Chapter 4: The Chief Public Health Officer's Report on the State of Public Health in Canada 2012 – Incorporating sex and gender into health interventions

Chapter 4: Incorporating Sex and Gender into Health Interventions

• Section One: Sex and gender and public health interventions
• Section Two: Sex and gender in select health outcomes
• Section Three: Sex and gender and socio-economic determinants
• Summary

This chapter explores broad and targeted Canadian and international interventions – research, programs, initiatives and policies – that address health issues and/or risk factors and consider and/or incorporate sex and gender into their design or execution. In doing so, this chapter shows how incorporating sex and gender into programs, policies and research makes a difference to health.

Examples of programs, policies and research that have incorporated sex and gender (in textboxes as well as in the text) are not intended to be a compendium of health issues. They are intended to complement – not mirror – the health issues and risk factors identified in Chapter 3 and also consider the broader determinants of health. The examples are chosen because they:

• address a known health inequality or gap;
• illustrate differences in experiences and outcomes;
• are available with some measure of effectiveness; and/or
• represent a specific region, sub-population or issue at different stages of the lifecourse.

Portraying a targeted perspective does not negate the existence or the severity of the health issue among populations not profiled. For example, profiling a men’s specific health issue or intervention does not suggest that the issue or response is isolated to men; rather this is an example of how Canada, as a society, is considering and incorporating sex and gender in health interventions.

Section One: Sex and gender and public health interventions

Considering sex and gender when developing and delivering programs, policies and practices is important to achieving better health outcomes. Doing so, in part, involves taking actions that generate positive relationships between sex and gender as well as among the broader determinants of health. A sex- and gender-based approach is part of systematically planned interventions that are consistent with population health approaches.^{Footnote 11, Footnote 218}

Integrating sex and gender into health research

There are many reasons for integrating or considering sex and gender into health research that include scientific, methodological and ethical reasons.^{Footnote 219, Footnote 260, Footnote 324-Footnote 327} The challenges that remain, however, stem from not knowing what sex and gender mean and/or how they apply as well as differences in approach and intensity by research field. Research standards and methodological recommendations are being developed across a number of jurisdictions to address these knowledge gaps.^{Footnote 216, Footnote 219, Footnote 326-Footnote 330}

Historically, research often relied exclusively on male subjects with specific cultural and racial characteristics, the resulting data extrapolated to the entire population.^{Footnote 216} Women were systematically excluded from research to avoid issues with pregnancy and breastfeeding during research, particularly clinical trials.^{Footnote 216, Footnote 331} Later research showed that sex alone had significant influences on human health in terms of physiology and chemistry and response to disease, pain and treatments.^{Footnote 216, Footnote 219, Footnote 328, Footnote 331} Failing to implement and consider sex in research compromised its validity and the applicability of programs. Following the advocacy of women’s movements, research began to focus on sex differences between men and women including the division of data by sex, treatment of women in clinical practices and consideration of social issues such as sex roles and sex-role socialization.^{Footnote 233} The evolution of the concept of gender followed, setting the stage for differentiation of sex and gender as two distinct concepts and a recognition that both matter to women’s and men’s health.^{Footnote 233} Understanding that sex- and gender-based health research was about everyone’s health – not solely about women’s health – was a transformative change that is still gaining momentum and endorsement across research areas.^{Footnote 217, Footnote 233, Footnote 328} (See the textbox “Incorporating sex and gender into research.”)

Incorporating sex and gender into research

Canadian researchers have long criticized approaches that assume that “one size fits all” in terms of programming and services and revealed the problems associated with “gender-neutral” approaches when applied to everyday issues.^{Footnote 216, Footnote 217, Footnote 233, Footnote 328}

Canada embarked on its commitment to sex- and gender-based work when evidence surfaced that pointed to gaps and inequalities created by not addressing research, programs and policies in the context of sex and gender. By ratifying the Beijing Declaration, Canada agreed to promote gender mainstreaming in all relevant policies and programs.^{Footnote 217, Footnote 342} As part of this agreement, the federal Health Portfolio uses sex- and gender-based analysis (SGBA) to develop, implement and evaluate research, programs and policies. Within the Portfolio, organizations such as the Canadian Institutes of Health Research (CIHR) developed guidelines for research applicants to consider how gender and/or sex might be integrated in areas of health research (including clinical, health systems and social factors).^{Footnote 23, Footnote 343} These guidelines provide key questions to ask about where and how sex and/or gender play a role in the research approach, hypotheses, methods and ethics.^{Footnote 343} CIHR also established the Institute of Gender and Health, which is the only health research funding institute that specifically focuses on gender, sex and health.^{Footnote 23} CIHR and its partner organizations within the federal Health Portfolio (including the Public Health Agency of Canada and Health Canada) are committed to upholding SGBA. (See the textbox “The Health Portfolio’s Sex and Gender-Based Analysis Policy.”)

The Health Portfolio's Sex and Gender-Based Analysis Policy

A population health approach relies on consistently measuring health indicators (variables that assess the health status as well as factors that influence health) and identifying trends that provide a comprehensive picture of the health of the population.^{Footnote 13, Footnote 239} Effective research involves understanding the different factors influencing health outcomes and building knowledge accordingly.^{Footnote 239} Too often data are under-reported, under-collected or aggregated in ways that mask variations associated with sex as well as miss other important factors such as age, ethnicity and socio-economic status. Sex-based disaggregated data exists in some areas and show differences, however, there are limited analyses that explain and understand why and how differences occur. Accounting for and highlighting diversity creates opportunities for better evidence-informed decision-making. This helps to ensure programs are designed that are able to meet the needs of those at greatest risk thereby avoiding an increase in health gaps.^{Footnote 333, Footnote 334} Applying SGBA to research helps to explain the complexity of health determinants, behaviours and outcomes, why differences occur and what can be done to address these gaps.^{Footnote 333}

Tools that incorporate sex, gender and other aspects of diversity into health indicators take SGBA to another level of sophistication. For example, the Aboriginal Women and Girls’ Health Roundtable (2005) highlighted the need to develop gender analysis in the context of First Nations, Métis and Inuit populations. As a result, Aboriginal-Specific Sex- and Gender-Based Analysis was developed to look at specific factors with Aboriginal perspectives as well as a sex and gender lens thus encompassing the unique cultural histories and perspectives of First Nations, Métis and Inuit while highlighting differences between and among these populations.^{Footnote 346, Footnote 347} (See the textbox “Approaches to implementing Aboriginal sex- and gender-based analysis.”) The Our Voices strategy evolved from the identified need to include issues specific to Aboriginal women’s health toward a sex- and gender-based approach to data and programs.^{Footnote 346, Footnote 347}

Approaches to implementing Aboriginal sex- and gender-based analysis

Integrating sex and gender in public health practice

Considering sex and gender in public health interventions involves a broader approach than addressing male and female health outcomes. A sex- and gender-based approach to interventions challenges assumptions that male, female and trans youth and adults similarly experience health outcomes and the interventions intended to address health issues.^{Footnote 233} Such an approach also challenges tendencies to focus on differences rather than understanding the factors that influence these differences. This approach also encourages planners and practitioners to identify how differences play out in programs and to consider how issues are framed, defined and communicated, how information is collected (and by whom), and how interventions will address the needs of diverse groups.^{Footnote 218, Footnote 233}

For example, human papillomavirus (HPV) immunization is a widely recognized public health practice where applying a sex- and gender-based approach can show different perspectives for disease, outcomes and interventions. (See the textbox “Changing perspectives with a sex- and gender lens on a public health issue: the HPV example.”) This example is intended to show the difference made by applying a sex and gender lens and does not assess the program per se.

Changing perspectives with a sex- and gender lens on a public health issue: the HPV example

The typical “one size fits all” approach masks diversity among individuals and the broad determinants of health. While it is easier to ask what is happening with girls or women and boys or men and to tailor programs accordingly, this assumes a simple binary classification of male or female rather than a masculine and feminine continuum. In addition, gender norms – in terms of expectations, roles and behaviours – and the continuum of these norms among social and cultural practices directly influence the health and well-being of girls and boys and women and men.^{Footnote 228} These expectations can directly influence attitudes towards health practices such as prevention, support and treatment as well as social practices, including relationships with partners, children and work.^{Footnote 216, Footnote 217, Footnote 228}

Gathering information on “males” or “females,” and assuming that it is indicative of biological sex and/or being masculine or feminine does not fully address important aspects of identity and biology that need to be addressed in sub-groups of the population. People who identify as trans (transgendered, transsexual, transitioning) do not reflect a homogeneous group. Identifying themselves as “other,” a choice often provided by surveys, perpetuates invisibility and lack of identity.^{Footnote 229}

A recent American trend analysis of medical publications from 1950–2007 showed that sexual and gender minority persons were largely invisible or excluded from studies and that medical professionals often did not recognize the health care needs of this diverse population.^{Footnote 357} Assuming gender neutrality can further health disparities as programs fail to examine sex and other socio-economic determinants contributing to ineffective interventions and unintended (but adverse) outcomes.^{Footnote 233} While the continuums of sex and gender are considered throughout this chapter, the continuum is often lost in the examples of research, programs and policies, and identifying and addressing health issues of trans sub-populations is an on-going challenge.

Embracing the inter-relationships between sex, gender and the broader determinants of health needs to become part of mainstream practice in public health.^{Footnote 15, Footnote 20, Footnote 25, Footnote 233, Footnote 333} The necessary work – in particular, knowledge translation and dissemination of sex- and gender-based research – is less than straightforward as the issues are complex and difficult to measure and communicate.^{Footnote 333} Nevertheless, accounting effectively for sex and gender health inequalities can contribute to cost savings to the health system and better services in communities.^{Footnote 216, Footnote 333} Further, the exclusion of sex and gender from research, programs and policies is ultimately unethical.^{Footnote 233} The remainder of this chapter focuses on the effective and promising approaches and interventions that consider sex and gender in terms of select examples of health outcomes as well as the social determinants of health.

Section Two: Sex and gender in select health outcomes

Sex, gender and physical health

Approaches to preventing and managing the onset of chronic disease must reflect differences among men, women, boys and girls so as to most effectively address and/or avoid adverse health outcomes. As outlined in previous chapters, interventions that focus on disease prevention and support healthy living (healthy behaviours and choices) can reduce risk factors for some adverse health outcomes.^{Footnote 184, Footnote 358-Footnote 360} Opportunities to positively influence health exist at different points across the lifecourse. Some approaches consider the influence of sex and gender that have worked to incorporate different needs within their design and execution.

