Exploring the gender gap in adolescent mental health

Previous studies have consistently shown a gender gap in mental health, with girls tending to report worse mental health compared to boys during childhood and adolescence. But, most of the data come from a small number of high-income Western countries. Researchers reporting in Elsevier’s journal SSM - Population Health opens in new tab/window have now looked to cross-national data to ask a critical question: Does the gender gap differ across regions or countries? “The thing about this paper and its findings that makes it interesting is the fact that the gender gap wasn’t consistent and is hence not ubiquitous,” says Praveetha Patalay of University College London. “If it was purely biological, you’d expect it to be similar across countries.” Patalay along with first author of the new study Olympia Campbell and co-author David Bann set out to examine the relationship between gender equality and the mental health gap in adolescents. They wanted to investigate this relationship in a broad sampling of countries, including low- and middle-income countries. While most earlier studies looked at just one measure of mental health, they wanted to capture mental health not just as an absence of mental illness but also as a state of wellbeing along a continuum. The researchers looked to the 2018 Programme for International Student Assessment (PISA). PISA is a multi-country study that surveys students at age 15 about their educational attainment and characteristics of their life. For the first time in 2018, the PISA study included multiple questions related to mental health. Participants were asked about 1) how satisfied they were with their life as whole, 2) how often they felt sadness, misery or fear, 3) how often they felt happy, lively, proud or cheerful, and 4) about their sense of meaning in life. Altogether, the data represent 73 countries and more than 565,000 adolescents.

The Atlas-winning researchers examined the data in search of differences between genders on these measures of mental health. They also looked for patterns related to wealth, inequality, and societal indicators of gender inequality. Their analyses led to four main results:

• The gender gap, with girls having poor mental health compared to boys, is found in the vast majority of countries.

• However, the size of the gender gap varies quite a lot, actually pointing in the opposite direction in a small number of countries.

• Wealthier countries have worse mental health outcomes and a larger gender gap than middle- or low-income countries.

• More gender equal countries also have larger gender gaps across all mental health outcomes.

Does that mean that gender equality isn’t all that? The researchers say that’s not the answer. “It’s important to note that we have no countries with full gender equality,” Campbell said. “There is no country in existence with perfect gender equality.’ Patalay says one possible explanation for worse mental health in wealthier, more gender equal countries may stem from a greater sense of dissatisfaction among girls in countries that espouse gender equality and yet fall short of that goal. Overall, the “findings point to the complex nature of gender disparities in mental health and possible incongruence between expectations and reality in more gender equal countries,” the researchers write. In future studies, they hope to explore the factors that drive the decline in girls mental health in adolescence, including violence and harassment, as well as differences among countries that may explain the variation in gap size and, in some cases, direction. Campbell reports that she’s also exploring connections between marriage practices and gender-based violence.

A conversation with Olympia Campbell and Praveetha Patalay

I talked with Olympia Campbell and Praveetha Patalay, co-authors of the Atlas-winning paper, about the gender gap in adolescent mental health across 73 countries, what their findings suggest about the causes of this gap, and their continued work in this area.

What else should we know about the data?

Olympia Campbell: This is dataset that's not been used for looking at mental health. It's a dataset that's normally used for comparing education between countries. Staring in 2018, the PISA study added questions on mental health, and it's a dataset looking at the whole distribution of mental health rather than clinical outcomes. That's a strength. We're not looking at clinical anxiety or depression. It's the whole spectrum of mental health.

Can you talk more about what you found? What struck you the most?

Praveetha Patalay: What I found most interesting is that the gap is so variable and heterogeneous and in some places it was flipped. So, there are countries in which 15-year-old boys had worse mental health than 15-year-old girls. It challenges the main psychiatric way of thinking that women just have worse mental health because they do and it's nothing to do with what they experience or how society is structured. When I talk about the findings in the context of my other mental health research that is the bit that people occasionally comment on. Most mental health research has been conducted in industrialized, Western, white majority countries. The assumption is that the findings in these countries is universal. The finding that it's not universal is, for me, the most important contribution.

