hypothesis on discrimination faced by a girl child

Gender and Sexuality Development pp 277–299 Cite as

Gender-Based Discrimination in Childhood and Adolescence

• Christia Spears Brown 4 &
• Michelle J. Tam 4  
• First Online: 31 August 2022

1986 Accesses

1 Citations

Part of the book series: Focus on Sexuality Research ((FOSR))

Gender-based discrimination, which includes any distinction, exclusion, or restriction made on the basis of socially constructed gender roles and norms, or biological sex/gender, gender identity, gender expression, or presumed sexual orientation, is prevalent throughout the world and is often directed at children and adolescents. Because childhood and adolescence are particularly vulnerable periods of development, there can be long-term consequences of experiencing such discrimination. In this chapter, we describe gender-based discrimination as it affects children and adolescents, beginning with a focus on how the field has shifted historically and in conjunction with historical and legal changes. We then detail the different types of gender-based discrimination targeting children and adolescents: discrimination at home, school, and media that involves (a) direct or indirect biased interactions targeting individuals, (b) structural biases within institutions, and (c) cultural expressions of stereotypes and prejudice.

• Gender discrimination
• Sexual harassment
• Adolescence

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Christia Spears Brown & Michelle J. Tam

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Doug P. VanderLaan

Gender Studies Programme and Department of Psychology, Faculty of Social Science, The Chinese University of Hong Kong, Hong Kong, China

Wang Ivy Wong

Spotlight Feature: Children’s Appraisals of Peer Gender Nonconformity

• Karen Man Wa Kwan &
• Wang Ivy Wong 

Department of Psychology, University of Hong Kong, Pok Fu Lam, Hong Kong

Karen Man Wa Kwan

Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong

Many adults encourage boys to play with cars and girls to play with dolls, believing that children should engage in gender-conforming activities. Interestingly, when children possess positive traits, if these traits are gender-nonconforming (e.g., a boy being gentle, well-mannered, eager to soothe hurt feelings), adults tend to perceive them less positively (Coyle et al., 2016). Similar to adults, children’s appraisals of gender-nonconforming peers are also less positive, and such appraisals are further complicated by several factors. One factor is the peers’ gender, with gender-nonconforming boys being more negatively appraised than gender-nonconforming girls (Wallien et al., 2010). Second, compared to feminine characteristics, masculine characteristics are perceived as having higher status in society and higher status members tend to be avoidant of characteristics which are perceived as having lower status (Leaper, 1994). This might explain why boys who show feminine characteristics are usually perceived negatively. Third, there are different  domains of gender nonconformity such as appearance, behaviors, traits, gender of playmates, and the appraisals depend on the combination of gender and domain of gender nonconformity. Boys with feminine appearance are perceived more negatively than girls with masculine appearance while girls who prefer masculine play activities are perceived more negatively than boys who prefer feminine play activities (Blakemore, 2003).

Apart from the above gender-related factors, age is another factor influencing children’s appraisals of gender nonconformity. Research shows that children, especially younger children aged 5 to 6 years old, are rigid in abiding to the gender norms (Trautner et al., 2005). Some children even act as gender police to correct other children’s gender-nonconforming behaviors. As children grow older, they begin to understand that both boys and girls can perform counter gender-stereotypical activities (Signorella et al., 1993). As a result of increasing gender-stereotypical knowledge and cognitive flexibility with age, children might become more accepting of gender-nonconforming peers. On the contrary, research found that older children tend to be less positive towards gender nonconformity than younger children (Carter & McCloskey, 1984). This suggests that children may not naturally grow out of their bias against gender nonconformity despite more advanced cognitive ability to understand the existence of diversity.

Bias against gender nonconformity may be a call for concern given that gender nonconformity is in fact common in the population. Although extreme gender nonconformity that constitutes gender dysphoria may be rare, research found that around 20% of boys and 40% of girls of school age show at least ten gender-nonconforming behaviors (Sandberg et al., 1993; Yu & Winter, 2011). Gender nonconformity is associated with mental health risks, of which poor peer relations may be a key contributing factor (Cohen-Kettenis et al., 2003; Kuvalanka et al., 2017). If children’s bias against gender nonconformity can be reduced, it is possible that the psychological well-being of gender-nonconforming children can be improved as well. Research have been conducted to explore ways to reduce gender-based bias. For example, Mundy-Shephard (2015) employed empathy, perspective taking and mere exposure in adolescents and young adults but the intervention could not successfully reduce bias against sexual minorities. Also, Coyle et al. (2016) showed that adults’ appraisals of gender-nonconforming children became more positive if these children were portrayed to possess positive gender-nonconforming characteristics (e.g., an independent girl and a gentle boy). Some studies focused on children’s appraisals but they emphasized appraisals of sexism (e.g., bias against one gender, usually women and girls) instead of gender nonconformity, for example, by training children to respond to others’ sexist comments (Lamb et al., 2009).

A recent study developed an intervention to reduce children’s bias against gender-nonconforming peers. This intervention of presenting positive and gender-conforming attributes of gender-nonconforming peers was successful in reducing bias against gender-nonconforming peers in Hong Kong children aged 8 to 9 years old (Kwan et al., 2020). It is suggested that by simply presenting the gender-nonconforming peers with a diverse range of traits (both gender-conforming and -nonconforming, and traits that would be considered positive such as performing well in school), children became more positive towards them. In fact, every individual, including gender-nonconforming individuals, possesses a diverse range of attributes. However, in our daily life, gender-nonconforming attributes can easily draw attention and children may hardly realize that gender-nonconforming children also share many attributes with them in common. By reminding children of the other attributes of gender-nonconforming children, bias was reduced in this study. Interestingly, although the intervention may be said to have worked by reminding children of the gender-conforming and generally positive attributes of the gender-nonconforming peers, it indirectly led the children to perceive those peers’ gender-nonconforming behaviors as less wrong (or more right) and to be less aversive of engaging in those same activities. The findings from this intervention opened up a gateway to build a more tolerant future generation from a young age.

Interestingly, the same intervention was not successful in reducing bias against gender-nonconforming peers in Canadian participants (MacMullin et al., 2020). Cultural differences in processing contradictory information might provide a possible explanation. Previous research suggested that when receiving contradictory information, Chinese accept the contradiction and adjust their views by finding a “middle” position between the two opposing views, whereas Westerners are more likely to ignore the contradiction and become polarized in their original views (Peng & Nisbett, 1999). The intervention involves presenting opposing information (i.e., peers possessing both gender-conforming/positive attributes and gender-nonconforming attributes). This may explain why only Hong Kong children adjusted their appraisals and became more positive towards gender-nonconforming peers. These suggested the importance of cultural consideration in devising interventions to reduce bias against gender nonconformity.

Different interventions in reducing bias against gender nonconformity in children can be explored in future studies. Meta-analysis of contact-based interventions suggested that both direct and indirect contact of individuals of different ethnicities showed some success in reducing ethnic bias (Lemmer & Wagner, 2015). Ethnicity and gender are both perceptually salient features and children tend to focus on these features when categorizing people into ingroup and outgroup members (Bigler & Liben, 2007). Intergroup contact theory suggested that interactions with outgroup members can lead to more positive attitude towards the outgroup members (Pettigrew & Tropp, 2011). Thus, future studies can explore whether interventions that enhance interactions between children of different gender expressions can potentially reduce bias against gender nonconformity.

There is increasing attention to gender nonconformity globally with research showing increasing prevalence rates in gender nonconformity (Zucker, 2017). Recent studies showed that perception and treatment of gender nonconformity might vary across cultures from early childhood. For example, Hong Kong children showed more consistent bias against gender nonconformity than Canadian children and were more receptive of the particular intervention (Kwan et al., 2020; MacMullin et al., 2020; Nabbijohn et al., 2020). It is worth exploring further how the expression, perception, and treatment of gender nonconformity differ across cultures.

Spotlight references

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Brown, C.S., Tam, M.J. (2022). Gender-Based Discrimination in Childhood and Adolescence. In: VanderLaan, D.P., Wong, W.I. (eds) Gender and Sexuality Development. Focus on Sexuality Research. Springer, Cham. https://doi.org/10.1007/978-3-030-84273-4_10

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Chapter 12: Rights of the Girl Child

Chapter summary.

