Chapter 3: The Chief Public Health Officer's Report on the State of Public Health in Canada 2012 – Sex, gender and health outcomes
Chapter 3: Sex, Gender and Health Outcomes
This chapter highlights one specific example in each of the areas of physical health, mental health and sexual health to illustrate key points in how health outcomes, including symptoms, diagnostic tools, treatment effects and access to care, are affected by sex and gender. It is not meant to provide an in-depth sex- and gender-based analysis of these issues but rather a brief demonstration of the ideas. The examples are not necessarily the most important or critical health issues affected by sex and gender. Nevertheless, they demonstrate the varied ways in which sex and gender can influence a range of issues. Using these illustrations, it can be seen how and why many health outcomes differ between men and women and can gain insights into the influences of sex and gender on those differences.
As seen in Chapter 1, some of the most common physical health issues for Canadians are chronic conditions that affect individuals across the lifecourse. One of the most prevalent of these is hypertension (high blood pressure), a leading modifiable risk factor for cardiovascular disease which, as seen in Chapter 1, is a leading cause of death for both men and women in Canada.Footnote 247 Since hypertension usually has no symptoms, it is easy to overlook its presence, allowing it to go undiagnosed.Footnote 247 Although hypertension is equally prevalent in men and women, they are neither equally affected nor do they have the same risks. To help improve the likelihood of screening and diagnosis, it is useful to understand the level of risk for men and women, how their risk varies and how the disease may affect individuals differently because of their sex and gender. This chronic condition is used to illustrate those influences on the physical health of Canadians.
How sex influences physical health risks and outcomes
The two numbers that make up the measure of blood pressure are systolic pressure (the “top” number) and diastolic pressure (the “bottom” number).Footnote 247 The percentage of Canadian men and women with high systolic or diastolic pressure or both are roughly equal. When those numbers are considered separately, however, women are more often diagnosed with isolated systolic hypertension (with normal diastolic blood pressure) than are men, whereas men are diagnosed with diastolic hypertension more often than are women.Footnote 248 Systolic blood pressure has been shown to be a better predictor of risk for cardiovascular disease and kidney disease than diastolic blood pressure.Footnote 249 In addition, hypertension is a greater risk factor for heart failure for women than for men.Footnote 250-Footnote 252
Prevalence and incidence rates of hypertension increase with age in both men and women. However, among those who are younger than age 70, the annual rate of newly diagnosed cases is slightly higher for men than for women, whereas from the age of 70 years and onward it is the reverse, with the annual incidence rate for women being higher.Footnote 247 Prevalence also starts out higher in men, yet tends to be higher in postmenopausal women than in men of the same age.Footnote 247, Footnote 253, Footnote 254 Evidence shows that sex hormones, specifically androgens such as testosterone, play a role in those differences. As early as adolescence, with increasing androgen levels during puberty, blood pressure is higher in boys than in girls.Footnote 255 Conversely, premenopausal women may be protected from hypertension by female sex hormones such as estrogens; as levels of these decrease after menopause, the prevalence of hypertension increases.Footnote 255
Two sex-specific forms of hypertension occur only during pregnancy: gestational hypertension and preeclampsia can seriously harm both mother and child and can even be fatal.Footnote 256 While both conditions resolve after the birth, they have been shown to increase the risk of future hypertension or cardiovascular disease for these women.Footnote 257-Footnote 259 Oral contraceptive users, regardless of age, level of physical activity, family history of hypertension, body mass index, alcohol consumption, cigarette smoking or ethnicity, are at increased risk of hypertension compared with women who do not use oral contraceptives.Footnote 254
Men and women also respond differently to treatment for hypertension. Canadian data show that among those aged 60 years and older who were using antihypertensive medications, women were significantly less likely to have their blood pressure controlled. Similar results have been found in other countries, but in all cases the sex and gender influences on this effect are not clear.Footnote 248
How gender influences physical health risks and outcomes
Canadian men and women who are aware that they have hypertension are equally likely to have it treated.Footnote 248 However, compared with women, men are significantly less likely to be aware of their hypertension and as such fewer receive treatment for their condition.Footnote 248 Men may be less aware of their hypertension because gender influences their health care-seeking behaviour. Men tend not to seek out care because social norms promote the idea that it is more masculine to not been seen as weak and to “tough it out,” whereas the idea of caring for one’s health and showing vulnerability are seen as feminine traits.Footnote 260
