Adolescent gender norms and adult health outcomes in the USA: a prospective cohort study

Beliefs About Cannabis Use Among Male and Female Andalusian Adolescents

Objectives: This study assessed potential differences between girls and boys in the prevalence rates of cannabis use, sociodemographic factors, and beliefs about cannabis use. Methods: 1,896 Andalusian adolescents aged 14-18 participated in an online survey based on the I-Change model. The survey assessed their beliefs about cannabis use, including attitudes, social influences, self-efficacy, action planning, and intention to use. Multivariate analyses of variance were then conducted to examine potential gender differences in these beliefs, while controlling for last month's cannabis use. Results: Significantly more boys used cannabis in the last month, had boyfriends/girlfriends, and had more pocket money compared to girls. Additionally, girls - in comparison to boys - were more convinced of the disadvantages of cannabis use, but were also more convinced of some of the advantages (such as freedom from boredom, and medicinal use), reported having less favorable social norms for cannabis use, had more female best friends using cannabis, and felt pressure to use cannabis from their female peers. Conclusion: These findings highlight the need for cannabis prevention programs to consider gender differences in beliefs about cannabis use. Programs should not only address general risk factors for cannabis use but also evaluate if their interventions effectively target beliefs that are particularly important for girls and boys.

Effect of Gender Attitudes of Young Adults on Levels of Perceived Social Support in Health Behaviors

The current cross-sectional descriptive study was performed to determine the effect of young adults' attitudes regarding social gender roles on perceived social support level in health behaviors. Participants comprised 209 young adults aged 18 to 21 years. Data collection tools included a sociodemographic characteristics form, the Gender Roles Attitude Scale, and Child and Adolescent Social Support Scale for Healthy Behaviors (CASSS-HB). Data were analyzed using percentile, correlation, and regression analysis. A significant positive correlation was found between total CASSS-HB score and the egalitarian gender role subdimension of the Gender Roles Attitude Scale. It was determined that participants with an egalitarian perspective toward gender roles had increased levels of social support in health behaviors. [Journal of Psychosocial Nursing and Mental Health Services, 62(4), 17-23.].

Associations of Adolescent School Social Networks, Gender Norms, and Adolescent-to-Young Adult Changes in Male Gender Expression With Young Adult Substance Use

PURPOSE

Male gender expression (MGE), which is shaped by sociocultural pressures around masculinity, has been previously associated with health. This study examines associations of adolescent social network variables and school gender norms with MGE changes from adolescence to young adulthood, and associations of these changes with young adult substance use.

METHODS

Analyzing data from Waves I (1994-95, adolescents, aged 12-18) and IV (2008-09, young adults, 24-32) of a nationally representative longitudinal cohort study, male participants' MGE was assessed in each wave using a validated, empirically derived measure. Linear regression was used to evaluate associations of adolescent-to-young adult MGE changes between waves with adolescent social network characteristics and school gender norms. Logistic regression was used to examine associations between adolescent-to-young adult MGE changes and young adult substance uses (cigarette, marijuana, heavy alcohol, and recreational drug use, and prescription drug misuse).

RESULTS

Among 4,776 male participants, adolescent-to-young adult MGE changes were significantly associated with school gender norms such that adolescents whose MGE markedly departed from their schools' average exhibited greater MGE changes in the direction of their schools' average (β = -0.83, p < .01) relative to those who were more similar to school means. Adolescent-to-young adult increases in MGE were significantly associated with greater odds of all young adult substance use behaviors except prescription drug misuse.

DISCUSSION

Adolescents' MGE relative to other males at their school was associated with MGE changes toward school norms, with implications for young adult substance use. Adolescent gender norms may be an underexplored strategy for interventions to reduce substance misuse.

Beyond femininity or masculinity: gender typologies and healthy eating in early adulthood

PURPOSE

In the field of health sciences gender is often confused with biological sex (male/female) or reduced to a dichotomous classification (masculinity/femininity). The concepts of sex and gender interact with each other, but they are not equivalent. According to Sandra Bem four gender typologies can be established (androgynous, masculine, feminine and undifferentiated). A relationship has been shown to exist between gender and health. Yet, there is little evidence as to the relationship between gender typologies and adherence to the Mediterranean diet. The aim of this research is to evaluate the association between Bem's gender typologies and adherence to the Mediterranean diet.

METHODS

Mediterranean Diet Adherence Screener (MEDAS) and Bem's gender typologies were the main variables. Sex, age, socioeconomic status (SES), body mass index (BMI) and obesity were analyzed as covariates.

RESULTS

Multilevel multivariate analysis showed that androgynous typology was associated with increased adherence to Mediterranean diet (β = 0.46 (SE 0.21), p = 0.033), adjusting by covariates, in a university population in Spain. Moreover, this was not the case with masculinity or femininity typologies.

CONCLUSION

Thus, the results of this study suggest (1) that androgynous typology is not only associated with better mental health but also with healthy/healthier lifestyles, and (2) the complexity of the relationship between sex-gender and health would advise researchers avoid dichotomies such as male/female or masculinity/femininity.