• Cultural Influences on the Treatment of Girl Children
• Profile: Bogaletch Gebre
• Project: Changing Hearts and Minds: Averting Child Marriage in Yemen

Additional Resources

“The girl child” is one of the critical areas of the 1995 Beijing Platform for Action; girls’ rights are codified within the U.N. Convention on the Rights of the Child and include non-discrimination, protection from harm and abuse, and full participation in family, social, and cultural life. Barriers to realizing these rights include practices such as female genital mutilation (FGM), sex-selective abortions, and child marriage, each of which is common in geographically specific areas.

Dr. Bogaletch Gebre founded the organization Kembatti Mentti Gezzimma-Tope (KMG) to support education and economic opportunity for young women in Ethiopia through fundraising, protest, and community-based research. The Yemeni Women’s Union (YWU) focuses on reproductive health and family planning by running education workshops on the harms of child marriage and pregnancy and engages with families on the risks and long-term implications of these practices. The YWU is one of several organizations which work using different approaches, including media campaigns, advocacy, lobbying, and sharing knowledge through network building, to enhance the effectiveness of strategies to improve the situation of girls worldwide.

• Bogaletch Gebre
• Child marriage
• Female genital mutilation (FGM)
• International Ethiopia-Development through Education
• Kembatti Mentti Gezzimma-Tope (KMG)
• Marriage Without Risks Network (MWRN)
• Safe Age of Marriage Project (SAWP)
• United Nations Convention on the Rights of the Child (UNCRC)
• Yemeni Women’s Union (YWU)

The Girl Child

By Robin N. Haarr

I n many cultures and societies, the girl child is denied her human rights and sometimes her basic needs. She is at increased risk of sexual abuse and exploitation and other harmful practices that negatively affect her survival, development and ability to achieve to her fullest potential. Because girls are particularly vulnerable, they require additional protections. The girl child is one of the 12 critical areas in the 1995 Beijing Platform for Action, which recommends elimination of all forms of discrimination and abuse of girls and protection of their rights.

The Convention on the Rights of the Child, adopted by the United Nations General Assembly in 1989, sets forth the basic human rights of children, usually those under 18 years of age. These rights include nondiscrimination; the right to survival and development of potential; protection from harmful influences, abuses and exploitation; and full participation in family, cultural and social life. The convention also spells out some human rights violations that are unique to the girl child, including discrimination based upon sex, prenatal sex selection, female genital mutilation and early marriage.

Cultural Influences on Treatment of Girl Children

Discrimination and harmful practices against the girl child vary depending upon cultural context. For instance, intentional abortion of female fetuses and female infanticide are common practices in East and South Asian countries where sons are strongly preferred. India and China have a significant sex-ratio imbalance in their populations as a result of these practices, according to the United Nations Population Fund (UNFPA, 2005). In India such practices are reinforced by the perception that daughters are an economic burden on the family. They do not significantly contribute to the family income and large dowries may be expected by in-laws when the girl marries. In China, sex selectivity and abandonment of infant girls have increased dramatically since the enactment of the one-child policy in 1989. Prenatal sex selection is more common where modern medical technology is readily accessible and open to misuse. According to the UNFPA 2004 report, sex-selective abortion and female infanticide have resulted in at least 60 million “missing” girls in Asia. The shortage of females in some Asian countries has led to other problems, such as increased trafficking in women for marriage and sex work. Despite government programs and efforts to end such practices with education, financial incentives and threat of punishment, sex-selective abortion and female infanticide continue.

The status of girls is significantly less than that of boys in some countries. This makes girls more vulnerable to discrimination and neglect. Available indicators reveal that girls are discriminated against from the earliest stages of life in the areas of nutrition, health care, education, family care and protection. Girls are often fed less, particularly when there are diminished food resources. A diet low in calories, protein and nutrients negatively affects girls’ growth and development. Less likely to receive basic health care, they are at increased risk of childhood mortality.

Girls are more likely to be denied education. In 2007, an estimated 101 million children worldwide — the majority of whom were girls — did not attend primary schools (UNICEF, 2010). Africa, the Middle East and South Asia have the largest gender gaps in education. Girls from poor and rural households are especially likely to be denied education. Knowledge and skills needed for employment, empowerment and advancement in status often are withheld because of customary attitudes about educating boys over girls. Girls are more likely to be used as child labor inside and outside of the home. Yet there are many benefits of investing in girls’ education. Healthier families, lower fertility rates, improved economic performance and poverty reduction are among them. Educating girls in a supportive, gender-sensitive environment is critical to achieving gender equality.

The United Nations Population Fund estimates that 100 million to 140 million girls and women have undergone genital mutilation and at least 3 million girls are at risk of the practice every year. Most cases occur in regions of Africa, the Middle East and Asia. In Egypt, it is estimated that 75 percent of girls between 15 and 17 years of age have undergone genital mutilation, a practice which has immediate and long-term negative consequences on girls and women’s health and well-being, and complications can be fatal. Some countries in Africa, Europe and North America have banned genital mutilation; nevertheless, the practice continues.

Child marriage is another human rights violation that occurs in Africa, South and Central Asia and the Middle East. The highest rates are in South Asia and sub-Saharan Africa, where girls are married as early as 7 years of age, but often before 15 or 18 years of age. According to UNICEF statistics, in Bangladesh, the Central African Republic, Chad, Guinea, Mali and Niger more than 60 percent of women married before 18 years of age. In India, 47 percent of women married before 18 years of age. In Yemen, more than 25 percent of girls marry before 15 years of age. Child marriage is a form of sexual abuse that separates girls from family and friends, isolates them socially, restricts education and leaves them vulnerable to violence from husbands and in-laws. Child brides face health risks and even death related to premature forced sex — often with a significantly older husband — and early pregnancies. They are also at increased risk of HIV and other sexually transmitted diseases.

However, grass-roots movements can implement change successfully. An example is the Kembatti Mentti Gezzimma–Tope, spearheaded by Dr. Bogaletch Gebre in Ethiopia to stop genital mutilation. Or the Marriage Without Risk Network in Yemen, which links several NGOs that educate communities and advocate to curb child marriage.

Besides eliminating abuse and discrimination, the Beijing Platform for Action recommends enhanced development and training to improve girl’s status and eliminate their economic exploitation. Awareness of girls’ needs and potential should be improved in society and among the girls themselves so they may participate fully in social, economic and political life. Progress has been made, but much remains to be done to protect girls’ rights and assure them a future in which they may benefit themselves and their communities.

Robin Haarr is a professor of criminal justice at Eastern Kentucky University whose research focuses on violence against women and children and human trafficking, nationally and internationally. She does research and policy work for the United Nations and U.S. embassies and has received several awards for her work, including induction into the Wall of Fame at Michigan State University’s School of Criminal Justice and the Coramae Richey Mann “Inconvenient Woman of the Year” Award from the American Society of Criminology, Division on Women and Crime.

PROFILE: Bogaletch Gebre – Trading New Traditions for Old

By Julia Rosenbaum

Fueled by a dream, Dr. Bogaletch Gebre worked hard with dedication to obtain an education. She became a physician. Ever since, she has worked to empower women in her native Ethiopia, replacing harmful practices with healthy ones — one village at a time.

N o mother, no family would intentionally harm their child,” explains Dr. Bogaletch Gebre, founder of the Kembatti Mentti Gezzimma–Tope (KMG), which means “women of Kembatta working together,” a women’s self-help center in southern Ethiopia. Gebre is a champion of women’s development. She has also worked hard to end female genital mutilation, a traditional practice in Africa.

Boge, as she is called, comes from a farming family in Kembatta, southern Ethiopia. Her father protected the weak, widowed and orphaned in their community, giving to those whose harvest was not enough. She describes her mother as a wise, generous and loving woman who believed people do wrong out of ignorance, “because,” their mother told them, “when one wrongs the other, it hurts oneself more than the one who was wronged.” Like all young women of her day, Boge looked forward to her circumcision ceremony, when, she said, “People would start seeing me differently; looking at me in a new and better light.”

