Gender Equality Index 2021: Health

Since the 1994 ICPD, governments have been advised to encourage and enable men to take responsibility for their sexual and reproductive behaviour. Hawkes and Hart (2000) note the importance of recognising from the outset that men’s reproductive concerns are unrelated to those of their female partners, and to acknowledge that ‘men’ around the world are not a homogeneous group with the same needs and worries. Just like women, men are characterised not only by their sex and gender, but also by their age, ethnicity, sexuality, educational status, income and occupation, geographical location, their position within a family, and their access to information and ability to use it.

Wessells (2021), while pointing out that urological disease burden among men becomes significant only after the age of 45 years, suggests that identifying men’s health risks and engaging them in their own health promotion should begin decades earlier. However, men have different priorities over their lifespan, and manage health risks differently from women. Often reluctant to seek medical attention even when symptoms are noticeable, men typically wait until a problem can no longer be ignored before contacting a healthcare professional (Pell, 2021).

Framing certain SRH conditions as affecting only one sex can be detrimental to health outcomes and reinforce gendered inequalities in health. WHO (2011) considers health interventions as gender transformative when they recognise gender differences and challenge and change the status quo of harmful gender norms, roles and relations.

Sex-based approaches to reproductive health focus on cervical and breast cancer, as these are also among the most common cancers among women. However, women-only cancers are not a concern for girls and women only. For example, cervical cancer is caused by human papillomavirus (HPV)^[1], which also causes tongue and tonsil cancer, both of which can affect everyone, regardless of gender or sexual identity. Although the prevalence of high-risk HPV types is higher in women, and women are overall more likely than men to develop cancer as a result of HPV infection (Wendland et al., 2020), tongue and tonsil cancers are more common in men (Näsman et al., 2020).

Gender-transformative strategies for SRH interventions include offering HPV vaccinations to boys and men, and Italy was the first EU Member State to do so (Audisio et al., 2016). Vaccinating boys as well as girls not only protects both sexes from tonsil and tongue cancer but also reduces the circulating pool of virus in the male population, thus reducing the risk of transmission to women during sexual intercourse and the risk of cervical cancer. In addition, HPV vaccination for all, to prevent poor SRH, has proven to be cost-effective, and is explicitly recommended for all Member States (ECDC, 2020b). However, according to data provided by WHO in 2019, only 14 Member States include boys in the primary group for HPV vaccinations, and in only 10 of these is HPV vaccination for boys funded (Bonanni et al., 2020).

In their literature review covering Europe, Canada and the United States, Gold et al. (2021) found that ambivalence towards pregnancy, miscommunication between sex partners and/or between patients and healthcare professionals increase women’s inconsistent contraceptive use. Research on men’s contraceptive behaviour is still limited, but findings from France suggest that miscommunication with partners also seems to contribute to unplanned pregnancies. Half of male survey respondents who had not used contraception, leading to an unplanned pregnancy, said they thought their female partners were using birth control (Kågesten et al., 2015).

Contraception availability and accessibility are not the only criteria for uptake. Reliable supply and low-cost interventions are other crucial factors for SRH outcomes. In Romania, Roma women have access to and know about contraceptives, for example the pill, injections and intrauterine devices, but they cannot necessarily afford them long term. Free SRH programmes are often discontinued or are not affordable because of transportation costs or corrupt health staff demanding bribes from Roma women (Kühlbrandt, 2019).

Overall, the UN estimates that 59 % of women in the EU can cover their contraception needs, with Finland outperforming all other Member States (Figure 40). However, data on contraceptive prevalence is lacking for men and for those defining their gender identity differently.

Male condoms and female hormonal contraception are the most prevalent birth control methods used by adolescents in the EU. On average, 65 % of 15-year-old girls and boys report using male condoms during their last intercourse, with the pill used by 28 % (WHO Regional Office for Europe, 2020a). A quarter of adolescents do not use either during intercourse, while more than a third in Croatia, Lithuania, Malta and Slovakia report not using any contraceptives (Inchley et al., 2020). Contraceptive access, availability, affordability and accountability vary greatly between Member States. According to the latest European Contraception Atlas (2020)^[2], only seven Member States have comprehensive contraception policies (BE, DE, FR, LU, NL, PT and SE). Eastern European Member States (CZ, LT, HU, PL and SK) are the worst performing, although only in Poland has access to contraception been further restricted in the last 4 years. However, it should be noted that limited access to contraception is not associated with increased fertility rates: the 10 countries with the lowest access to contraception have lower fertility rates than the 10 countries with the highest contraception access.

Figure 40. Estimated prevalence of contraceptive use of any method among women, by EU Member State (%, 15–49 years, 2020)

Note: Percentage of women of reproductive age (15-49 years) who are currently using any method of contraception

Citation: United Nations, Department of Economic and Social Affairs, Population Division (2021). Model-based Estimates and Projections of Family Planning Indicators 2021, custom data acquired via website. Source: UN database, 2020.

