EIGE-2021 Gender Equality Index 2021 Report: Health
Rights, access and outcomes – sexual and reproductive health in focus
The 1994 International Conference on Population and Development (ICPD) framed SRH as a basic human right. Building on landmark agreements of the ICPD in Cairo and the Fourth World Conference on Women in Beijing (1995), governments and advocates have worked to realise and expand international commitments on SRH. Since then, the protection and promotion of SRH without any discrimination, while tackling gender inequalities on this issue, have been on UN agendas and included in the SDGs.
Gender inequalities significantly impact SRH outcomes. They are shaped and structured in accordance with gender norms and unequal power relations in society, and may strip women and men of their ability to control their SRHR. However, biological sex determines the extent to which an individual can access SRH. Women, in particular, are subjected to sexual and reproductive control and limited in their bodily autonomy (UNFPA, 2021). Inequalities based on age, (dis)ability, race, ethnicity, migration status and sexual orientation, as well as gender, influence access to SRH. This section looks specifically at family planning and birth control, sexually transmitted infections (STIs) and STDs, and abortion and pregnancies. It also explores SRH developments during the COVID-19 pandemic. Gender-based violence is considered a contributing factor to poor SRH, and specific findings are included where relevant.
Gender-sensitive approaches to sexual and reproductive health are key to public health
Women and men have different SRH needs, and gender-specific approaches to SRHR highlight sex-specific diseases, for example breast or prostate cancer. Unique challenges in this area constrain the health of both women and men.
Women may experience a range of gynaecological conditions influencing their SRH. Issues relating to the female reproductive cycle – from menstruation to menopause – including painful periods and endometriosis, are particularly common. Other SRH problems faced by women and girls are uterine fibroids, interstitial cystitis, polycystic ovary syndrome, infertility of various causes, limited access to abortion, and the impacts of sexualised violence. Unplanned pregnancies, complications around pregnancy and childbirth, unsafe abortions, gender-based violence, STIs, STDs and reproductive cancers threaten the well-being not only of women, but also of men and families (Starrs et al., 2018).
Men’s reproductive health issues include male factor infertility, androgen deficiency, undescended testis, testis mass, scrotal disorders, phimosis, congenital chordee, Peyronie’s disease, premature ejaculation and sexual dysfunction, as well as concerns over contraception, HIV infection and STIs (Wessells, 2021).
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), 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).
Gender-biased reproductive health often overlooks men
Counselling, access to information and services, and birth control methods used to avoid unintended pregnancy enable people to make informed choices in their sex lives. Starrs et al. (2018) state that modern contraception was arguably the most revolutionary intervention in SRH in the 20th century, facilitating the delinking of sex and reproduction and enabling couples and individuals to choose the number and timing of their children.
On average, almost 95 % of family planning needs are met among women in the EU, but differences remain between Member States. In Slovenia, only 3 % of women and girls report having unmet needs for family planning, but in Spain this figure is more than double that (8 %) (Figure 39).
Studies from Europe and worldwide show that family planning and birth control methods largely remain women’s responsibility, with men frequently kept out of the contraceptive decision-making process (de Irala et al., 2011; Dereuddre et al., 2017). Although contraceptive options include methods for men, and some require their participation, family planning programming has predominantly focused on women. Contraceptive options and methods follow a gender-binary approach in their design, since they concern male condoms and female hormonal contraception, for example the pill or injections. Female condoms have existed for decades, but are either less known or perceived as too expensive in comparison with the male version (Peters et al., 2010). Similarly, male hormonal contraception is still under development, with clinical trials previously being interrupted because of side effects such as dizziness, depression and changes in weight (Yuen 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), 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.
Women and men both vital to stop sexually transmitted illnesses
Not only do contraceptive methods help prevent pregnancies, but barrier methods such as condoms also make sex safer by limiting the spread of STDs and STIs. The most common STI in the EU is chlamydia, in many cases a symptomless infection in both women and men. Safer sex habits and testing are, therefore, essential tools to stop chlamydia from spreading. Infection rates are highest among women younger than 24 years (ECDC, 2020a), but social stigma can result in young women often avoiding chlamydia testing (Balfe et al., 2010). However, understanding men’s risk-taking behaviour can play an important role in preventing the spread of chlamydia. A study of young Swedish men tested for STDs revealed a variety of sexual risk behaviours and reasons why different subgroups did not use condoms. Migrant men reported more unprotected sex and more sexual partners overall, while men who have sex with men reported greater exposure to coercion to have unprotected sex (Helsing et al., 2021). Therefore, chlamydia prevention cannot solely rely on testing and safer sex practices. External factors, such as gender-based violence and gendered social stigma, also need to be taken into consideration in prevention policies.