Growing up in a family of 14, she and her younger sister Fikirte were inseparable. They were the first girls in their village to have higher education. Boge attended Hebrew University in Jerusalem on a full scholarship. Later the sisters went to the United States. Boge was a Fulbright Scholar at the University of Massachusetts, where she studied epidemiology and public health. News of the 1984-87 famine in their homeland prompted the sisters to help. Fikirte focused on improving access to clean water for her village. She started a business brewing up tasty sauces and donated part of the profits to her water project. Boge tackled education and livelihood for young women by founding Parents International Ethiopia–Development through Education. She rallied U.S. supporters to end a “book famine” as pervasive as the food famine. She ran fundraising marathons which sent more than 300,000 books on science, medicine and law to Ethiopia.

Boge’s own awakening about genital mutilation grew from the rage and horror over what was done to her as a young woman, what was done to all the girls of her village. “I understood that the purpose of female genital excision was to excise my mind, excise my ability to live my life with all my senses intact,” she said. “I was never meant to be educated, to think for myself, because I am a woman born in a small village in Ethiopia. It’s a system that looks at a woman as an object of servitude. She starts serving her family at the age of 6 — before she even knows who she is. When she marries she is literally sold to the highest bidder. From one servitude to another, we are exploited.”

Boge returned home in 1997 with $5,000 and a vision. With her sister she founded KMG in 1999. The self-help center now includes a skills training center, library, heritage house, a health care center and a guest house and hosts a women’s discussion group. At first they were uncertain about how to realize their vision to break the cycle of violence against women and provide development opportunities.

Boge started with a baseline survey about women’s conditions: health and HIV/AIDS; men’s and women’s education; economic opportunities for women; and female genital mutilation. The results were presented in a community forum where the discussion lit a spark. “Women started speaking out … crying. … Everyone knew the pain and risk of cutting, but perpetuated the practice because they thought it was God-given and was essential if a woman was to be considered marriageable.”

Momentum was building. In June 2002, 78 young schoolgirls marched with placards that read: “I refuse to be circumcised, learn from me.” Two young sweethearts boldly defied tradition, to marry without genital mutilation. They appealed to the local priest, who was already sensitized through KMG outreach. He agreed to support them. At their wedding the bride wore a placard declaring that she was not circumcised, and the groom wore a sign stating his happiness to marry “an uncircumcised, whole girl.” Similar marriages followed, in which couples publicly rejected female genital mutilation. Support groups were formed; there was peer outreach education. “They’ve become our foot soldiers, a social force in their communities,” says Boge. “Girls rally together, singing songs and wearing signs, ‘We are your daughters! Do not harm us.’” A new event introduced in 2004, “Whole Body, Healthy Life — Freedom from Female Genital Excision,” which aims to replace harmful mutilation rituals with life celebrations, has been very well attended. The day is recognized as a freedom day, a new tradition that is celebrated every year.

Today, female genital mutilation has been largely eliminated in KMG’s outreach area of 1.5 million people. A 2008 UNICEF study documents the transformation after a decade of intervention in which female circumcision has dramatically decreased to less than 3 percent. This has been accomplished by law and through education of communities about the harm of the practice.

Boge says that support from KMG has helped communities “to trust and unleash their collective wisdom, thereby recognizing their own capacity to effect measurable and sustainable change. We just need to give them the space.”

Community representatives — students and teachers, boys, girls, literate and illiterate, women and men, midwives, religious leaders, and elders — all meet regularly to discuss concerns, build relationships, share learning and reach consensus. Boge says, “Solutions lie within.” KMG facilitates and encourages discussion. “Once they make their commitments, they abide by them.”

It is a holistic approach, Boge says, that recognizes “the indivisibility of social, cultural, economic and political dynamics that affect societies and women in particular … linking ecology, economy and society.” She adds, “In Kembatta, as in other rural regions, social turmoil, environmental degradation and loss of the traditional income base all reinforce attitudes which victimize women and perpetuate violence against women.”

The success of Bogaletch Gebre has meant broader influence of the KMG model in other regions and countries and in policymaking. “We don’t need miracles,” she says. “We need commitment to action, creativity and hard work. And, of course, we need to support each other, as people who share this one world.”

“My dream for African women? That the world realizes that women’s suppression is no good for business, for the economy, nor for human development. We must end gender apartheid,” she says.

Julia Rosenbaum is senior program officer, Health, Population and Nutrition Group, for the Washington-based Academy for Educational Development. She provides technical input and management to global maternal and child health programs. She has worked in Ethiopia for the past six years through USAID’s Hygiene Improvement Project on community-led approaches for hygiene and sanitation improvement and related HIV care and support programs.

PROJECT: Changing Hearts and Minds – Averting Child Marriage in Yemen

By Dalia Al-Eryani and Laurel Lundstrom

Child marriage is one of the biggest threats to young girls in Yemen. It often prevents them from getting an education and following their dreams. It can be devastating physically, psychologically, economically and socially. Local organizations work to improve the prospects of girls by ensuring that they remain unmarried and in school.

S he speaks from the heart, like a typical 8-year-old. “I want to be a doctor,” says Arwa (not her real name), revealing a gap in her smile from a missing baby tooth. But her future is not her own.

“I want to work with all sick people,” she quietly insists. “I don’t want to get married at all. I want to stay with my mother.” Despite her dreams, Arwa already understands that the desires of her grandfather will more likely dictate her future.

And her grandfather has different plans. He has already betrothed Arwa to her cousin. Like most child brides, she will not continue with her education. She will be taken from her mother, forced out of school and required to abandon any aspirations of a medical career.

“The greatest problem facing Yemeni women today is child marriages,” says Wafa Ahmad Ali of the Yemeni Women’s Union (YWU), one of several local nongovernmental organizations (NGOs) trying to change the prospects of young girls like Arwa by ensuring they remain unmarried and in school until they are at least 18. The YWU is reaching out to Arwa’s grandfather, hoping he will allow her to live out her dreams. The YWU has helped avert the marriages of 79 children in 2009-2010, through an initiative called the “Safe Age of Marriage” Project.

The YWU works with the Extending Service Delivery Project, which focuses on reproductive health and family planning, and the Basic Health Services Project to transform the opinions of religious leaders, community leaders and families to value girls’ education over early marriage. It’s not an easy task. The YWU faces resistance from community members who think the organization is “meddling with local norms and traditions,” says Wafa Ali. Poverty and conservative views about the role of women are also problems.

Coordinators from the YWU oversee a team of 40 volunteer community educators — 20 men and 20 women — concentrated in Amran governorate’s Al Sawd and Al Soodah districts, where 59 percent of families marry off their daughters before the age of 18. The governorate’s capital city, Amran, an ancient trading center, is located about 50 kilometers north of Yemen’s capital, Sana’a. Only 1 percent of women in Amran governorate have attended school, according to a baseline assessment conducted by the Safe Age of Marriage Project.

The volunteers raise awareness about the social and health consequences of child marriage through lively discussions, film screenings, plays, writing competitions, poetry readings, debates and literacy classes. One of their main lessons is about the healthy timing and spacing of pregnancy. The messages about family planning are tailored to be appropriate for Islamic communities, and encourage girls not to get pregnant for the first time until they are at least 18.

Safia, one of YWU’s community educators, frequently hears about the consequences of child marriage and early pregnancy. “My 16-year-old daughter is cursed,” says a woman at one of Safia’s sessions. She adds that each time the girl has tried to bring a new life into the world, she has failed. “The babies always die,” she says. “But my 20-year-old daughter, she is not cursed. She has healthy babies.” Safia advised the woman that because her daughter had married early, she and her babies were at an increased risk of death. The mother’s reaction: “My daughter isn’t cursed after all!”

By delaying marriage, the project aims to slow maternal, newborn and infant deaths and associated conditions such as obstetric fistula, childhood deformities, mental illness, depression and domestic violence. Other organizations around the country with similar goals include the Marriage Without Risks Network, a group of five local NGOs funded by the Middle East Partnership Initiative. Each NGO approaches child marriage from a different angle: some focus on grass-roots awareness campaigns, classroom workshops or media campaigns; others conduct studies to determine the prevalence and effects of early marriage on girls and their families; and others advocate for change by engaging decisionmakers such as parliamentarians and religious leaders. The network outreach allows the groups to connect with other like-minded organizations throughout Yemen, from international organizations to community groups to Islamic foundations, that work to eliminate child marriage. By sharing successful approaches, members of the network enhance its effectiveness.

