Chapter 2: The Chief Public Health Officer's Report on the State of Public Health in Canada 2012 – Sex, gender and public health

Chapter 2: Sex, Gender and Public Health

This chapter both explains the concepts of sex and gender and discusses why and how sex and gender matter to public health. It describes and broadly examines the ways in which sex and gender interact with other determinants of health and how they influence health behaviours and outcomes. In addition, this chapter identifies sex- and gender-based analysis (SGBA) as a tool to help researchers, policy makers and program advisors understand and address the influence of sex and gender on health. SGBA can improve the effectiveness and efficiency of services and programs by showing how to create supportive conditions for better health and reduce specific risks and barriers to achieving optimal health for all Canadians.

Clarifying sex and gender

Although the two terms are often used interchangeably, sex and gender have different meanings.

Sex refers to the biological characteristics such as anatomy (e.g. body size and shape) and physiology (e.g. hormonal activity or functioning of organs) that distinguish males and females.Footnote 22

Gender refers to the array of socially and culturally constructed roles, relationships, attitudes, personality traits, behaviours, values and relative power and influence that society ascribes to two sexes on a differential basis.Footnote 22

While there are no agreed-upon definitions, “sex” typically refers to the biological and physiological characteristics that distinguish women and men.Footnote 216-Footnote 218 Sex is a multi-dimensional construct that encompasses characteristics such as hormones, genes, anatomy and physiology.Footnote 219 Although sex is often referred to in binary terms – men/women or male/female – many of the attributes of sex (e.g. variation in hormone levels, chromosomal differences, etc.) are often described as existing on a continuum.Footnote 216-Footnote 221

Similarly, “gender” is commonly associated with socially and culturally constructed roles, relationships, behaviours, relative power and other traits that society ascribes to females, males and people of diverse gender identities.Footnote 216, Footnote 217, Footnote 222, Footnote 223 As with sex, gender is often thought of in binary terms – masculine/feminine or male/female.Footnote 217, Footnote 218 However, the masculine/feminine division does not accurately reflect or capture the range of human experience or the expressions of self and identity that gender encompasses.Footnote 216-Footnote 218 Most of us experience or embody gender on a spectrum or as a continuum of characteristics and behaviours rather than as mutually exclusive categories. While gender and sex are inter-related, sex neither determines gender, nor gender sex. For example, someone born female might have a masculine gender identity. Some individuals identify as transgender, that is, their gender identity and/or gender expression differ from their biological sex.Footnote 216, Footnote 217, Footnote 224-Footnote 226

Gender has multiple dimensions including, but not limited to, gender roles, gender identities and gender relations.Footnote 219

Gender identity refers to how we define ourselves on the gender continuum (as man, woman or another identity in a spectrum of gender identities). This identity can affect our feelings and behaviours.Footnote 216, Footnote 226 Gender identity is not the same as sexual orientation – one can identify as female and be sexually attracted to women, men, neither or both. Rather, gender identity encompasses one’s sense of being a woman or man. Most individuals develop a gender identity within the context of societal prescriptions about the appropriate expression of gender for their biological sex (as female or male). In other words, as we learn to think of ourselves as female or male, we also learn what behaviours, emotions, relationships, opportunities and work are considered appropriate for females and males.Footnote 216

Gender roles are the means by which we express or enact our gender identity.Footnote 216 They are the “behavioural norms typically applied to males and females in societies, that influence individuals’ everyday actions, expectations and experiences, for example, how we dress or talk, what we aspire to do and what we feel are valuable contributions to make as a woman or a man.”Footnote 216

Gender relations “refer to how we interact with or are treated by people in the world around us, based on our ascribed gender. Gender relations affect us at all levels of society and can either restrict or open opportunities for us.”Footnote 216

Gender roles, identities, expressions, norms and relations can serve both as protective and/or risk factors for health.Footnote 227 Evidence shows that gender norms – social expectations of appropriate roles and behaviours for males and females – influence overall health and well-being, as does the social reproduction of these norms in institutions and cultural practices.Footnote 228, Footnote 229 A variety of key social institutions, such as the family, culture, media, education, law, and religious and political establishments shape gender expectations, experiences, roles and relationships.Footnote 216, Footnote 227 These institutions can also serve to continue and/or perpetuate social and cultural norms and images and ideals of masculinity and femininity that are neither always based in reality nor positive for human growth and development. These societal perceptions can also serve to increase pressure and stress for females and males who are either unable to – or discouraged from – fulfilling or assuming certain roles and responsibilities because they do not fit the prescribed norm.Footnote 216, Footnote 217, Footnote 227

Gender norms and roles influence attitudes and behaviours in many areas, including relationships, parenting, schooling, work and health practices (e.g. seeking care, support and treatment).Footnote 216, Footnote 228 Gender roles can also create economic and cultural pressures that affect the health of females and males differently.Footnote 218 Gender norms concerning work roles, the division of paid and unpaid labour and the occupations of males versus females can result in different exposures and vulnerabilities. These, in turn, result in varying health needs, behaviours and outcomes. For example, women are more often the primary caregiver (i.e. of children and/or elderly parents), which can create obstacles or barriers to education, employment and career advancement, resulting in increased stress or burden that impacts their health.Footnote 218, Footnote 230-Footnote 232

Why sex and gender matter to public health

Public health serves to support, promote and protect the health of all Canadians.Footnote 4 It strives to ensure that all people – from birth to the end of life – enjoy universal and equitable access to the basic conditions that are necessary to achieve optimal health and well-being.Footnote 5, Footnote 6 By helping to provide opportunities to achieve optimal health and well-being, more Canadians can live longer, healthier lives.