Review of the India Adolescent Health Strategy in the context of disease burden among adolescents

Background

A nuanced understanding of the health needs of adolescents in the context of the India Adolescent Health Strategy (IAHS) is needed to inform policy interventions for improving the health and well-being of adolescents in India.

Methods

Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, we identified the top ten causes of years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) disaggregated by sex and age group (10-14 and 15-19 years) for India and its states in 2019. To inform the IAHS of refinement or expansion in focus needed to improve adolescent health in India, we reviewed the extent to which the top 10 causes of disease burden are addressed in the IAHS, and the availability of and age- and sex-disaggregation in the service utilisation data for adolescents captured in the Adolescent Friendly Health Clinic monitoring information system (AFHC MIS) and Health Management Information System (HMIS). We also reviewed the availability of and age-and sex-disaggregation in the data capture at the population level for the IAHS outcome indicators in the data sources identified in the IAHS operational framework.

Findings

Females in the 10-14 and 15-19 years age groups suffered 6.75 million and 9.25 million DALYs, respectively, 39.1% and 44.2% of which were YLLs; the corresponding DALYs for males were 6.71 million and 9.65 million (42.3% and 41.1% YLLs), respectively. Within the 6 thematic areas of the IAHS, most strategies and indicators identified are for sexual and reproductive health followed by nutrition, and broadly these conditions accounted for YLDs and not YLLs in adolescents. Significant gaps in the IAHS in comparison to the disease burden for fatal diseases and conditions were seen across injuries, communicable diseases, and non-communicable diseases. Injuries accounted for 65.9% and 45.3% of YLLs in males and females aged 15-19 years, and 40.8% in males aged 10-14 years. Specifically, road injuries (15.3%, 95% UI 11.0-18.0) and self-harm (11.3%, 95% UI 8.7-14.2) accounted for most of the injury deaths in 15-19 years whereas drowning (7.7% 95% UI 5.8-9.6) and road injuries (6.9%, 95% UI 4.7-8.6) accounted for the most injury deaths in 10-14 years males. However, only self-harm and gender-based violence are specifically addressed in the IAHS with non-specific interventions for other injuries. Diarrhoea, lower respiratory infections, malaria, encephalitis, tuberculosis, typhoid, cirrhosis, and hepatitis are the other disease conditions accounting for YLLs and DALYs in adolescents but these are neither addressed in the IAHS nor in service provision under the AFHC MIS. There is no age- or sex-disaggregation in the cause of death data captured in the HMIS to allow an understanding of mortality in adolescents. For the IAHS outcome indicators at the population level, data capture for the 10-14 years irrespective of sex was largely missing from the population surveys and none of the surveys captured data for either females or males aged 15-19 years for physical inactivity and mental health indicators.

Interpretation

The considerable differences seen in the IAHS thematic focus as compared with the leading causes of fatal and non-fatal disease burden in adolescents in India, and in the availability of population-level data to monitor the outcome indicators of the IAHS can pose substantial limitations for improving adolescent health in India. The findings in this paper can be utilized by decision makers to refine action aimed at improving adolescent health and well-being.

Funding

Bill & Melinda Gates Foundation.

Parental practices and their association with alcohol and cannabis use among adolescents in Chile

Background

Adolescent alcohol and cannabis use are common in Chile. The present study aimed to assess the relationship between perceived parenting practices and alcohol and cannabis use among adolescents in a Latin American context.

Methods

We adapted and implemented a substance use prevention strategy in Chile, which included surveys of tenth-grade students from six municipalities in the Metropolitan Region of Greater Santiago. We assessed the reliability and factorial structure of the parenting scale with 16 items, which formed part of the survey. We dichotomized parenting scores into high (above the median) and low. The association of parenting practices with alcohol and cannabis use in adolescents was assessed using multivariate multilevel regression models.

Results

A total of 7,538 tenth-grade students from 118 schools were included in the study. The 16-item scale of parenting practices showed good internal consistency (Omega total = 0.84), and three factors representing Relationship between parents and adolescents, Norms and monitoring, and Parents knowing their children's friends and the parents of their children's friends. High total scores of parenting were associated with lower odds of lifetime alcohol use (OR 0.57; 95% CI: 0.49-0.65), past-month alcohol use (OR 0.63; 95% CI: 0.57-0.70), lifetime drunkenness (OR 0.64; 95% CI: 0.58-0.72), and lifetime cannabis use (OR 0.54; 95% CI: 0.47-0.61). Above median scores on each parenting subscale were associated with significantly lower odds of substance use. The strongest associations were observed for the subscale Norms and monitoring. Interactions between parenting and gender showed a significantly stronger effect of parenting practices on alcohol and cannabis use among girls.

Conclusion

Different types of parenting practices were associated with a lower prevalence of adolescent alcohol and cannabis use. Improving parenting practices has the potential to prevent adolescent substance use in Chile, especially among girls.

