Concepts of gender and sex
The concepts of gender and sex are distinct but connected. Sex "refers to a set of biological attributes. It is primarily associated with physical and physiological features including chromosomes, gene expression, hormone levels and function, and reproductive/sexual anatomy. Sex is usually categorized as female or male but there is variation in the biological attributes that comprise sex and how those attributes are expressed" (Canadian Institute of Gender and Health).
Gender "refers to the array of socially constructed roles and relationships, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis" (Health Canada's Gender-based analysis policy).
Gender norms are learned and are not fixed; they evolve and change over time. The roles, behaviours or activities accepted as ‘normal’ can differ between societies. Societies vary in how rigidly they apply gender stereotypes, and the amount of flexibility they allow individuals in interpreting their own gender identity. Unless challenged, gender stereotypes can be formed and reinforced very early in a child's life (see: Zero Tolerance's training resources Just Like a Child). Uncritical social acceptance of gender stereotypes implies more limited opportunities for individuals and physical and mental health risks if they do not comply. Harassment and discrimination based on gender are illegal in the UK Equality Act 2010 .
Biological sex does not only consist of the simple binaries of male and female (Sen et al, 2007 (734KB). People can choose their gender, including non-binary gender identities, while sex can also be changed in both a physical and a legal sense. The challenge to heterosexual norms by the LGBT (Lesbian, Gay, Bisexual and Transgender) movement goes beyond biological sex to reflect how sexuality and gender are defined and expressed.
These web pages cover issues related to gender and sex. A new section of the website focusing on transgender issues will be published in March 2017. The gender pages of NHS Health Scotland's website give further information.
Sex, gender and health
Sex differences and gender expectations can condition behaviours and opportunities and therefore also affect health risks. Differences in health between men and women can therefore result from biological differences, from gendered social determinants, or a combination of both.
Sex affects health at the individual level through specific vulnerabilities which may be related to anatomy (e.g. cervical cancer is exclusive to women and prostate cancer to men), or the result of physiological or genetic susceptibilities. Gender affects health at a social level, through norms and expectations, access to resources and power, and differentials in roles and responsibilities. The social determinants of health, including income, employment, education, transport and housing are influenced by gender expectations and discrimination.
“Sex and gender therefore interact with other factors that influence health to create conditions and problems that are unique, more prevalent, more serious or different with respect to the risk factors or effective interventions between genders” (Canadian Institute of Gender and Health).
Gender inequality may be experienced by women in relation to the pay gap, occupational segregation, primary caring responsibilities for children/family, gender-based violence and less economic and political power, all of which can contribute to poor health.
Although gender confers many privileges on men, a significant number of health outcomes are worse amongst men. The reasons for this are not completely understood but may relate to direct exposure to more hazardous environments (e.g. through occupational exposures), gender-influenced behaviours (e.g. substance misuse (see our alcohol and drugs pages)) or differences in service use.
In relation to mental health, differences between the sexes become apparent in adolescence with young women at greater risk of reporting and being diagnosed with depression, anxiety and eating disorders while young men experience a higher prevalence of hyperactivity disorders, drug & alcohol problems, suicide and violence. See our report on Scotland’s Mental Health: Children and Young people. Experience of gender-based violence is strongly associated with higher levels of mental health problems.
Intersections between gender and other social hierarchies
Health inequalities by sex and gender differ by age, ethnicity, disability, religion, sexual orientation, and transgender status. Relative inequality between socio-economic groups (SEGs) in health status by gender can be different within each of these equality strata. A study on the interaction by sex between SEG and ethnic, disability, religious and age groups was recently carried out by NHS Health Scotland.
Health inequalities in cause of death show different patterns for each sex by age range (see our Older people: pages on age and inequalities in cause of death).