3. Non-communicable diseases and gender norms

A number of health traits that often emerge during adolescence have been identified as leading risk factors for non-communicable diseases (NCDs) in later life: low physical activity, overweight and obesity, air pollution, and the use of tobacco and, alcohol. Public health experts tend to focus on these as individual behaviours that threaten health outcomes without necessarily linking them to gender norms.

Low physical activity

Regular physical activity has major health benefits, yet global data indicate that 81% of adolescents have levels of activity below the minimum recommended levels, with adolescent girls less active than boys. Worldwide, 84% of girls compared to 78% of boys were insufficiently active in 2010, and girls become less active as they grow older.

Norms about feminine and masculine bodies and attributes

A scoping review of literature on high-income settings concluded that adolescent girls have a complex relationship with physical activity, one that is dominated by discussions of the female body and requires the negotiation of gender norms. Although girls report enjoying physical activity, they can find it difficult to reconcile being feminine with being athletic.

They may be more likely to take part in activities such as dance and gymnastics than boys, who may prefer football or hockey. Girls may be concerned that such physical activities could make them look more aggressive or muscular, or worry that they might provoke peer criticism or rejection for appearing to challenge heterosexual normative ideals. They may believe that qualities promoted by physical activity, such as competitiveness and strength, are incompatible with traditional feminine ideals. Another global review also noted that physical activities in schools are often dominated by sports that promote precisely these qualities. Teachers and peers may reinforce gender norms and stigmatise both girls and boys who do not conform to stereotypes.  

Norms about mobility and safety

Girls and young women tend to stay indoors if their mobility is restricted by normative expectations. They may not take part in physical activities in public spaces as this could damage their own reputation and that of their family. Such restrictions in parts of South Asia and the Middle East and North Africa (MENA) promote a sedentary lifestyle.

In recent years, however, international bodies, governments and civil society have supported girls’ right to physical education. They have also implemented programmes in safe spaces that combine physical activities with life-skills training to empower girls and tackle the norms that constrain their lives.

Overweight and obesity

In 2016, almost 340 million children and adolescents aged 5-19 years worldwide were overweight or obese – almost one in every five. While high-income countries (HICs) still have the highest prevalence rates, obesity rates for this age group are increasing much faster in LMICs. Gender norms and context influence divergent dietary habits, from over-eating to extreme dieting. Two studies combining comparable obesity prevalence data with indicators of gender inequality have found that gender gaps in the obesity prevalence are larger in countries with greater gender inequality.

Norms about feminine and masculine bodies and attributes

Globally, a higher proportion of boys are obese than girls. However, girls have a higher prevalence rate in Africa. In South Africa, two-thirds of black girls perceived fatness as a sign of happiness and wealth and saw themselves as attractive. In some Pacific islands, female thinness is associated with illness and infertility. Gender disparities in obesity are also high in the MENA region, where some societies favour larger body sizes as a sign of fertility, good health or prosperity, while there are also constraints on girls’ mobility and physical activity. Between 40% and 81% of older adolescent girls in the region identified cultural factors as important barriers to physical activity.

Tobacco use

Tobacco use is a major risk factor for NCDs, including breathing difficulties and asthma among youth and cancers among adults. In 2016, more than 1.1 billion people aged 15 years and older smoked tobacco. Globally, men and boys have a far higher prevalence of smoking than women and girls (34% of men compared to 6% of women).

Tobacco is often the first substance used by youth who start smoking in early adolescence. WHO estimates that there are 24.2 million smokers aged 13-15. Globally, one in every five boys aged 13-15 years and one in every ten girls of the same age uses tobacco, with the prevalence rates highest in Europe and lowest in Africa and Asia, with significant variations within regions. While rates are declining in some HICs, they are increasing in lower middle-income countries.

Norms about masculine and feminine behaviours

In many contexts, tobacco use is seen as a male attribute: as part of a man’s social life. Women, however, are discouraged from smoking as it is seen as unfeminine and immodest. However, such social constraints have weakened in HICs as female autonomy and economic independence has increased, leading to high rates of smoking among women and girls.

