6. Physical integrity and gender norms

Physical integrity includes issues of violence, body modification and unintentional injuries that affect adolescents and youth, particularly in LMICs. The Global Accelerated Action for the Health of Adolescents (AA-HA!) refers explicitly to gender and social norms that must change to end all forms of violence against adolescents, and to prevent road traffic injuries.

Violence

Violence affects millions of young women and men, with long-lasting health and social consequences. Girls and women account for the vast majority of both survivors and victims.  Experts agree that violence has strong links to social and gender norms and unequal gender relations: violence against women and homophobic violence, for example, are clear manifestations of power that are rooted in hierarchical and unequal social relationships. There is agreement, therefore, that strategies to tackle violence should promote gender quality and include efforts to change harmful norms that support the use of violence.

Intimate partner violence

Global estimates indicate that nearly one in three women aged 15 and over has experienced intimate partner violence (IPV) at some point in her lifetime. Nearly 37% of women in Africa, the Eastern Mediterranean and South-East Asia report having experienced IPV, with higher prevalence rates in LMICs.

Such violence starts early: an estimated 29.4% of girls aged 15-19 and 31.6% of women aged 20-24 years have experienced physical and/or sexual IPV. Some evidence actually suggests that the younger the woman, the higher the risk, with girls who marry early in particular danger.

Norms about male authority and the subordination of women

Girls and women are often seen as male property to be controlled. The IMAGES survey found that men who adhere to rigid masculine norms are more likely to report the use of violence against a female partner. And a study of survey data from 44 countries found that living somewhere where male authority over female behaviour is widely accepted increases the risks. Qualitative research in South Asia has confirmed that both men and women accept and justify such violence as necessary to teach women obedience.

Norms that justify male violence against women

Male agreement with wife beating is a strong predictor of IPV, while women who support wife beating are at greater risk of IPV. However, men are more likely to condone and perpetrate violence against women if they witnessed inter-parental violence and experienced violence in childhood, while women who have seen their own fathers beating their mothers are far more likely to experience IPV.

Norms about the use of violence to punish ‘transgression’

The use of violence is seen as particularly justifiable when women and men transgress gender norms that regulate their sexual behaviour. ‘Bad girls’ are at greater risk of violence and may be seen as ‘deserving’ it for defying norms of female respectability through, for example, premarital sex or immodest dressing. Male family members who monitor the behaviour of young women may intervene with violence when they do something that could damage family honour.

Norms about male toughness and aggression

The IMAGES study suggests that men who carry guns and who participate in any violent act or criminal behaviour are more likely to report having used IPV. Analysis of population survey data has also found that men who often resort to violence to settle disputes are more likely to abuse their partners with ideals of masculinity linked to aggression.

Norms about gender roles

Men who cannot live up to the traditional gender role of the provider and protector of the family may resort to violence to reaffirm their damaged masculinity. The IMAGES survey found a clear association between men reporting economic stress and higher rates of IPV.

Sexual violence

Global estimates indicate that 18% of girls and 8% of boys have experienced sexual abuse, while over 7% of women report having experienced sexual violence by a non-intimate partner. The UN multi-country study on men and violence in Asia and the Pacific found that between 10% and 62% of all men interviewed reported perpetrating some form of rape against a girl or a woman in their lifetime, half of them for the first time when they were adolescents.

Sexual violence intensifies during conflict. A systematic review has estimated that nearly one in five refugee or displaced women have suffered some form of sexual violence – a proportion that is very likely to be an underestimate, given the sensitivity of such information. Boys and young men are also vulnerable to sexual violence during conflict, with sexual violence against men reported in 25 countries affected by conflict between 1998 and 2008.

Norms about heterosexual performance and sexual dominance

Studies find that sexual violence is often associated with aggressive masculinity: it is used as a tool to regulate the gender performance of women and men. Findings from the IMAGES study show that men who engage in transactional sex, who have multiple sexual partners and who hold gender-inequitable attitudes are more likely to perpetrate rape. The IMAGES study also emphasised that men who were exposed to violence during childhood are more likely to perpetrate sexual violence than those who were not.