Promoting healthy weights

Being overweight or obese is a major public health challenge with many contributing factors.^{Footnote 193, Footnote 361, Footnote 362} Unhealthy weights can influence the development of many chronic diseases in later life.^{Footnote 193, Footnote 361-Footnote 363} Generally, those who have poor nutrition and lower levels of daily physical activity are most likely to have excess body weight and hence an increased risk of developing related adverse health outcomes across the lifecourse.^{Footnote 361, Footnote 362} The WHO has developed strategies to address diet, physical activity and health.^{Footnote 364} It recommends broad inter-sectoral approaches aimed at several factors, including education, as well as tailoring interventions that take into account context, gender roles and culture.^{Footnote 364}

An Alberta-based study examined whether sex and gender should be considered in the development and implementation of healthy weight interventions for youth.^{Footnote 363} The study suggested that because differences exist between pre-adolescent boys and girls in terms of behaviours, diet and physical activity, interventions should incorporate sex and gender. Understanding differences based on sex and gender as well as other factors (such as cultural and geographic location) are important to increasing our understanding of how to encourage positive healthy practices among youth.^{Footnote 363} (See the textbox “Healthy Dads, Healthy Kids.”) The results of the study reinforce the need for increased sex and gender consideration in health interventions to maximise effectiveness and delivery.^{Footnote 363}

While Canada has recently developed strategies to address obesity, sex and gender were not specifically highlighted. Recognizing gender differences in these areas would allow for the development of more effective health promotion programming.^{Footnote 363, Footnote 365, Footnote 366} Providing a gender-focused health promotion intervention could better address physical activity among girls and healthy eating among boys.^{Footnote 363} To be effective, healthy weights programs will also need to consider the needs of visible minorities, sexual minorities and those who live in rural and remote regions.

Healthy Dads, Healthy Kids

Systematic reviews and meta-analyses found that school-based health programs can be effective in promoting healthy weights.^{Footnote 374}, ^{Footnote 375} The studies have shown the importance of sex-based programming with a gender-based perspective. Generally, girls benefit from learning environments with a social context that emerge though observation, role-playing/cognition and transition; boys benefit more from programs targeted in environments that support their interests.^{Footnote 376} Canadian-based research synthesized best practices on achieving appropriate evaluation techniques that address childhood obesity and related chronic diseases.^{Footnote 377} This research considered effectiveness, program development and evaluation as well as the impact on broad population health and certain sub-populations. Results indicated that interventions do not focus on the needs of sub-populations of children and youth – particularly young males – despite the known longer-term rates of obesity-related chronic disease among men.^{Footnote 377}

School-based programs were found to be beneficial for physical activity interventions, but the benefits were short term, and more could be done to integrate effective programs that address and encourage maintenance of healthy weights.^{Footnote 377} The comprehensive school health framework encompasses a whole of school approach that support students educational outcomes while also integrating school health.^{Footnote 378} The Pan-Canadian Joint Consortium for School Health, a partnership between federal, provincial and territorial ministries of health and education, supports and encourages the interrelationship between learning and health.^{Footnote 378, Footnote 379} The Consortium works across jurisdictions and sectors to share information and experiences, identify best practices, leverage resources, minimize duplication, foster partnerships and conduct further research in promising area.^{Footnote 379} Systematic reviews of comprehensive school health approaches have found that multifactorial interventions, particularly those involving changes to the school environment, were effective in promoting healthy eating and physical activity.^{Footnote 380} Research also showed that age and gender mattered as comprehensive school health programs showed greater benefits in girls and older students.^{Footnote 380}

Where men and women are involved in similar physical activities, gender-neutral statistics on activities and chronic disease can mask the underlying motivation for exercise and the effectiveness of programs.^{Footnote 219} The socially constructed contexts in which gender influences physical activity is important to how interventions are managed. In addition, policy and program initiatives need gendered evaluations to assess their effects on and among women and men, girls and boys.

Sex and gender stereotypes influence perceptions of ability and physical activity. Enrolments in sports and physical activities across the lifecourse show stereotypical preferences. Girls often prefer “feminine” activities, for example figure skating, instead of more contact style sports, for example hockey, which see higher enrollment among boys. Similarly, some older women report feeling uncomfortable weight training in a gym as they report perceiving this to be a masculine activity.^{Footnote 381} What is typically considered “locker-room talk” can take on gendered or sexist language and behaviours; particularly for those boys who do not perform well in physical activities and sports. Strong, physically active girls who exhibit qualities and/or skills socially connected with boys can be stigmatized as tomboys or have their behaviours extrapolated into presumed sexual orientation.^{Footnote 381}

Students should be able to participate in physical education classes and team sports in a safe, inclusive and respectful environment. Participation in sports, locker room access and privacy for changing clothes often create stress for some youth.^{Footnote 223} To address the issue of physical activity for transgender and transsexual youth, the Canadian Teachers’ Federation created a guide to assist educators in supporting transgender and transsexual youth who, like their cisgender peers, should be able to participate in physical activity classes and recreational and/or competitive sports.^{Footnote 223} Policies and procedures should be inclusive, regardless of gender identity or gender expression, in an environment free of discrimination and harassment.^{Footnote 382} Schools can create this environment by educating staff and coaches, and by working with parents so transgender and transsexual youth are understood and accommodated in schooling.^{Footnote 383}

Communities across Canada offer programs that educate and encourage women and girls in sports. Broad-based initiatives such as the Canadian Association for the Advancement of Women and Sport and Physical Activity (CAAWS) have created several projects to promote sport for girls and women and challenge gender stereotypes and homophobia. (See the textbox “Canadian Association for the Advancement of Women and Sport and Physical Activity.”) In 2009, Canadian Heritage adopted Actively Engaged: A Policy on Sport for Women and Girls to promote meaningful opportunities for women and girls as athletes, coaches, technical leaders and officials, both nationally and internationally, by having sporting organizations provide quality experiences and equitable support.^{Footnote 384, Footnote 385} The objective of the policy is to foster a positive sporting environment for women and girls that will transcend through a lifetime of sport participation.^{Footnote 386} Evaluations of this approach are to begin five years after implementation.^{Footnote 386}

Sex differences in physical capacity, where men often seem to have more strength and endurance, is also an issue.^{Footnote 387} For example, the higher number of ankle and knee injuries among female endurance athletes is seen as a result of the differences in physical composition of muscle and tendons.^{Footnote 388-Footnote 393} However, while physiology plays a significant role, young men often receive more appropriate care and training at an earlier age.^{Footnote 390-Footnote 393} Women’s participation in sport and physical activities has required them to challenge gender stereotypes and roles as well as to seek out community facilities available to them.^{Footnote 387}

Canadian Association for the Advancement of Women and Sport and Physical Activity

The Public Health Agency of Canada’s Innovation Strategy illustrates how SGBA as well as health equity considerations can be incorporated into programs and practice.^{Footnote 399, Footnote 400} In 2011, 37 projects funded in the first phase of the Innovation Strategy’s Achieving Healthier Weights in Canada’s Communities initiative were reviewed to determine the manner and extent to which sex, gender, and equity considerations were taken into account.^{Footnote 400} As a result of that analysis, the Agency identified ways it could improve its own practices to support and encourage organizations to more clearly consider those factors in developing, implementing and evaluating their interventions. Those improvements were reflected in the next round of solicitations.

• Project proposals were rated in part on the extent to which health equity as well as sex, gender and sexuality roles and factors were integrated in the implementation, adaptation, and evaluation of the proposed interventions.
• The solicitation materials supported organizations in developing those elements, by:
  • providing examples of gender differences in obesity, and describing different societal expectations and roles of men and women that could influence healthy weights (e.g. access to financial resources, who purchases food, roles in child care and how that could affect activity and eating patterns of both caregiver and the children), and
  • describing ways to address gender-specific needs in the design, implementation and evaluation of the intervention.^{Footnote 400}

Promoting heart health

Addressing the influence of sex and gender on health requires challenging assumptions and historic practices. These assumptions about sex, gender and health influence perceptions of risk as well as individual and collective approaches to healthy living. For example, the fact that women generally live longer than men and that men are more likely to have heart disease (see Chapter 1 for data) assumes that women are not impacted by heart disease.^{Footnote 242} As a result, past approaches, particularly around cardiovascular health focused on men’s health which has influenced the identification and treatment of disease for women.^{Footnote 242}

Historically, health and disease research has rarely considered sex and gender in relation to prevention, identification, diagnosis, treatment or management of ill health.^{Footnote 242} Cardiovascular health is a prime example of how research has typically focused on male norms and standards that apply neither to women nor to all men.^{Footnote 242, Footnote 401-Footnote 403} Evidence shows that factors such as sex affect symptom presentation and disease identification whereas gender can influence treatment-seeking as well as health care practitioners’ reactions to cardiac symptoms.^{Footnote 242} The combined interaction of sex, gender and the broader health determinants can affect health status, health system responses and short- and long-term health outcomes.^{Footnote 18, Footnote 242}

Perceptions of cardiovascular disease (CVD) have affected the health of women, who used to be under-represented in cardiovascular research, treatment and health prevention practices.^{Footnote 242, Footnote 402, Footnote 403} CVD has only recently been recognized as one of the leading causes of death and ill health among Canadian women.^{Footnote 77, Footnote 404} Prior to this CVD was assumed to be a “man’s disease” with only 13% of Canadian women (and 15% over 35 years) identifying heart disease as their most significant health concern.^{Footnote 405} To address this perception, heart health organizations began targeting women through social marketing, public awareness and health promotion programs.^{Footnote 406, Footnote 407} In 2008, the Heart and Stroke Foundation of Canada launched The Heart Truth campaign to call on women to put their own health first, change their habits, recognize heart attack and stroke symptoms and seek prompt treatment.^{Footnote 406, Footnote 407} (See the textbox “Targeting women: The Heart Truth Campaign.”)

Targeting women: The Heart Truth campaign

Sex, gender and mental health and well-being

Each of the annual Chief Public Health Officer’s reports has stressed the importance of mental health and well-being as well as the need to support individual Canadians and their families a nd communities. Applying a sex- and gender-based approach to mental health interventions can help better understand how the determinants of health contribute to mental health and well-being.^{Footnote 408}

Policies and strategies are beginning to recognize the role of the broader determinants of health in mental health. In 2006, the Standing Senate Committee on Social Affairs, Science and Technology report Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addictions Services in Canada highlighted the relevance of the broader determinants of health – including sex and gender – to good mental health.^{Footnote 409} The Standing Senate Committee’s recommendations for a Canadian body to promote mental health with federal and provincial/territorial support led to the creation of the Mental Health Commission of Canada (MHCC) in 2007.^{Footnote 409, Footnote 410} The MHCC’s framework emphasizes the importance of a population health approach as well as the importance of mental health literacy and of resilience.^{Footnote 411} As the socio-economic determinants interrelate with gender, taking this approach should implicitly benefit both men and women in tailored ways. However, the framework was criticized for not citing specific sex- and gender-based prevention, intervention or system responses.^{Footnote 270, Footnote 412}

In 2012, the MHCC released Canada’s first mental health strategy, developed in part from the testimony of Canadians with mental health problems and illness as well as of their families.^{Footnote 413} Among the six strategic directions identified in the strategy (promotion and prevention; recovery and rights; access to services; disparities and diversity; First Nations, Inuit and Métis; and leadership and collaboration), gender and sexuality are considered as priority areas in addressing disparities and diversity.^{Footnote 413} This involves looking at the different ways that gender influences vulnerability and how gender needs can be considered in prevention and early intervention efforts. Addressing the impacts of stigma and discrimination based on sexual orientation and gender identity can affect both mental health and how effectively needs are met.^{Footnote 413} Regarding sex and gender, the mental health strategy recommends:

• increasing understanding of gender and sexual orientation;
• providing mental health services that are sensitive to gender and sexual orientation;
• reducing risk factors for women’s mental health (e.g. poverty, caregiving and family violence); and
• improving the capacity of lesbian, gay, bisexual, transsexual and questioning (LGBTQ) organizations to address stigma and offer support within communities.^{Footnote 413}

The following discussion highlights examples that demonstrate the influence of sex and gender on mental health and were chosen based on several factors: prevalence and/or rate of the issue; a lack of awareness, stigma and the need to draw attention to the subject/issue; or issues that affect many populations but in different ways.

