facilitated Sexual Violence Scales were found to be valid and reliable instruments, supporting our recommendation for the use of these scales. Network analysis and solution-based exploratory factor analyses showed that the dimensions of online sexual coercion and nonconsensual pornography clustered together. All the perpetration variables were related to sexism. Finally, cis women and nonheterosexual people reported higher victimization scores overall compared to cis men and heterosexuals, respectively, while cis men reported higher perpetration scores overall than cis women.

Physical punishment and effective verbal communication in children aged 9-36 months, according to sex: secondary analysis of a national survey

BACKGROUND

A substantial number of children in the world are regularly subjected to physical punishment by their parents as a method of upbringing. Evidence suggests that it has negative effects on the development of brain function. However, evidence regarding its association with verbal communication is limited and heterogeneous. It is also unknown whether the effects are the same in both boys and girls; especially in the contexts of developing countries, where the highest rates of physical punishment are found.

OBJECTIVE

This investigation aimed at analyzing the association between physical punishment administered by both fathers and mothers and effective verbal communication among children aged 9-36 months according to sex.

METHODS

A secondary analytical cross-sectional study was conducted based on the 2018-2019 Peruvian Demographic and Family Health Survey. Physical punishment, based on the mother's report of the use of hitting and/or slapping, was considered as a method to correct children by the father and/or mother. Effective verbal communication (EVC) was measured using the Battle scale which consists of age-appropriate questions included in the early childhood development module. A generalized linear model of the family and Log Poisson link option was used to identify the association between them, using the crude, general adjusted, and sex-stratified models.

RESULTS

Of all the children, 16.31% received physical punishment from their father and/or mother, wherein 16.65% were boys and 15.97% were girls. Moreover, 36.48% exhibited EVC, wherein 32.55% were boys and 40.50% were girls. Adjusting for socioeconomic level, witnessing violence, mother's marital status, age, occupation, education level, language, number of children, and moderate-to-severe depressive symptoms, it was found that boys who received physical punishment from their father and/or mother have a 31% lower probability of EVC (adjusted prevalence ratio (aPR) 0.69, 95% confidence interval (CI) 0.58-0.83, p < 0.001), whereas no association was found in girls who received physical punishment from their father and/or mother and EVC (aPR 0.93, 95% CI 0.81-1.06, p = 0.278).

CONCLUSIONS

An association was found between physical punishment administered by father and/or mother and reduced EVC among boys, whereas no such association was found among girls. It is possible that even though a significant impact has not been observed in girls during this early stage, they may experience consequences in later stages of life, further research is needed.

Trends in the disease burden of anxiety disorders in middle-aged and older adults in China

BACKGROUND

Anxiety disorders in middle-aged and older adults are an important public health concern in China. Based on the data in the global disease burden (GDB) research database, this study evaluated and analyzed the trend of the disease burden of middle-aged and older patients living with anxiety in China in the past 30 years.

METHODS

The incidence and disability-adjusted life years (DALYs) data of anxiety disorders in China for individuals aged 45-89 years were collected from the Global Burden of Disease Study 2019, and the effects of age, period, and cohort on the incidence of and DALY rate for anxiety disorders were analysed using an age-period-cohort model. Because of the COVID-19 pandemic, the global disease burden research database has not been updated since 2019. However, this did not affect the analysis of future trends in this study, which combined data in the past three decades from 1990 to 2019.

RESULTS

(1) The overall age-standardised incidence rate (ASIR) and age-standardised DALY rate (ASDR) for anxiety disorders in middle-aged and older adults in China decreased by 4.0 and 7.7% from 1990 to 2019, respectively, and the ASIR and ASDR were always higher in women than in men. (2)Age-period-cohort analysis showed that the net drifts for incidence and DALY rate were - 0.27% and - 0.55% per year, respectively. For both genders, the local drifts for incidence were lower than zero in those aged 45-79 years and higher than zero in those aged 80-89 years; the local drifts for the DALY rate were lower than zero in all groups. (3) From the 1990-1994 to 2015-2019, the relative risks of anxiety disorder incidence and DALY decreased by 5.6 and 7.3% in men and 4.3 and 11.7% in women, respectively.

CONCLUSION

The disease burden of anxiety disorders in middle-aged and older adults in China has been relieved over the past 30 years; however, recent ASDR, ASDR, period, and cohort effects have shown adverse trends. The incidence and DALY rate decreased with age in women, while men showed a trend of increasing first and decreasing afterwards.

