5.2 AMR and gender differences
The specific ways that people are exposed to antimicrobials and resistant infections, experience AMR, and have knowledge of AMR are significantly influenced by biology, gender and other intersectional inequities.
Susceptibility : Biological susceptibility is affected by malnutrition, co-morbidities and exposure to pollutants and occupational hazards (e.g. mining). For example, high levels of HIV infection among young women in Nigeria increase their biological susceptibility to drug-resistant tuberculosis (TB). These high levels of HIV infection are thought to be due to intergenerational relationships where young women marry older men who are more likely to be living with HIV (Oladimeji et al., 2023).Exposure : Exposure to resistant infections can be influenced by gender norms and roles. Frontline health workers are predominantly women (O'Donnell et al., 2010) and consequently they have high exposure to resistant infections (Gautron et al., 2023). Sex workers have a high risk of exposure to resistant sexually transmitted infections and limited ability to negotiate for safer sex with clients (WHO, 2012; Deering et al., 2013). Lack of access to adequate water, sanitation and hygiene (WASH) systems can create environments in which people experience high exposure to resistant infections (Cocker et al., 2023). Research suggests that women are more likely to be prescribed antimicrobials than men (Schröder et al., 2016).- Access to health services, treatment and continuity: Low-income communities and particularly female-headed households may not have finances to access formal health services or to ensure continuation of antimicrobial treatment for HIV infection or TB, which both require long-term courses of medication (Shembo et al., 2022). This can also intersect with issues of food insecurity because some medications are to be taken on a full stomach (Kiekens et al., 2021; Taylor et al., 2022).
- Health-seeking autonomy: Household power relations can affect health-seeking autonomy. In many patriarchal settings, men or older women have decision-making power over younger women and girls. For example, among pastoralist communities in Tanzania, boys’ health may be prioritised because of their herding duties; girls and women may have to seek the permission of men to seek healthcare (Barasa and Virhia, 2022).
- Impacts: Catastrophic costs associated with healthcare can hit people already living in poverty hardest. People with multi-drug-resistant TB may have to take multiple, long-term treatments that can reduce their ability to work and push them further into poverty (Kaswa et al., 2021). Stigma relating to resistant infections can also be gendered: one study found that UTIs were thought of as illnesses resulting from poor hygiene, which prevented women in particular from seeking early care (Barasa et al., 2022).
Optionally, if you are interested in exploring this area further, you may be interested in reading ReAct’s report Scoping the Significance of Gender for Antibiotic Resistance report by the ReAct group.
Now try Activity 5, which illustrates how SDHs shape susceptibility and exposure to, and the treatment of, AMR.
Activity 5: Rani’s story
The following scenario has been developed to illustrate how gender and other inequities shape susceptibility and exposure to, and the treatment of, AMR through the life course of Rani. Rani is a fictional character, but her experience is based on reality.
As you read through the scenario, think about the specific ways in which gender inequality impacted Rani's health and access to healthcare throughout her life. Reflect and take notes on the following:
- How did various environmental factors increase Rani’s risk of infection?
- How did the roles she held in her family and community contribute to these exposures?
Infancy: Rani’s life began in a small village in rural Maharashtra, India. She experienced poor living conditions, food insecurity and lack of clean drinking water as an infant and so was malnourished with a weakened immune system. Her brothers always seemed to get the larger portions, leaving Rani hungry. Her childhood was spent fetching water from the village well, a daily chore that exposed her to contaminated water sources. The inadequate sanitation system meant that resistant infections spread frequently and widely, particularly among the girls in her community.
Adolescence: When Rani became a teenager, the burden of domestic labour fell heavily upon her shoulders. She spent hours cooking over smoky chulhas [stoves], the acrid smoke stinging her eyes and lungs, making her prone to pneumonia. Handling uncooked food, she was constantly exposed to bacteria.
Her menstrual cycles brought another layer of vulnerability, and she contracted recurring UTIs and reproductive tract infections (RTIs). Information about proper hygiene and antibiotic use was scarce. Household elders had decision-making authority to decide when and where to seek healthcare; Rani was not involved in making these choices.
Adulthood: After getting married, Rani fell pregnant and suffered from a UTI. Her husband purchased a medication from a local informal pharmacy without diagnosis. Rani, needing permission from her mother-in-law to seek medical help, often delayed treatment.
Rani wanted to provide for her new family so started working as a waste picker on the fringes of an informal settlement next to an industrial area, where the air was thick with smoke. She collected plastic bottles, caps, boxes and metals to sell on to scrap dealers, with no personal protection. She carried heavy loads in the heat of the day and was physically exhausted and dehydrated. She woke before light to do this work and was worried for her safety. Women she worked with were sometimes victims of sexual gender-based violence, exposing them to sexually transmitted infections.
Rani also kept chickens. The agricultural extension programmes, dominated by men, rarely targeted women like Rani, leaving her uninformed about safe farming practices.
Older life: As she aged, menopause brought hormonal shifts that made her susceptible to infections. Rani didn’t have many friends or family to talk to and lacked access to medical help. Limited access to social networks and health facilities meant she was isolated, lacking vital information about AMR and appropriate antibiotic use. She became the primary caregiver for her grandchildren and relatives.
One day, Rani developed a persistent cough and fever. The antibiotics she bought from a local pharmacist were ineffective, but she did not have the money to pay for diagnostic testing. Rani succumbed to an untreatable infection.
Discussion
Hopefully this case study has illustrated to you the ways in which gender, poverty and other inequitable power structures can drive AMR. You may have noted some of the following:
- Gender preferences for boy children may have led to malnutrition for Rani. This can increase susceptibility to infections, including resistant infections.
- Gender roles within the family meant domestic tasks such as cooking and caregiving were given to Rani, which increased her exposure to infections.
- Gendered power structures in both the family and society meant that Rani had limited access to or information about healthcare.
- Power structures also meant that Rani was exposed to infections (including resistant infections) through her work as a waste picker. These environments can also stress the environmental microbiome, furthering resistance.
- Biological factors also intersected with gendered norms in terms of Rani’s susceptibility to drug-resistant infections.
While gender differences in AMR highlight disparities in exposure, access and care-seeking behaviours, revisiting the broader social and structural drivers explores how these gendered inequities are both shaped by and reinforce systemic AMR risks.
5.1 AMR and sex differences