There is a positive relationship between the frequency and severity of these factors and the frequency and severity of mental health problems.^{Footnote 268}, ^{Footnote 278} For many, mental health outcomes result from major life events – having a child, losing a loved one (as a result of death or separation) or experiencing poverty or abuse.^{Footnote 268}, ^{Footnote 278} Evidence shows that protective factors against the development of mental health problems (such as depression) include resilience, self-esteem, coping skills and a sense of control; being able to access and make informed choices about resources and services; and having a supportive environment (family, friends, and accessible health and social service providers).^{Footnote 414} Supporting mental health now and into the future involves building evidence on causes and mitigating their impacts; promoting mental health and well-being across the lifecourse; and increasing the capacity of health care providers to identify and address not only mental health outcomes but also to identify and influence broader factors that influence these outcomes.^{Footnote 414}, ^{Footnote 415}

Addressing depression: reproduction and mental health example

Gender roles, life experiences and event-specific risk factors (such as intimate partner violence, low socio-economic status and associated disadvantages) are often cited as contributors to common mental disorders that disproportionately affect women.^{Footnote 268} The over-representation of women in rates of depression and anxiety suggests that more can be done to address individual factors such as reducing stress, addressing risk factors, and developing resilience among girls and women.^{Footnote 268, Footnote 411, Footnote 416} While there are many underlying factors that influence women’s mental health and well-being, this discussion focuses specifically on depression and reproductive health, and postpartum depression (PPD) in particular. Despite this focus on women, the discussion raises questions about what is happening among men and other sub-populations (e.g. lower socio-economic status) as they become parents.

Managing reproductive processes and/or life events (e.g. premenstrual syndrome, childbirth, infertility, menopause, and sexual distress) can influence mental health. While many Canadian women (up to 80%) experience mild mood disturbances after giving birth, about 10% to 15% of women can be affected by postpartum depression.^{Footnote 276}, ^{Footnote 278}, ^{Footnote 417}, ^{Footnote 418} In fact, this is likely an under-estimate given that PPD is often stigmatized and under-diagnosed.^{Footnote 417} While the cause of PPD is unclear, research has identified many contributing factors (e.g. physiological hormonal changes, life stress, partner conflict, caring for a newborn, low self-esteem and lack of social support) that put some sub-populations at greater risk.^{Footnote 68}, ^{Footnote 276}, ^{Footnote 278}, ^{Footnote 419}-^{Footnote 421} Possible long-term health impacts include a significant likelihood of experiencing depression later in life.^{Footnote 417}, ^{Footnote 419} In addition, adverse outcomes of PPD may influence mother’s relationship with her infant.^{Footnote 417}, ^{Footnote 419}, ^{Footnote 420} Addressing PPD and its risk factors involves consideration of biology and socio-economic factors as well as knowledge of the interactions and interrelationships.^{Footnote 422} Many studies have been inconclusive about the effectiveness of prevention interventions; however there are still opportunities for interventions to reduce, mitigate and manage the effects of PPD on families.

The Saskatoon Postpartum Depression Support Program is a community wellness program that offers support to mothers managing PPD.^{Footnote 423, Footnote 424} An evaluation of this and other similar programs found that most women, particularly those with their second baby (more women are underdiagnosed for their first baby and seek help with the second and subsequent), reported that they had benefited from a number of aspects of these types of programs.^{Footnote 418, Footnote 421, Footnote 424} Overall, most women benefited from group discussions and peer support. However, others reported that these programs could be expanded to offer greater social and cultural relevance (e.g. for older or for Aboriginal women).^{Footnote 417, Footnote 418, Footnote 424, Footnote 425}

Mother Reach London & Middlesex (Ontario) educates and supports women and their families who are at risk for, or coping with, prenatal and postpartum mood and anxiety disorders.^{Footnote 426} The Mother Reach weekly drop-in program offers opportunities to gain educational support, and connect with other mothers with similar issues. A Father Reach program is also available in the community. Collaborative agreements with mental health professionals and other counseling supports are in place to support families. The Mother Reach Coalition is comprised of a team of community members and professionals in London and Middlesex County whose purpose is to provide and promote public and professional awareness of prenatal and perinatal mood and anxiety disorder.^{Footnote 426} Mother Reach is held at the Merrymount Family Support and Crisis Centre where additional education and resource supports are available along with a Nurse Practitioner led clinic, mental health counseling, emergency respite care and a variety of parenting and support groups.^{Footnote 426} Systematic reviews of similar type programs show that positive outcomes for a mother’s well-being and infant care can be achieved through environments and programs that offer individual treatment and support for those entering parenthood.^{Footnote 417, Footnote 418, Footnote 424, Footnote 427, Footnote 428}

Addressing the outcomes of maternal depression involves a greater understanding of the complex interactions between mental health and other factors. Meta-analysis results have been inconclusive as to whether socio-economic factors are predictors for PPD.^{Footnote 279, Footnote 429} However, most studies have been limited in reach given they were conducted on demographically similar populations (e.g. Caucasian, heterosexual, and relatively high socio-economic status).^{Footnote 279, Footnote 429} Also needed are studies on the moderating effects of psychosocial, cultural and spiritual factors on depression.^{Footnote 279} For some mothers community, family and traditional values and practices can be protective and offer support to women and their children. On the other hand, some mothers may be influenced by traditional and cultural practices that may under-recognize illness and influence seeking treatment.^{Footnote 430}

Some sub-populations, such as recent female immigrants, can experience challenges and barriers to receiving adequate and equitable care.^{Footnote 279, Footnote 280, Footnote 430} Given the complexity of the psychosocial issues facing some immigrant women, there is a need to develop a comprehensive response to these health challenges of immigration to include:

• acknowledging that responsibilities and policies surrounding immigration can contribute to stress;
• offering adequate community resources and social services to address broader social determinants of health;
• including cultural elements into prevention strategies;
• working towards equitable access to culturally appropriate services;
• building capacity for marginalized communities; and
• offering culturally relevant interventions at the individual level.^{Footnote 430}

In the area of reproduction and mental health, Canadian researchers and clinicians have played significant roles in knowledge development and translation. Since the 1980s, Canadian researchers have been involved in leadership areas within the North American Society for Psychosocial Obstetrics and Gynecology, The Marce Society (for postpartum mental disorders) and the International Association for Women’s Mental Health. In 1993, Canadian researchers worked on the first book on this topic, Psychological Aspects of Women’s Health Care: The Interface Between Psychiatry and Obstetrics and Gynecology and subsequent editions have been translated into several languages and used in clinician training internationally.^{Footnote 431}

Further efforts are being made to increase knowledge and understand mental health issues in a gender-based research context in research centres across Canada.^{Footnote 422} For example, the Centre for the Study of Gender, Social Inequities and Mental Health, based at British Columbia’s Simon Fraser University brings together researchers and community partners from Canada, United States, United Kingdom and Australia to work together to develop programs and policies on intersections between gender, social inequities and mental health as well as the necessary interventions.^{Footnote 432}-^{Footnote 434} Research development, knowledge exchange, training and capacity building is on-going in five priority areas: mental health reform and policy; recovery and housing; reproductive mental health; violence, mental health and substance use; and the criminal justice system, mental health and substance use.^{Footnote 432}, ^{Footnote 434}

Men’s experiences with impending and new fatherhood, paternal depression, stress about partners’ pregnancies and the role they play in women’s mental health are important factors that are slowly being considered and implemented in research, programs and policies.^{Footnote 417}, ^{Footnote 435}-^{Footnote 438} Research has found that depressive symptoms during new fatherhood as well as partners’ pregnancies and postpartum periods are also significant problems for men.^{Footnote 270}, ^{Footnote 438} In particular, having a depressed partner, a poor relationship between the parents, and low social support are the most common correlates of depression in men during pre and post natal periods.^{Footnote 438} An increase in depression in one partner may lead to an increase in the other.^{Footnote 438} While paternal depression among new fathers is receiving media attention, identifying the problem is lagging because the tools currently used to assess depression may not adequately identify symptoms in men. Scales such as the Edinburgh Postnatal Depression Scale, Beck Depression Inventory, General Health Questionnaire and Postpartum Depression Screening Scale routinely measure effects in women. They can also be effective to measure paternal depression in men; however, research suggests that the scales will need to be adapted to better reflect men’s symptomatic criteria.^{Footnote 439}-^{Footnote 444} Paternal postpartum depression has been studied by few researchers and has primarily focused on middle-class, married Caucasian fathers. Additional research is needed to expand the focus to new fathers from various cultural and socio-economic backgrounds.^{Footnote 442}, ^{Footnote 444} Addressing depression and anxiety of new parents also requires consideration of the needs of sub-populations, for example, sexual minorities. More work also is required to identify and address the reproductive mental health of men and the role they play in women’s reproductive mental health.

Preventing suicide: addressing male suicide

Recent research and programs reveal that men are at risk for a range of mental health problems, in particular depression.^{Footnote 270, Footnote 445} Mental illnesses among men are often underdiagnosed and under-reported and mental health issues of men are often considered a “silent crisis” and this suggests the mental health gender gap may not be as wide as originally thought.^{Footnote 270} Differences between men and women in outcomes and diagnoses may be the result of factors that are biological, as well as how problems are socially and culturally framed, and how symptoms are manifested and experienced.^{Footnote 68} In addition, focusing on and addressing the manifested physical symptoms as well as practicing certain coping strategies (e.g. substance use) may mask or disregard underlying mental illness.^{Footnote 68}

Suicide is an example of a gender paradox in public health. While four out of five suicides are completed by men, women attempt suicide more often and also have higher reported rates of depression than men.^{Footnote 68, Footnote 269, Footnote 270, Footnote 274, Footnote 446} Thus, addressing suicide through prevention practices is challenged by a number of factors including gender differences in suicide and suicide ideation.^{Footnote 447} A sex- and gender-based approach points to questions about differences in underlying experiences, social roles and behaviours as well as gender bias in diagnostic tools.