Impacts of recreational cannabis legalization on use and harms: A narrative review of sex/gender differences

Legalization of cannabis use for non-medical (recreational) purposes is changing the global cannabis landscape. As attitudes toward cannabis use become more positive and prevalence of use increases in complex ways, concerns emerge about the potential for increased cannabis-attributable harms. Understanding the who, why, and when of this likely increase in cannabis-attributable harms is thus an important public health priority. Both sex and gender contribute to variability in the use, effects, and harms of cannabis and thus sex/gender considerations are important when evaluating the impacts of cannabis legalization. The goal of this narrative review is to broadly discuss sex/gender differences in attitudes toward and prevalence of cannabis use, whether there are sex/gender differences in the impacts of cannabis legalization, and why these sex/gender differences might exist. One of our strongest conclusions is that men have always been more likely to use cannabis than women, yet the sex/gender gap in prevalence of cannabis use has narrowed over time, and this might be partly due to cannabis legalization. The existing evidence suggests that there have also been sex/gender differences in the impacts of legalization on cannabis-attributable harms such as cannabis-involved motor vehicle collisions and hospitalizations, though these results are more variable. The body of literature reviewed has focused almost exclusively on samples of cisgender research participants, and thus future research should encourage inclusion of transgender and gender-diverse participants. More consideration of sex- and gender-based analysis in research evaluating long-term impacts of cannabis legalization is a clear research priority.

The Association of Adolescent Gender Performance and Adult Intimate Partner Violence

PURPOSE

A quarter of women and nearly 1 in 10 men in the United States have reported experiencing intimate partner violence (IPV) that had lasting negative impacts at least once during their lifetime. To prevent IPV over the lifecourse, adolescence has been identified as an ideal period for healthy relationship education that addresses the various IPV risk factors. One of those risk factors is believing in traditional gender roles, but the behavioral aspect of gender performance has been understudied. This study explores the relationship between adolescent gender performance and adult IPV perpetration and victimization/survival.

METHODS

We used logistic regression to estimate associations of adolescent gender performance and adult IPV perpetration and victimization/survival in a sample of 2,197 males and 2,587 females from The National Longitudinal Study of Adolescent to Adult Health (Add Health) between 1994 and 2008.

RESULTS

Male adolescent gender performance was associated with increased adult IPV perpetration (adjusted odds ratio [AOR] = 1.11; 95% confidence interval [CI], 1.05-1.18 per 10% increase in gender performance) and victimization/survival (AOR = 1.07; 95% CI, 1.03-1.11 per 10% increase in gender performance). Female adolescent gender performance was not associated with adult IPV perpetration or victimization/survival.

DISCUSSION

The more similarly adolescent males behave to their adolescent male peers, the more likely they are to perpetrate and experience IPV in adulthood. This study supports the implementation of gender transformative education during adolescence and the specific need to address how the behaviors associated with male gender performance are risk factors for adult IPV.

Sex and gender associations with indicators of neurodevelopmental compromise in schizophrenia spectrum disorders

BACKGROUND

It has been proposed that sex and gender differences described in schizophrenia can be explained from a neurodevelopmental perspective.

AIM

In this study, we examined the associations of biological sex and gender role endorsement with putative indicators of neurodevelopmental compromise.

METHODS

We used the Bem Sex Role Inventory to calculate masculinity scores in 77 patients with a first episode of a schizophrenia spectrum disorder, and selected the following indicators of neurodevelopmental compromise: family history of schizophrenia, obstetric complications, premorbid functioning, neurological soft signs, and cognitive function. Secondary objectives included the moderating effects of age of onset of illness, substance use and negative symptoms on these associations.

RESULTS

There were no significant sex differences across any of the indicators of neurodevelopmental compromise. However, lower masculinity scores correlated significantly with poorer premorbid adjustment, sensory integration deficits and worse overall cognitive performance. Stepwise linear regression identified poorer premorbid adjustment in early adolescence and lower verbal learning scores as independent predictors of lower masculinity scores. In contrast to sex, gender showed several associations with indicators of neurodevelopmental compromise.

CONCLUSIONS

Lower masculinity scores may represent part of a phenotype for a neurodevelopmental anomaly that places some individuals on a pathway to schizophrenia.

Innovative methods to analyse the impact of gender norms on adolescent health using global health survey data

Background

Understanding how gender norms affect health is an important entry point into designing programs and policies to change norms and improve gender equality and health. However, it is rare for global health datasets to include questions on gender norms, especially questions that go beyond measuring gender-related attitudes, thus limiting gender analysis.

Methods

We developed five case studies using health survey data from six countries to demonstrate approaches to defining and operationalising proxy measures and analytic approaches to investigating how gender norms can affect health. Key findings, strengths and limitations of our norms proxies and methodological choices are summarised.

Findings

Case studies revealed links between gender norms and multiple adolescent health outcomes. Proxys for norms were derived from data on attitudes, beliefs, and behaviours, as well as differences between attitudes and behaviours. Data were cross-sectional, longitudinal, census- and social network-based. Analytic methods were diverse. We found that gender norms affect: 1) Intimate partner violence in Nigeria; 2) Unhealthy weight control behaviours in Brazil and South Africa; 3) HIV status in Zambia; 4) Health and social mobility in the US; and 5) Childbirth in Honduras.