Cooperation of men in the community is essential. Here Sheikh Yahya Ahmed Abdulrahman Al-Naggar engages other Yemeni religious leaders and men as he sensitizes them to the importance of reproductive health and family planning.

“Fistula!” shouts a young girl in response to a question about the health risks of early marriage. The girl, who wears a white scarf, speaks confidently to the audience, describing how this injury, caused by complications during childbirth, can ruin a woman’s life. Girls whose bodies are not fully developed are particularly at risk for fistula. Community educators explain such risks to impress upon the girls and their families the importance of marriage at a safe age.

By attending a similar session, Ali, another community member, changed from being an advocate for child marriage into a strong advocate for delaying marriage. In fact, when he met a father whose daughter, at age 13, was about to be married, he argued so passionately to stop the marriage that he convinced the father to break off the engagement — and he paid the father back part of the dowry already sacrificed to the groom-to-be. There was no wedding, and the daughter is back in school.

The Safe Age of Marriage Project has reached nearly 41,000 people, and child marriage for girls between 10 and 17 has decreased in both districts. In Al Soodah, the community is trying to pass a local law dictating a “safe age of marriage.”

The intervention is now being spread to two neighboring districts, with plans to expand it nationally in the future.

Ali says that the YWU will spread the intervention to seven to eight more governorates. “Part of the strategic plan for the YWU is to do advocacy with local authorities and decisionmakers and ask them to take measures to guarantee girls get married at a safe age,” he says.

Dalia Al-Eryani is the project coordinator of the Safe Age of Marriage Project in Yemen, which educates communities on the risks of early marriage. A Fulbright Fellow, she works with Yemen’s Basic Health Services Project.

Laurel Lundstrom served as the communications officer for the Extending Service Delivery Project, USAID’s flagship reproductive health and family planning project. She has written for the United Nations, Global Health magazine and the World Health Organization, and co-produced a short documentary on maternal and newborn health in Yemen.

Multiple Choice Questions

• Daughters are an economic burden on the family
• Daughters do not contribute to family income
• Girls are less likely to receive proteins and nutrients necessary for growth and development
• Girls are more likely to be denied education
• All of the above
• As young as 7 years old, but often below 15 – 18 years
• Between 10 – 15 years
• Between 20 – 22 years
• Between 10 – 20 years
• None of the above
• Social turmoil
• Environmental degradation
• Loss of traditional income
• That societies value all genders equally
• That people realize that suppression of women is bad for business, the economy, and human development
• That women are paid the same as men and achieve full political and economic participation
• The organization is meddling with local traditions
• The medical concerns of early marriages are unfounded
• Girls and families are unharmed by early marriages
• The emotional impact on girls is not a concern
• Discussions
• Film screenings
• Writing competitions
• Poetry readings
• The correct answers are A and B. The perceptions that lead to a preference for sons over daughters are that daughters are an economic burden on the family and do not contribute to family income. Answers C and D are both forms of discrimination against girls, not perceptions of daughters.
• The correct answer is A (as young as 7 years old, but often below 15 – 18 years).
• The correct answer is C (75 percent).
• The correct answer is d. (all of the above).
• The correct answer is for people to realize that suppression of women is bad for business, the economy, and human development (answer B).
• The correct answer is A (that the organization is meddling with local traditions by working to stop early childhood marriage). While there may be individual proponents of early and child marriage that believe the medical concerns of the practice are unfounded (answer B), that girls and families are unharmed by early marriages (answer C), and that the emotional impact on girls is not a concern (answer D), these objections were not mentioned in the text.
• The correct answer is E (all of the above).

Discussion Quetsions

• How are the risks of early and child marriage represented in the Millennium Development Goals (MDGs)? What about the Sustainable Development Goals (SDGs)? What progress has the international community made in reducing this practice?
• What types of programs are discussed in the chapter that aim to prevent early and child marriage? Are they effective? Why or why not?
• Why should combatting child marriage be a priority for governments and the international community?
• What are the economic, social, and institutional root causes that lead to rights violations against girls, such as child marriage?
• Reviewing both the chapter and additional resources provided, consider how the perspective given on FGM in the chapter  contrasts with the perspective given by Lisa Wade in her article.
• Why does early/child marriage happen in states where it is illegal? What are the ways in which a robust nation-state and civil society can counteract such practices?

Essay Questions

• Why should child marriage and FGM be concerns of the U.S. government when these practices are largely happening on separate continents? More broadly, what should be the role of the United States in intervening in the familial customs of sovereign countries?
• Review the post-colonial critiques of the anti-FGM movement provided in the additional resources section. How can one address the practice of FGM in a way that is consistent with these critiques?
• Discuss the role that culture and religion determine in setting one’s values in relation to female genital mutilation and early/child marriage, as well as in forming policies to address them.
• What is the relationship between economics, poverty, and child marriage? Assuming that poverty and child marriage are linked, is it more effective to stop child marriage itself or to address the poverty that surrounds the practice?

Al-Jazeera. “Too Young to Marry: Child Marriage in Bangladesh.” Documentary on the illegal practice of child marriage in Bangladesh.

http://video.aljazeera.com/channels/eng/videos/too-young-to-wed%3A-child-marriage-in-bangladesh—101-east/4705007823001;jsessionid=5CA4674666308D69CF511C30A0FE66FB

Blackstock, C. “ Jordan & Shannen: First Nations Children Demand that the Canadian Government Stop Racially Discriminating Against Them.” First Nations Child and Family Caring Society of Canada. 2011. Shadow Report to the Committee on the Rights of the Child on Canada’s implementation of the convention in the context of services for Indigenous children.

https://fncaringsociety.com/publications-and-resources

Frohmader, C. “The Sexual and Reproductive Rights of Women and Girls with Disabilities.” International Conference on Human Rights.” (2014). Examines sexual and reproductive rights of women and girls with disabilities as it relates to the post-2015 development agenda.

http://wwda.org.au/wp-content/uploads/2013/12/issues_paper_srr_women_and_girls_with_disabilities_final.pdf

Nirantar Trust. “Early and Child Marriage in India: A Landscape Analysis.” Nirantar Trust. Comprehensive report on the root causes of child marriage in India, including the compounding of patriarchy, class, caste, religion and sexuality.

Santhya, K. G. & Jejeebhoy, S. “Sexual and Reproductive Health and Rights of Adolescent Girls: Evidence from Low and Middle-Income Countries.” Global Public Health 10(15), 189 – 221: (2015). Proposes increased sexual education, health services, and safe spaces programs for vulnerable girls.

http://www.tandfonline.com/doi/full/10.1080/17441692.2014.986169

UNICEF. “Child Friendly Resources.” UN Convention on the Rights of the Child in Child Friendly Language. Accessible version of the rights contained within the UNCRC.

http://www.unicef.org/rightsite/484_540.htm

UNICEF Jordan. “A Study on Early Marriage in Jordan 2014.” (2014). Findings of a qualitative and quantitative study on early marriages in Jordan, as well as Palestinians and Syrian communities within the country in the wake of the Syrian civil war and resulting refugee crisis.

http://www.unicef.org/mena/UNICEFJordan_EarlyMarriageStudy2014(1).pdf

Wade, L. “The Trouble with American Views of Female Genital Cutting.” Sociological Images. (2015). Critique of American discourse on Female Genital Cutting, which suggests that it has alienated the women it seeks to support.

https://thesocietypages.org/socimages/2015/12/27/the-trouble-with-american-views-of-female-genital-cutting/

This work ( Global Women's Issues: Women in the World Today, extended version by Bureau of International Information Programs, United States Department of State) is free of known copyright restrictions.

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a Department of Sociology, University of Alabama at Birmingham, Birmingham, Alabama, USA

b RECETOX, Faculty of Science, Masaryk University, Brno, Czech Republic

Sanjeev Acharya

c Department of Criminology, Sociology, and Geography, Arkansas State University, Jonesboro, Arkansas, USA

Alejandra Colón-López

Safa abdalla.

d Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA

Jana Klanova

Gary l. darmstadt, associated data.