While clinical depression is a suicide risk, epidemiological and clinical research reports that the prevalence of depression is inversely correlated to the frequency of suicide.^{Footnote 448} Several factors to consider when addressing men’s suicide are that men are less likely to seek the necessary help and care; they can be reluctant to show perceived weakness; they differ from women in the way symptoms appear and how the illness is diagnosed and treated; and many inflict self-harm in decisive and violent means.^{Footnote 447} Alcohol and other substance misuse may be a way of self-medicating depression or anxiety.^{Footnote 68}, ^{Footnote 448}

Suicide among older men is concerning and more needs to be done to address this at risk population.^{Footnote 25, Footnote 68, Footnote 87} In 2006, the Canadian Coalition for Seniors’ Mental Health (CCSMH) developed their CCSMH National Guidelines for Seniors’ Mental Health, which focuses on several mental health issues facing Canada’s seniors. Suicide was specifically targeted via the National Guideline, The Assessment of Suicide Risk and Prevention of Suicide, which examined seniors’ suicide in social and cultural contexts, specifically the sex and gender aspects of behaviour and the role of culture in risk factors.^{Footnote 449} Building on the guidelines for the prevention of suicide, CCSMH developed a Late Life Suicide Prevention Toolkit for health care providers, physicians, nurses, front-line workers and mental health professionals and to be used in health education programs.^{Footnote 450}

Suicide is often associated with younger men and notably sexual minority men.^{Footnote 25, Footnote 68, Footnote 451} A 2011 review of suicide and suicide risks in diverse American sexual and gender minority populations indicates that there has been insufficient research on suicidal behaviour in this population and the extent to which public health policies, prevention strategies and targeted interventions are needed and are effective.^{Footnote 286} The review also indicates that, in general, there is no authoritative or reliable way to establish rates of completed suicide in the sexual and gender minority population. However, international research indicates links between sexual and gender minority status and elevated rates of both suicide ideation and attempts.^{Footnote 286, Footnote 452} It also points to links between mental disorders and suicide attempts of sexual and gender minorities.^{Footnote 286} While mental disorders are the leading risk factor, the report also points to other explanatory factors including the social stigma, prejudice and discrimination that sexual and gender minorities face at an individual level – rejection by family and friends, harassment, bullying and physical violence – as well as on an institutional level with non-inclusive laws and policies.^{Footnote 286}

Some jurisdictions have developed suicide prevention strategies that include broad to targeted initiatives. New Brunswick, for example, has been acknowledged for its broad suicide prevention strategy which identifies and targets those at greatest risk for suicide.^{Footnote 453} The program builds on existing community-based resources and the capacity of local partners to know how best to respond to local needs by engaging in community action, continuous education and interagency collaboration.^{Footnote 453, Footnote 454} The Australian government attributes the reduction in its overall rate of suicide over a 10-year period in part to its prevention strategy.^{Footnote 455} The LIFE Framework (Living is for Everyone) is based on the premise that all Australians have a role to play in suicide prevention through broad population and targeted interventions.^{Footnote 455} The LIFE Framework also indicates that providing effective sex- and gender-specific suicide prevention interventions is important. For men this includes:

• developing practical, action-oriented approaches and strategies that provide coping and skills training, improve employment and parenting skills, help deal with stress and anger, encourage openness and provide opportunities for retired men to socialize;
• creating friendly and relevant programs and services within safe environments at appropriate locations;
• providing services that proactively engage at-risk men as they may admit having difficulties if the subject is broached but will not necessarily self-identify;
• training local service providers and bringing programs and services to the places where men are to be found – workplaces, pubs, sports and service clubs;
• building capacity to recognize and respond to men’s needs and value men’s role in the community;
• addressing health and well-being from a positive perspective as men respond better to being and staying healthy than dealing with a problem;
• building networks of like-minded men for social support to address loneliness; and
• promoting mental health screening.^{Footnote 456}

Applying a sex, gender and diversity lens to health outcomes can expand the understanding of issues such as men’s suicide.^{Footnote 273} Certain sub-populations, for example, men living in remote communities and Aboriginal men, have high rates of suicide.^{Footnote 457-Footnote 459} The Men at Risk program addresses issues of depression and suicide risk among men living and working in remote regions of Alberta, including those in the oil, forestry and agricultural sectors, who are often isolated from family and community.^{Footnote 448, Footnote 460} Systematic reviews have shown that there is a broad range of effective approaches in suicide prevention programs.^{Footnote 461} This program follows recognized best practices for suicide prevention, mental health-care support and counselling. It uses emotional messages, storytelling and testimonials from survivors of attempted suicide as well as messages from mental health professionals. It neither normalizes nor glamorizes suicide behaviours. The Men at Risk program can be considered promising in addressing the unique pressures and challenges facing men in these distinctive fields and situations.^{Footnote 448}

Over the last few decades, social change has made it more difficult for men to connect to the broader community and with each other.^{Footnote 462} Changes to the employment environment – finding work in isolated and remote areas, a movement away from traditional labour and the expectation of being employed and having years of retirement while healthy – and relationships with significant partners have created situations where men may feel isolated, depressed, lonely and overwhelmed by family responsibilities or else unfulfilled and undervalued. Such feelings contribute to mental health risks including suicide. Evidence shows that positive health outcomes are associated with creating men’s networks. Programs such as Australia’s Men’s Sheds are contributing to greater health and well-being among men, particularly older men and those living in less populated regions.^{Footnote 462} (See the textbox “Australia’s Men’s Sheds program.”) Such programs address disparities in continued learning, adult education and social network organizations by focusing on men’s spaces and learning needs.^{Footnote 462}

Australia's Men's Sheds program

Reluctance to identify a problem, seek help and be diagnosed can limit the success of suicide prevention interventions. The decision to seek help often comes at a point of crisis and not during the development of illness. The reasons for men being reluctant to seek help may stem from traditional feelings of masculinity or a perceived weakness, lack of awareness or control, or a need to mask symptoms through substance use/abuse.^{Footnote 448, Footnote 470} Suicide prevention programs must challenge perceptions of masculinity and men’s reluctance to identify need and/or ask for help. Social marketing tactics can be tailored to inform and encourage men with mental health problems to seek help.^{Footnote 448, Footnote 470} Mental health practitioners and tools used to assess men need to address barriers to seeking help.^{Footnote 470} A review of mental health practices found that more men would seek help for mental health issues if the programs suited those with traditional male gender roles. Traditional counselling that involves discussing issues were found to be less effective than structured interventions. Cognitive behavioural therapy, for example, encourages individuals to replace traditional coping skills with adaptive behaviours that replace adverse norms (such as not sharing negative thoughts) with more effective processes that engage coping.^{Footnote 448, Footnote 470} Broad-based media campaigns that challenge male norms must be intensive and target the at-risk populations.^{Footnote 448, Footnote 470}

Reducing mental health stigma and increasing access to care

Stigma for any reason – a health issue, culture, gender, sexual orientation – can affect many and can occur in a variety of settings. Mental health stigma is the result of poor understanding that leads to prejudice and discrimination, and many individuals who have a mental illness or a mental health problem have experienced stigma.^{Footnote 471} Stigma can negatively affect an individual's ability to develop holistically, socialize, go to school, work and volunteer, and seek care and treatment.^{Footnote 471-Footnote 473}

Among social constructs, gender and sexuality can be tools used to shape status hierarchy whereby, some may be less likely to attain positions of power and leadership among specific groups.^{Footnote 217, Footnote 474} Level of status can manifest into other forms of inequality such as the value placed on symptoms and outcomes and how to interact with health care providers. Since stigma affects many life opportunities, research and programs must account for a range of outcomes.^{Footnote 217, Footnote 471} A full assessment of the impacts must also recognize that many stigmatizing circumstances may have contributed to that outcome.^{Footnote 474}

Several approaches have had promise in breaking down mental health-related stigma. Early education (focusing on primary school and then high school) and increasing awareness of mental health disorders can challenge misconceptions about mental illness and reduce associated stigma.^{Footnote 471, Footnote 475} Teaching children and youth about mental illnesses can promote empathy and acceptance before negative attitudes emerge.^{Footnote 471} Early education interventions have also been shown to have greater benefits in reducing stigma rather than broad population-based initiatives.^{Footnote 471} Programs such as Roots of Empathy (profiled in the CPHO’s Report on the State of Public Health, 2009) have been shown to significantly reduce levels of aggression among school children from kindergarten to Grade 8 by raising social/emotional competence and increasing empathy.^{Footnote 476, Footnote 477} Simultaneously, learning about discrimination (regardless of disease, social status, sex, sexual orientation, gender identity, race or age) can help establish equitable practices that individuals can adopt into other areas of their lives across the lifecourse (e.g. workplace).

An American study found that gender roles can moderate the extent of stigma.^{Footnote 478} For example, stereotypes concerning substance abuse and violence/aggression generally fall along gender lines. The study results consistently showed that gender-atypical mental illness-related symptoms (i.e. those that are not expected) evoke positive responses, more sympathy and a greater sense of support. On the other hand, individuals with gender-typical (i.e. one that is expected) symptoms often received adverse reactions that implied responsibility and blame and were less likely to be seen as having a genuine mental illness.^{Footnote 478} Deviation from typical gender scripts could be perceived as cause of illness. Although this study only addressed broad public perceptions, a greater understanding of the perceptions of the range of mental health practitioners and other care providers have about mental health conditions in relation to sex and gender is needed.^{Footnote 478}

Research and programs lag behind in recognizing how masculine norms and stigma influence care and treatment. While there are significant sex and gender differences in mental illness (e.g. brain function, structure and chemistry), to be complete, research should also take into account social pressures and environmental factors. Men typically ignore symptoms, exacerbating disconnections between physical and mental symptoms. For example, physical symptoms such as headaches and digestive problems are not often linked to mental health conditions with the same symptom assessment criteria as they are for women. Traditional views on masculinity have often hidden mental health problems. Perceptions of male roles and responsibilities around being protectors and providers are built upon ideals of strength and stoicism. The social stigma associated with men’s use of mental health services stems from these traditional ideas of masculinity. As a result men do not often show signs and/or acknowledge their own risk factors, have low mental health literacy, and can mask mental health problems with other types of coping strategies and risk behaviours (e.g. substance use and violence).^{Footnote 448, Footnote 470, Footnote 479, Footnote 480}

A population health approach is necessary to address gender-specific risk factors as well as to improve access and delivery of mental health policies and programs.^{Footnote 11, Footnote 481} By expanding the approach to include the social determinants of health, SGBA of gender discrimination, policies and programs can be made more effective.^{Footnote 217} Overall, practices to encourage men to seek care fall across several intervention categories: group education (e.g. discussions and/or awareness building), service-based (e.g. health and social services), community outreach (e.g. awareness and local education as well as informational products) and integrated (a combination of the other three types).^{Footnote 228} Evaluations of these interventions have shown promise in terms of changes in behaviours and attitudes related to sexual health, father-based programs (building relationships with children) and reductions in aggression and violence. Results have also demonstrated the potential for attitudinal changes in areas such as increased contraception, reliance on sexual/reproductive programs and partner communication and decreased physical, sexual and psychological violence toward a partner (self-reported).^{Footnote 228} The results are effective in the short term but this is often a reflection of the short term nature of interventions.^{Footnote 228}

Following consultations with communities, British Columbia’s Northern Health noted key concepts relevant to promoting and delivering men’s health programs. These include:

• supporting and conducting more research on men’s health, risk factors and the access and delivery of health care services;
• consulting with men to understand the environments in which they work and live;
• supporting programs for knowledge translation between research and program delivery;
• creating supportive environments by using clear and relevant messages and by encouraging men to seek information and speak about health on their own terms;
• working within established structures and networks (e.g. workplace safety programs);
• specifically focusing on improving health and social services programs for men at risk as well as access to these; and
• developing and delivering innovative outreach services to involve men in developing programs to meet their needs (e.g. Men’s Night Out).^{Footnote 446, Footnote 482}