A greater awareness and understanding of the role of sex and gender in an individual’s health can help to improve the health of all Canadians.Footnote 233 Sex can be a factor that influences health, for example, men and women may show different symptomology for diseases and conditions and may respond differently to drugs and therapeutics due to physiological and hormonal differences as well as differences in body composition.Footnote 218 Some diseases and conditions may exclusively affect women or men, may be more prevalent in either of the sexes or may affect men and women differently.Footnote 18

Gender is another important variable. It can affect health as a result of the different roles and responsibilities ascribed to people according to their gender. For example, masculinity is often associated with strength and resilience, which means that some masculine individuals (whether they are male or female) may be less likely to seek help for health concerns if they prefer to “tough it out.” Males tend to take more safety-related risks and are more often injured.Footnote 218, Footnote 225, Footnote 228 On the other hand, femininity is often associated with appearing “delicate,” which can discourage some females and males from participating in certain physical activities that might otherwise improve their physical and mental health.Footnote 216, Footnote 218

Exploring gender can be complex due to the dynamic and changeable nature of the social and cultural environment in which Canadians live. Cultural norms and values can shape and determine gender, and such norms and values differ from place to place and evolve over time. As a result, our experiences of health are a complex blend of our “maleness” and “femaleness” mixed with our cultural identity and social environment.Footnote 18 Attention to gender contributes to a greater understanding of how cultural and social environments can affect both males’ and females’ exposure to disease and injury, access to resources that promote and protect health, and differences in risk factors, including the manifestation, severity, frequency and social and cultural responses to illness and disease.Footnote 18

Applying a sex and gender lens to health can help identify how both influence health status.Footnote 18 It is crucial to understand and appreciate the impacts of sex and gender and to attend to these impacts in public health.Footnote 219 Doing so facilitates better health for all Canadians and encourages more comprehensive health research, policies and programs. This results in public health interventions that are more effective and inclusive.Footnote 219, Footnote 234, Footnote 235

Consideration and integration of sex and gender into health research, policies and programs is critical to progress and advancement in population health.Footnote 236 A population health approach “considers the full range of social, economic and physical factors that can influence health and plans how interventions will be informed, targeted, implemented and evaluated accordingly.”Footnote 218 The approach focuses on maintaining and improving the health status of the entire population to reduce health inequalities among population groups.Footnote 11, Footnote 237, Footnote 238 Taking a population health perspective that is cognizant of sex and gender differences can increase knowledge and encourage awareness and participation. Doing so will aid researchers and policy makers in developing promising practices that will help address health issues for all Canadians.Footnote 216, Footnote 217

Sex, gender and the broader determinants of health

Sex and gender interact with a variety of other determinants of health to influence individual and population health.Footnote 218 Each determinant of health can, in turn, influence health risks, opportunities, behaviours and outcomes at every stage of life.Footnote 10, Footnote 16 (See “Determinants of health.”) Consequently, each determinant of health by itself is important for optimal health and well-being.Footnote 10 In addition, these factors intersect with each other, creating complex and varied contexts within which people make choices and enact behaviours that ultimately also affect health outcomes across and within populations.Footnote 10, Footnote 216-Footnote 218, Footnote 232, Footnote 233

Determinants of health

  • income and social status
  • social support networks (e.g. family, peers)
  • education and literacy
  • employment and working conditions
  • social environments (e.g. community, workplace)
  • physical environments (e.g. housing, community infrastructure)
  • personal health practices and coping skills
  • healthy child development (including/during pregnancy)
  • biology and genetic endowment (e.g. sex)
  • health services
  • gender
  • culture (e.g. Aboriginal status, racial and cultural identities)Footnote 10

Within the broader determinants of health, socio-economic factors such as income, education and employment, often referred to as the “social determinants of health” interact with both sex and gender and can lead to differences in health status.Footnote 218, Footnote 239 These factors relate to an individual’s place in society – the circumstances in which people are born, live, work, play, interact and age.Footnote 240, Footnote 241 Socio-economic factors can contribute to inequalities in health outcomes not only between women and men, but among and between different groups of women and men.Footnote 218 These factors can influence opportunities for good health and well-being.Footnote 10, Footnote 240, Footnote 241