Interpretation

Researchers can use existing global health survey data to examine pathways through which gender norms affect health by generating proxies for gender norms. While direct measures of gender norms can greatly improve the understanding of how gender affects health, proxy measures for norms can be designed for the specific health-related outcome and normative context, for instance by either aggregating behaviours or attitudes or quantifying the difference (dissonance) between them. These norm proxies enable evaluations of the influence of gender norms on health and insights into possible reference groups and sanctions for non-compliers, thus informing programmes and policies to shape norms and improve health.

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This article presents effective methods to study gender norms in existing global health survey data.

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We devised conceptual pathways linking gender norms to gender-based health disparities.

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We identified gender norms proxies and reference groups enforcing the norm.

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We tested hypotheses linking gender norms to health.

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These methods can aid policy and programme design to advance gender equality and health.

Health and Health Care Among Transgender Adults in the United States

Transgender (trans) communities in the USA and globally have long organized for health and social equity but have only recently gained increased visibility within public health. In this review, we synthesize evidence demonstrating that trans adults in the USA are affected by disparities in physical and mental health and in access to health care, relative to cisgender (nontrans) persons. We draw on theory and data to situate these disparities in their social contexts, explicating the roles of gender affirmation, multilevel and intersectional stigmas, and public policies in reproducing or ameliorating trans health disparities. Until recently, trans health disparities were largely made invisible by exclusionary data collection practices. We highlight the importance of, and methodological considerations for, collecting inclusive sex and gender data. Moving forward, we recommend routine collection of gender identity data, an emphasis on intervention research to achieve trans health equity, public policy advocacy, and investment in supporting gender-diverse public health leadership. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Racial/Ethnic, Sex, Sexual Orientation, and Socioeconomic Disparities in Suicidal Trajectories and Mental Health Treatment Among Adolescents Transitioning to Young Adulthood in the USA: A Population-Based Cohort Study

Suicide is the second leading cause of death for people aged 10-34 years old. Limited research has documented extant heterogeneities in suicide across the life course and among diverse sociodemographic groups. There is also limited research on the influences of mental health utilization on suicidal trajectories across the life course. This study aims to: (1) identify racial/ethnic, sex, sexual orientation, socioeconomic status, and intersectional differences in suicidal trajectories among adolescents transitioning to adulthood; and (2) examine influences of mental health service utilization on disparities in suicidal trajectories. The study included 9421 respondents (Mage = 14.99 [SD = 1.61]) from Waves I-IV National Longitudinal Study of Adolescent to Adult Health (1994-2008). Latent class growth analyses were used to identify trajectories of suicidal ideation and suicide attempts. Multivariate multinomial logistic regression was used to examine the influences of mental health treatment and sociodemographic characteristics on suicidal trajectories. Three suicidal ideation (low-stable, high-decreasing, moderate-decreasing-increasing) and two suicide attempt (low-stable, moderate-decreasing) trajectories were identified. Compared with the low-stable trajectories, the risks of being in high-decreasing suicidal ideation trajectories were higher among females (AOR = 1.45, 95% CI 1.01-2.13) and sexual minorities (AOR = 1.82, 95% CI 1.21-2.74). Sexual minorities (AOR = 2.63, 95% CI 1.69-4.08) and low-SES adolescents (AOR = 1.79, 95% CI 1.08-2.98) were more likely to be in the moderate-decreasing suicide attempt group. Mental health service utilization predicted engagement in high-risk suicidal trajectories. Sociodemographic disparities in suicidal trajectories initiate early and persist over time. Individuals in high-risk trajectories received mental health treatment during adolescence. Suicide prevention should target vulnerable subpopulations and mental health service utilization in the early stage.

Positive Youth Development and Wellbeing: Gender Differences

The five C’s of positive youth development (PYD) (competence, confidence, character, caring, and connection) have been associated with adaptive development among young people. Gender differences in young people’s wellbeing and mental health have been studied and analyzed, but the investigation into their association with the five C’s is still in its infancy. In the present study, we analyzed the influence of the five C’s on the wellbeing, more specifically, anxiety, social alienation, general wellbeing, physical symptoms, and psychological symptoms, of Portuguese adolescents, by gender. Participants were 5^th–12th grade students attending public schools in Lisbon, Portugal. The questionnaire was administered to 384 adolescents. The results indicated important gender differences in young people’s wellbeing. The results revealed some differences between genders that should be considered in interventions that aim to promote the wellbeing of adolescents. On the other hand, confidence was positively associated with mental health and wellbeing for both boys and girls, skill should be promoted among young people, because it was competence that revealed the greatest association with wellbeing, among the variables analyzed.

Changes in the Sexual Double Standard Associated With Sociodevelopmental Factors Among Young Adolescents in Kinshasa

PURPOSE

This study aimed to describe the changes in adolescents' perceptions of a sexual double standard (SDS) over time and to examine the developmental and social factors associated with these changing perceptions.