By interacting more often with the health care system than men, women have more opportunities to have their blood pressure checked, increasing their awareness of their hypertension status.Footnote 44, Footnote 261 In 2010, women – particularly younger women – were consistently more likely to report having had their blood pressure checked within the last two years than were men.Footnote 44 The two most common reasons given by Canadians who had never had their blood pressure checked were that they did not think it was necessary and that they had not “gotten around to it.” Men and women were equally likely to respond in this way. However, significantly more women reported that they had not had their blood pressure checked because their doctor did not think it was necessary.Footnote 44
Gender intersects with sexual orientation which can influence health outcomes. For example, in addition to the general stresses experienced by all Canadians, sexual minorities can be affected by the additional stress associated with the stigma, discrimination and harassment they often experience.Footnote 262, Footnote 263 Given that stress is a risk factor for hypertension, this “minority stress” may help explain the fact that when self-reported rates of hypertension are broken down by sexual orientation, outcomes vary from those of the population as a whole.Footnote 44, Footnote 262-Footnote 264 The roughly equal rates of hypertension in men and women hold true among heterosexual Canadians, but not for gays, lesbians and bisexuals. Rates of hypertension are higher among gay and bisexual males than rates among lesbian and bisexual females. Gay and bisexual males also have higher rates of hypertension than do heterosexual males, whereas lesbian and bisexual females have lower rates than do heterosexual females.Footnote 44
Obesity, sodium intake and lack of physical exercise are all risk factors for hypertension. These factors, in turn, are related to gender and socio-economic factors.Footnote 265, Footnote 266 For example, there is some evidence that hypertension rates vary by income, although the patterns vary with gender. Canadian data shows that prevalence of hypertension tends to decrease as income increases for women, whereas for men it tends to fluctuate as income changes, with no clear pattern.Footnote 44
Sex and gender play a critical role in the mental health and well-being of Canadians. Biology and the physiological changes that occur over the lifecourse affect an individual’s likelihood of particular outcomes and also influence their responses to developmental stages and life events. For example, biological and socially constructed differences between men and women interact to affect individual susceptibility to particular mental health risks and health-seeking behaviours. They also affect the responses of the health care sector and society as a whole, to mental health. It is important to recognize how culturally imposed gender roles affect the control that some men and women have over the socio-economic determinants of their mental health.Footnote 68, Footnote 267, Footnote 268
Of the various mental health issues and illnesses that affect Canadians, schizophrenia, suicidal behaviours and mood disorders provide some compelling examples of the differences in mental health status that may be related to sex and gender. For example, while rates of schizophrenia are roughly equal among men and women, men develop the illness earlier in life whereas women develop it later when they also display mood symptoms more prominently.Footnote 269 In the case of suicide, men account for four out of every five deaths by suicide in Canada, yet women attempt suicide more often. Most individuals who attempt or complete suicide have some form of mental illness – most often depression.Footnote 68, Footnote 269-Footnote 271
As seen in Chapter 1, mood disorders, including bipolar disorder and depression, are the most common forms of chronic mental illness, affecting individuals of all ages.Footnote 269 In 2002, 12.2% of Canadians 15 years or older (15.1% of females and 9.2% of males) met the criteria for having experienced an episode of major depression at some point during their lifetime.Footnote 68 Rates increased with age after puberty, except among the oldest age range, and were consistently higher among females.Footnote 68 These rates, based on self-reported data may actually be an underestimate given the potential for recall bias in survey responses. Additionally, they do not include those living in care facilities, such as seniors living in residential care where it is estimated that 44% of residents live with a diagnosis or symptoms of depression.Footnote 272 Survey data also indicate that the rates of depression among Aboriginal populations are higher than among Canadians overall. In 2001, 12% of First Nations adults not living on a reserve suffered an episode of major depression during the previous year, compared with only 7% of all Canadians that year. As with the overall population, First Nations women experience higher rates of depression than do First Nations men. Only 3.1% of the Inuit population met the criteria of having experienced a major depressive episode based on 2001 Statistics Canada survey responses.Footnote 68 However, suicide rates in Inuit regions are more than 11 times higher than the rest of Canada.Footnote 273 It is possible that some incidences of depression may not be acknowledged, particularly among men where depression may manifest as alcohol abuse, violence or conflict with the law.Footnote 68, Footnote 269
The specific example of depression is used here to examine the influence of sex and gender on the mental health of Canadians.