Norms about the male ‘right’ to sex and the use of female bodies

In many settings, ‘real men’ are seen as those who appear unable to control their sex drive – a drive that they are also entitled to satisfy; such norms coexist with those that devalue and objectify women. Norms about male sexual entitlement exclude both the possibility of a woman rejecting a sexual advance and any notion of consent.

Norms about masculine behaviours and access to support services

Studies have also noted that dominant norms and expectations of masculinity have negative consequences for boys and men who experience sexual violence and abuse. Male survivors find it difficult to access health and support services because they need to show strength and because of homophobia. In Kenya, only 46% of women and 36% of men who experienced sexual violence in childhood revealed the incident. In some cases, male vulnerability to sexual violence is seen as inconceivable and boys and men may have less legal protection than girls and women, limiting their access to services.

Youth violence

Over 80% of deaths caused by youth violence occur among men, with boys and men aged 15-29 having the highest homicide rate of any age group - 18.2 per 100,000 compared to average rates of 10.8 for males and 3.2 for their female peers. Most youth homicide deaths occur in LMICs, particularly in Latin America, followed by West and Central Africa.

Norms around male toughness, aggression and dominance

Boys in many settings are taught that they must be strong, tough and aggressive, and data confirm that boys are more vulnerable to physical abuse than girls in childhood. Parents and teachers, for example, may be more likely to use physical violence to boys. Boys learn that it is a normal and valid way to show their masculinity and earn respect, with nearly one in two males across all countries reporting involvement in physical fighting compared to one in four females.

Boys who display traits that challenge acceptable norms are often bullied and may face greater sanctions than girls. A study with adolescents aged 11-13 years in urban poor sites in four countries found that boys who challenged local gender stereotypes faced insults and name-calling. Analysis of a large national sample of American youth aged 14-22 found that gay males and lesbians were more likely to report having been bullied than their heterosexual peers. Another study found that adolescent boys who do not demonstrate standard masculinity traits are more likely to be targeted by their peers in school. Those who were short, overweight, had a disability, belonged to an ethnic minority, had a different religion or were seen as poor were also viewed as valid targets for other boys who wanted to prove their manhood.

Norms around male risk-taking behaviours

In some settings, the possession of weapons is a symbol of masculinity and their use is normalised as a way for men to settle disputes. The IMAGES study found that gender attitudes are linked to criminal activity: men who adhere to more gender-inequitable norms are more likely to have a firearm and to have used a weapon to fight. However, the most significant risk factor for men’s participation in criminal activity is their socioeconomic status.

Body modification

Gender norms influence practices that change the appearance and shape of the body to make an individual more ‘acceptable’ or ‘attractive’. Body modification practices range from tattooing and skin lightening to muscle-toning and cosmetic surgery. Some are individual choices, while others are imposed.

Norms about feminine bodies and behaviours

Adolescent girls and young women undergo various types of body modification practices. While they sometimes set out to challenge established norms, the goal is often to re-shape their bodies to align with dominant gender expectations of how they should look. Both girls and boys often equate femininity with beauty and attractiveness and their peers enforce such norms. Studies note that body modification is sometimes presented as an individual choice and an act of agency, as is the case with tattoos, for example. Yet Western feminist scholarship’s critique of cosmetic surgery has stressed that women continue to be reduced to their looks as objects of the male gaze.

As well as restrictive dietary regimes that can lead to eating disorders, young women are increasingly having cosmetic surgery to change body parts that they believe fail to conform to dominant ideals of feminine beauty. The number of adolescent girls modifying their bodies is on the rise, as seen in Brazil.