Olympia Campbell: What some others seem most taken by, and it’s quite nuanced, is the fact that it is more gender equal countries that appear to have larger gaps, with worse mental health outcomes for girls in more gender equal countries across our mental health measures, aside from life satisfaction. People picked up on this and it feeds into the narrative that’s popular at the moment that maybe gender equality isn’t all that. That’s not what we’re saying at all. But, it got picked up a little bit on twitter on that theme. It’s important to note that we have no countries with full gender equality. There is no country in existence with perfect gender equality. It also might be a more U-shaped distribution. Perhaps in the middle ground of gender equality, female mental health decreases and perhaps it would increase again as gender equality increased further—if there’s a causal link at all.

Praveetha Patalay: There’ve also been reasons proposed for why in medium-equality countries these gaps in mental health might be wider. This includes the gap between expectations and reality. If you think about countries with the highest gender equality, you grow up expecting gender equality but there still isn’t.

What we also miss is the blank space where gender equal countries don’t exist. That’s the problem. There isn’t a country yet in which there’s perfect gender equality, so we don’t know what the rest of the scale looks like. We know what it looks like going from really bad to OK. We see there’s a widening gap, but we don’t know what happens if you go from OK gender equality to really good because we don’t have that yet in any country.

How would you like to see the work put into practice? What are you planning to do next with it?

Praveetha Patalay: The hope is that it ignites more discussion and research into the drivers of the gender gap rather than assuming that it’s there and so let’s not care about it, which is how it’s been for a long time. That could reflect on research practice but also wider practice. Taking findings from some countries and generalizing isn’t good. Even here, there are many countries we don’t have. We still have primarily middle- and high-income countries. We have no country in Africa.

My research broadly is in inequalities in mental health. One of the things we’re working on, for example, is to look at sexual violence in early adolescence. There’s lots of evidence on gender-based violence in adults and child sexual abuse. But, there’s not so much on the kind of peer-to-peer and general harassment that teenage girls face as they go from puberty to adolescence and the impact that has on mental health. I’m doing some work at the moment trying to look at these experiences in the adolescent period and mental health.

We’re trying to think of more social things that could be drivers of the gender gap and sexual violence is an obvious one because it’s very gendered. There’s lots of focus already placed on body satisfaction and body image. Everybody automatically assumes it’s driven by appearance norms and pressures. But I think to focus only on that is limiting. There are so many other things that are really gendered and violence is one of those.

Olympia Campbell: This was the first paper I ever wrote and my first work on mental health as well. I’m also now looking at gender-based violence. It’s not strictly related to mental health, but I’m looking at the relationship between marriage practices in different ecologies and the rate of gender-based violence.

Is there anything else you’d like for general audiences to think about or know regarding your work?

Olympia Campbell: I find it interesting that, for people who work in mental health research, it’s well known that women have worse mental health. Among the general public, I think it’s less well known. A lot of friends were like, ‘Since when do women have worse mental health?’ And that was surprising. One reason for this is because the suicide rate in men is higher. As a result, it’s often assumed men have worse mental health.

Do women have worse mental health in terms of clinical diagnoses as well?

Praveetha Patalay: Yes, for depression, anxiety, and self harm, women have much higher rates—almost double in lots of countries compared to men. Women also attempt suicide more than men. So suicide rates are higher in young men especially, but pretty much every other related mental health outcome is worse in women.

Has there been a change over time, do we know?

Praveetha Patalay: The data we have is from 2018. The problem is this latest iteration of PISA is the first time they included a range of mental health measures. The study is really about educational attainment and performance. So, right now, you can look at the change over time in education but not mental health. However, this happens every three years. If they carry on with this battery for another few years, we can start to look at time trends. Evidence from other types of studies indicates that the gender gap has been there for quite a few decades. It’s definitely not a new thing. But, we can’t tell yet if there’ve been changes or different rates in different countries with different social systems or social change, which would be very interesting to examine.

Related resources

• Programme for International Student Assessment (PISA) opens in new tab/window

• Mental Health (World Health Organization) opens in new tab/window

• Sustainable Development Goal 5 Gender Equality (United Nations) opens in new tab/window

• Praveetha Patalay (University College London) opens in new tab/window

• Olympia LK Campbell (University College London) opens in new tab/window