How sex influences mental health risks and outcomes
Depression is the most common mental health problem among women, among whom it may also be more persistent and more severe.Footnote 268, Footnote 269, Footnote 274 Before puberty however, rates of depression are slightly higher in boys than in girls. Between puberty and menopause, rates in women are two to three times higher than in men. After menopause, the prevalence rates of depression in women begin to decline until they become similar to those in men near the end of the lifecourse.Footnote 275 This pattern of sex differences in prevalence rates over the lifecourse suggests that sex hormones may play a significant role in rates of depression.
Women may be at risk of depression both during and after pregnancy, due in part to the dramatic hormonal changes that occur at that time.Footnote 267, Footnote 276 Up to 13% of women experience depression at some point during pregnancy, and following pregnancy up to 80% of women may experience mild mood disturbances lasting a few days, known as the “baby blues,” which generally do not require clinical treatment.Footnote 68, Footnote 277 However, hormonal and other physical changes combined with caring for a newborn and other environmental stressors can trigger postpartum depression (PPD), a serious condition that affects about 10% to 15% of mothers and is characterized by long-lasting depressed feelings, low self-esteem, anxiety and agitation.Footnote 68, Footnote 276, Footnote 278 Previous depressive episodes are a risk factor; 25% of women with a history of depression and over one-half of women with previous episodes of PPD are at risk.Footnote 68 Research also shows that, compared with Canadian-born women, immigrant women are more likely to suffer from PPD; they may be especially vulnerable if they are socially isolated and lack the support of an extended family.Footnote 279, Footnote 280 There is also evidence that the risk of depression increases for women during the transition to menopause. Again, it is fluctuating hormone levels which appear to be the cause of the increased risk.Footnote 281
Although many studies have examined the possible link between levels of women’s sex hormones and depression, few have explored any possible connection between male sex hormones and depression. Research has attempted to explain lower rates of depression in men in terms of differences in the way in which male and female brains respond to stress.Footnote 282, Footnote 283 The results of these are inconclusive, however, and more research is needed.
Self-reported signs and symptoms of mental health often differ between men and women. Women tend to report feelings of helplessness or worthlessness as well as persistent sad moods, whereas men are more likely to report feeling discouraged, angry and irritable.Footnote 269 It is unclear whether this is a biological difference in the symptoms or a gender influence in how those symptoms are described and interpreted.
