Intended for healthcare professionals

Analysis Leaving No One Behind

Structural determinants of gender inequality: why they matter for adolescent girls’ sexual and reproductive health

BMJ 2020; 368 doi: (Published 27 January 2020) Cite this as: BMJ 2020;368:l6985

Read our Leaving No One Behind collection

  1. Asha S George, South African research chair in health systems, complexity, and social change1,
  2. Avni Amin, violence against women technical officer2,
  3. Claudia Marques de Abreu Lopes, research fellow3,
  4. T K Sundari Ravindran, principal visiting fellow3 4
  1. 1School of Public Health, University of the Western Cape, Bellville, South Africa
  2. 2Department of Reproductive Health Research World Health Organization, Geneva, Switzerland
  3. 3United Nations University-International Institute for Global Health, Kuala Lumpur, Malaysia
  4. 4School of Public Health, University of Witwatersrand, Johannesburg, South Africa
  1. Correspondence to: A S George asgeorge{at}

More comprehensive understanding of gender inequality is required, particularly the broader structural drivers that underpin the political economy of gender power relations, say Asha George and colleagues

In sub-Saharan Africa, four out five new HIV infections among 15-19 year olds are in girls according to UNAIDS 2019 estimates.1 Surveys during 2011-16 showed that more than half of rural women aged 15–24 in sub-Saharan Africa had been pregnant before their 18th birthday,2 and as recently as 2016, 40% of young women in sub-Saharan Africa and 30% in South Asia were married while still children.3 These examples highlight how gender power relations profoundly affect adolescent girls with lifelong consequences.

Research on gender inequality in global health has focused on factors operating at the individual level (age of marriage, literacy, etc), household level (decision making, household composition4), or community level (social norms,56 access to services78). Although gender inequality is experienced by and between individuals, it is also a result of power relations that structure how societies are organised, laws are set, economies function, and ideologies are shaped.9 We review some of these structural determinants of gender inequality, unpacking what they are and why they matter, with a focus on the sexual and reproductive health of adolescent girls.

Puberty is a formative period of rapid physical, cognitive, social, emotional, and sexual development, when differences in gender roles and gender inequalities become ingrained.10 These influence adolescent mortality and risk factors everywhere but particularly in low income countries (tables 1 and 2). Gender norms that encourage men to be strong and take risks partly explain the health harming risk behaviours of boys.1112 Gender inequalities are also particularly harmful to the sexual and reproductive health of adolescent girls and reverberate with lifelong effects.

View this table:
Table 1

Leading causes …

View Full Text