Australia’s Centre for Advancement of Men’s Health and the Centre for Rural and Regional Health Education use the Men’s Awareness Network model of health (MAN Model) for disease prevention and health promotion by improving ways for men and young males to access the health care system. The concept of the MAN Model stems from the need to address traditional masculine behaviours regarding health but also acknowledges the non-homogeneity of men and the importance of tailored programs.^{Footnote 483} This evidence-based approach to stimulate community responses to men’s health issues is found in both rural and urban settings where general practitioners and other health care professionals communicate with men about health issues in places where the men congregate. For example, workplace health programs are often used to address strategies of safety, stress and relationships. Adding to the MAN Model, the Lifeskills program extends the program’s reach to include the specific needs and issues of adolescent males.^{Footnote 483-Footnote 485} Programs such as Men’s Night Out adopt the MAN Model to align health promotion activities with items that attract interest. They hold events in licensed locations with invited guest speakers (e.g. sport and television celebrities) to discuss topics that include chronic conditions, parenting, and accessing or navigating the health care system.^{Footnote 483} The adoption of the MAN Model Men’s Health Night program by a range of health organizations in Australia and Canada have exposed large audiences – since its inception it is estimated that more than 80,000 men have participated – to more open discussions about men’s health that have led to an overall increase in visits to the family doctor.^{Footnote 483, Footnote 486} Using the Men’s Night Out program and health check-up practices, the model has also had some success in Australian rural and remote Indigenous communities.^{Footnote 483} The Men’s Night Out program has now been implemented in British Columbia where a series of Men’s Health Nights, workplace programs and Lifeskills sessions were held at several post-secondary institutions.^{Footnote 483}

Raising awareness about the vulnerability of men to depression is a rising trend and is promising to help reduce the stigma attached to mental health. A slowly growing number of focused promotional efforts and networking groups targeting men and their mental health awareness are helping break the silence that has long surrounded this topic. A study in Australia reports that a men-only prompt list for physicians and patients, designed to overcome male reticence and low mental health literacy, assisted 60% of male patients in raising issues with their doctor.^{Footnote 270}

There is a growing interest among researchers in developing preventive interventions aimed at improving workplace health and well-being and to help reduce the burden of absenteeism and lost productivity; however, employers often consider the investment too high.^{Footnote 470}, ^{Footnote 487} The MHCC is working with partners to develop National Standard of Canada for Psychological Health and Safety in the Workplace that will provide organizations with the tools to achieve measurable improvement in psychological health and safety for Canadian employees.^{Footnote 488}-^{Footnote 490}

Canada is making progress in addressing mental health related stigma in Canada and internationally through the development of research initiatives, professional training in mental health stigma, knowledge sharing and identifying and evaluating anti-stigma programs.

• In 2009, the MHCC launched a 10-year anti-stigma/anti-discrimination initiative called Opening Minds. This is the largest systematic effort to reduce the stigma of mental illness in Canada, and MHCC will work with communities, stakeholders and specific at-risk groups.^{Footnote 473} Early evaluations of a number of the Opening Minds programs are on-going. However, the Interior Health Authority of British Columbia evaluated its program using Ontario Central Local Health Integration Networks anti-stigma training program. Among results were changes in attitudes among training participants in areas of social responsibility, disclosure, self-stigma, prejudice and devaluation. Positive results will encourage the use of this anti-stigma training as a resource for delivery and development of future programs.^{Footnote 491}
• A research initiative has been established at Queen’s University (Kingston, Ontario) an anti-stigma research initiative that develops outreach programs.^{Footnote 492}
• In 2012, Canada hosted an international conference gathering 700 researchers, mental health professionals, policy makers and those with experience with mental illness from more than 28 countries. The conference concluded with the message that everyone has a role to play at eliminating stigma that prevents individuals from getting the care they may require.^{Footnote 493, Footnote 494}
• Canada is represented on the World Psychiatric Association section on Stigma and Mental Illness with a Canadian chair and by engaging in activities to reduce stigma and discrimination as well as improve inclusion and access for those with mental illness (and their families).^{Footnote 495}
• Mood Disorders Society of Canada and its project partners have launched a new initiative that offers physicians an accredited online continuing medical education program using a contact based approach based on the best evidence for changing stigmatizing attitudes and behaviours towards people living with mental illnesses.^{Footnote 496}

Sex, gender, healthy relationships and sexual health

Healthy sexuality involves acquiring knowledge, skills and behaviours for positive sexual and reproductive health and experiences across the lifecourse.^{Footnote 497-Footnote 499} It also includes options to avoid negative outcomes (e.g. sexually transmitted infections [STIs] and unplanned pregnancies).^{Footnote 500} Developing and maintaining healthy sexuality often involves a number of complex decisions and relationships.

Building healthy relationships

All healthy relationships – with family, partners and peers – help build resilience and reduce risks for a variety of negative health outcomes.^{Footnote 502-Footnote 504} Interventions that promote healthy relationships should be delivered as early as possible so that young men and women learn to value and understand the importance of respect, equality and harmony with relationships.^{Footnote 505} The CPHO’s Report on the State of Public Health in Canada, 2011 identified the value of developing healthy relationships during adolescence as youth become more involved with peers, initiate sexual relationships and may become parents themselves.^{Footnote 20} Dating relationships are particularly important for the transition into adulthood as such developing healthy and respectable relationships are important to current and future relationships.^{Footnote 506} Although it can occur at any age, youth and young adults may be at higher risk for dating violence, and the most police-reported victims of dating violence are female.^{Footnote 507} To be effective, programs that target at-risk youth need to address a range of individual experiences as well as account for other factors such as gender, culture and sexual orientation. Youth Relationships Project or RESOLVE Alberta, for example, have shown promise in reducing relationship violence by focusing on issues influenced by gender roles.^{Footnote 508-Footnote 510} Communities and schools also play an important role in integrating and increasing the scope of interventions that help young people develop healthy relationships including sexual relationships. In-school programs such as STOP! and PASSAJ offer broad gender-based programs to all youth in Quebec schools.^{Footnote 511} (See the textbox “Addressing youth and violence.”)

Addressing youth and violence

An important aspect of building healthy relationships is the ability to recognize and change unhealthy relationships, including those that involve various forms of violence. Developing healthy relationships may involve challenging harmful gender stereotypes and sharing power in intimate relationships.^{Footnote 521, Footnote 522} For example, within heterosexual sexual relationships, women are stereotypically portrayed as being responsible for contraception use.^{Footnote 253} Unequal and unfair power imbalances within relationships can directly affect decisions about contraceptive methods (e.g. refusal to use condoms).^{Footnote 522} Gender stereotypes and power imbalances can also contribute to violence within intimate relationships. Interventions that have shown promise in supporting the prevention of intimate partner violence are those that provide the tools to ensure the safety of victims and potential victims and that address violence in a broader context of equality, rights and responsibility.^{Footnote 523, Footnote 524} (See the textbox “Healthy Relationships Curriculum – Men for Change.”) Healthy relationships focused on the concerns of sexual and gender minorities can also challenge heteronormative (the view of heterosexuality as the normal or preferred sexual orientation) understandings of relationships, opening up possibilities for expanding sexual health education to address what constitutes healthy relationships for sexual and gender minority youth and adults.^{Footnote 525}

Healthy Relationships Curriculum – Men for Change

Women generally experience higher rates of partner violence than do men; and some sub-populations, including Aboriginal women, have rates higher than that of women in the general population.^{Footnote 530} Intergenerational experiences, poverty, addictions, loss of cultural identity and poor relationship skills may be contributing factors for many in violent relationships.^{Footnote 531}-^{Footnote 533} Access to services and care may be hindered by lack of awareness, geographic location, perceived ineffectiveness or lack of awareness of a program, and complex relationships between the victim, abuser, family and community members.^{Footnote 531}, ^{Footnote 532}

Those who self-identified as gay or lesbian were more than twice as likely as heterosexuals to report having experienced spousal violence, while those who self-identified as bisexual were four times more likely than heterosexuals to self-report spousal violence.^{Footnote 534} Nearly three-quarters of the victims of violence in same-sex partnerships were gay men.^{Footnote 535} However, support networks for men and women experiencing intimate partner violence in same-sex relationships may be limited due to social stigma and isolation.^{Footnote 536}

To address the problem of intimate partner violence, the Government of the Northwest Territories initiated the NWT Action Plan on Family Violence 2003–2008. The goal of this plan was to raise awareness of the issue of family violence specifically towards women and children in Northwest Territories.^{Footnote 537} The plan was extended to the second phase, NWT Family Violence Action Plan: Phase II (2007–2012).^{Footnote 537, Footnote 538} A key initiative within this plan includes research, development and implementation of a pilot program for men who use violence in their relationship.^{Footnote 537, Footnote 538} Although the plan has yet to be formally evaluated, improvements can be seen in terms of awareness and intersectoral collaboration to ensure the vision of the plan is being met.^{Footnote 538}

Communicating: sexualization and healthy relationships

How sexuality is portrayed and described can influence how individuals view themselves and others in relationships. Popular culture media – television, movies, music videos and lyrics, video games and magazines – expose young people to unrealistic body shapes and images. The sexualization of men and women has increased significantly over the past few decades, especially following the development and uptake of the Internet.^{Footnote 539-Footnote 543} Such messages start early: even children and adolescents are being presented with sexualized themes and experience pressure to act and look like adults. For example clothing, video games as well as dolls and action figures, present unrealistic and sexualized body images.^{Footnote 539-Footnote 541, Footnote 543}

Young boys and girls are exposed to sexualized portrayals of young men and women – women more often than men – through the Internet, television, radio and print.^{Footnote 539-Footnote 542, Footnote 544} Girls and young women often misconstrue these images as empowering and as such sexual objectification of women can influence girls to value their sex appeal over other qualities and/or activities.^{Footnote 540, Footnote 541, Footnote 543, Footnote 545} Numerous research studies have demonstrated that the sexualization of women reinforces the lower status of women and contributes to feelings of dissatisfaction among girls and women.^{Footnote 539-Footnote 541, Footnote 545} Girls who have been repeatedly exposed to overly sexualized cultural representations may have their confidence in and comfort with their own bodies undermined and may develop self- and body-image issues such as embarrassment, shame and anxiety.^{Footnote 540, Footnote 541} Likewise, repeated exposure to images of young and muscular males with unrealistic V-shaped torsos emphasizing broad shoulders, developed arms and chest muscles and a slim waist may compromise boys’ self-image and healthy physical development.^{Footnote 541, Footnote 544}

The sexualization of men and women can have negative effects on cognitive and emotional development and can affect their mental and physical health outcomes by contributing to eating disorders, low self-esteem and depression.^{Footnote 539, Footnote 540, Footnote 543, Footnote 545} It can also have a broader implication on relationships with others. Narrow views of female and male attractiveness and other societal effects may exacerbate personal and societal experiences with sexism, sexual harassment and sexual violence.^{Footnote 540, Footnote 544}

Individuals can learn to interpret, challenge and ultimately change the negative effects perpetuated through sexualized and stereotypical portrayals. The United States’ task force, the National Task Force on Girls and Women in the Media was formed to develop steps and goals to promote healthy and positive depictions of girls and women in the media that:

• support age-appropriate education about the negative effects of sexualization of young girls, adolescents and adults;
• promote healthy, balanced and positive images of girls and women in the media; and
• build young girls’ self-esteem and confidence to reject messages that sexualize and objectify them.^{Footnote 546, Footnote 547}

These American-based control measures may have positive effects on Canadians as American television is accessible in many Canadian households. Broad programs to limit the exposure of young girls and boys to radio and television content, including advertising, exists through highly developed codes of ethics and conduct. The Canadian Broadcast Standards Council requires Canadian broadcasters to be sensitive to sex-role stereotyping, refrain from sex exploitation, and portray the intellectual and emotional equality of both sexes.^{Footnote 548-Footnote 550} Regulations in Quebec ban commercial advertising to children under 13 years of age on French language television.^{Footnote 551} However, these measures have no effect on out-of-province transmissions. Measuring the effectiveness of even the strictest controls is challenged by the inability to fully implement practices within a global arena where influences may be sourced outside provincial and national jurisdictions.