How gender influences mental health risks and outcomes
Gender plays a key role in the diagnosis of depression. Women report higher levels of distress than do men and are more likely to seek help from health care professionals for mental health concerns.Footnote 68, Footnote 267 When experiencing similar symptoms, women are more likely than men to perceive an emotional problem. Similarly, even when men and women present identical symptoms or score similarly on depression measures, physicians are more likely to diagnose depression in women than in men.Footnote 267, Footnote 268 Accurate diagnosis is further impeded by men’s tendency to acknowledge physical symptoms more easily than emotional ones.Footnote 270
One of the principal barriers preventing men from seeking help for mental health problems is the expectation that they be tough and strong. This societal expectation may foster a silence that prevents accurate diagnosis and treatment of psychological disorders. Rather, men may adopt negative coping mechanisms and act out with hostility, violence, alcohol and/or drug abuse and other risky behaviours. This may mask their depression and result in damaging consequences to themselves or others.Footnote 68, Footnote 268-Footnote 270
Because of their socially constructed role, men may be particularly affected by unemployment and changes in socio-economic status. A 2005 United Kingdom study indicated that men who experienced a drop in socio-economic status were four times more likely to develop poor mental health, including depression, than men who had improved their socio-economic status. While more women than men in the study experienced poor mental health, there was no apparent difference between those who experienced upward or downward changes in socio-economic status.Footnote 284 A study of 2000/2001 Canadian Community Health Survey (CCHS) data however, found that men who were recent immigrants and who had low incomes reported lower rates of depression than their middle- or high-income counterparts, whereas low-income recent immigrant women reported higher rates of depression than their middle-/high-income counterparts.Footnote 285 This difference suggests that there may be an absence of risk for low-income recent male immigrants or even a low-risk advantage.
Due to internalized and environmental homophobia, biphobia and transphobia, and consequential prejudice and discrimination, sexual and gender minorities commonly experience anxiety and depression and are more likely to have thoughts about or complete suicide.Footnote 286 Historically, Two-Spirit Aboriginal people were valued members of their communities, recognized for their special gifts. Since the imposition of a western worldview they have become stigmatized and devalued, which adds to distress and impacts on the mental health of some of these individuals.Footnote 287, Footnote 288 Gender expectations and roles may also lead to disproportionate rates of poor mental health among sexual minorities. For example, gay men in particular transgress the gender role expectations of “masculinity” (head of the traditional heteronormative family, etc.). This may lead to stigmatization, alienation and discrimination, which can cause reduced self-esteem and internalized homophobia, and hence depression, substance use and other mental health issues.Footnote 263, Footnote 289, Footnote 290 Data from the 2003 and the 2005 CCHS indicate that comparatively high proportions of bisexuals reported mental health problems. Bisexual men described their mental health to be “fair” or “poor” at more than twice the rate of heterosexual men, whereas bisexual women were over three times as likely as heterosexual women to report “fair” or “poor” self-perceived mental health.Footnote 291 Significantly higher proportions of sexual minority groups also reported diagnoses of mood and anxiety disorders than did the heterosexual population. Gay and bisexual men were almost three times as likely as heterosexual men to report a mood disorder, while lesbians were one-and-a-half times and bisexual women more than three times as likely as heterosexual women to report such a diagnosis.Footnote 291
Overall, lesbian, gay and bisexual (LGB) Canadians are more likely to consult mental health service providers and have higher utilization rates of professionals providing emotional and mental support. It has been suggested that there is a positive norm for using mental health services in LGB communities and that lesbians and bisexual women in particular may consider psychological counselling to be important. This health care-seeking behaviour could be triggered by stress related to discrimination faced by individuals in this population.Footnote 291
To date, little research has examined the physical, mental and sexual health needs and concerns of transgendered and transsexual youth or adults.Footnote 286, Footnote 292 One recent large-scale study that examined the mental health needs of 392 male-to-female and 123 female-to-male transgendered persons found that low self-esteem was common among all participants. In addition, 60% were classified as clinically depressed, and 32% reported attempting suicide. The study also found that attempted suicide was significantly associated with depression and low self-esteem as well as with a history of forced sex, drug and alcohol treatment and gender-based discrimination.Footnote 293 In general, gender minorities have difficulty addressing their trans health needs with health care professionals who are under-prepared and inadequately trained to deal with the comprehensive health needs of this population.Footnote 229
Stress is considered a major risk factor for depression, and socially constructed gender roles may influence the different sources of stress experienced by men and women.Footnote 68 The 2002 Mental Health and Well-being Survey asked respondents to identify the most important source of feelings of stress in their lives. A greater percentage of men than women reported their work situation and finances as the most important sources of stress. Women were more likely to report that caring for a child, personal or family responsibilities, and health of family were the most important sources of stress.Footnote 68 Other sources of stress for women include environmental factors such as sexism, heterosexism and the associated discrimination; experiences of physical and sexual violence, including as a result of childhood maltreatment or intimate partner violence; and the pressures of lone parenting.Footnote 225, Footnote 267 These differences in sources of stress seem to reflect societal constructions of gender roles and expectations of men as providers and women as caregivers.
