Girls have worse average mental health than boys across 4 measures of mental health; this sex gap is largely ubiquitous cross-culturally; more gender equal countries have larger gender gaps in mental health

The gender gap in adolescent mental health: a cross-national investigation of 566,829 adolescents across 73 countries. O.L.K. Campbell, David Bann, Praveetha Patalay. SSM - Population Health, January 26 2021, 100742. https://doi.org/10.1016/j.ssmph.2021.100742

h/t David Schmitt https://t.co/KwrxHghoSv https://t.co/GBqRca2YL1itter

Highlights

• Girls have worse average mental health than boys across 4 measures of mental health.

• The gender gap in mental health is largely ubiquitous cross-culturally.

• The gap is most pronounced for psychological distress and life satisfaction.

• More gender equal countries have larger gender gaps in mental health.

• Gender equality correlates with less psychological distress in boys but more in girls.

Abstract: Mental ill-health is a leading cause of disease burden worldwide. While women suffer from greater levels of mental health disorders, it remains unclear whether this gender gap differs systematically across regions and/or countries, or across the different dimensions of mental health. We analysed 2018 data from 566,827 adolescents across 73 countries for 4 mental health outcomes: psychological distress, life satisfaction, eudaemonia, and hedonia. We examine average gender differences and distributions for each of these outcomes as well as country-level associations between each outcome and purported determinants at the country level: wealth (GDP per capita), inequality (Gini index), and societal indicators of gender inequality (GII, GGGI, and GSNI). We report four main results: 1) The gender gap in mental health in adolescence is largely ubiquitous cross-culturally, with girls having worse average mental health; 2) There is considerable cross-national heterogeneity in the size of the gender gap, with the direction reversed in a minority of countries; 3) Higher GDP per capita is associated with worse average mental health and a larger gender gap across all mental health outcomes; and 4) more gender equal countries have larger gender gaps across all mental health outcomes. Taken together, our findings suggest that while the gender gap appears largely ubiquitous, its size differs considerably by region, country, and dimension of mental health. Findings point to the hitherto unrealised complex nature of gender disparities in mental health and possible incongruence between expectations and reality in high gender equal countries.

Discussion

Across four mental health outcomes - life satisfaction, psychological distress, hedonia, and eudaemonia - we find that girls typically had worse mental health than boys. Whilst there is considerable cross-cultural variation in the size of this average difference, it appears largely ubiquitous in this global sample - particularly for life satisfaction and psychological distress. Perhaps counterintuitively, richer European countries including the Scandinavian nations, such as Sweden and Finland, have some of the largest gender gaps in mental health. By contrast, countries with worse society gender equality scores – such as Jordan, Saudi Arabia, and Lebanon - have some of the smallest gender gaps and the direction of the gap is sometimes reversed (with boys having worse mental health). The outcomes vary in their distributions and where in the distribution the gender gap appears, indicating that mean differences are driven by different parts of the mental health distribution for the different outcomes. This highlights the importance of considering the underlying distributions of any mean differences observed. An identical mean difference may be driven by different parts of the population distribution, and this may have public health consequences. For example, we found that girls were less likely than boys to report the highest life satisfaction score, rather than having particularly higher counts in the lower part of the life satisfaction distribution. Previous research typically only focuses on mean differences – future research to understand cross-national differences in mental health may benefit from such analyses.

Higher GDP per capita was associated with a larger gender gap, albeit the magnitude of effect was small. This contrasts with other findings where a positive relationship between GDP and adolescent wellbeing has been found (Torsheim et al., 2006), and this may be due to our inclusion of a wider range of countries beyond rich Western economies. The Easterlin paradox of increasing per capita wealth not associating with increasing wellbeing is well known (Easterlin, 2003) — once basic requirements are met, material desires often increase with increasing incomes so that one is never completely satisfied (Carol Graham et al., 2010). This however does not completely explain the negative association with mental health we found in both genders, or the larger mental health gender gap in richer countries. In line with previous literature we find an inconsistent and weak relationship between income inequality and mental health outcomes (Ngamaba et al., 2018), although it is associated with a wider gender gap in all cases. It could be the case that income inequality and GDP per capita are not particularly important amongst adolescents, and a more specific measure such as the purchasing power of adolescents might be more relevant. Or, for income inequality, the association may be dependent on a country’s level of development, with higher income inequality associating with better mental health in developing nations and worse mental health in developed nations (Ngamaba et al., 2018).

More gender equal countries had larger gender gaps across all outcomes examined, consistent with previous literature in adults (Zuckerman et al., 2017). While the gender equality measures used are not specifically designed to capture exposures directly experienced by adolescents, they reflect multiple dimensions of gender equality which influence experiences through all live stages in these countries and hence provide relevant information about the societal experiences for each gender. Whilst the nature of the associations between gender equality and adolescent mental health were inconsistent across outcomes it was striking that where the association was positive, it was particularly strong for males. This is in contrast to previous findings that show an equivalent positive relationship between gender equality and life satisfaction in boys and girls (Looze et al., 2018). Whilst previous work has shown that social norms of gender equality may be particularly important for mental health outcomes (Tesch-Römer et al., 2008) it is unclear if the multiple available gender equality indicators we used fully capture this. The newly created gender social norms index (GSNI), despite attempting to capture the distinct attitudinal aspects of gender equality, does not appear to measure gender equality in a qualitatively different way than the GII as they are highly correlated. By contrast, the GGGI captures a greater detail of gender equality by including more and more diverse indicators (Table S3), making it more granular, whilst also separating itself from a country’s level of development. For example, the GGGI includes five indicators for economic participation, such as ratio of female earned income to male, and ratio of female professional and technical workers to males, compared to the GII’s one measure of female and male labour force participation rates.