Gender discrimination may be a novel mechanism through which gender inequality negatively affects the health of women and girls. We investigated whether children's mental health varied with maternal exposure to perceived gender discrimination.

Complete longitudinal data was available on 2,567 mother-child dyads who were enrolled between March 1, 1991 and June 30, 1992 in the European Longitudinal Cohort Study of Pregnancy and Childhood-Czech cohort and were surveyed at multiple time points between pregnancy and child age up to 15 years. The Strengths and Difficulties Questionnaire (SDQ) was administered at child age 7, 11, and 15 years to assess child emotional/behavioural difficulties. Perceived gender discrimination was self-reported in mid-pregnancy and child age 7 and 11 years. Multilevel mixed-effects linear regression of SDQ scores were estimated. Mediation was tested using structural equation models.

Perceived gender discrimination, reported by 11.2% of mothers in mid-pregnancy, was related to increased emotional/behavioural difficulties among children in bivariate analysis (slope = 0.24 [95% confidence interval (CI): 0.15, 0.32], p< 0.0001) and in the fully adjusted model (slope = 0.18 [95% CI: 0.09, 0.27], p< 0.0001). Increased difficulties were evident among children of mothers with more depressive symptoms (slope = 0.04 [95% CI: 0.03, 0.05], p< 0.0001), boys (slope = 0.26 [95% CI: 0.19, 0.34], p< 0.0001), first children (slope = 0.16 [95% CI: 0.09, 0.23], p< 0.0001), and families under financial hardship (slope = 0.09 [95% CI: 0.04, 0.14], p< 0.0001). Effects were attenuated for married mothers (slope-0.12 [95% CI: -0.22, -0.01], p< 0.05]. Maternal depressive symptoms and financial hardship mediated about 37% and 13%, respectively, of the total effect of perceived gender discrimination on SDQ scores.

Interpretation

Perceived gender discrimination among child-bearing women in family contexts was associated with more mental health problems among their children and adolescents, extending prior research showing associations with maternal mental health problems. Maternal depressive symptoms and, to a lesser extent, financial hardship both partially mediated the positive relationship between perceived gender discrimination and child emotional/behavioural problems. This should be taken into consideration when measuring the societal burden of gender inequality and gender-based discrimination. Moreover, gender-based discrimination affects more than one gender and more than one generation, extending to boys in the household even moreso than girls, highlighting that gender discrimination is everyone's issue. Further research is required on the intergenerational mechanisms whereby gender discrimination may lead to maternal and child mental health consequences.

Bill and Melinda Gates Foundation; Ministry of Education, Youth and Sports, Czech Republic and European Structural and Investment Funds.

Research in context

Evidence before this study.

Gender discrimination has been proposed as a stressor through which gender inequality negatively affects the health of women and girls. We searched Pubmed and Google Scholar databases for peer-reviewed publications in English and Czech before January 1, 2021, and screened the English abstracts of papers in Czech, using the key words “gender bias,” “sexism,” “discrimination,” “child mental health,” and “child emotional/behavioural problems” to identify empirical evidence on the relationship between gender discrimination and child mental health. We found emerging evidence suggesting that gender discrimination and sexism, like discrimination based on race and ethnicity, may lead to stress responses and adversely affect mental health; we showed previously using data from the European Longitudinal Cohort Study of Pregnancy and Childhood-Czech (ELSPAC-CZ) cohort that maternal perceived gender discrimination was associated with increased risk for maternal depression.

Added value of this study

We advanced our prior analysis to examine longitudinal effects of perceived maternal gender discrimination on the mental health of their children, and found that children born to the 11.2% of women who perceived mid-pregnancy that they had experienced gender discrimination had significantly ( p< 0.0001) higher levels of emotional/behavioural problems compared to the children born to women who did not perceive the experience of gender discrimination. Higher SDQ scores were associated with maternal depressive symptoms ( p< 0.0001), financial hardship in the family ( p< 0.0001), first children ( p< 0.0001), children of unmarried mothers (p = 0.022) and boys ( p< 0.0001), but not low birth weight. Maternal depressive symptoms and financial hardship significantly mediated the relationship between perceived gender discrimination and SDQ scores.

Implications of all the available evidence

This study using population-based, longitudinal data is the first, to our knowledge, to demonstrate a link between maternal perceived gender discrimination and adverse mental health outcomes for their children, and furthermore, that maternal depression linked to gender discrimination explained more than one-third of the adverse emotional/behavioural effects displayed by their children. Importantly, the effects of maternal gender discrimination were transmitted to boys and girls in households, with accentuated effects in boys, demonstrating the broader societal implications of gender discrimination for people of all genders that can occur over a relatively short period of time. While gender, racial, and other forms of discrimination appear to have some commonalities in effects, further research is needed to understand the pathways whereby gender discrimination becomes embodied and is translated into mental and physical effects; this knowledge will inform individual, household, societal, and structural interventions to prevent gender discrimination and its widespread effects on human health and well-being.

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Introduction

Emotional/behavioural problems have surged among children and youth in recent decades, with the largest increases for emotional problems and antisocial behaviour observed in high-income countries. 1 The estimated prevalence of mental disorders among children and adolescents is 13.4% worldwide. 2 Anxiety disorders are most common (6.5%), followed by disruptive disorders (5.7%), attention-deficit hyperactivity disorders (3.4%), and depressive disorders (2.6%). 2 In Europe, 22% of children ages 6-12 years report symptoms that meet criteria for a mental disorder diagnosis. 3

This research focuses on the role of gender inequality, manifest as perceived gender discrimination, in early origins of mental health disorders. Women face considerably higher risk of gender discrimination compared to men. 4 In an overwhelming majority of societies, women occupy a subordinate position relative to men, holding less power and privilege. Beliefs, norms, and stereotypes widely held by men and women alike bolster social arrangements that disadvantage women. Ninety-one percent of men and 86% of women worldwide express pro-male biases in the areas of politics, education, economics, and physical integrity, e.g., intimate partner violence. 5

The Lancet Series on Gender Equality, Norms and Health advanced gender discrimination as a mechanism through which gender inequality negatively affects the health of women and girls. 6 , 7 Emerging evidence from cross-sectional research supports the argument that gender discrimination and sexism lead to poorer mental health outcomes. 8 Population-based data from the European Longitudinal Cohort Study of Pregnancy and Childhood-Czech (ELSPAC-CZ) cohort indicated that perceived gender discrimination of child-bearing women was associated with significantly increased risk for maternal depressive symptoms. 9

Implications of maternal exposure to gender discrimination for the child are largely unknown but studies report adverse mental health outcomes for children whose parents were exposed to racial or ethnic discrimination and discrimination due to any cause. 10 Discrimination presents a special concern if it takes place during pregnancy and early life when the child's nervous system is immature and undergoing rapid development. Mother's exposure to discrimination as a stressor may lead to physiological stress responses, with stress hormones crossing the placenta and potentially dysregulating fetal neuro-endocrine development. Additionally, psychosocial stressors caused by exposure to discrimination may undermine parents’ mental health, 8 , 11 compromise parent-child bonding, and lead to more hostile parenting, 12 all factors in child emotional and behavioural problems.

Our conceptual model for this study centers on gender discrimination as a stressor and acknowledges the importance of mutual influences within parent-child dyads. 13 , 14 , 15 Exposure to perceived discrimination causes stress responses in mothers and children, leading to potential dysregulation in child psychological functioning directly though biological pathways and indirectly through mediated mechanisms. The direct effect ( Figure 1 , Arrow A1) mainly represents effects of stress hormone exposure on fetal neurodevelopment, including changes in structure-function of the brain and neuro-endocrine system, and epigenetic processes. Such changes are especially likely during the fetal stage, when foundations of brain architecture are being laid, but cannot be ruled out as occurring during infancy and later childhood. The brain remains remarkably plastic throughout the entire period of childhood and adolescence and sensitive periods for development open up at different stages along this time course.

Conceptual model of key factors in the association of maternal perceived gender discrimination and child emotional/behavioural difficulties .