METHODS

The sample includes 2,163 10- to 14-year-old adolescents from Kinshasa, interviewed at two time points (T0 and T1), 1 year apart. We examined associations between SDS and pubertal onset, family interactions, peer interactions, and media exposure. We conducted sex-stratified generalized estimation equation models to test associations between changes in SDS and sociodevelopmental factors at T0 as well as with changes in sociodevelopmental factors between T0 and T1.

RESULTS

At T0, the SDS score was 4.15/5 among boys and 4.43/5 among girls, signaling highly gender unequal perceptions. SDS scores increased over time, shifting toward greater inequality. Adolescents who were prepubertal at T0 experienced greater increases in SDS scores than those who were pubertal at T0. The greatest increase in SDS scores was observed among girls who transitioned through puberty between T0 and T1. High parental monitoring of boys mitigated the increase in SDS as did boys' increased exposure to social media between T0 and T1. Girls who had mixed-sex friendships also experienced less change in SDS perceptions compared with those who socialized in same-sex groups.

CONCLUSIONS

Puberty was associated with changes in SDS perceptions for all adolescents, whereas family interactions and media exposure affected changes in SDS perceptions for boys and peer interactions affected changes in SDS perceptions for girls.

Assessing the Spectrum of Gender Norms Perceptions in Early Adolescence: A Cross-Cultural Analysis of the Global Early Adolescent Study

PURPOSE

There is increasing recognition that gender norms affect adolescent health and well-being. This study explores the consistency of adolescents' gender norm perceptions across different dimensions (roles, traits, relations) and describes how the patterns of these perceptions vary across four culturally different settings.

METHODS

The study includes 8,977 adolescents aged 10-14 years from Kinshasa, Shanghai, Cuenca, and Indonesia. Three gender norm scales were examined: sexual double standard, gender stereotypical traits, and stereotypical roles. We investigated patterns of gender norms across dimensions (roles, traits, and relations) and compared results between sites. We also examined how adolescents' individual responses across the scales compared with average responses in their site, to assess the consistency of their gender views.

RESULTS

Patterns of gender norms varied across sites, reflected in different levels of endorsement of each gender norms scale, from least equal in Kinshasa to most equal in Shanghai, while greater variation of perspectives across gender dimensions was noted in Cuenca and Indonesia. Moving from a societal to an individual perspective, most adolescents in each site (62%-67%) held both more progressive and less progressive views compared with their average peer depending on the gender dimension.

CONCLUSIONS

Our study demonstrates the coexistence of multiple gender worldviews that are assessed and enacted as per adolescents' experiences and social context. Accounting for such complexities is essential for gender-transformative programs, as shifting gender attitudes in one area does not necessarily translate in more gender equitable views across other spheres of life.

Gender Norms, Beliefs and Academic Achievement of Orphaned Adolescent Boys and Girls in Uganda

This study examined the traditional gender norms and beliefs held by orphaned adolescent boys and girls, and the role of such norms and beliefs on their academic performance. Data from a NIMH-funded study known as Suubi-Maka in Uganda were analyzed. Results indicate that overall, adolescents held strong gendered norms and beliefs that favor males over females. Compared to boys, girls were more likely to report more egalitarian gender norms and beliefs that give equal consideration to both girls and boys. In addition, more egalitarian gender norms and beliefs were associated with better school grades. Study findings point to the need to integrate targeted components that address harmful gender norms and beliefs in programs that support vulnerable adolescents, including education policy, if we are to address inequalities in education access and achievement, as well promote and strengthen education for all in sub-Saharan Africa.

Food Insecurity, Sexual Risk, and Substance Use in Young Adults

PURPOSE

The aim of the study was to determine the association between food insecurity, sexual risk behaviors, sexually transmitted infections (STIs), and substance use in a nationally representative sample of U.S. young adults.

METHODS

Cross-sectional nationally representative data of U.S. young adults aged 24-32 years from Wave IV (2008) of the National Longitudinal Study of Adolescent to Adult Health were analyzed. Multiple logistic and linear regression analyses were conducted with food insecurity as the independent variable and self-reported STIs, sexual risk behaviors, and substance use as the dependent variables, adjusting for covariates and stratifying by sex.

RESULTS

Of the 14,786 young adults in the sample, 14% of young women and 9% of young men were food insecure. Food-insecure young women had greater odds of any STI, HIV, chlamydia, exchanging sex for money, and multiple concurrent sex partners in the past 12 months compared to young women reporting food security, adjusting for covariates. Food insecurity was associated with higher odds of any STI, chlamydia, and exchanging sex for money among young men who identify as gay or bisexual, but not in the general population of young men. Food insecurity was associated with greater odds of marijuana use, methamphetamine use, and nonmedical use of prescription opioids, sedatives, and stimulants in both young men and women.

CONCLUSIONS

Food insecurity is associated with risk behaviors and self-reported STIs, including HIV, in young adulthood. Health care providers should screen for food insecurity in young adults and provide referrals when appropriate.