Our results present a complex picture for the relationship between gender equality and the adolescent gender mental health gap. While the feminist movement is itself old, extensive judicial and social change towards gender equality is a fairly recent development, with the UN Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) only being instituted in 1981.

Graham and Pettinato (C. Graham & Pettinato, 2002) coined the term ‘frustrated achievers’ to describe individuals that experience improvements in wealth but report negative perceived past mobility and lower happiness, as a result of still facing discriminatory practices and barriers to their continued ascent. In terms of women, whilst gains have been made, there remain many barriers to full equality that may explain part of our association between gender equality and worse female mental health, or only very slightly better female mental health in the case of life satisfaction. Similarly, expectations of equality may rise faster than actual experience of equality and this may result in worse mental health as women are not able to realise their goals. Another characteristic of upwardly mobile groups is that their reference categories for social comparison are usually beyond their original cohort (Easterlin, 2003). Thus, women or girls attempting to achieve the same successes as men and boys will look to them as their reference group and this may highlight the inequalities between them, producing lower life satisfaction and mental health, while in less gender equal countries reference groups might be limited to their own sex (Costa et al., 2001). Furthermore, in a number of more gender unequal countries, boys and girls might be more socially segregated at adolescence (Talbani & Hasanali, 2000) which reduce between gender comparisons.

In more gender equal countries girls and women are now faced with a double burden of balancing both increased economic and political participation as well as the traditional female responsibilities and norms. While in more gender equal countries women have entered traditionally male dominated areas of employment, men have not entered female dominated areas of employment to the same extent, nor do they do equal amounts of domestic work (England & Folbre, 2005; Garcia & Tomlinson, 2020). In countries with lower gender equality women’s roles are more fixed, whereas in more gender equal countries they are less prescribed, leading to potential conflict between roles, which may affect mental health (Hopcroft & Bradley, 2007).

Adolescence and puberty marks a particular period of changing identity (Blakemore & Mills, 2014) including developing conceptions of what it means to be a man or a woman (Greene & Patton, 2020), and while there are cross-cultural differences in experience of adolescence, identity development is common (Gibbons & Poelker, 2019). Adolescence can be particularly stressful when the norms of femininity potentially contradict with the norms of gender equality and attempting to balance the two may be additionally difficult. Previous research indicates that stress and educational pressure is particularly correlated with worse mental health in adolescent girls (M.a, Gotlib, & Hayward, 1999; Wiklund et al., 2012). Indeed, changing norms of female education and economic participation can increase educational stress and psychological distress for girls whilst they are still burdened with traditional anxieties related to maintaining a female identity and appearance (West & Sweeting, 2003) - and adolescent girls experience many more anxieties related to their appearance than boys (Smolak, 2004). Additionally, evidence suggests that individuals who violate gender stereotypes may receive backlash (Rudman et al., 2012), which may have negative consequences for mental health. Overall, adolescence marks a period of emerging new stressors which may negatively affect girl’s mental health to a greater degree than boys, and in more gender equal countries there may be more of these stressors. For example, having to balance multiple gender norms, or the stress related to the mismatch between expected and experienced gender equality and opportunities, which is potentially greater in countries perceived to have higher gender equality.

Future research should examine some of the theories we have highlighted above to better understand the individual level mechanisms. For example, to examine whether girls who attempt to satisfy multiple gender norms, such as being - femininely attractive, high achieving, and ‘one of the boys’ - have worse mental health. Additionally, examination of other country-level indicators may yield further results to help explain country-level differences in the gender gap, such as, availability and access to mental health support (Saraceno et al., 2007), levels of stigma and literacy around mental health (Corrigan & Watson, 2002), and broader factors such as estimates of environmental degradation, which may have gendered impacts (Patel et al., 2020).

Limitations

Firstly, our study relies exclusively on cross-sectional cross-country correlations; thus, we cannot make any strong conclusions regarding the causal pathways involved. However, cross-country comparisons are necessary to elucidate risk factors that operate at the population level (Pearce, 2000), such as indicators of gender and income inequality. Secondly, whilst we cannot exclude cultural differences on likert scale responses, such as positivity biases, that may confound cross-country differences (Oishi, 2010) invariance testing of the measures indicated that the measures behaved similarly across gender and region. Thirdly, the gender gap itself may partly be a product of reporting bias – with boys being less willing to report negative mental health than girls. However, self-reports are necessary to measure mental health and wellbeing, and the extent and distributions of the gender gap being different across mental health outcomes suggests reporting biases might not be the only explanation. Fourthly, there could be systematic differences across genders in school attendance amongst the countries in our sample that could potentially bias comparison of gender gaps across countries. However, investigation of the gender ratio in secondary enrolment (obtained from the GGGI) suggests that there are not large differences in our sample. The female to male ratio in secondary enrolment ranges from 0.9 to 1.1 for our whole sample, apart from Germany (0.89), the Philippines (1.19) and Qatar (1.25). Lastly, our measure of gender was binary in nature and does not allow investigation of non-binary gender identities on mental health.