The reasons for smoking vary by gender: adolescent boys and young men may see it as masculine and as sexually attractive, and face peer pressure as well as tobacco marketing. Girls and young women, however, may equate smoking with empowerment, freedom and fashion. In high-income settings, female smoking can also be linked to beliefs that it curbs appetite and can aid slimming.

Research on the tobacco industry and its aggressive marketing strategies confirms its manipulation of gender norms to expand markets that target youth and women, with advertising emphasising smoking as a manly habit when young men are targeted, and as a way to challenge traditional gender norms when young women are the targets.

Alcohol use

Harmful use of alcohol is a major risk factor not only for NCDs, but also for many injuries, including those caused by road accidents and violence. It is also a risk factor for infectious diseases, including HIV and STIs.

In 2016, harmful alcohol use accounted for over 5% of all deaths worldwide. Although alcohol-use disorders were more prevalent in HICs, the disease burden attributable to alcohol was highest in low-income countries and lower-middle income countries.

Alcohol use tends to start in adolescence. Globally, about one in four 13-15-year-olds report having used alcohol during the last 12 months, with alcohol cited as the substance used most commonly by school students worldwide. More than a quarter of all older adolescents aged 15-19 are current drinkers, with the highest prevalence of alcohol abuse found among boys in Europe, the Americas and the Western Pacific regions. The 2013 Global Burden of Disease study found that alcohol use was the leading global health-risk factor associated with mortality among adolescent boys aged 15-19 years.

Norms about masculine and feminine behaviours

Social attitudes towards the acceptability of drinking and drunkenness are clearly influenced by masculine and feminine ideals. Drinking is seen as a demonstration of masculinity and, therefore, more acceptable for boys and men. It is linked to male risk-taking and the male perception that alcohol enhances sexual performance. It is also seen as a bonding activity for boys and young men, and as a way to avoid responsibilities or deal with feelings of powerlessness.

Young men may drink heavily at times of economic hardship and limited opportunities. The sharp drop in male life expectancy recorded in Russia in the 1990s, for example, was linked partly to increased risky behaviours such as heavy alcohol consumption at a time of economic and political upheaval. The IMAGES survey has found that younger men, men with lower education levels, those with work stress and men with gender-inequitable attitudes are more likely to report regular alcohol abuse.

Evidence shows that drinking is often less acceptable for women, especially in public spaces, as it is seen as unfeminine, immoral or immodest. Young women who get drunk may be perceived as sexually available or promiscuous. However, changes in female education, employment and economic independence, coupled with a shift in gender roles, have contributed to increased alcohol consumption among women and increasing convergence in male and female drinking patterns.

Even so, persistent norms about alcohol consumption mean that women who have alcohol-related problems find it more difficult than men to access health care and face more criticism and rejection from partners and society. There is evidence that – as with smoking – urban youth and women in LMICs are targeted explicitly by alcohol manufacturers. Using aggressive marketing techniques that build on shifting gender norms, they aim to attract new consumers.

Air pollution

Exposure to air pollution, whether outside or in the home, has adverse and life-long health effects, including respiratory infections, heart disease, stroke and cancer, with the heaviest disease burden recorded in LMICs. WHO estimates that ambient (outdoor) air pollution caused 4.2 million premature deaths in 2016, with 91% of these deaths occurring in South-East Asia and the Western Pacific. In addition, nearly 4 million people die prematurely each year from illnesses attributed to household air pollution, largely because they lack access to clean cooking fuels and technologies.

Norms about gender roles and exposure to risk

In many LMICs, women and girls are the main providers and users of household energy services as they prepare meals, tend fires and keep the home warm, and spend more time at home than men. They often rely on polluting fuels and technologies such as wood, dung and charcoal, open stoves and kerosene lamps and their greater exposure to these pollutants heightens their risk of associated diseases. Women and children accounted for 60% of all premature deaths attributed to household air pollution in 2012: the second most important health-risk factor for women and girls worldwide.

This health risk links to poverty, as it is low-income and rural households that depend on such fuel sources. Data from Pakistan show that more than 99% of women and girls from the poorest rural households lack access to clean fuel, compared to only 1% of those from the wealthiest urban households. Similarly, in Colombia, 76% of indigenous women and girls in the poorest rural households lack access to clean cooking fuels.