Title: The influence of Gender Norms on Women’s Sexual and Reproductive Health Outcomes:
A Systematic Review.
Version: 1 Date: 26 Dec 2024
Reviewer:  Anna Baleige
Reviewer's report:
This paper is an account of a research project aimed at synthesizing recent knowledge
on underlying mechanisms of women's poor sexual and reproductive health from a health
promotion and systems transformation perspective.
First of all, I would like to congratulate the authors on their global approach to scientific
production. This is truly one of the paper's strong points.
However, this strength is not found in other essential places which need to be further developed
or better framed to make the results globally relevant:
- l70-72: in the definition and generally in the paper, sexual health is reduced to infectious
risks. Yet the WHO definition of sexual health includes dimensions of pleasure, non-infectious
risks and respect for the diversity of sexualities. These elements are not addressed in the paper.
It would be more accurate to replace sexual health in the paper with the control of sexually
transmitted infections, or failing that, to set out the limited definition given by the authors in the
introduction and limits of the work.
- l74: the authors use the term equity, whereas the abstract uses equality. These two terms are
not equivalent and do not fit into identical normative frameworks. It is essential that the authors
use consistent concepts, especially in a paper whose introduction and discussion refer to social
power issues.
- l152: the authors explain their intention in the introduction and conclusion to aim for systems
transformation. Why, then, have they resorted to narrative synthesis rather than other more
appropriate methods, such as thematic synthesis? This rationale should be apparent in the paper.
- l177: the authors mention sexual minorities without definition. This element is not present
in the rest of the paper. Firstly, the terms should be defined, and in particular the absence of
gender minorities in the results should be discussed. Secondly, this element is put forward to add
value to the results, but is nowhere to be found in the rest of the paper. If it does not appear in
the results of the synthesis and is not discussed, arguing for added value is misleading. Finally,
the paper focuses on a very specific case of women, namely cisgender, heterosexual women.
Under no circumstances can it claim to give an account, as it does twice, of a broad vision of
women, but above all these issues must be set out in the introduction and discussed within the
limits of the article. The gain in knowledge from this paper is almost nil for all non-cisgender
or non-heterosexual women. This framework cannot be left implicit, all the more so in a paper
that discusses the role of invisibilization and power imbalances in the reproduction of health
inequities.
- l268: the authors use the concept of empowerment in a transitive way, which does not
correspond to knowledge on the subject. Empowering women is nonsense by definition. The
authors should rework their formulations with regard to empowerment and base themselves on
solid concepts such as those posited by the WHO.
- l316-317: is silence a target for intervention or a manifestation of power imbalances? This
whole argument needs to be reworked to reflect the realities of science in the field. As it stands,
the article does not allow us to conclude on intervention targets, due to its objective and method.
- conclusion: there is a risk of circular and fallacious reasoning. The article's introduction states
that power issues are responsible for health inequalities. This cannot also be the conclusion of
the paper. It's probably a salient result that can be discussed because it stands out, but the study
doesn't allow you to conclude on something it takes as a hypothesis.
Overall, this paper suffers from errors in the structuring of its ideological frameworks:
- the notions of sexual health and women need to be redefined as downplayed; on the contrary,
the article aims for a universality it does not possess
- the links between power issues, community action and scientific knowledge need to be
completely reworked
- the methodological choices made by the authors call into question their objectives, and must
be justified or modified.