3 Introduction to gender as a social determinant of health

Sex and gender are both determinants of health: sex is a biological determinant of health and gender is an SDH. At a global level, SDHs are a more significant driver of health inequities than biological determinants of health.

Sex refers to the anatomical or genetic attributes that separate males, females and intersex people, and is usually assigned at birth. Someone’s gender identity may differ from their sex. Sex can influence biological susceptibility to infection, immune responses and responses to treatment; for example, urinary tract infections (UTIs) are more common in females for anatomical reasons, but more severe in elderly males. Sexually transmitted infections (STIs) tend to be less symptomatic in women but have greater reproductive impacts.

Gender is a social process that creates and shapes norms and power relations between women, men, boys, girls and non-binary individuals. This includes power imbalances, differential opportunities, cultural roles and discrimination. These processes, in turn, can influence the risk of exposure to infection, health-seeking behaviour, discrimination in health systems and stigma surrounding ill-health.

For example, gastrointestinal infections tend to be more common and more severe in males, due in part to:

• the fact that men are more likely to handle food in contexts and ways that carry a high risk of food-borne diseases (a gender factor)
• biological differences (including hormones) in immune response that place males at a higher risk of poor outcomes (a sex factor) (Dias et al., 2022).

Gender is relational and operates at multiple levels.

You may hear the terms ‘gender norms’, ‘gender roles’, ‘gender relations’ and ‘gender mainstreaming’. These concepts are integral to understanding gender as an SDH. Broadly these terms are defined as follows:

• Gender norms are a sub-set of social norms that describe how individuals are expected to behave in a given social context and as a result of the way individuals or others identify gender, as women, men and non-binary identities. Gender norms intersect with other norms related to age, ethnicity, class, disability, sexual orientation and gender identity – among other factors – and the way in which individuals experience them (ALIGN, n.d.).
• Gender roles are behaviours that are widely considered to be socially appropriate for individuals of a specific sex or gender within a culture, dictated by gender norms.
• Gender relations are the social power relations between people of different genders within households, communities and wider levels.
• Gender mainstreaming is the systematic consideration of gender equity in policies, programming and actions.

Gender analysis frameworks can support our understanding of how gender interacts with other processes, such as poverty.