Arrows A2-A5 in our conceptual model represent indirect effects of gender discrimination through adverse birth outcomes (A2, A3) and maternal psychological problems (A4, A5) as mediators ( Figure 1 ). These mediators were selected as plausible mechanisms linking gender discrimination to child mental health. Prior evidence indicates that they correlate with child psychopathology 16 , 17 , 18 and gender discrimination. 19 , 20 , 21 , 22 Individuals who report racial discrimination, for instance, face an increased risk for major depression 19 and maternal depression is an established risk factor for emotional problems in children. 14 , 17 Racial discrimination is linked to adverse birth outcomes, 20 known predictors of child psychopathology. 23 Another proposed mediator is socio-economic disadvantage (A6, A7), represented by financial hardship. 24 Gender discrimination commonly happens in workplaces, adversely affecting women's access to job opportunities, training, and career advancement. For instance, women may perceive discrimination when they are rejected as job candidates in favour of a male, passed up for a promotion, or when they know of pay differences between male and female in the company who perform the same job. When gender discrimination happens in the job market or workplace, it has a potential to negatively affect the socio-economic prospects of the family and have adverse implications for the children. 16 , 25

Here we build on our prior analysis showing increased risk for depressive symptoms in child-bearing women associated with perceived gender discrimination, 9 and examine longitudinal effects on their children. Using the proposed conceptual model, we derive the following hypotheses to be tested with prospective data: 1) Maternal perceived gender discrimination is linked to child emotional/behavioural problems, and 2) The relationship between maternal perceived gender discrimination and child emotional/behavioural problems is mediated by low birth weight, maternal depression, and financial hardship.

Study design

This longitudinal, observational cohort study utilised data from the population-based, longitudinal ELSPAC-CZ cohort in the Czech Republic. 26 ELSPAC studies were initiated by the World Health Organization to investigate maternal and child health in several European countries, including the influence of biological, psychological, social, economic and environmental factors on the health of children and adolescents. Families were followed longitudinally for two decades, during pregnancy and through age 18 years of the children.

ELSPAC-CZ was conducted in Brno, a large metropolis, and Znojmo, a small nearby town to represent urban and rural populations, respectively. The study population was defined as all pregnancies and births in these two regions of the Czech Republic in 1991 and 1992. Over 99% of the residents in both regions consisted of the Czech ethnic group in 1991-92. 26 Participants were recruited in mid-pregnancy. Eligibility criteria included residence in one of these two cities and an expected date of delivery between March 1, 1991 and June 30, 1992. Mothers were enrolled between the ultrasound examination at week 20 of pregnancy and the birth. Eligible mothers received information about the study from their obstetricians who forwarded contact information of women who were interested in the study to the study team. These women were officially invited by mail to participate in the study. Detailed information on the study methodology and cohort profile are available elsewhere. 26 Health records were collected for 7589 births: 96% of all eligible births. A subsample ( n =  4,811) were surveyed at 20 weeks gestation (henceforth called mid-pregnancy, identified as described above) and among these, 4630 women (96.2%) completed a baseline questionnaire which included a measure of perceived discrimination. Follow-up questionnaires were mailed to participants at 15 time points between the child's birth and age 19 years; intervals between successive mailings ranged from six months to four years. Child mental health symptoms, our main outcome, was assessed using the Strengths and Difficulties Questionnaire (SDQ) administered to participating mothers at child ages 7, 11, 15, and 18 years. We did not use child-reported data because they were not consistently available across all ages. SDQ data were available for 2619 7-year-old children, which represents 54.4% of the 4811 in the original sample. Among the mothers of these children, 98.0% ( n =   2,567) had complete baseline data on perceived gender discrimination collected in mid-pregnancy and thus were included in our final analytical sample. Among these, 1,873 also completed the SDQ questionnaire at child age 11 and 1,278 at child age 15 (Table S1); to account for the missing data, we used information avaialable in the final analytical sample and applied multiple imputation methodology. Figure 2 summarises inclusion and exclusion of respondents due to non-response.

Flow chart showing inclusion and exclusion of respondents due to non-response .

MI, multiple imputation; SDQ, Strengths and Difficulties Questionnaire

Delivery characteristics were extracted from medical documentation at the time of birth; the remaining measures were obtained by maternal self-report on written surveys administered at the times indicated below.

Scores from the SDQ, used as the primary outcome, are a validated measure of child and adolescent symptoms indicating emotional and behavioural problems, including hyperactivity, emotional symptoms, conduct problems, and peer problems. SDQ was mother-reported at ages 7, 11, and 15 years. Since slightly different response categories were used in some waves, we calculated z-scores within each wave. The resulting standardised scores were used to achieve comparability across years. We did not use SDQ data at child age 18 years due to a relatively large number of missing cases.

Maternal depressive symptoms, low birth weight, and financial hardship were used for the purposes of mediation analysis. Maternal depressive symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS), which has been validated for assessment of depression during pregnancy and the first year postpartum. 27 Controlling for maternal depression was important because deprerssed mothers may report more discrimination and rate their children's behaviour as more problematic. 28 , 29 The EPDS consists of ten items rated on a four-point scale (0 = “Never”, 3 = “Most of the time”), such as “I have felt sad or miserable.” The scale was administered at baseline (mid-pregnancy), childbirth, and child ages 6 and 18 months, and 3, 5, 7, and 11 years. Low birthweight (<2,500 grams) was extracted from medical documentation to represent adverse birth outcomes.

For the financial hardship scale, women reported how difficult it was to provide for their family food, clothing, heating, rent/mortgage payments, and provisions for their child at ages 3, 5, and 7 years. Each item was rated on a four-point scale (0 = “Not difficult”, 3 = “Very difficult”). The mean across items was used to represent overall financial hardship.

Perceived gender discrimination, the main predictor, was assessed in mid-pregnancy and when the children were ages 7 and 11 years. Respondents were asked, “Would you say that during the past twelve months, someone treated you unfairly because of your gender?” The measure captures respondents’ perceptions of whether they have experienced any gender discrimination (“yes”) vs. no gender discrimination (“no”). Self-reported perceived discrimination is widely used in observational studies of discrimination based on race, ethnicity, language, religion, and sexual identity. 30 , 31

Confounders included social support at baseline, which was measured with a scale consisting of five items: 1) “How many people can you talk to about your personal problems?”, 2) “How many people talk to you about their inner feelings?”, 3) “When you need to make an important decision, with how many people can you discuss it?”, 4) “How many people in your family would lend you 1000 Czech crowns if you needed them?”, and 5) “How many people in your family would help you in the time of need?” The mean was used to indicate the average number of supportive individuals in respondents’ lives. Additional confounders included demographic and delivery characteristics. Maternal marital status (single, married, divorced/separated, widow) and maternal education (in years at baseline) were assessed; age was recorded at the birth of the focal child. Delivery characteristics extracted from medical documentation included child sex (male vs. female), singleton vs. multiple birth, and number of childbirth complications. To proxy parity, pregnant women reported whether they already had children. Pregnancy with the first child was coded as 1; second and higher-order children were coded as 0. Confounders were selected because they correlate with psychological issues among children.

