Gender, sex and their intersections with other social determinants of health such as poverty, education and livelihoods shape peoples’ vulnerability to neglected tropical diseases (NTDs). According to a new discussion paper, understanding the social factors underlying the sex, gender and NTDs nexus is essential to the design of effective health interventions.
The elimination of NTDs is a key target of the 2030 Agenda for Sustainable Development. NTDs are most relevant to SDG 3 (health and well-being), but they are also linked to various other SDGs including those related to: poverty (SDG 1); education (SDG 4); gender equality (SDG 5); water and sanitation (SDG 6); decent work and economic growth (SDG 8); inequalities (SDG 10); climate change (SDG 13); and global partnerships (SDG 17).
Gender, sex and their intersections with other social and environmental determinants of health shape peoples’ vulnerability to and experience of NTDs, as well as their ability to access related care and treatment. Understanding how these vulnerabilities manifest in people of all genders and sexes can support governments, international and national partners and researchers to accelerate responses to NTDs and deliver equitable prevention, diagnosis and treatment services.
The Gender Dimensions of Neglected Tropical Diseases, commissioned and published by the UNDP-led Access and Delivery Partnership and funded by the Government of Japan, reviews the available evidence of how gender impacts NTDs risks and outcomes, highlights current data and implementation gaps and proposes a set of five recommendations as a way forward to better understand and act on the gender dimensions of NTDs.
‘Sex’ and ‘gender’ are distinct factors that influence vulnerability to and experience of NTDs. ‘Sex’ refers to the biological characteristics of a person, attributed to male, female, or intersex. Different anatomies and immune responses that affect exposure to NTDs, how they manifest, their intensity and treatment, vary by sex. WHO defines ‘gender’ as “the socially constructed characteristics of women and men – such as norms, roles and relationships of and between groups of women and men. While most people are born either male or female, they are taught appropriate norms and behaviours – including how they should interact with others of the same or opposite sex within households, communities and work places. When individuals or groups do not ‘fit’ established gender norms they often face stigma, discriminatory practices or social exclusion – all of which adversely affect health. It is important to be sensitive to different identities that do not necessarily fit into binary male or female sex categories.”
The 2013 Global Burden of Disease Study1 showed that men have a greater burden of NTDs overall. However,the longer-term impact on women and trans people may be more severe, due to gender inequities. Women and trans people face barriers to health care interventions, due to factors such as disproportionate poverty, limited access to education and reduced health literacy, minimal land ownership and political voice. Available evidence underpins an increasing recognition that some NTDs are certainly disproportionately affecting girls and women. The Gender Dimensions of Neglected Tropical Diseases focuses on urogenital schistosomiasis – which includes S. haematobium, urinary schistosomiasis, female genital schistosomiasis (FGS) and male genital schistosomiasis (MGS) as a case study and closely examines how sex and gender differentials have an impact on transmission, manifestation and treatment.
In 2002, WHO reported2 that women living in schistosomiasis-endemic areas spend up to 25 percent of their reproductive lives pregnant and 60 percent lactating, which leaves them vulnerable to missing treatment, due to their exclusion from mass drug administration (MDA) campaigns. Although the treatment for pregnant women was recommended by WHO in 2002, pregnant and lactating women are still mostly excluded from MDA campaigns due to safety concerns, leaving them vulnerable to the disease and its complications. Additionally, a stigma relating the disease to sexually transmitted infections (a complication of the disease) and, therefore, promiscuity, prevents health-seeking behaviours, meaning that women and girls tend to only approach health services for FGS when it causes infertility. FGS can also lead to anemia, low birth-weight infants and increased infant and mortality rates, which have severe psychosocial and economic impacts that further reduce opportunities to achieve gender equality.
Male genital schistosomiasis (MGS), the manifestation of the Schistosomiasis haematobium infection in boys and men, is usually contracted through occupational and leisure activities in contaminated water, and problems with diagnosis usually relate to mis-diagnosis and false negatives. MGS also has implications for reproductive and sexual health, as well as long-term risks of bladder cancer.
Examining the sex- and gender-specific implications of urogenital schistosomiasis spotlights the factors that can affect vulnerability, access to prevention and treatment and the outcomes of living with an NTD. However, NTD research relating to sex and gender is currently limited and, where it is available, has focused mostly on women, with less understanding of the impacts on men and transgender or intersex people.
Recommendations in the new discussion paper call for research examining how sex and gender relate to:
- NTD risk and prevention;
- accessibility and acceptability of diagnosis and treatment services;
- stigma and mental health.
Greater investment in sex-disaggregated data and implementation research on sex and gender in NTDs are equally important.
The ways in which gender roles and relations shape vulnerability to and experience of NTDs is too often ignored. Improved clarity on the underlying social factors will help countries towards meeting WHO NTD targets by 2020 and ensuring that no one is left behind. If NTD programmes can reach people living in endemic areas through strengthening of health systems and engaging communities to achieve equitable and effective coverage, lessons could be learned that can help inform other health interventions, contribute to the attainment of universal health coverage and accelerate progress towards Agenda 2030.
The Gender Dimensions of Neglected Tropical Diseases discussion paper was launched at a symposium held on the sidelines of the American Society of Tropical Medicine and Hygiene Annual Meeting in Maryland, USA, on 22nd November 2019. The symposium was co-organized by the UNDP-led Access and Delivery Partnership (ADP), the Special Programme for Research and Training in Tropical Diseases (TDR) and the Countdown consortium led by the Liverpool School of Tropical Medicine (LSTM).
ADP acknowledges and appreciates the Government of Japan’s leadership in global health and its strong commitment to the attainment of universal health coverage, as well as its support for gender equality.
- 1 Herricks JR, Hotez PJ, Wanga V, Coffeng LE, Haagsma JA, Basáñez M-G, Buckle G, Budke CM, Carabin H, Fèvre EM, et al: The global burden of disease study 2013: What does it mean for the NTDs? PLOS Neglected Tropical Diseases2017, 11:e0005424.
- 2 World Health Organization (2002). Report of the WHO Informal Consultation on the use of Praziquantel during Pregnancy/Lactation and Albendazole/Mebendazole in Children under 24 months.