Cross-cutting research creates nuanced and context-specific evidence to improve SRHR policies, taking global, regional and local diversity into account. In the case of HIV, for example, such research would help policymakers move beyond individual focus to consider the multilevel root causes of HIV infections, such as biased and/or gender-blind healthcare systems, not enough funding for or ill-equipped prevention programs, etc. Co-factors such as drug use, poverty, low health literacy, and the relationship between different factors shaping health inequalities (Hankivsky, 2012).

Gender inequalities in relation to HIV determine access to prevention and treatment outcomes, especially for women and girls. Factors such as younger age, pregnancy, gender-based violence, limited access to transportation and financial resources, and lack of bodily autonomy expose women and girls to HIV risk (Ghanotakis et al., 2012; UNFPA, 2021). Primary health services should not only respond to the effects of HIV, but should also begin to address the underlying gendered problems of HIV so that interventions are better attuned to different population groups. HIV prevention, for example, mostly targets men who have sex with men, despite the fact that 30–40 % of new cases are in heterosexual men infected by women (Weber and Castellow, 2012).

While sex between men is the main driver of HIV transmission in the EU, heterosexual HIV transmission is the second most common mode overall. In nine Member States – Estonia, France, Italy, Latvia, Luxembourg, Portugal, Romania, Finland and Sweden – it accounts for most new infections (ECDC/WHO, 2019). This underlines the need for women and men of all sexual orientations to be included in HIV awareness campaigns. The same holds true for other interventions and policies concerning STIs and STDs. The ECDC continuously advocates for gender, age, HIV status and other characteristics to be recorded to obtain better-quality data to help tackle STIs and STDs in the EU (ECDC, 2021).

Lastly, many abortions are carried out unregistered, either by medical staff or outside the healthcare system altogether, which can explain that in the UN European region, between 2010 and 2014, 11 % of all abortions were deemed unsafe (Ganatra et al., 2017). The same study also found that countries with highly restrictive abortion laws and policies had a higher share of unsafe abortions than countries with less restrictive laws.

Figure 41. Adolescent birth rate by EU Member State (per 1 000 population, 15–19 years, 2018)

Source: SDG 3.7.2., UN, https://unstats.un.org/sdgs/unsdg, 2018.

Sexuality education is essential to prevent unplanned pregnancies in adolescence. Young people are in need of comprehensive sexuality education to understand and enact their rights to health, well-being and dignity. Access to rights-based sexuality and relationship education varies between Member States (EIGE, 2020a). The German Federal Centre for Health Education (BZgA)^[5] developed sexuality education standards for Europe in 2010 as a framework for policymakers, education and health authorities, and specialists (WHO Regional Office for Europe and BZgA, 2010). An assessment carried out in 2018 (BZgA and IPPF EN, 2018) found that the implementation of sexuality education differed widely between and within EU countries. While sexuality education is mandatory in most Member States (except Bulgaria, Italy, Cyprus, Lithuania, Poland and Romania), exemptions can be granted based on faith and moral grounds (EIGE, 2020a). Inadequate sexuality education, along with other factors, such as lack of access to contraceptives, can contribute to higher birth rates among adolescents. In the EU, birth rates in this group are highest in the eastern European Member States, with rates in Bulgaria, Hungary, Romania and Slovakia more than double the EU average (Figure 41). In these countries, sexuality education is optional, with students also start learning about sexual health issues later in their school life in comparison to their peers in other Member States. (Picken, 2020).

In the EU, only 11 Member States – Belgium, Germany, Estonia, Greece, Spain, France, Italy, the Netherlands, Portugal, Romania and Sweden – have laws regulating free or subsidised maternal care for undocumented migrants (Center For Reproductive Rights, 2020). However, implementation of legal frameworks is not necessarily automatic. Greece, Spain and Italy, which receive more than half of all migrant arrivals in the Mediterranean, have unfavourable maternal health outcomes for documented and undocumented migrants, despite existing policies granting access to care (Grotti et al., 2018). Undocumented pregnant migrants in Germany, Croatia, Slovenia and Sweden fear deportation if they seek medical assistance, as healthcare staff in these countries are required to report their patients’ immigration status (Make Mothers Matter, forthcoming 2022). But it is not only undocumented migrants who can experience limited access to maternal care. Foreign workers’ visa status also determines their access to SRHR. In some Member States, women who work as au pairs must be unmarried and without children as a precondition for obtaining a visa. Au pairs who become pregnant are effectively stripped of their residency permit and, consequently, their right to healthcare (PICUM, 2016).

Roma women also have less favourable access to maternal care than the majority population in their EU Member States (Franklin et al., 2021). This is particularly worrying, as some Member States with high maternal mortality rates have large Roma populations (FRA, 2016). Other racial inequalities in maternal mortality are well documented in the United Kingdom, where black mothers are at least four times as likely, and Asian mothers twice as likely, to die during childbirth as their white peers (MBRRACE-UK, 2020).