No man left behind
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2020)

The fight for equal political, social, and economic entitlements for women is rightfully front-and-centre in the public consciousness, after centuries of injustices experienced by women, particularly those in marginalised groups. As such, the term gender equality is often thought of as synonymous with female empowerment; as one example, the fifth Sustainable Development Goal includes both in a single breath. But this misconception overlooks part of the equation: the inequalities disadvantaging men. International Men's Day, celebrated on Nov 19, encourages us to consider all we still need to do to improve men's health and wellbeing. The event seems especially pertinent this year, given findings that about 1·5 times more men than women die from COVID-19, despite an apparently equal infection risk. And, beyond COVID-19, there is a lot left to do. In this issue of The Lancet Global Health, Elissa Kennedy and colleagues analyse gender inequalities in the first 20 years of life, in 40 countries in the Asia-Pacific region. Girls faced considerable disadvantages relative to boys in many aspects of health and wellbeing. However, beginning around puberty, boys showed higher all-cause mortality, and higher mortality associated with injury, interpersonal violence, alcohol and drug use, and suicide. Kennedy and colleagues note that, during puberty, physical changes are accompanied by intensified gender socialisation, cementing and socially rewarding behavioural gender norms (eg, violence or binge drinking in boys) that can lead to the negative health and wellbeing of oneself or others. Continuation of these behaviours and their long-term outcomes can be seen in the Global Burden of Disease Study (GBD) 2019. In 2019, tobacco was the leading risk factor in males for attributable deaths globally, accounting for 6·56 million deaths, versus 2·15 million female deaths. A similar disparity was seen in deaths attributable to alcohol use: 2·07 million deaths in men versus 0·37 million deaths in women. Differential use of these substances continues throughout the life course, leading to a greater burden of associated cardiovascular diseases, cancers, and several other morbidities borne by men. GBD 2019 also found that 524 000 men died by suicide, which was more than twice the number of deaths by suicide in women (235 000). The difference in interpersonal violence is even more stark, at 344 000 deaths in males versus 71 000 deaths in females. These behaviours often intersect with mental ill health. Drug use, for instance, can be a coping strategy for many men experiencing depression or anxiety, but can lead to job loss and social exclusion, increasing the risk of suicide. As discussed in a UNAIDS report on the blind spot in male HIV testing and treatment, men are less likely to seek or to be able to access health care, increasing their likelihood of poorer disease outcomes. Vulnerable groups mostly comprising men, such as migrants, homeless people, and prisoners, are particularly susceptible to exclusion from care, often due to social marginalisation and poverty. Because women have more contact with health services during their reproductive years, and due to the existence of a specific specialty dedicated to those with a uterus—obstetrics and gynaecology—with no male equivalent, women are potentially more likely to view primary health-care attendance as normal. Taken with a perceived gender expectation prizing male physical resilience and avoidance of showing weakness, thereby stigmatising careseeking, it is unsurprising but tragic that this disparity persists. What can be done? First, reporting sex-disaggregated data is key in assessing the situation and tracking change. Analysing the contributions of gender, race, sexual orientation, and socioeconomic status to outcomes is also crucial. Second, we must translate these data to evidence-based, gender-responsive solutions that are specifically adapted to the lives and circumstances of susceptible men. One important step will be in normalising use of primary health care. For instance, voluntary male circumcision services could represent an excellent opportunity to engage men in health services, and workplace or community testing efforts can help to destigmatise service use. Finally, we must actively undermine gender norms (such as concepts of male self-reliance) during childhood, before they take hold. Many health risks mostly affecting men are modifiable and relate to normalisation or promotion of unhealthy behaviours as masculine, with profound long-term impacts on individuals and society. The 2030 Agenda for Sustainable Development signatories pledged that “no one will be left behind”. As progress on issues mostly affecting women speeds ahead, we must ensure that men are also on board. Gender inequalities in health and wellbeing across the first two decades of life: an analysis of 40 low-income and middle-income countries in the Asia-Pacific regionThese findings call for a focus on gender policy and programming in later childhood and early adolescence before gender inequalities become embedded. Full-Text PDF Open Access