Socially determined gender roles more frequently place women in situations where they have little control over important decisions concerning their lives. For example, women more often carry the responsibility of caring for relatives with physical or mental illnesses while lacking the social support required to perform this function. Resultant feelings about such a lack of autonomy can result in low morale and high stress and are associated with depression.Footnote 267
Sexual health outcomes are often described in terms of their links to fertility and sexually transmitted infections (STIs). Sexual health also encompasses attitudes and behaviours pertaining to sexual acts (e.g. intercourse) and other factors (e.g. relationships) that may influence the sexual health of men and women in positive or negative ways. In this section, nationally notifiable STIs are used to illustrate the relationship between sex, gender and sexual health outcomes.
As discussed in Chapter 1, the rates of STIs reported to the Canadian Notifiable Disease Surveillance System (CNDSS) differ for men and women. In 2009, young adults between 20 and 24 years had the highest reported rates of chlamydia, with the rate among young women twice that among young men.Footnote 169 The highest reported rates of gonorrhea were also among those in the same age group, but in this case, there was no significant difference between young men and young women. However, the infection rate was more than twice as high among adolescent girls than adolescent boys (15 to 19 years), whereas among adults 25 years and older, men had higher rates than women.Footnote 171 Unlike chlamydia and gonorrhea, reported rates of infectious syphilis in 2009 were higher in males than in females in all age groups.Footnote 170
How sex influences sexual health risks and outcomes
Biological differences between men and women can result in differences in susceptibility and in the effects of STIs. In general, female anatomy makes women more vulnerable to acquiring STIs through some forms of sexual contact, which partly accounts for the higher reported rates of particular STIs in this population.Footnote 294, Footnote 295 Physiological changes in the cervix during adolescence increase the risk of infection among girls in this age group.Footnote 296
If left untreated, STIs can lead to dangerous outcomes in both men and women. Women with chlamydia or gonorrhea are at risk of developing pelvic inflammatory disease that may lead to scarring of the fallopian tubes, infertility and potentially fatal ectopic pregnancy.Footnote 296-Footnote 299 Babies born to women with chlamydia may be premature or have eye infections or pneumonia, whereas those who contract gonorrhea during birth can suffer blindness, joint infections or life-threatening blood infections.Footnote 297, Footnote 298
Although complications from chlamydia and gonorrhea are less common in men, both can lead to epididymo-orchitis (painful swelling of the epididymis portion of the spermatic ducts and the testes) as well as scarring of the urethra, possibly resulting in infertility.Footnote 297, Footnote 298, Footnote 300
Outcomes of a syphilis infection can be equally serious for both men and women if left untreated. Syphilis can cause damage to the brain, heart, bones and other internal organs, possibly causing death regardless of biological sex of the infected person. Women who are infected during pregnancy can also pass this infection to their babies, which can result in congenital abnormalities, stillbirth, developmental delays, seizures or death.Footnote 301, Footnote 302
How gender influences sexual health risks and outcomes
In addition to biological sex differences, gender influences affect the risk, incidence and outcomes of STIs as well as the likelihood that someone will be tested for and diagnosed with these conditions. Gender acts through societal roles and expectations about power sharing within sexual encounters, to affect sexual health outcomes.
The consistent use of male and female condoms and dental dams is known to be among the best ways to prevent STIs.Footnote 303 Several gender-related issues affect the use of such protection, however. For example, negotiating the use of barrier protection during sexual activity is influenced by the gendered nature of sexual relations and the power relations between the individuals involved. Depending on the circumstances, the likelihood of not using protection may increase, thereby increasing the risk of contracting STIs.