Statistical analysis

Descriptive statistics and bivariate tests of the relationships between SDQ and other analytical variables were obtained. Next, the proposed hypotheses were tested using multi-level mixed-effects linear regression, also known as linear mixed error-component models. They are a type of hierarchical linear modeling that accounts for time and correlations among the repeated observations nested within respondents. Here, the model accounts for both within-person (i.e., within mother) and across-mother variability in the final estimates. Standardised SDQ scores served as the primary outcome; others were secondary outcomes. Perceived gender discrimination was the main explanatory variable. Time was coded as years since baseline. For time-varying predictors that were not collected in all survey waves, the nearest value for that variable in time was assumed. For example, perceived gender discrimination at 5 years after delivery (not collected) was assumed to be the same as perceived gender discrimination at 7 years after delivery (collected). This technique allowed us to use all available predictor data and also allowed for covariates which were assessed in selected waves only to vary over time. This was done with all predictors so that all waves in which SDQ data were collected could be included in the analyses. Sensitivity analyses included testing for interactions between perceived discrimination and each covariate. We also assessed whether there were non-linear effects of time and maternal depression, and whether the slope of over-time change in SDQ scores varied between exposed and non-exposed children. Mediation analysis was conducted using structural equation models (SEM) as described by Gunzler et al. 32 The purpose was to test whether maternal perceived gender discrimination and child emotional/behavioural problems were mediated by low birth weight, maternal depression, and financial hardship. Direct, indirect, and total effects were estimated using bootstrapping with 1,000 replications. Significance testing of indirect effects of perceived gender discrimination on SDQ through potential mediators was performed using medsem Stata package. The medsem is a post-estimation command to test mediation hypotheses using Baron and Kenny's approach modified by Iacobucci et al. as described by Mehmetoglu. 33 , 34 , 35 The medsem command also utilises an alternative approach proposed by Zhao et al. 36 to test the indirect effects after computing mediation models with the sem command in Stata, as described by Mehmetoglu. 33 We used both Sobel and Monte Carlo methods to test the significance of indirect effects. To account for the loss to follow-up and missing data, we used multiple imputations with chained equations, i.e., sequential regression multivariate imputation. 37 Imputations were conducted on the wide data version (one observation per individual). We imputed SDQ at 11 and 15 years, but not at 7 years, to have a consistent sample size. Unless otherwise stated, the results presented here are based on the data after multiple imputations. Analyses were conducted using Stata statistical software, version 16.1 (StataCorp LLC, College Station, Texas, USA).

Ethical approval

ELSPAC-CZ was approved by the Scientific Committee of Masaryk University. All participants provided written informed consent. The study was also approved by the Stanford University Institutional Review Board protocol # 42971.

Role of the funding source

The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. All authors had full access to the data in the study and the corresponding author had final responsibility to submit the paper for publication.

Sample characteristics

At baseline, participating women were mostly married (89.4%, n =  2,295 of 2,567) and had a mean age at childbirth of 25.9 years with an average of 12.3 years of education ( Table 1 ). Women reporting perceived gender discrimination were significantly older (26.5 vs 25.8 years, p =  0.019) and more educated (12.8 vs 12.2 years, p< 0.001), and had higher levels of financial hardship (0.61 vs 0.49, p =  0.013) and lower levels of social support (3.09 vs 3.26, p =  0.005) than women who did not report perceived gender discrimination. Alpha coefficients for reliability based on the pooled sample were 0.68 for the financial hardship scale, 0.78 for the social support scale, and 0.87 for the maternal depression scale, indicating acceptable levels of reliability. For over a third of women (38.9%, n =  999 of 2567), the index child was their first child. Most births were singleton infants (98.2%, n =  2521 of 2567) (compared to multiple births), with normal birthweight (95.8%, n =  2459 of 2567). Male children (51.8%, n =  1330 of 2567) were in a slight majority. There were no differences in pregnancy and childbirth characteristics between women with and without perceived gender discrimination, except that women with perceived gender discrimination had a lower rate of low birthweight (1.6% vs 4.5%, p =  0.020).

Characteristics of the sample of Czech Republic mothers and their children at baseline, shown by mothers who did and did not report perceived gender discrimination at mid-pregnancy. a

Perceived gender discrimination rates ranged from 10.6% to 11.2% across survey years (11.2%, n =  288 of 2295 in mid-pregnancy; 10.6%, n =  272 of 2295 at age 7 years; 10.6%, n =  273 of 2295 at age 11 years) ( Table 2 ).

Maternal perceived gender discrimination and child strength and difficulties questionnaire (SDQ) scores.

SDQ score trajectory by gender discrimination

The alpha coefficient for reliability (0.75) for SDQ scores based on pooled data indicated acceptable reliability. Mean SDQ scores were similar before and after multiple imputations ( Table 2 , Table S1), and showed an increase between ages 7 and 15 years ( Figure 3 ), with higher scores for children exposed to perceived gender discrimination during pregnancy. The mean difference in SDQ scores between exposed and non-exposed children before adjustment for covariates ranged from 0.03 to 0.07 ( Table 2 ).

Trends over time in adjusted predictions (with 95% confidence intervals) of Strengths and Difficulties Questionnaire scores of boy and girl children of mothers who did and did not perceive gender discrimination .

Consistent with our hypothesis, the relationship between perceived gender discrimination and SDQ scores persisted after adjustment for time, auto-correlations, and maternal- and child-level covariates in multilevel mixed-effects linear regression models (slope = 0.18, 95% CI 0.09-0.27; p< 0.0001, Table 3 , model 2). The over-time trend in SDQ scores between ages 7 and 15 years increased linearly, with similar slopes for boys and girls and statistically different predicted SDQ scores for boy and girl children of mothers who did or did not have experience of perceived gender discrimination ( Figure 3 ). Among covariates in the regression models for the relationship between perceived gender discrimination and SDQ scores, maternal depressive symptoms (slope = 0.04, 95% CI 0.03-0.05; p< .0001) and financial hardship in the family (slope = 0.09, 95% CI 0.04-0.14; p< 0.0001) were linked to higher SDQ scores ( Table 3 , model 2). First children (slope = 0.16, 95% CI 0.09-0.23; p< .0001) and boys (slope = 0.26, 95% CI 0.19-0.34; p< .0001) showed higher SDQ scores, while children of married mothers (slope = -0.12, 95% CI -0.22 to -0.01; p =  0.022) had lower SDQ scores. Time, maternal age, education, social support, age at birth, and childbirth complications were not associated with SDQ scores.

Multi-level mixed-effects linear regression model outputs for mother-reported child Strengths and Difficulties Questionnaire scores in relation to maternal perceived gender discrimination ( N= 2,567).

Sensitivity analyses (available upon request) revealed no statistically significant non-linearity for time and no interactions between gender discrimination and any of the covariates. A significant quadratic effect of maternal depression was present, indicating that as mothers are more depressed, the effect of depression on child SDQ is diminished (unsquared term, slope = 0.05, 95% CI 0.04-0.06; p< 0.0001; squared term, slope = -0.001, 95% CI -0.002–0.0002; p< 0.05).

Mediation between perceived gender discrimination and SDQ scores

The structural equation models showing the direct, indirect and total effects of perceived gender discrimination are presented in Table 4 . The relationship between perceived gender discrimination and SDQ was mediated by maternal depression, which was significantly linked to SDQ (statistics above) and gender discrimination. Maternal depression accounted for 37% of the total effect of perceived gender discrimination [ratio of the indirect effect to the total effect (RIT) = 0.369, Table 5 ], and explained 2.4% of the total variance (direct effect slope 0.21, 95% CI 0.10-0.31, p< 0.0001; indirect effect slope 0.12, 95% CI 0.09-0.15, p< 0.0001; total effect slope 0.33, 95% CI 0.22-0.44, p< 0.0001) ( Table 4 ). Financial hardship correlated with SDQ (results above) and perceived gender discrimination and mediated 13% of the total effect of perceived gender discrimination, accounting for 1.5% of the total variance (direct effect slope 0.21, 95% CI 0.10-0.31, p< 0.0001; indirect effect slope 0.03, 95% CI 0.01-0.04, p< 0.0001; total effect slope 0.24, 95% CI 0.13-0.34, p< 0.0001). The interpretation is that maternal depression and financial hardship significantly mediate the association between gender discrimination and child emotional/behavioral problems. Low birth weight was not linked to perceived gender discrimination ( p =  0.890).

Summary of total, direct, and indirect effects of maternal perceived gender discrimination on child Strengths and Difficulties Questionnaire scores based on Structural Equation Modelling mediation analysis ( N =  2,567). a

Significance testing of indirect effects of maternal perceived gender discrimination on child Strengths and Difficulties Questionnaire scores mediated through maternal depressive symptoms and financial hardship ( N =  2567)

This prospective observational study followed mother-child pairs from mid-pregnancy until age 15 years and evaluated the relationship between maternal perceived gender discrimination and child emotional/behavioural problems. We found that the children of women who perceived that they had experienced gender discrimination between pregnancy and child age 11 years had more emotional/behavioural problems between ages 7 and 15 years compared to the children of women who had not experienced perceived gender discrimination. First children and boys displayed greater emotional/behavioural problems, while children of married mothers had fewer such problems. Importantly, maternal depressive symptoms and financial hardship in the family were linked to higher child SDQ scores, and furthermore were found to significantly mediate the relationship between maternal gender discrimination and child emotional/behavioural problems.