Relationship satisfaction and family routines of young parents before and during the first year of the COVID-19 pandemic: A latent growth curve analysis

With the onset of the COVID-19 pandemic, parents had to reorganize their family routines under many external stressors (e.g., limited external childcare), which could have negatively affected their relationship satisfaction. This study aimed to examine the changes in relationship satisfaction of young parents from pre-pandemic times up to the second wave of the COVID-19 pandemic in Germany in December 2020 and whether these changes were different for mothers and fathers. Additionally, the role of perceived pandemic-related stress and changes in family routines was investigated. Data from 564 participants from DREAMCORONA, a sub-study of the prospective longitudinal cohort study "Dresden Study on Parenting, Work, and Mental Health" (DREAM), were analyzed. Relationship satisfaction was assessed at three measurement points (T0: pre-pandemic, i.e., August 2018-March 2020; T1: May-June 2020; T2: October-December 2020). To estimate changes in relationship satisfaction over time, Latent Growth Curve Models were calculated. Changes in family routines (i.e., changes in the division of housework and childcare from T0 to T1 as well as the availability of external childcare facilities at T1) and perceived pandemic-related stress at T1 were used as predictors. The models were adjusted for education and number of children per household. There was no significant change in relationship satisfaction over time, with no differences between mothers and fathers. The multi-group model revealed that changes in the division of housework and childcare predicted changes in relationship satisfaction in mothers, but not in fathers. For mothers, doing more housework than before the pandemic was negatively associated with changes in their relationship satisfaction over time. Additionally, reporting that their partner did more childcare than before the pandemic was positively associated with the relationship satisfaction of mothers. Our results indicate no general negative prospective association between the COVID-19 pandemic and parental relationship satisfaction over time. Nevertheless, our findings highlight the importance of the division of housework and childcare for mothers' relationship satisfaction and how pandemic-related changes in family routines alter this association.

Multilevel experiences of carceral violence in Los Angeles, California: first-hand accounts from a racially diverse sample of transgender women

Transgender women face a disproportionate burden of carceral violence, or violence related to policing and the criminal legal system, with transgender women of colour experiencing even greater disparities. Several frameworks conceptualise the mechanisms through which violence impacts transgender women. However, none of them directly explore the role of carceral violence, particularly as it is experienced by transgender women themselves. Sixteen in-depth interviews were conducted with a racially/ethnically diverse sample of transgender women in Los Angeles between May and July 2020. Participants were between 23 - 67 years old. Participants identified as Black (n = 4), Latina (n = 4), white (n = 2), Asian (n = 2), and Native American (n = 2). Interviews assessed experiences of multilevel violence, including from police and law enforcement. Deductive and inductive coding methods were used to identify and explore common themes concerning carceral violence. Experiences of law enforcement-perpetrated interpersonal violence were common and included physical, sexual and verbal abuse. Participants also highlighted structural violence, including misgendering, the non-acceptance of transgender identities, and police intentionally failing to uphold laws that could protect transgender women. These results demonstrate the pervasive, multilevel nature of carceral violence perpetrated against transgender women and suggest avenues for future framework development, trans-specific expansions of carceral theory, and system-wide institutional change.

Interpersonal Violence and Gender Inequality in Adolescents: A Systematic Analysis of Global Burden of Disease Data From 1990 to 2019

PURPOSE

Interpersonal violence is a leading cause of adolescent deaths and disability. This study investigates sex differences in burden of interpersonal violence for adolescents and explores associations with gender inequality.

METHOD

Using data from the 2019 Global Burden of Disease study, we report numbers, proportions, rates of interpersonal violence deaths and disability adjusted life years (DALYs) for all ages, and rate of change (from 1990 to 2019) in adolescents aged 10-24 years disaggregated by sex and geography. We explored associations with gender inequality using gender inequality index.

RESULTS

One in four (24.8%) all-age interpersonal violence deaths are in adolescents. In 2019, the rate of deaths in adolescent males was almost six times higher than females (9.3 vs. 1.6 per 100,000); and since 1990, the rate of decline in DALYs for females was double than that for males (-28.9% vs. -12.7%). By contrast, the burden of sexual violence is disproportionately borne by adolescent females, with over double the rate than males (DALYs: 42.8 vs. 17.5 per 100,000). In countries with greater gender inequality, the male-to-female ratio (deaths and DALYs) was increased among older adolescents, pointing to benefits for males in more gender equal settings.

DISCUSSION

Social identities, relationships, and attitudes to violence are established in adolescence, which is an inflection point marking the emergence of disproportionate burdens of interpersonal violence. Our findings affirm that global agendas must be expanded to address interrelated factors driving multiple forms of interpersonal violence experienced by adolescents and reverberating to the next generation.