Gender inequalities in health
The conditions in which women and men live, work and spend their time affect their health. Gender and other factors, such as age, education, ethnicity, economic status, sexual orientation or disability, influence the resources that women and men can access, their exposure to environmental risks, their options for tackling ill health and the support they can receive from public institutions.
Men’s lower life expectancy and women’s poorer mental well-being reflect the effect of gender inequality and gendered norms on health by leading to differences in exposures and vulnerabilities to disease, health-related behaviours and access to care. Employment status influences people’s physical and mental health through working conditions, income and social status, while gender-biased health research and healthcare systems reinforce and reproduce gender inequalities.
In the wake of the COVID-19 pandemic, health inequalities will continue to accumulate and have the greatest impact on those not in paid work and those with a low income, such as women with a low level of education and women and men with disabilities. Although healthcare in the EU is generally accessible, these groups are most likely to be in poor health and to have poor access to healthcare services. With costs and waiting lists the most common reasons for unmet health needs in 2019, any pandemic-related economic crisis and unemployment could be expected to significantly restrict healthcare access for far more people. The EU’s population is ageing, and this means that access to affordable and high-quality long-term care is increasingly important. The European Pillar of Social Rights reflects this. A strong commitment to the implementation of the recommendations of the European Pillar of Social Rights – particularly those relating to long-term care needs – has taken on a greater urgency in the light of the COVID-19 pandemic.
Pathways to poor health are gendered
Gender influences the development and course of risk factors and conditions for NCDs, with norms and behaviours profoundly affecting health throughout life. The COVID-19 pandemic is taking a particularly high toll on women and men already suffering from NCDs. A renewed commitment to fully implement the WHO strategies adopted in 2016 and 2018 relating to the health of women and men is needed to mitigate the impact of gender inequalities on public health (WHO Regional Office for Europe, 2016a, 2018b).
Mental health disorders have profound consequences on an individual’s ability to learn and work, and on family and social life, as well as ramifications for society as a whole. Untreated mental illnesses are a significant economic cost to society through reduced productivity and lost healthy years of life (Mackenbach et al., 2011; Stefko et al., 2020). Of particular concern is morbidity and mortality among young people.
There is ample evidence of the connection between low socioeconomic status and poor mental and physical health. It is widely argued that reducing socioeconomic inequalities would improve overall population health (Allen et al., 2014; Cairns et al., 2017; Reiss, 2013; Silva et al., 2016). Social policies to reduce gender and income inequalities through universal health coverage, providing care leave to improve work–life balance and expanding educational attainment opportunities can also reduce gender inequalities in mental health morbidity and mortality (Cairns et al., 2017; Patel et al., 2018). Preventing all types of violence against women is among the most effective and impactful mental and physical health interventions (Bhui, 2018). Providing treatment and support is just as important. Mental illness symptoms observed by health service providers should be considered as a potential indicator of past or current intimate partner violence or non-partner domestic violence (Ferrari et al., 2016). Mental health services need to be both aware of such violence among women and men and provide gender-sensitive and cross-cutting support to address it (Sian Oram et al., 2017).
Harmful gender norms, such as toxic masculinities and unachievable beauty standards, have similarly far-reaching negative impacts on mental health. This is exemplified by high suicide rates among young men, poor mental health among LGBTI people and the high prevalence of anxiety and eating disorders among young women. Stigma remains a barrier to seeking help for mental health problems, affecting men more than women (Clement et al., 2015). Reducing mental health stigma should be a health priority, as it would encourage more people to seek help, reduce mental health treatment gaps and improve mental health globally (Wainberg et al., 2017).
Sexual and reproductive health and rights
Gender inequalities undermine the ability of women and men to control their SRHR, with significant consequences. Availability, access, cost and stigma issues around contraceptives introduce barriers to SRH, especially for young people. In parallel, laws, policies and comprehensive sexuality education vary across the EU. The curricula in many Member States focus on the biological aspects of SRHR, leaving knowledge gaps on key areas, such as sexual pleasure, consent, gender-based violence and access to abortion (BZgA and IPPF EN, 2018; Picken, 2020). Such gaps contribute to higher birth rates among adolescents (UNFPA, 2021). Abortion services and care are an essential part of public health and are essential for good SRH outcomes for women and girls (WHO, 2012). Abortion legislation and services also vary across the EU. With free movement of people and goods a pillar of the European single market, abortion tourism (Mecinska et al., 2020) and cross-border sales of abortion pills (Calkin, 2021) enable women and girls to obtain otherwise inaccessible services. However, age, (dis)ability, race, ethnicity, migration status and sexual orientation influence access to SRH, meaning that certain groups of women are disproportionately affected.