Women's business? A social network study of the influence of men on decision-making regarding female genital mutilation/cutting in Senegal

There exist two dominant but conflicting views on the role of men in the perpetuation female genital mutilation/cutting (FGM/C). One paints men as culprits, with FGM/C viewed as a manifestation of patriarchal oppression of women. An alternative portrays men as relatively uninvolved in a practice described as 'women's business'. These two perspectives lead to divergent predictions: if FGM/C underpins patriarchal structures, men should be expected to be ardent supporters of FGM/C as it bolsters their power and status; if FGM/C is a women's affair, men should have little involvement. We test these predictions using data from a mixed-method study of norms and social networks in two regions of Senegal. Data show that men comprise 50% of core network members, although they exert influence in different ways in each study site. In South Senegal excision is upheld by men, as well as older women, through a constellation of norms that define FGM/C as prerequisite to marriage and social inclusion. In Central Senegal these gender norms have eroded, opening possibilities for abandonment of FGM/C, and men, particularly fathers, at times successfully advocate this change. This suggests that men can play an important role in ending FGM/C, and should be involved in intervention efforts.

Gender inequalities in health and wellbeing across the first two decades of life: an analysis of 40 low-income and middle-income countries in the Asia-Pacific region

BACKGROUND

By adulthood, gender inequalities in health and wellbeing are apparent. Yet, the timing and nature of gender inequalities during childhood and adolescence are less clear. We describe the emergence of gender inequalities in health and wellbeing across the first two decades of life.

METHODS

We focused on the 40 low-income and middle-income countries in Asia and the Pacific. A measurement framework was developed around four key domains of wellbeing across the first two decades: health, education and transition to employment, protection, and a safe environment. Specific measurement constructs were then defined by considering gender indicator frameworks, the Sustainable Development Goals, indicator frameworks for child and adolescent health and wellbeing, and key stakeholder input. Available data were then mapped to define 87 indicators, subsequently populated using databases (UN agencies and the Global Burden of Diseases, Injuries, and Risk Factors Study) and nationally representative surveys. Where possible, estimates in girls were compared with boys to report relative risks.

FINDINGS

Although son preference is evident in some settings-as shown by higher than expected male-to-female sex ratios at birth in India, Vietnam, and China (all >1·10 compared with an expected ratio of 1·05) and excess mortality of girl children in some South Asian and Pacific nations-it is during early adolescence where marked gender inequalities consistently emerged. Adolescent girls face considerable disadvantage in relation to sexual and reproductive health (notably in South Asia and the Pacific), with high rates of child marriage (≥30% of women aged 20-24 years married before 18 years in Bangladesh, Nepal, and Afghanistan), fertility (≥65 livebirths per 1000 girls in Nauru, Laos, Afghanistan, Nepal, Marshall Islands, Bangladesh, Vanuatu, and Papua New Guinea), and intimate partner violence (>20% in Timor Leste, Afghanistan, Pakistan, and Myanmar). Despite educational parity in many countries, females aged 15-24 years were less likely than males to be in education, employment, or training in 17 of 19 countries for which data were available. Compared with girls, adolescent boys experienced excess all-cause mortality and substantially higher mortality due to unintentional injury, interpersonal violence, alcohol and other drugs, and suicide, and higher prevalence of harmful drinking and tobacco smoking.

INTERPRETATION

These findings call for a focus on gender policy and programming in later childhood and early adolescence before gender inequalities become embedded.

FUNDING

UNICEF.

Intersecting inequalities, gender and adolescent health in Ethiopia

Background

Until recently, global public health initiatives have tended to overlook the ways that social factors shape adolescent health, and particularly how these dynamics affect the specific needs of adolescents in relation to information about puberty, menstruation and sexual health. This article draws on mixed methods data from rural and urban areas of Ethiopia to explore how access to health information and resources - and subsequently health outcomes - for adolescents are mediated by gender and age norms, living in different geographical locations, poverty, disability and migration.

Methods

Data was collected in 2017–2018 for the Gender and Adolescence: Global Evidence (GAGE) mixed-methods longitudinal research baseline in three regions of Ethiopia (Afar, Amhara and Oromia). Quantitative data was collected from over 6800 adolescents and their caregivers, with qualitative data obtained from a sub-sample of 220 adolescents, their families and communities. Adolescent participants shared their experiences of health, illness and nutrition over the previous year; their knowledge and sources of information about sexual and reproductive health and puberty; and their attitudes toward sexual and reproductive health. Regression analysis was used to explore differences by gender, age, rural/urban residence, and disability status, across a set of adolescents’ health knowledge and other outcomes in the quantitative data. Intersectional analysis was used in analysing the qualitative data.

Results

Analysis suggested that gender inequality intersects with age, disability and rural/urban differences to shape young people’s access to information about puberty, with knowledge about this topic particularly lacking amongst younger adolescents in rural areas. Drought and lack of access to clean water exacerbates health challenges for adolescents in rural areas, where a lack of information and absence of access to preventive healthcare services can lead to permanent disability. The research also found that gaps in both school-based and alternative sources of education about puberty and menstruation reinforce stigma and misinformation, especially in rural areas where adolescents have higher school attrition rates. Gendered cultural norms that place high value on marriage and motherhood generate barriers to contraceptive use, particularly in certain rural communities.