In male-female relationships, preventing pregnancy may also motivate the use of condoms. However, such a decision may be influenced by gender norms and roles in which the woman has been given the option, and often the expectation, to control pregnancy prevention for herself.Footnote 253 If other contraception methods are being used, condoms may be considered unnecessary, increasing the risk of STIs in new or non-monogamous relationships. For some men, cultural influences, such as being seen as “macho,” may deter them from using condoms.Footnote 304, Footnote 305 For men who have sex with men (MSM), increased condom use in the 1990s paralleled increased knowledge of the dangers of HIV and AIDS, which indicates the value of education regarding condom use.Footnote 306
Both men and women may also participate in consensual sex for reasons other than personal pleasure, such as the desire to please others, or in exchange for money, drugs or other material goods.Footnote 175, Footnote 307 Those involved in survival sex (exchanging sex for money, drugs, shelter or food), or who are abused or forced to have sex against their will may be at a particular disadvantage in negotiating the use of protection during sexual activity. Survival sex, unwanted sex and sexual assault more often place women at risk, although they are a concern for both men and women.Footnote 225, Footnote 307 All of these situations may make it more difficult to negotiate the use of condoms or other latex barriers.Footnote 175
According to the 2010 CCHS, almost two-thirds (65%) of sexually active single youth and young adults, between 15 and 29 years, reported using a condom the last time they had sexual intercourse during the past year.Footnote 44 The proportion was higher among males (70%) than females (60%).Footnote 44 Less than one-half (47%) of single adults between 30 and 49 years had used a condom during their last sexual encounter in the past year – 50% of men and 43% of women.Footnote 44 According to the 2008/2010 First Nations Regional Health Survey (RHS), 18% of sexually active First Nations youth (between 12 and 17 years) living on a reserve or in northern communities reported only occasionally or never using a condom.Footnote 146 Among sexually active First Nations adults living on a reserve or in northern communities, nearly one-half (48%) reported never using a condom.Footnote 146
Having unprotected sex with multiple partners may also increase an individual’s risk of contracting an STI simply by increasing the chance of being exposed to someone already infected. In 2010, 14% of Canadians between 15 and 49 years who reported having had sex in the previous 12 months said they had had more than one sexual partner (17% of males and 11% of females).Footnote 44 Younger respondents between 15 and 29 years were much more likely to report multiple partners than were those aged 30 to 49 years (27% compared with 7%). In both age groups, the proportion of males reporting multiple partners was much higher than the proportion of females – 32% compared with 22% for the younger group, and 9% compared with 5% for the older group.Footnote 44 Although multiple partners were reported across all types of relationships, those who were single (including widowed, separated or divorced) reported the highest proportion overall (36%) of multiple partners in the past year.Footnote 44 More specifically, younger (15 to 29 years) divorced females and younger separated males were the most likely (77% and 65% respectively) to report multiple partners, while younger widows (0.0%) and older (30 to 49 years) married females (0.7%) were the least likely.Footnote 44 Among sexually active First Nations youth (12 to 17 years), 44% reported in the 2008/2010 RHS that they had more than one sexual partner in the past year.Footnote 146 For First Nations adults, a higher proportion of males (23%) than females (17%) reported having more than one partner.Footnote 146
Adolescence is a particularly important period when social contexts provide clues and cues about what constitutes safer or riskier sexual behaviour. Early age of sexual debut has been associated with increased likelihood of early age pregnancy and STIs.Footnote 308, Footnote 309 In 2010, of those between 15 and 29 years who reported having had sexual intercourse, the average age of first intercourse for both males and females was around 17 years with 26% having done so for the first time before age 16 years (27% of males and 25% of females).Footnote 44 In comparison, among adults aged 30 to 49 years, the average age of first sexual intercourse was a little older than 18 years (slightly younger than age 18 years for males and closer to age 19 years for females). In addition, only 18% reported that they had had sexual intercourse before age 16 years, and the proportion was much higher among males than females (23% compared with 14%).Footnote 44 This suggests that the age of sexual debut in Canadians is decreasing and the gender gap is closing. According to the 2008/2010 RHS, 47% of Aboriginal youth between 15 and 17 years reported being sexually active.Footnote 146
Although STI rates are highest in Canadians under 30 years of age, they are increasing faster among adults between 40 and 59 years. The reasons for these increases in older adults are not entirely clear, but it has been noted that middle-age or older people are usually ignored in prevention programs that tend to focus on younger age groups who are more at risk.Footnote 310, Footnote 311 Older adults rarely discuss the topic of sexual health during visits with their physician and often delay seeking treatment, perhaps due to shame, fear and embarrassment in discussing their sexual health concerns.Footnote 177, Footnote 310 Given their stage of life, older adults may consider condom use unnecessary because they are less concerned about pregnancy risk.Footnote 310
Timely and appropriate testing, diagnosis and treatment prevent the spread of STIs and ongoing negative health consequences. However, as mentioned earlier, gender norms influence access to care and men and women do not access health care systems at the same rate or for the same reasons.Footnote 260 Since women tend to interact more frequently with the health care system, they are more likely than men to have the opportunity for routine screening or to seek treatment for STIs.Footnote 44, Footnote 312 This may partly explain the differences in reported infection rates: because more women are tested, more infections are diagnosed and reported among women than men.