Norms about female modesty, family honour and subordination of women are embedded in traditional body modification practices that are seen as essential for group identity, regardless of the consequences for health and wellbeing. Female genital mutilation/cutting (FGM/C) is a prime example with very harmful effects. While accurate data are unavailable, it is estimated that at least 200 million girls and women have been cut in 30 countries, and that the practice continues in some migrant communities in Europe and North America. It is widely perceived as a form of violence against women and girls. Yet supporters argue that it is important for a woman’s status, chastity and family honour, marriageability, beauty or even health. One common thread is its collective character with social rewards, but also punishments for those who do not conform.

The gradual abandonment of FGM/C has been linked to the adoption of a social-norms perspective Given its roots in context-specific values and beliefs, attempts to eliminate the practice focus on work with communities, including boys and men, to change attitudes and behaviours, as well as legislative change and targeted campaigns.

Such norms can be overcome: foot binding was practised on young girls in China for nearly a thousand years, but it was abandoned within just one generation. This was the result of concerted education campaigns and the creation of societies whose members pledged that they would never bind their daughters’ feet and never let their sons marry girls whose feet had been bound.

Norms about masculine bodies and behaviours

Although most research has focused on women, body modification issues are increasingly affecting men. Young men are increasingly undergoing cosmetic surgery, using skin lightening and other beauty products and exercising or dieting to address body dissatisfaction. One study in Mexico, UK and the US found that nearly half of the young men surveyed were dissatisfied with the size of their muscles and said that their weight or body shape were the aspects of their appearance they would most like to change.

Where masculinity is linked to muscularity, adolescent boys and young men may engage in muscle-enhancing techniques such as excessive exercise, or use muscle-enhancing substances such as anabolic steroids and other supplements to achieve the desired appearance, despite the serious health risks. A significant percentage of young Lebanese men exposed to overly muscular male models in media, including pornography, were more likely to believe that women prefer muscular men and used dietary supplements or steroids to enhance their body image.

Unintentional injuries

Hundreds of thousands of adolescents and youth die from unintentional injuries every year, while those who survive often face serious health and social consequences. Unintentional injuries are a leading cause of death and disability for adolescents, especially those living in LMICs and in poor settings. There are five main types: road traffic injuries, drowning, burns, falls and poisonings. Gender norms tend to shape adolescent and youth vulnerability to unintentional injuries.

With the exception of burns, boys and young men are more vulnerable to unintentional injuries and suffer more frequent and severe injuries than girls and young women. For example, boys and young men are at high risk of suffering injuries from road traffic accidents in LMICs and twice as likely to drown as females. Adolescents and youth in hazardous occupations are particularly vulnerable to falls, while older adolescents have a high prevalence of poisoning that may be linked to substance use or to workplace risks.

In contrast, young women have higher rates of death from burns, sometimes exceeding those of men by up to 50%. The vast majority of burns occur in LMICs, with almost two-thirds in Africa and South Asia.

Norms about masculine behaviours

Taking risks is seen as ‘masculine’ in many settings. Adolescent boys and young men may engage in behaviours that increase their risk of traffic injury such as consuming large amounts of alcohol and driving fast to demonstrate their masculinity. Research in Mexico, the UK and the US has demonstrated that young men who conform to traditional masculine norms are up to three times more likely to report having had a traffic accident. Some research finds that young drivers experience higher peer pressure than older drivers to commit traffic violations such as speeding, not using seat belts, or drinking and driving.

Norms about mobility and exposure to risk

Different rates of injuries between male and female youth are sometimes linked to norms about mobility that may constrain women, while encouraging men to spend more time outdoors where they are more likely to experience traffic injuries.

Norms about gender roles and exposure to risk

Because they may work in hazardous jobs, older adolescent boys and young men are more vulnerable to traffic accidents, drowning, falls and occupational injuries. Girls and young women, however, spend more time in the kitchen, where they are more exposed to fire and hot substances.  In low-income settings, female burns are often caused by open-fire cooking or unsafe cook stoves and by flames that ignite loose female clothing. However, growing evidence from South Asia links higher incidence of burns among young women to violence. In India, for example, burn-related injuries and deaths among young women could be caused by kitchen accidents, but also by domestic violence, or even suicide disguised as an accident.