Conclusions

As they progress through adolescence, young people’s overall health and access to information about their changing bodies is heavily shaped by intersecting social identities. Structural disadvantages such as poverty, distress migration and differential access to healthcare intersect with gender norms to generate further inequalities in adolescent girls’ and boys’ health outcomes.

Patterns of Health-Related Gender Inequalities-A Cluster Analysis of 45 Countries

PURPOSE

The paper explores gender inequalities between 45 countries across 10 health indicators among adolescents and whether those differences in health correlate with gender inequality in general.

METHODS

Data from 71,942 students aged 15 years from 45 countries who participated in the 2018 Health Behaviour in School-aged Children survey were analyzed. For this purpose, 10 indicators were selected, representing a broad spectrum of health outcomes. The gender differences in the countries were first presented using odds ratios. Countries with similar risk profiles were grouped together using cluster analyses. For each of the 10 indicators, the correlation with the Gender Inequality Index was examined.

RESULTS

The cluster analysis reveals systematic gender inequalities, as the countries can be divided into seven distinct groups with similar gender inequality patterns. For eight of the 10 health indicators, there is a negative correlation with the Gender Inequality Index: the greater the gender equality in a country, the higher the odds that girls feel fat, have low support from families, have low life satisfaction, have multiple health complaints, smoke, drink alcohol, feel school pressure, and are overweight compared with boys. Four indicators show a divergence: the higher the gender equality in a country in general, the larger the differences between boys and girls regarding life satisfaction, school pressure, multiple health complaints, and feeling fat.

CONCLUSIONS

Countries that are geographically and historically linked are similar in terms of the health risks for boys and girls. The results challenge the assumption that greater gender equality is always associated with greater health equality.

Gender Norms and Weight Control Behaviors in U.S. Adolescents: A Prospective Cohort Study (1994-2002)

PURPOSE

The aim of this article was to determine the relationship between gender norms and weight control behaviors in U.S. adolescents.

METHODS

We analyzed prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health (N = 9,861), at baseline in 1994-1995 (ages 11-18 years, Wave I), 1-year follow-up (ages 12-19 years, Wave II), and 7-year follow-up (ages 18-26 years, Wave III). The primary exposure variable was a measure of one's gender normativity based on the degree to which males and females behave in ways that are similar to the behaviors of their same-gender peers. The outcome variable was an individual's weight control attempts (trying to lose or gain weight) and behaviors (dieting, fasting/skipping meals, vomiting, or weight-loss pills/laxatives/diuretics to lose weight or ate different/more foods than usual or taking supplements to gain weight).

RESULTS

In logistic regression analyses controlling for potential confounders, a higher baseline individual gender normativity score (higher femininity in females and higher masculinity in males) was associated with weight loss attempts (β = .10; p = .01) and weight loss behaviors (β = .18; p < .001) in girls but was associated with weight gain attempts (β = .18; p < .001) and behaviors (β = .16; p < .001) in boys at 1-year follow-up. Higher individual gender normativity score was protective of weight loss attempts (β = -.15; p < .001) and weight loss behaviors (β = -.17; p < .001) in males but not females at 7-year follow-up. Loess plots provided visualizations of significant relationships.

CONCLUSIONS

Gender norms may reinforce a thinner body ideal for girls but a larger ideal for boys.

The Intersectionality of Gender and Wealth in Adolescent Health and Behavioral Outcomes in Brazil: The 1993 Pelotas Birth Cohort

PURPOSE

Brazilian society is characterized by deep socioeconomic inequalities. Using data from a population-based birth cohort, we explored how the intersectionality of family income and gender may affect adolescent health and behavioral outcomes.

METHODS

Children born in 1993 in the Brazilian city of Pelotas have been followed up prospectively at the age of 15 years when the follow-up rate was 85.7% of the original cohort. Participants answered standardized questionnaires, and anthropometric measures were obtained. Outcomes in five domains were studied: overweight (body mass index above +1 SD of the World Health Organization standard for age and sex), cigarette smoking (in the previous month), violence (fight in which someone was injured, in the past year), self-reported unhappiness (based on a face scale), and psychological symptoms (Strengths and Difficulties Questionnaire). Monthly family income was recoded in quintiles.

RESULTS

Results were available for more than 4,101-4,334 adolescents, depending on the outcome. Overweight was more common among boys than girls (29.7% and 25.6%; p = .004) and was directly related to family income among boys (p < .001), but not among girls (p = .681). Smoking was less common among boys than girls (12.3% and 21.0%, p < .001) and showed strong inverse association with income among girls (p < .001), but not among boys (p = .099). Reported violence was twice as common among boys than girls (16.4% vs. 8.0%; p < .001); an inverse association with income was present among girls (p < .001), but not for boys (p = .925). Boys and girls were similarly likely to report being unhappy (18.4% and 20.1%; p = .176), with an inverse association with family income in girls. Psychological symptoms were slightly less common among boys than girls (25.3% and 28.3%; p = .014), with strong inverse associations with income in both sexes (p < .001). Adolescent girls from poor families were the group with the highest prevalence for three of the five outcomes: smoking, unhappiness, and psychological problems.