Each determinant has the potential to influence a person differently depending on their sex and gender.Footnote 218 To enable all Canadians to achieve good health and well-being, people need opportunities to access the conditions and services necessary to achieve optimal health.Footnote 216, Footnote 217

Health inequalities are differences in health status experienced by various people or groups in society. These can be the result of genetic and biological factors, choices made or by chance, but often they are due to unequal access to key factors that influence health, for example, income, education, employment and social support.Footnote 24

Diversity refers to variations or dissimilarities between and among people. It is often used to denote observable differences, such as visible ethnic variations in a population and distinctions in age or location of residence. However, diversity can also include differences that are not always evident, such as sexual orientation and level of education.Footnote 216, Footnote 217

Canadians constitute a diverse population marked by differences in income, living conditions, geographic location, level of education, employment, ability, age, sex, gender, sexual orientation, Aboriginal status and racial and cultural identities. Diversity can influence opportunities for health; exposures and susceptibility to risk; and access to health, social services and supports. It can also contribute to increased risk or affect exposures to various risk factors, diseases and health outcomes, ultimately resulting in inequalities in health status.Footnote 22, Footnote 242, Footnote 243

By understanding and addressing factors that contribute to inequalities in health, it is possible to influence and create the conditions for meeting the diverse needs of individuals, supporting healthy choices, diminishing and/or reversing unhealthy living practices, mitigating risky behaviours, reducing barriers and promoting positive lifelong health.Footnote 10, Footnote 16, Footnote 216-Footnote 218, Footnote 240, Footnote 241

Sex- and gender-based analysis: a tool

Gender mainstreaming, as defined by the United Nations Economic and Social Council, is the process of assessing the implications for women and men of any planned action, including legislation, policies or programs, in any area and at all levels. It is a strategy for making the concerns and experiences of women and men an integral part of design, implementation, monitoring and evaluation of policies and programs in all political, economic and societal spheres, so that women and men benefit equally and inequalities are not perpetuated. The ultimate goal of mainstreaming is to achieve gender equality.Footnote 244

Sex- and gender-based analysis (SGBA) is a systematic approach to research, policies and programs that explores biological (sex-based) and sociocultural (gender-based) similarities and differences between women and men, boys and girls.Footnote 22, Footnote 218

Gender mainstreaming in public health is a process of working towards systematic and consistent consideration of both sex and gender in the development, implementation and evaluation of studies, policies and programs in the interest of advancing health equality. While many recognize the benefits of applying a sex and gender lens to public health action, some challenges remain.

SGBA is a valuable tool for analyzing how both sex – rooted in biology – and gender – rooted in social roles shaped by environment and experience – influence an individual’s health and well-being.Footnote 245 Being a man or woman can have a considerable impact on our resources and opportunities for good health, exposure and susceptibility to health risks, access to and effectiveness of health services and programs, and overall health outcomes.Footnote 22, Footnote 245

SGBA allows for critical examination of research, policies and programs to ensure they meet the diverse needs of all women and men, girls and boys. It can help identify how various factors may differentially affect women’s or men’s health status, including their access to and interaction with the health care system and related public health and social services (see Chapter 4 “Incorporating Sex and Gender into Health Interventions” for more information on how SGBA can be considered and implemented into public health practice).Footnote 22, Footnote 216, Footnote 217, Footnote 236

SGBA is consistent with the population health approach in that it analyzes variations in health status by sex and gender. It also demands consideration of the different ways determinants of health influence the health of men and women, boys and girls.Footnote 218 As a tool, SGBA can challenge the assumption that women and men are affected in the same way by research, policies and programs or that the risk, cause, impact and service delivery of certain health issues are unaffected by sex and/or gender.Footnote 22 Rather than assuming that “one size fits all,” SGBA reminds us to ask questions about differences and similarities between and among individuals of different sexes or gender identities.Footnote 217 By asking these questions, SGBA can help reduce inaccurate assumptions and lead to positive changes in how programs are offered and how we can most effectively allocate resources.Footnote 216, Footnote 217

SGBA is both necessary and possible in all areas of health research, planning and policy-making. It can help foster a deeper understanding of how women and men differ in patterns of illness, disease and treatment. It can also advance research and development on how these factors and patterns are influenced by social structures, experiences, norms and culture.Footnote 216, Footnote 217 When this information is then applied to practice, it can encourage appropriate and effective developments, recommendations and interventions, ultimately in an effort to promote, improve and maintain positive health outcomes for all women and men, girls and boys and those who do not strictly identify themselves using these categories.Footnote 246 It helps ensure that interventions reach those at greatest risk and are appropriate to their needs, which improves both effectiveness and efficiency. It can help to secure the best possible health for all Canadians.Footnote 22, Footnote 216, Footnote 217

Summary

Sex and gender are critically important considerations to all areas of public health including research, programs and policies. Understanding the relationships among sex, gender and the other determinants of health and how they intersect to influence health opportunities, risks and outcomes is critical to achieving optimal health and well-being for all Canadians.

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