Addressing sex and gender stereotypes and sexual health

The discourse of sexuality – the language used to talk about sexual health – rarely includes ideas associated with sexual pleasure and reproduction.^{Footnote 552} Women in particular are exposed to messages that focus on addressing possible adverse outcomes (e.g. STIs, unplanned pregnancy). As a result, public health interventions tend to focus on developing negotiation skills to protect against negative sexual experiences and outcomes rather than positive aspects of sexual interactions and/or pleasure.^{Footnote 552} Sexual health education and discourse also primarily focuses on heterosexual relationships.^{Footnote 552} When non-heterosexual relationships are covered, it is usually in terms of pathologizing such relationships, with gay men as a particular target, or linking them to the spread of STIs and HIV.^{Footnote 552}

A variety of sexual health education interventions have been designed to prevent adverse outcomes, many of which target youth. While the evidence of success is mixed, several practices appear to hold promise:

• In-school educational programs that combine addressing teen pregnancy and preventing STIs have been effective.^{Footnote 553} Efforts that address sexual risk and protective factors as well as non-sexual factors are more likely to positively influence behaviours.^{Footnote 553} Evaluations show that both male and female adolescents who received comprehensive sex education had lower risks for STI acquisition and unintended pregnancy. They also delay the onset of sexual activity compared with those who received abstinence-only or no sex education.^{Footnote 553, Footnote 554}
• Programs that increase the knowledge and skills of parents and community members who interact with youth and have the opportunity to increase youths’ knowledge and information about sexual health.^{Footnote 553, Footnote 555}
• Programs that provide access to health services for all youth and that include diversity (applicable to geographic location, age, gender, sexual orientation and culture) are more effective.
  • Programs that include adolescent boys and young men in sexual health initiatives and encourage open discussions about sexual health are effective.^{Footnote 556, Footnote 557} Too often, prevention programs do not focus on the sexual education of males and their skills with contraception and negotiation. This issue is further complicated by the fact that traditionally young women have been less empowered to negotiate safer sex, even if they know about the positive and negative outcomes.^{Footnote 556-Footnote 558}
  • Programs that improve life opportunities for youth (e.g. relieve boredom, support future outlooks) may also reduce risky sexual behaviour.^{Footnote 558, Footnote 559}
  • Sexual health is an important part of life and sexual health programs could benefit individuals of all ages. Community-based programs that provide support, training and resource materials to parents and adults who work with youth can be effective.^{Footnote 559} In addition, comprehensive sexual education is effective when combined with other programs such as clinical services, counselling and social services to all members of the community regardless of age.^{Footnote 559}

Prevention programs must consider different views and perceptions to be effective. More research is needed to understand young women’s perceptions and experiences concerning early pregnancy, contraceptive practices and access to services.^{Footnote 560} In addition, little is known about young men and their perspectives on women, pregnancy and their role in the family. New male-based prevention programs could help to develop skills, understanding and relationships.^{Footnote 558}

Sexual health campaigns tend to target youth, but similar programs and tactics have not been used for older populations, and a cultural and generational gulf exists when talking about sexuality among older adults.^{Footnote 180, Footnote 182, Footnote 561-Footnote 563} Negative perceptions about older adults’ sexuality persist as do the risks of being uninformed or ineffectively treated. Despite an increase in cases of STIs including HIV infection and AIDS among older adults, interventions designed to prevent infections among this population are rare.^{Footnote 180-Footnote 182, Footnote 562-Footnote 565} Widowed and divorced baby boomers may be starting new relationships and may not have the most recent knowledge on sexual health.^{Footnote 182, Footnote 183, Footnote 561, Footnote 562} Stigma, embarrassment and discrimination can lead to additional barriers for older adults (particularly women), to discuss sexual health with their health care providers.^{Footnote 180, Footnote 182, Footnote 183, Footnote 562} A United States study showed that a large majority of women agreed that physicians should ask older patients about their sex lives, but nearly one-half had not talked about sex and fewer still were offered an HIV or STI test.^{Footnote 180, Footnote 181, Footnote 183} General practitioners reported being reluctant to discuss sex and STIs with older (particularly female) patients, and caregivers also reported difficulties addressing older adults’ sexual health issues especially those of older women.^{Footnote 181-Footnote 183, Footnote 562, Footnote 564, Footnote 565} Researchers also tend to ignore this segment of the population (e.g. STI risk reduction clinical trials do not typically include older people).^{Footnote 564, Footnote 565}

Social marketing campaigns can be used to proactively address negative perceptions of sexual health, gender and age.^{Footnote 566} Seniors a GOGO is an example of a Canadian program that is raising awareness and challenging stereotypes about age, gender, diversity and sex in a creative way. (See the textbox “Raising awareness about age, gender and sexual health.”) Further developments have led to age and sex sensitivity training for health care professionals in Alberta.^{Footnote 567}

Raising awareness about age, gender and sexual health

Traditional gendered constructs of sexuality focus either on “performance” or on “lack of interest” based on assumptions about what constitutes “function” and for what outcome.^{Footnote 182} Discussions about older men’s sexual health often focus on improving performance.^{Footnote 182} The release and marketing of erectile dysfunction drugs (e.g. sildenafil) has focused on older men’s sexuality and the importance of male sexual performance, responsiveness and capacity. Studies on sexual enhancement medication seem to perpetrate stereotypes about women’s sexuality.^{Footnote 182, Footnote 574} For example, women’s sexual health is often discussed in a negative context of low libido, chronic disease and sexual abuse.^{Footnote 182} Research indicates that prevalence of female sexual dysfunction may be overestimated with women’s sexuality being measured by standards used to assess men.^{Footnote 574} Promoting gender-sensitive approaches to sexual health to address underlying health issues such as sexual dysfunction in the context of the broader determinants of health is important.^{Footnote 574} While undoubtedly more light needs to be shed on these issues, there are few interventions that focus on healthy sexuality, well-being and aging.

Applying comprehensive sexual health education

Comprehensive sexual health education increases knowledge, understanding, personal insight, motivation and the skills needed to achieve sexual health.^{Footnote 559, Footnote 575} To be effective, sexual health education should be relevant and sensitive to gender experiences.^{Footnote 559} Education and services that have positive sexual health messages that are not exclusively heteronormative have the potential to reach a wider group, rather than stigmatizing more vulnerable sub-populations at risk for poor sexual health outcomes.

The United Nations Educational, Scientific and Cultural Organization (UNESCO) supports starting sexual health education early in childhood and continuing it throughout adolescence. The 2009 two-volume scientific guide International Technical Guidance on Sexuality Education: An Evidence-Informed Approach for Schools, Teachers, and Health Educators provides a detailed rationale for comprehensive sexual health education, identifies evidence-informed characteristics of effective sexual health programs, and describes how to incorporate key sexuality education topics and learning objectives into curriculum and programs designed for children and youth.^{Footnote 576, Footnote 577} This guide also recognizes population diversity, including sexual and gender minorities, the importance of behavioural interventions to promote positive sexual health outcomes, and the need for interventions to occur simultaneously in individual, group and community contexts.^{Footnote 576, Footnote 577}

The Canadian Guidelines for Sexual Health Education state that educational programs are most effective when they are comprehensive in scope to help people achieve positive outcomes (e.g. respect for self and others, self-esteem, non-exploitive sexual relations and making informed reproductive choices) and to avoid negative outcomes (e.g. STIs and HIV infection, sexual coercion, etc.).^{Footnote 559} Age-appropriate school-based sexual health education is an important and cost-effective public health strategy that has, over the long term, been shown to reduce risks of HIV infection and AIDS, other STIs and unplanned pregnancies.^{Footnote 578} Nevertheless, barriers to effective sexual health education remain. These include structural issues with in-school teaching such as allotted teaching time and teaching resources as well as the comfort level of students, teachers, families and the community at large.^{Footnote 575} In addition, gender, sexual orientation and culture combine to create additional barriers. LGBTQ respondents to the Toronto Teen Survey indicated that LGBTQ issues were invisible in sexual health education, for example.^{Footnote 318, Footnote 579} Research on the sexual health education needs of sexual minorities demonstrates the complexity of identity, behaviour and attraction. It also shows that sexuality is complex, diverse and heterogeneous.^{Footnote 580, Footnote 581}

The research and interventions that focus on sexual and gender minority adolescents are largely limited by the predominance of heteronormative approaches to sexuality. More work needs to be done to develop dependable, objective methods for conceptualizing and assessing sexual orientation and gender identity earlier in human development and for recognizing them as complex heterogeneous biological, physiological, psychological, social and cultural constructs.^{Footnote 582-Footnote 585} (See the textbox “Breaking down barriers: sexual minority youth and education.”)

Breaking down barriers: sexual minority youth and education

Addressing sexual health risks

Addressing STIs requires a multi-faceted approach. A systematic review of STI and HIV infection prevention programs indicates four key areas in reducing risky sexual behaviours:

• Target those behaviours that are manageable and attainable as these interventions reduce short- and long-term risky sexual behaviours and can potentially reduce STI and HIV infection rates;^{Footnote 593}, ^{Footnote 594}
• Tailor programs for the target populations as interventions must consider different racial and cultural practices, ages, behavioural risks, developmental levels, sexual orientations and gender identities;^{Footnote 593}, ^{Footnote 594}
• Adapt learning and cognitive theories that include skill-building and increase awareness and self-efficacy to guide choices, skills and communication with partners to learn how to articulate safer sex intentions;^{Footnote 594} and
• Address more than sexual risk by addressing broader determinants of health.^{Footnote 594}

Broad population-based interventions and social marketing campaigns are part of a population health approach, but they do not specifically address sex and gender issues.^{Footnote 595} Most Canadian adults would have been exposed to such broad prevention campaigns for safer sex. Programs like “no glove, no love,” while memorable, are considered prescriptive, as the message is disconnected both from the situation and what drives risky sexual behaviours.^{Footnote 595} Systematic reviews show that while people can recall these kinds of messages, the uptake in terms of modifying behaviours – practicing safer sex – is less successful.^{Footnote 596} While these types of programs can be useful in establishing overall social norms, they can be ineffective in reaching those facing particular barriers to safer sex. This includes individuals from cultures that particularly discourage sexual activity, from LGBTQ communities, or in abusive/aggressive or power-imbalanced relationships.^{Footnote 313} Targeted approaches may be more effective when focused on behaviour modifications while also addressing gender and contextual barriers.^{Footnote 595}

Practicing safer sexual behaviours can also depend on having access to health care and being able to comfortably discuss practices with an available health care practitioner. SGBA has shown that issues surrounding access to sexual health care differs for men and women and also depends on other factors such as sexual orientation and culture.^{Footnote 313} For men, barriers range from concerns about their masculinity being compromised to fears about specimen collection techniques and physical examinations.^{Footnote 313, Footnote 317} For both women and men – and especially young people, sexual minorities, and/or those living in small communities – barriers include privacy concerns, inaccessible clinic hours, homophobia and heteronormative practices.^{Footnote 313} Approaches to preventing HIV infection and AIDS illustrate how applying a sex and gender lens can strengthen public health policies and programs by looking beyond those typically considered at risk to the diversity within sub-populations.^{Footnote 217} Since the introduction of HIV, investments in prevention, care and management practices targeting at-risk populations (e.g. MSM and people who inject drugs) have had some success in decreasing overall rates of infection.^{Footnote 217} However, patterns of infection showed that certain sub-populations (e.g. women), were representing an increasing proportion of positive HIV tests.^{Footnote 175, Footnote 176, Footnote 217} Consideration of sex and gender along with other influencing factors such as age, race, socio-economic factors as well as risk factors (e.g. heterosexual contact and injection drugs) were particularly important to understanding new HIV infections.^{Footnote 175, Footnote 597} As such, applying SGBA allows for a greater understanding of how gender-related roles and responsibilities can describe the potential impacts of HIV and AIDS policies, programs and services.^{Footnote 598}

Some sub-populations experience additional barriers to sexual health services. LGBTQ respondents to the Toronto Teen Survey reported encountering problems accessing sexual health services.^{Footnote 318, Footnote 579} LGBTQ adults may choose to not communicate about their sexual practices with their physician or health care provider for fear of repercussion such as loss of trust with or losing their health care practitioner in areas of limited services.^{Footnote 321, Footnote 599-Footnote 602} Addressing these issues may require targeted campaigns and the provision of new points of service.^{Footnote 318} In addition, it is important for health care professionals to increase their knowledge about the health issues and health inequalities experienced by some sexual and gender minorities that are associated with social factors (e.g. family, school, street violence) and medical factors (e.g. lack of youth’s knowledge of STIs and health care professionals’ possible misunderstanding, bias, and/or homophobia and transphobia).^{Footnote 603-Footnote 606} Certain programs improve access to health care services by coming to where clients work. (See the textbox “Increasing access to sexual health care: the Immigrant Women’s Health Clinic.”)