CONCLUSIONS

Gender norms influence adolescent health and behavioral outcomes, but the direction and strength of the associations are modified by socioeconomic position. Preventive strategies must take into account the intersectionality of gender and wealth.

The role of mental health, academic stress, academic achievement, and physical activity on self-rated health among adolescents in Iran: A multilevel analysis

BACKGROUND

Health promotion of adolescents requires appropriate evidences of its determinants. The aim of this study was to investigate predictors of self-rated health (SRH) among adolescents in Qazvin, Iran.

MATERIALS AND METHODS

In this descriptive cross-sectional study, with a multistage sampling method, we recruited 1740 adolescents aged 12-19 years from 53 schools in Qazvin, Iran (2018). We used the Strengths and Difficulties Questionnaire and Adolescents' Academic Stress Questionnaire for data collection. The analysis was conducted using a multilevel logistic regression model. Gender, educational period, and socioeconomic status were considered as confounders.

RESULTS

Almost 21% of the adolescents reported their SRH suboptimal. Suboptimal SRH was higher in girls and older adolescents. Mental health disorders and academic stress had a positive association with SRH. However, this association was negative for academic achievement and physical activity. The interaction between mental health disorders and academic stress with SRH had a significant association in a crud regression model.

CONCLUSION

Mental health, academic stress, academic achievement, and physical activity were important predictors for SRH. Interventions that focus on promoting mental health, academic stress, academic achievement, and physical activity such as physical activity for 1 h and each day for 3 days per week can improve SRH in adolescents. Hence, policymakers should pay more attention to this issue in health promotion programs of adolescents.

Forward, Together: A Collaborative Path to Comprehensive Adolescent Sexual and Reproductive Health and Rights in Our Time

The 1994 International Conference on Population and Development established a basis for the advancement of adolescent sexual and reproductive health and rights (ASRHR) that endures today. Twenty-five years later, our vision for the future warrants reflection based on a clear understanding of the opportunities and challenges before us. Inclusion of adolescents on global, regional, and national agendas; increased investment in ASRHR policies and programs; renewed commitments to universal health coverage; increased school enrollment; and advances in technology are all critical opportunities we can and must leverage to catalyze progress for adolescents. At the same time, a range of significant challenges remain, have newly emerged, or can be seen on the horizon, including persistent denial of adolescent sexuality; entrenched gender inequality; resistance to meaningfully engaging adolescents and young people in political and programmatic processes; weak systems, integration, and multisectoral coordination; changes in population dynamics; humanitarian and climate crises; and changes in family and community structures. To achieve as much progress toward our vision for ASRHR as possible, the global ASRHR community must take strategic and specific steps in the next 10 years within five areas for action: (1) mobilize and make full use of political and social support for ASRHR policies and programs; (2) increase and make effective use of external and domestic funding for ASRHR; (3) develop, communicate, apply, and monitor enabling and protective laws and policies for ASRHR; (4) use and improve available ASRHR data and evidence to strengthen advocacy, policies, and programs; and (5) manage the implementation of ASRHR strategies at scale with quality and equity.

Implications of gendered behaviour and contexts for social mobility in the USA: a nationally representative observational study

BACKGROUND

We constructed measures of an individual's gendered behaviour and their gendered environment to investigate the salience of gender norms during adolescence for social mobility during the next decade of life.

METHODS

In this nationally representative observational study, we collected individual-level data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), which enrolled a cohort of nationally representative school students aged 11-19 years from across the USA and followed them up for 14 years (ie, to age 25-33 years). We characterised gendered behaviour for adolescents in a performative sense via self-reports of behaviours and beliefs. We aggregated this individual-level measure to create a proxy measure of an individual's social context by taking averages for an individual's peers of the same sex and school year.

FINDINGS

Between Jan 5, 1994, and Dec 26, 1995, Add Health collected data on a cohort of 20 745 students. 14 540 respondents were followed-up 14 years later between April 3, 2007, and Feb 1, 2009, of whom 7722 (53·1%) were female. More masculine male respondents were downwardly mobile; they were enrolled in school for fewer years and were more likely to have lower status jobs than their less masculine same-sex school peers. More masculine male respondents were also more likely to have jobs in occupational categories with larger proportions of males than their same-sex school peers. Gendered behaviour was not predictive of future educational and occupational attainment for female respondents. Male adolescents in school years with more masculine same-sex peers than male adolescents in other school years also tended to have lower educational and occupational attainment than their male peers. Educational and occupational attainment in early midlife for female respondents was not affected by their gendered environment.

INTERPRETATION

Gender, when measured as a set of gender-distinct behaviours in adolescence, was associated with differential patterns of social mobility from adolescence to young adulthood. Moreover, variation in an individual's local gender norms has implications for subsequent socioeconomic attainment, especially for male adolescents. These findings have potential implications for observed health disparities.

FUNDING

Bill & Melinda Gates Foundation.