"We hypothesize that rigid social norms and gender-based discrimination limit the perceived control that both girls and boys have over their own lives and futures, and that this perceived lack of control can have deleterious effects on their mental health and overall well-being."
This paper was written to stimulate discussion about the influence of gender and gender norms on mental health in adolescence and to provide some initial considerations to help guide a research and programme agenda moving forward. It was developed in advance of an expert consultation that the International Center for Research on Women (ICRW) and United Nations Children's Fund (UNICEF) jointly convened in April 2017. It begins with a broad discussion of gender and health during adolescence, then turns more specifically to what is known about gender and mental health in this important life phase. It then highlights some existing interventions, poses imperatives for future work, and draws conclusions for further consideration.
As the authors explain, there is growing recognition within the international community that mental health improvement is a neglected yet essential lever for achieving the Sustainable Development Goals (SDGs). Despite this recognition, few donors have prioritised the issue, and a mental health programme gap continues among low- and middle-income countries (LMICs). While very little is known about the gendered drivers of depression among adolescent girls and boys, self-harm, and suicide in LMICs, evidence from neuroscience and social science suggests that the experience of pervasive gender-based discrimination may be a significant contributor to poor mental health, depression, and suicide among adolescents. Self-harm, which encompasses both suicide and accidental death resulting from self-harm, is among the three leading causes of adolescent mortality. UNICEF describes good mental health as critical to ensuring healthy transitions to adulthood, with implications for overall well-being, growth and development, self-esteem, positive education outcomes, social cohesion, and resilience in the face of future health and life changes. But, according to the authors, few programmes and policies have effectively addressed the mental health needs of adolescents. Further, programmes and policies that do exist rarely take gender differences into account or reach the most marginalised.
The paper explores the kinds of social and cultural factors that place girls living in many LMICs at risk of poor health. Boys and young men also face gendered influences on their health. Cultural expectations of "what it means to be a man" may lead boys to engage in risky and health-harming behaviours, such as early and heavy smoking and use of alcohol and illicit drugs. The Lancet Commission on Adolescent Health and Wellbeing recommends that the global development community adopt a broader concept of adolescent health that includes, among other things, mental health and substance misuse. To that end, the paper examines the complex links among the adolescent developmental phase, gender norms, and mental health. Gender intensification - the increased pressure for adolescents to conform to culturally sanctioned gender roles - has been posited as an explanation for gender differences in depression. As explained here, these pressures come from a variety of sources, such as parents, peers, educators, and the media. While gender socialisation starts at birth, early adolescence (age 10-14) is a critical point, as puberty intensifies social expectations from family members and peers related to gender.
The authors stress that attitudes that endorse norms perpetuating gender inequality can be harmful to both boys and girls. Evidence from diverse countries demonstrates that exposure to gender discrimination, physical and emotional abuse, violence, poverty, social exclusion, educational disadvantage, harmful gender norms, and psychological stress that accompanies humanitarian crises can all increase mental health problems, including depression. The paper examines some of the gender-specific risk factors associated with poor mental health. For instance, girls can face factors that can contribute to depression, such as: unequal access to resources, decision-making power and education; gender-based violence; and discriminatory practices such as child marriage. As reported here, stigma and discrimination increase vulnerability to depression and suicide, and stigma and discrimination can be fueled by gender norms. Girls and boys of a different sexual orientation or gender identity than social norms or laws prescribe face even greater risk of depression and suicide.
Evidence that shows how gender norms and gender-based discrimination may harm the mental health of girls and boys can inform policies and programmes that seek to improve their overall well-being. To that end, the next section of the paper provides several concrete examples of adolescent mental health interventions in LMICs (see also the Annex, pages 10-17). In LMICs, mental health and psychosocial support programmes for adolescents have largely been confined to the humanitarian sphere. Few programmes specifically address gender norms, and scientific evidence on the mental health and psychosocial supports that prove most effective in emergency settings is still thin. Indeed, it is likely that programmes addressing the impact of gender norms on adolescent mental health will not necessarily have an explicit mental health focus. Programmes that promote more equitable gender norms and aim to empower adolescent girls may not only shift social norms but also have the consequence, intended or not, of improving mental health outcomes for both boys and girls.
The paper offers some "imperatives for the future", such as:
- Mental health policies and programmes in LMICs must incorporate a greater understanding of gender dynamics to be most effective. Further, they should be developed in consultation with adolescent girls and boys to increase their relevance and effectiveness.
- Qualitative and quantitative research can generate a deeper understanding of the intersections between gender, adolescence, and mental health in LMICs, including among hard-to-reach adolescent populations. Results from such studies could be used to design suitable intervention programmes at the school, community, and primary-care levels.
- School health services may be a priority area for strategic mental health interventions. School-based programmes incorporating life skills and social and emotional learning, along with early interventions to address emotional and behavioral problems, have been shown to reduce depression and anxiety while improving coping skills. In many contexts, community-based interventions may also be effective and likely to remain important in places where harmful gender norms prevail and where rates of secondary school attendance are low.
- Governments need to develop comprehensive national suicide prevention strategies that give context to the problem and outline specific actions to take at multiple levels. Health care services also need to incorporate suicide prevention as a core component, including mental health care training for health workers and community outreach workers. If gender discrimination, gender-based violence, gendered barriers to care, and gender-role stereotyping underlie mental health problems, these must be addressed through policies, programmes, and interventions that can be offered by medical professionals and clinicians.
Recommendations from the April 2017 convening by ICRW and UNICEF, which drew together 32 experts from academia, civil society, and bilateral, multilateral, and private donor institutions, will be available in a forthcoming publication.
ICRW website, December 6 2017. Image credit: Ashley Binetti