According to WHO (2016c) and ECDC (2019) data, gonorrhoea is increasingly resistant to conventional antibiotics in Europe. Although this heightens the health risk for all people, gender implications need attention. While infertility is a serious consequence of an untreated gonorrhoeal infection for women and men, it is also associated with adverse pregnancy outcomes. Mother-to-child transmission of gonorrhoea can cause blindness in the newborn (WHO, 2016b). Since gonorrhoea is mostly asymptomatic, especially in women, women partners of those diagnosed should be screened. Prevention efforts should also include the supply of male and female condoms (Ndowa et al., 2012).
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).
Abortion, pregnancy and maternal care disparities across the European Union
Estimates suggest that almost half (48 %) of pregnancies worldwide are unplanned (Bearak et al., 2020). This shows that abortion services and care are essential components of public health, to ensure high-quality SRH for women and girls (WHO, 2012). The physical and mental health of women and girls who have an abortion requires more than just that the procedure is medically safe. Abortion can be considered safe only when it is performed without the risk of criminal or legal sanction, stigmatisation, stress or isolation (Starrs et al., 2018). Laws and policies on accessing abortion services, with reproductive health consequences for those using them, vary greatly across Europe. Although barriers to legal abortions differ across the EU, all Member States except one allow it under certain conditions. In Malta, all abortions are banned (IPPF, 2019).
Eleven Member States – Belgium, Germany, Ireland, Spain, Italy, Latvia, Luxembourg, Hungary, the Netherlands, Portugal and Slovakia – have a mandatory waiting period. Belgium, Germany, Italy, Lithuania, Hungary, the Netherlands and Slovakia mandate pre-abortion counselling. The only countries not requiring third-party consent, for example parental consent, for abortion in underaged children, are Belgium, Ireland, the Netherlands, Portugal and Finland (IPPF, 2019). Legal provisions can change in both directions: more liberal abortion policies were recently adopted in Ireland (UNFPA, 2021), while Poland tightened its already restrictive abortion legislation in 2020. Overall, eastern European Member States have the most unwanted pregnancies and 66% of unintended pregnancies end in abortion here (Bearak et al., 2020). They also rank low on the Contraception Atlas (2020), suggesting inadequate SRHR policies. According to the most recent WHO data available (2015–17), the fewest abortions in the EU are in Member States with the most restrictive abortion laws – Ireland, Malta and Poland.
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.
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) 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).
Maternal care inequalities persist, especially for migrants
Although maternal and child mortality has been steadily decreasing in the EU, pregnancy still carries health risks (WHO, 2017). Some health conditions occur only during or after pregnancy and require assessment from a gender-informed perspective. Researchers and practitioners alike have long overlooked several pre- and postnatal health conditions, with care in these areas requiring improvement. For example, hyperemesis gravidarum, or chronic morning sickness, affects an estimated 2–4 % of pregnancies and is potentially deadly (McCarthy et al., 2014). Yet it is often unrecognised by healthcare professionals and classified as something imagined or exaggerated by women suffering it (Jansen et al., 2020). Likewise, violence in childbirth, known as obstetric violence, poses a risk to maternal health in the EU.
UNICEF data shows that the maternal mortality ratio (per 100 000 live births) in the 27 Member States in 2017 ranged from 2 in Italy and Poland to 19 in Latvia and Romania. Maternal mortality and care inequalities are higher among marginalised and vulnerable communities such as migrants, refugees, asylum seekers, women with disabilities, prisoners and victims of trafficking. Access to maternal healthcare services and midwifery in the EU is affected by the interplay between health systems, laws, policies, socioeconomic factors and attitudes of healthcare professionals and users.
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).