Various factors may prevent men and women from being tested for STIs. One is misinformation surrounding testing procedures, such as the assumption that Pap tests also test for all STIs, or that STI testing for men involves a painful urethral swab.Footnote 313, Footnote 314 Males have also reported concerns related to sexualization of the clinical experience, fearing that they or the provider may see, or react to, the interaction sexually since it involves the genitals.Footnote 314 Stigma also acts as a deterrent to testing for males and females of all ages, and is a particular problem for sexual and gender minorities.Footnote 313, Footnote 315, Footnote 316 College students in the United States reported concerns about testing for STIs, including the gender of the provider, accessibility, confidentiality and potential damage to their reputation.Footnote 317 In 2009, 27% of surveyed Toronto youth feared they would be judged or subjected to embarrassment if they accessed sexual health services.Footnote 318 Screening sites and clinic procedures have been found to be more welcoming and directed towards females, which may discourage males from accessing the services. Research in British Columbia also found that privacy concerns, inaccessible clinic hours, clinic decor and perceived homophobia were barriers to testing for some young men and women.Footnote 313
The private and personal nature of sexual health issues can make it difficult for many individuals to seek and receive services. This is particularly the case for marginalized groups whose experiences with gendered power relations and their intersections with other social, environmental and structural influences have important implications for a person’s ability to negotiate safer sex practices and/or to access appropriate sexual health services.Footnote 315, Footnote 319 Stigma and discrimination faced by sexual minorities because they transgress the socially constructed gender role expectations and notions of “femininity” and “masculinity” can negatively influence their health care-seeking behaviours and experiences as well as whether they disclose their sexual orientation and behaviours to their health care providers.Footnote 313, Footnote 320
Primary care settings need to continue to improve their provision of sexual health services so as to meet the needs of sexual and gender minority individuals.Footnote 229, Footnote 321 Sexual health education has also yet to adequately address the needs of sexual and gender minorities individuals; coupled with persistent homophobia and transphobia in schools, workplaces and other public arenas, some sexual and gender minority individuals face multiple vulnerabilities that contribute to STI/HIV infection risk, and must overcome serious barriers to enacting sexual self-efficacy (i.e. the belief in one’s ability to deal effectively with their sexuality).Footnote 321-Footnote 323
This discussion demonstrates how sex and gender influence behaviours, risks, and ultimately, health outcomes. Approaches to prevent or improve outcomes and/or provide services for those affected need to take into account the roles of biological sex and gender in general. They also need to enhance efforts to address diversity across sexual orientations, ages and settings. The examples included in this chapter highlight the importance of accounting for sex and gender. They also illustrate the significance of constructing interventions that appropriately balance individual and structural approaches to reducing risk and promoting health over the lifecourse. This information can be used as a starting point for determining approaches that ensure all Canadians can benefit from interventions, programs and supports.
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