Increasing access to sexual health care: the Immigrant Women’s Health Clinic

Stigma associated with sexual health topics, in particular STIs, is a significant barrier to testing, early diagnosis, care and access to treatment and support for all ages, genders and sexual orientations.^{Footnote 317} While there is value to providing broad-based information to young people on the risks of STIs and HIV infection, messages tailored to gender, culture, age and sexual orientation are important for at-risk populations. Innovation and creativity are required to better address the sexual health service needs of the Canadian population. The Government of Ontario has published a best practices document to address public health infection control, case management and contact tracing.^{Footnote 611} This document recommends using social networks, social marketing and testing and screening to manage STIs and long-term effects of illness and infertility.^{Footnote 611} The BC Centre for Disease Control recently developed an online sexual health service program including online STI and HIV testing service, which will be launched to complement existing face-to-face clinical services to improve participation in STI and HIV testing.^{Footnote 612}

Risky sexual behaviours are not limited to younger Canadians.^{Footnote 559} The rates of reported STIs have increased among those between 40 and 59 years, most noticeably among men.^{Footnote 169-Footnote 171, Footnote 183, Footnote 253, Footnote 561} Sexual health educational programs must address not only the changing social trends but also sexual practices of older adults. In 2010, the United Kingdom was the first country to launch a national sexual health campaign for those over 50 years old.^{Footnote 613} This program targeted adults who were single and/or dating and possibly not aware that safer sex applies to them.^{Footnote 613} The campaign included posters representing the target demographic, thereby increasing opportunities for self-recognition in the message. As part of this campaign, the United Kingdom’s Family Planning Agency created a guidebook that specifically addresses health and social issues related to sexual health and STIs to help older adults explore old and new relationships.^{Footnote 614}

Section Three: Sex and gender and socio-economic determinants

Looking at sex and gender by selected health outcomes is only part of the broader story, as there are many cumulative factors that directly or indirectly influence health across the lifecourse. In many cases, addressing socio-economic determinants by sex and gender can also make a difference. This section looks at employment and education and how sex and gender influence them. These examples of socio-economic determinants of health were selected for this report because they influence other factors such as income, work-related issues (e.g. stress) and the social sphere in which people interact, and because there are opportunities to make a difference by considering the influence of sex and gender in interventions.

Work and employment: health and stereotypes

Often men and women work in different types of jobs.^{Footnote 615} Employment and working conditions, as well as the outcomes of employment (e.g. income), are determinants of health. In its various forms, work – formal and informal, paid and unpaid – can influence individual wealth and social status.^{Footnote 616} Two factors need to be considered: employment conditions (e.g. salary, number of hours, leave opportunities, insurance and benefits) and job content (e.g. tasks, responsibilities).^{Footnote 617}

The effect of gender on how occupational health issues are experienced, expressed, defined and addressed can help identify risk factors for both women and men.^{Footnote 618} Sex- and gender-based stereotyping can increase the health risks for both men and women.^{Footnote 616} Those jobs that are typically considered women’s (and that employ more women) tend to involve higher rates of repetition, agility/dexterity, speed and concentration, whereas men-centric jobs tend to involve more heavy manual labour.^{Footnote 617, Footnote 619-Footnote 621} Risks of injury and disease can be further confounded by biology, workplace seniority, social status, age, tasks, techniques and external life experiences.^{Footnote 616, Footnote 617} Despite the differences, little information is gathered on women’s and men’s work and their long-term health effects based on sex and/or gender. There are assumptions about work and the health risks of work that fall into gender stereotypes of who does what job and the value and associated risks of the work, for example, that women’s work is often not as “risky” as men’s.^{Footnote 616} While men generally experience more occupational accidents, risks still exist for women, particularly in the jobs that can be undervalued by stereotyping.^{Footnote 108, Footnote 616} In cases where men and women perform the same jobs, the tasks, approach and risks can differ within job types and are often gendered, with men and women with the same job title being assigned “light” tasks (e.g. dusting, mopping, refilling) and “heavy” tasks (e.g. waxing, washing, cleaning at greater heights). In addition, job-related equipment and protective clothing is generally designed for men’s physiques and can be a poor match to an average woman’s body and strength.^{Footnote 617, Footnote 619, Footnote 621}

The assumptions about women’s work have biased data collection such that the indicators are not relevant and risk can be reassigned.^{Footnote 616}, ^{Footnote 618} Women are also less likely to receive disability support; almost one-third (29%) of women received no supplemental income during injury-related work absences between 1993 and 2005.^{Footnote 622} Their workplace health is often invisible, a reality that is even more pronounced among recent immigrants.^{Footnote 622} Occupational health and safety programs and standards also often have a sex and gender bias with requirements and equipment developed based on men’s characteristics and workplace-associated risks.^{Footnote 616}

Being able to identify and track workplace injuries, illness and pain relies on having a health and safety program in place that monitors activities. The lack of such a program and other factors (e.g. reluctance of the employee or employer to report problems) means that workplace health outcomes are un- or under-reported. Workers can encounter barriers to reporting; for example, pain and discomfort may be perceived as typical for certain types of work. An imbalance of power may lead to fear of loss of work, wages, respect and an inherent blame for one’s own injury.^{Footnote 620} In particular, evidence shows that women’s occupational injuries and illnesses are under-estimated and underdiagnosed more often than those of men.^{Footnote 616} Compensation claims can often be denied based on the perception that women’s work is a “safe” type of work.^{Footnote 616} Differences also exist between men and women regarding treatment and rehabilitation.^{Footnote 616} Men are more likely to be offered training and access to a range of new jobs and support at home post-injury; women receive rehabilitation benefits for shorter periods of time but are more likely to receive support for stress-related illnesses and musculoskeletal disorders.^{Footnote 616} Conversely, little attention has been paid to men’s mental health issues or occupational health exposures, and the relationships to sexual reproduction are often perceived as female issues.^{Footnote 616} Further, gender perceptions of responsibilities and tasks matter in the workplace and can contribute to adverse outcomes such as harassment, stress and under-promotion especially in fields where there are historically gender stereotypes.^{Footnote 616}, ^{Footnote 623}

Jobs with historical gender roles, such as nurses, flight attendants, construction workers and welders, have difficulty breaking down gender-based stereotypes.^{Footnote 620} For example, male nurses are perceived as better able to lift and engage in the physical elements of the profession than their female counterparts.^{Footnote 617, Footnote 624, Footnote 625} Yet it is this physical requirement that puts male nurses at greater risk. In addition, 46% of male nurses have been physically assaulted by a patient compared with 33% of female nurses.^{Footnote 626} The suggested reasons for this gender difference include that male nurses may have a greater exposure to violent patients and that social norms may perceive men as physically and emotionally stronger as well as protective of colleagues.^{Footnote 626, Footnote 627} Most nurses (60%, and a higher number of males than females) report that their job has high physical demands.^{Footnote 626, Footnote 628} Implementation of injury prevention practices in this field needs to consider sex and gender and the role these play in how injuries occur and how they are managed. A comprehensive gender analysis of workplace experiences is necessary to address the work-life issues relevant to retaining male and female nurses in the field as well as increasing the number of male nurses (in order to reach the Toward 2020 goal of 10% of all Canadian nurses be male).^{Footnote 629} The latter requires addressing gendered stereotypes in training, promotion and practices.

Challenging gender stereotypes and addressing gender bias is necessary to attract and retain individuals in non-traditional fields.^{Footnote 627} Workplace interventions need to acknowledge the realities of work such as risk, location and the role of confounding factors (e.g. environment, assumptions). The approaches must take care not to isolate those whose job content is outside of the norm by engaging smaller populations with relevant approaches where appropriate. For example, while women may have the largest component of the health nursing services sector, it is important to understand that men are a significant minority with different levels of risk that should be addressed with specified intervention.^{Footnote 628}

Gender and informal work: supporting caregivers

Many Canadians participate in unpaid and informal work such as caregiving. Informal care providers play a vital role in raising children and assisting elderly adults in their daily activities.^{Footnote 630}, ^{Footnote 631} In 2006, more women than men (56% and 43% respectively) provide some type of informal care, and women spend more than double the number of hours (23 million hours altogether) providing informal care.^{Footnote 230}, ^{Footnote 231} Social factors such as cultural roles, social norms and employment status contribute to the perception that caregiving is a feminine role. Canadian survey data does show a balance between men and women and the provision of care to elderly family members.^{Footnote 632} However, the type of care differs based on gender roles and expectations. Men typically perform tasks external to the home such as maintenance and outdoor work; women perform more personal care and tasks that take place inside the home.^{Footnote 230}, ^{Footnote 231}, ^{Footnote 437}, ^{Footnote 632}, ^{Footnote 633}

Most caregivers report that they are generally coping or coping very well with their caregiving responsibilities and find it rewarding. However, some experience adverse health and social outcomes.^{Footnote 230, Footnote 231, Footnote 632, Footnote 634, Footnote 635} Caregiving can negatively affect paid employment (especially for those who care for their family) as their responsibilities may prevent caregivers from working outside of the home and/or they have to reduce or change their hours of work.^{Footnote 230, Footnote 231, Footnote 634} Caregivers may also incur expenses that are not reimbursed and may experience social isolation and/or poorer health.^{Footnote 230, Footnote 231, Footnote 634} Women in particular were more likely to report negative health outcomes as a result of their caregiving. They also had to make changes to their employment (in terms of numbers of hours and work patterns) in order to meet caregiving demands.^{Footnote 230, Footnote 231, Footnote 634, Footnote 635} Many women also report experiencing the stress of being in the “sandwich generation,” that is, caring for children at the same time as caring for aging family members.^{Footnote 636} One factor that contributes to the adverse impact of caregiving is the intensity with which people undertake their responsibilities. Those who caregive for under ten hours per week experience fewer adverse effects in terms of their participation in the labour force.^{Footnote 230, Footnote 231, Footnote 637}