Data gaps on SRH prevail, particularly on men’s contraceptive use and unmet family planning needs. SRH data needs to be broader in its scope and demographics to make this aspect of public health a visible concern for everyone, not just girls and women. Information on laws and regulations providing women and men equal access to SRH services and education – an SDG indicator essential for monitoring SRH (UNFPA, 2021) – is incomplete in most Member States. This limits the ability to evaluate and compare key SRHR policy areas across the EU, for example on maternal health and abortion. Another gap concerns the thorough disaggregation of data for the most common STIs by gender, age, sexual orientation and HIV status (ECDC, 2021). Without this, the mechanisms of transmission and options for prevention remain unknown, ensuring HIV’s continued threat to public health.
Although the EU 2020–2025 anti-racism action plan calls for race to be mainstreamed into EU public policies, race is often not recorded in EU research. Based on the findings of UK research, it is very likely that the race gap in maternal mortality in the EU-27 is underexplored. Most women and girls exposed to FGM are black and face racial and gender inequalities, limiting their access to and representation in maternal healthcare.
The COVID-19 pandemic
The full impact of the pandemic on the EU population will take time to emerge, as numbers of registered cases and deaths are believed to be underestimated. On average, the mortality rate between 2020 and 2021 was 17 % higher for men than in previous years and 14 % higher for women. Beyond the effects of biological differences, pre-existing gender inequalities in society have shaped the pandemic’s impact on the health and lives of all women and men.
With NCDs linked to an increased risk of severe COVID-19, the pandemic has underlined the importance of tackling causes of illness, such as unhealthy lifestyles or highly gendered risky behaviours. The need for immediate and long-term mental healthcare acknowledging gender differences has become clearly evident.
The pandemic has taken a high toll on men. While infection rates are rather similar for women and men overall, men have been at significantly higher risk of hospitalisation and death from COVID-19. As of June 2021, EU data shows that men account for 55 % of COVID-19-related deaths. Older men, men with NCDs and those in essential and precarious jobs have been particularly affected. The pandemic has also been devastating for nursing home residents.
Working-age women in the EU have been greatly exposed to infection, partly because of their over-representation in some frontline professions. Vulnerable workers, such as migrant women or women in precarious jobs, have been most at risk. Evidence is emerging that women are more affected by ‘long COVID’, pointing to potentially long-term consequences for large segments of the female population. Classifying COVID-19 as an occupational disease would help ensure that workers have adequate social protection while dealing with long-terms effects of the infection.
Apart from the direct health consequences of the virus, there are also secondary impacts on physical and mental health. These are likely to be gender specific and long-lasting. The true extent of the pandemic’s mental health consequences will take time to unfurl, with experts warning that the peak may come long after the pandemic is controlled. Mental well-being is the lowest since the outbreak, with large segments of the population at risk of depression (Eurofound, 2021c). Women have had lower levels of mental well-being than men in each of the three pandemic waves, with the lowest levels noted among working-age women during the third wave. This reflects not only the pervasive impact of social isolation, but also the increased and sustained burden of unpaid work triggered by school closures and movement restrictions during lockdowns (EIGE, 2021c).
The COVID-19 pandemic has raised barriers to accessing healthcare services in the EU, including for SRHR. This is either because some medical procedures and treatments have been deferred or deprioritised, or because help has not been sought for fear of infection. The situation has put long-term strain on public healthcare systems, which are now expected to resolve this care debt with very limited resources. Healthcare professionals are at particular risk of severe mental illnesses and should have access to appropriate mental healthcare services. The pandemic has also highlighted poor working conditions and staff shortages in the health and social care sector. These will need urgent redress if health system resilience is to be strengthened.
There is great concern over the global surge in intimate partner violence (Graham-Harrison et al., 2020; UNFPA, 2021; WHO, 2020c), causing a ‘shadow pandemic’ (UN Women, 2020) that is likely to peak only when restrictions are lifted.
In this situation, the strategic objectives of the EU health programme within and between Member States and WHO’s strategy to improve health and reduce health inequalities will not be achieved without a clearly gendered approach to mitigating the impact of COVID-19. At the Global Health Summit in Rome in May 2021, the EU and G20 countries committed to 16 principles to guide action on managing the current pandemic and preparing for future health emergencies. Among them are the need to invest in the health and care workforce and the need to develop gender-sensitive public health responses to future health crises. High-level political will and resources are required in policy responses to long-term health impacts – and to build resilient and gender-responsive health systems better able to tackle all health inequalities.
 Global Health Summit, the Rome Declaration, https://global-health-summit.europa.eu/rome-declaration_en.