Overall, the proportion of male caregivers has been increasing, with men often caring more for partners with mental health issues and dementia than they had in the past. Men in caregiving roles have fewer opportunities for community support and less social services. Research on programs to support male caregivers is limited given their lack of recognition in this role.^{Footnote 634} Men in same-sex partnerships find that support for caregivers is particularly limited by the lack of benefits, the stigma associated with certain diseases and illnesses (e.g. HIV and mental health issues) and limited access to caregiving supports that usually focus on women or individuals in heterosexual couples.^{Footnote 638}

Supporting caregivers is complex, as individual and situational needs vary and addressing needs involves many players including governments, employers, communities and individuals. Several programs exist in Canada to support caregivers which vary from financial support (including wages, tax relief and labour policies) to community supports and services.^{Footnote 639} Labour policies, such as expanded and flexible paid leave for caregiving, are believed to help balance work and caregiver tasks. Canada's Employment Insurance Compassionate Care Benefit provides financial support to caregivers who require time away from their jobs to take care of gravely ill family members or friends.^{Footnote 639, Footnote 640} The federal government provides a range of supports, including the Caregiver Tax Credit, the Eligible Dependant Tax Credit and the Infirm Dependant Tax Credit, and the transfer of the unused amount of the Disability Tax Credit which recognize the reduced ability of caregivers to earn and consequently pay income tax as a result of supporting a dependant.^{Footnote 639, Footnote 641-Footnote 645} Tax recognition for a dependent spouse is also provided through the Spousal Credit.^{Footnote 646} Under the Medical Expense Tax Credit, caregivers can claim up to $10,000 in eligible medical expenses on behalf of a dependent relative.^{Footnote 647, Footnote 648} In addition, some employers also offer a variety of flexible work arrangements for employees with family and caregiving responsibilities (e.g. telework, flexible work hours, on-site adult daycare centres) so that employees can better balance work and care responsibilities.^{Footnote 649} These kinds of flexible workplace initiatives can be mutually beneficial by reducing costs as a result of absenteeism, higher rates of illness among working caregivers and the loss of skilled employees to their caregiving responsibilities.^{Footnote 650}

Results of a meta-analysis of caregiver interventions determined that supportive interventions were effective but that the effectiveness was dependent on other factors including gender and ethnicity as well as program deliverables (e.g. duration, setting).^{Footnote 651, Footnote 652} However, the effects of the interventions were specific to caregivers and not global in outcome, and most effective interventions were tailored to the specific needs of caregivers of individuals with dementia.^{Footnote 651, Footnote 653} Further studies revealed that including gender and acknowledging gender roles that influence stress and coping strategies was effective in reducing the burden to caregivers experiencing stress and coping difficulties.^{Footnote 653} While mechanisms are in place to support caregivers, needs related to gender roles – impact, burden and outcomes – are not often considered in terms of the caregiver and the recipient. Gender influences the broader determinants of health and can have lasting lifelong effects. 

Considering sex and gender in education

Education is an underlying determinant for many future health outcomes. As with other social determinants, sex and gender make a difference in how education is approached and used. Hence they have positive long-term health influences.^{Footnote 10}

Young males and females drop out of school for different reasons. Young men often leave school to work, and young women often leave due to pregnancy and childcare requirements.^{Footnote 654} However, despite their continued higher high school drop-out rates, a greater proportion of young men who drop out do return to successfully complete their schooling later.^{Footnote 91, Footnote 655} Thus, interventions that target youth to stay in school and pursue training and post-secondary education must consider the roles that sex and gender play.

Despite overall educational successes, questions remain as to why boys are not faring as well as girls.^{Footnote 654} The Programme for International Student Assessment (PISA) showed that a large international sample of 15-year-old girls performed significantly better than their male counterparts on reading tests across participant countries.^{Footnote 654} Boys scored slightly higher in math and science, but the differences in these scores were much smaller than those for reading.^{Footnote 654}

Applying a sex and gender lens to educational attainment suggests looking at the criteria used to measure success and checking for possible gender bias in this measurement; the factors that encourage in-school participation and academic practices and the suitability of activities for gender and diversity; gender roles and expectations after graduation; perceptions of success; and teaching methods and suitability to learning styles by gender and behaviour and management. To varying degrees all of these reasons have been cited for differences in academic performance and outcomes. However, addressing issues of performance involves the consideration of sex and gender as well as other factors.^{Footnote 654}, ^{Footnote 656} Broad interventions assume homogeneous populations of girls and boys and may ignore diversity. For example, boys’ academic outcomes can be influenced by culture as those who are recent immigrants achieve higher academic standards than do boys (and girls) of the same age in the overall population.^{Footnote 657}

In addition, traditional learning structures may not be conducive to some children learning in academic institutions.^{Footnote 656} Evidence shows that schools that offer physical activity programs within daily routine are better able to meet the needs of all children but especially those who are often distracted. Physical activity programs provide opportunities to feel healthy, expend energy and refocus activities that are particularly effective for boys’ academic performance. Social factors are also important contributors.^{Footnote 656} Pressure to conform to expected performance indicators by peers and/or parents and teachers – for boys to be uninterested in academics and/or for girls to want to achieve academically – may influence how boys and girls respond in school and to peers.

Similarly, coming from a disadvantaged household (e.g. lower income, lower educational attainment) may be a motivating factor.^{Footnote 656}, ^{Footnote 658} Girls overcome adversity more often than do boys; for boys the lack of support and resources is more often detrimental to their academic achievement. For some girls family expectations for achieving high academic performance encourage positive outcomes; for others, repeated messages of failure are counterproductive.^{Footnote 658} Some girls from families where the educating of girls is not held in high regard also tend to have lower academic outcomes.^{Footnote 656} The perceived normalcy of boys misbehaving and performing poorly in school (“boys will be boys”) results in negative stereotypes that reduce academic achievement and interest.^{Footnote 656} Strong role models at home are important for all children to achieve academically and socially, and for boys in particular male role models can positively influence their academic performance.^{Footnote 656}

Supporting fathers

The role that fathers play in parenting and building healthy relationships should not be under-estimated.^{Footnote 659}, ^{Footnote 660} Where fathers are positively involved, outcomes in children’s cognitive, emotional, relational and physical well-being are also positive.^{Footnote 659}-^{Footnote 661} People who identify as fathers, regardless of sex, gender and/or sexual orientation play key roles in the lives of children, family and the greater community.^{Footnote 660}, ^{Footnote 662}, ^{Footnote 663} In particular, boys with strong relationships with their father and/or male mentors have greater success in school and in relationships with others.^{Footnote 656} In general, perceptions of fatherhood and masculinity are changing as roles and responsibilities in society and families are changing. Being a good father used to be equated with being a good worker and provider; however, fathers who are directly involved with their children define being a good father as being a good role model.^{Footnote 659}, ^{Footnote 661}

Over time, several reasons have been cited for less paternal involvement including limited and disruptions to parenting, adverse policies on child welfare (e.g. residential schools), employment models (e.g. lack of parental supports for fathers), social norms (e.g. men not being the primary caretaker) and issues around guardianship.^{Footnote 659, Footnote 660, Footnote 662}

The experiences of many Aboriginal peoples provide examples of the importance of fathering. The introduction of residential school systems disrupted parenting in many First Nations, Inuit and Métis families as well as the cultural, linguistic, spiritual and family practices that were passed down through generations by parents, affecting individual health and well-being.^{Footnote 154, Footnote 662} Out of every six First Nations children, one has one or more parents who attended residential school, and almost 60% have one or more grandparents who attended a residential school.^{Footnote 154} Thus many Aboriginal men who were first- or second-generation residential school survivors lacked positive role models to teach them about parenting, communicating, showing affection and developing coping strategies, and there are few community supports and resources to provide information and skills in the absence of familial connections.^{Footnote 662, Footnote 664} To address these effects, promising parenting programs are developing among Aboriginal peoples that include traditional practices and aspects of Aboriginal spirituality (e.g. traditional drumming, dancing, healing ceremonies, and hunting and fishing) that are working towards engaging fathers and integrating them and their children into the cultural traditions.^{Footnote 662} (See the textbox “Supporting Aboriginal fathers.”)

Supporting Aboriginal fathers

Addressing fatherhood diversity is also important. New and promising initiatives such as Toronto’s Young and Potential Fathers Initiative (YPF) address cycles of socio-economic factors, a lack of resources and few role models for young, racialized fathers in a disadvantaged neighbourhood.^{Footnote 668}, ^{Footnote 669} The program connects young fathers with a range of community health and social services (e.g. employment services, money management, parenting skills and legal aid); as well as provides spaces for fathers to interact with their children, other fathers and mentors.^{Footnote 669}, ^{Footnote 670}

Over time society’s view on father involvement has evolved. Since the 1970s, Canadian fathers have become increasingly more involved in their children’s activities and lives, as a result of a number of factors including mothers working outside of the family home, greater gender equity, the need for fathers to socially and practically support partners and fathers’ desire to be involved with their children.^{Footnote 671} As well Canada, as a society, has made some progress in supporting research and/or programs on fatherhood. Interventions that target fathers are continuing to grow and recognize the importance of fathers to the health and well-being of Canadians.^{Footnote 671} (See the textbox “Acknowledging the importance of fathers’ involvement.”)

Acknowledging the importance of fathers’ involvement

The past decade has seen a significant expansion in academic interest in father involvement, efforts to be more inclusive and supportive of fathers in programs and services for families, the level of knowledge about fathers’ experiences as parents and how to support them. However, more can be done to see that knowledge about father involvement is disseminated to professionals and policymakers who wish to support families and healthy child development.^{Footnote 680}

Summary

Considering sex and gender in public health interventions is important. This chapter highlights examples of broad and targeted research, programs and policies where sex and gender influence health outcomes and the socio-economic determinants of health. There is a need for sex- and gender-based approaches that move past perceptions of male and female dichotomies to encompass factors such as gender norms and identities, masculinities/femininities as well as sexual/gender diversity.

Canada has made progress in incorporating sex and gender considerations into research as well as a variety of public health practices, but many challenges remain. The first section of this chapter sets out the value of considering sex and gender in public health interventions. Examples such as the HPV intervention illustrate that applying a sex and gender lens can provide a range of perspectives towards health and wellness interventions. In the second section, examples of physical, mental and sexual health outcomes illustrate where sex- and gender-based approaches can be applied and where diversity within sub-populations is also important. Examples of effectively considering sex and gender in the formulation and implementation of safer sex messages has encouraged taking into account other relevant factors such as age, culture and sexual orientation. The third section considers the role that sex and gender play in the determinants of health, and how programs and policies can address socio-economic inequalities that have the potential to positively affect health. Programs that support parents provide opportunities to positively influence the health and well-being of children as well as the parents themselves.

The path that considers and incorporates sex and gender interventions into future public health interventions will be challenging as interventions evolve to:

• show that sex and gender influence everyone’s health and well-being;
• challenge existing assumptions and stereotypes about disease and sex and gender (namely that applying a sex and gender lens is not solely about adding a women’s component);
• move towards programs that encompass sex and gender together with other forms of diversity in order to remove barriers and reduce stigma; and
• expand capacity, capture more relevant data and develop and evaluate programs that include sex, gender and diversity.