To our knowledge, this represents the first study – using robust population-based, longitudinal data – to document a link between maternal gender discrimination and adverse mental health outcomes for their children. Specifying the link between mother's experience of gender discrimination and child psychopathology extends prior research, which documents that mental health problems can develop among victims of gender discrimination. 9 , 38 Consistent with the concepts of inter-generational transmission of health risk, 39 as seen, for example, following adverse childhood experiences, 14 , 15 , 40 our findings indicate that gender inequality in a society experienced individually as gender discrimination may have negative health implications for the victim's offspring. This should be taken into consideration when measuring the societal burden of gender inequality and gender-based discrimination – an important area for future investigation.

This study evaluated several potential mechanisms through which maternal gender discrimination may link to child mental health. We found that the statistical effect of gender discrimination was strongly mediated through maternal depression and less so by family financial difficulties but not through low birth weight of the child. Mechanisms through which gender inequality translates into health disadvantages for children are poorly understood and require further research that encompasses measures of biological processes as well as social determinants and their interactions with biology. 6 , 41 These processes have been described as “embodiment,” 6 , 41 the process of translation of stressors into stress and thence into biological pathways toward disease. For gender discrimination more specifically, we know of no research on embodiment mechanisms linking maternal discrimination exposure to child health, though previous studies considering perceived racial and ethnic discrimination among mothers link it to adverse health outcomes among their children through a mechanism of maternal depression. 42 While there appear to be similarities in effects of discrimination based on gender, race, and ethnicity, further research is needed to better understand ways in which these and other stressors become translated into adverse mental and physical health. Understanding similarities and differences in pathways for the effects of different forms of discrimination is an important step in informing effective individual, household, societal, and structural solutions to prevent, mitigate and treat the consequences of discrimination broadly.

This study represents a significant contribution to the literature on the impact of gender inequality and gender-based discrimination by clearly illustrating that it is not an issue that affects one gender or one generation but extends to all children – even moreso in boys than girls – in the household, presumably due in part to its effects on, or reflections of, the environment in which children grow up, leading to broader societal effects on people of all genders and across generations. The larger direct effect that we found is better considered a residual effect that is yet to be explained because of the possible presence of unmeasured common causes or mediators. Illustrating that gender discrimination is everyone's issue and not only a women's issue can help to alter the conversation at household and community levels where gender roles and norms are constantly negotiated, 6 as well as at policy level and regarding structural-institutional factors which create the ecosystem in which gender discrimination occurs. Gender discrimination is everyone's issue and addressing gender discrimination and shaping gender norms to promote equality requires interventions involving a broad range of stakeholders and utilising a variety of levers at multiple levels of society. 43 , 44 , 45

More specifically, interrupting the pathways that extend the mental health impact from mothers to their children can be one way of limiting the adverse impact of gender-based discrimination. One approach is to address the causes of mental health distress in clinical settings. The discourse around addressing the mental health impact of discrimination in clinical settings is limited thus far to the context of racial discrimination. Important lessons, however, can be drawn from this literature. Concepts like cultural safety where practitioners examine their own attitudes, cultural humility that encourages practitioners’ self-reflection, and cultural narrative where practitioners attend carefully to their patients’ stories are advocated to help practitioners provide more holistic care for mental health problems that supports and empowers patients to take control of their aggravating circumstances. 46 Extending such concepts to gender-based discrimination may be similarly impactful, but can be challenging given the complexity that gender discrimination often takes place in the context of close interpersonal relationships with norms that include unfair distribution of household labour and decision-making. 6 , 47 Interestingly, we have found in previous research that while social support was an important factor in development of depression among women who perceived gender discrimination, 9 while here we found that social support was not associated with mental health problems in their children. Another challenge is that prevalent gender stereotyping in the community may prevent women with perceptions of discrimination to voice their concerns or acknowledge such perceptions as a potential cause of their mental health issues.

Addressing gender-based discrimination remains a key policy approach for preventing its adverse impacts. 45 A barrier to women's economic participation and opportunity, discrimination can adversely affect the overall financial situation of the family through segregation of women into less desirable jobs, barriers to women's career advancement, part-time employment, precarious work, and unemployment. Importantly, mother-reported financial hardship emerged in our study as an important mechanism through which gender discrimination translated into adverse effects on child mental health. Women are at higher risk for economic difficulties and poverty compared to men in many societies throughout the world. In the Czech Republic, women are overrepresented in the public sector, where jobs tend to be less lucrative. In contrast, the Czech non-public sector offers higher earnings on average but women tend to earn alarmingly less compared to men. 48 A substantial gender gap in earnings remains even after considering job characteristics, workers’ skills, and training, suggesting a considerable extent of gender discrimination. In a worldwide ranking of women's economic participation and opportunity in 2014, the Czech Republic placed in the bottom third, 49 lower than many counterparts with similar economic levels. Major strides have been taken in terms of policy development to eliminate all forms of gender-based discrimination against women in the Czech Republic. 50 Policy change to promote gender equality remains focused, however, on overt discrimination in institutional settings and may not exert influence in situations where perceptions of discrimination arise from more subtle social interactions within the community or family; unpaid care work and unfair household division of labour can be such sources. Therefore, a wider array of policy responses than currently considered may be required to address this multi-faceted problem.

A chief strength of this study is the population-based, longitudinal design which enabled us to establish the temporal association between perceived experience of gender-based discrimination and subsequent mental health outcomes for the children of the women who experienced the discrimination. Standard, validated scales were used to measure the mental health outcomes.

Limitations to note concern the fact that not all potential confounders were measured and some of the scales consisting of multiple items differed across years in wording and numbers of included items. To account for these differences and for missing values, and to make indicators comparable, we used statistical standardisation. We relied on answers to a single question about the presence of perceived gender discrimination. While this enabled powerful insights to be gained, we lacked biological correlates to corroborate that this perceived stressor led to biological stress responses, and we lacked additional data to explore pathways whereby the stressor became embodied in the biology of the women who experienced perceived gender discrimination and in their children. Another potential factor not examined here is cohabitation. At the time the ELSPAC survey was conducted, however, cohabitation not oriented toward marriage was rare among childbearing couples. 51 We also lacked sufficient data on socio-demographic and clinical characteristics of fathers. Finally, the generalisability of the findings outside of the Czech Republic is unknown, but it is likely that they apply to other regions inside the Czech Republic. The demographic profile of the ELSPAC-CZ sample is similar to the entire Czech population. The proportion of the population of non-Czech ethnicities is low and the sample does not contain enough of these respondents. Thus, the findings are considered applicable to people of Czech ethnic group residing in the Czech Republic. Gender discrimination is pervasive globally but the social and political context of the study is unique, making it important to examine gender discrimination and child issues in other ethnic groups and other regions.

In conclusion, this study demonstrates that gender-based discrimination could have far reaching consequences for the health and well-being of societies – extending within families across generations and genders. It is not a women's issue only but can be transmitted inter-generationally and extend within households to people of all genders within a relatively short time span. These amplified effects are a cause for concern in a society where progress to implement gender equality policies can be slow. Efforts to address gender-based discrimination in all its manifestations are critical for preventing its adverse effects. While important lessons can be learned from literature on racial and ethnic discrimination, further research should specifically examine potential pathways and other direct and indirect outcomes of gender-based discrimination in the Czech Republic and beyond, given its ubiquitous and varied nature.

Contributors

I.S. and G.L.D. conceptualised the paper; S.A., I.S. and J.K. managed data curation; formal analysis was conducted by S.A and I.S.; G.L.D. acquired funding; investigation was conducted by S.A and I.S.; methodology was devised by I.S., S.A., and S.Abdalla; G.L.D. managed project administration and resources; G.L.D. and I.S. provided supervision; S.Abdalla and A.C.L. validated study findings;: I.S. and S.A. led data visualisation; I.S., G.L.D., and S.Abdalla led writing of the original draft; all authors contributed to writing review and editing. All authors contributed intellectual content and approved the final draft for publication. All authors had full access to the data in the study and take responsibility for the integrity and accuracy of the data analysis; I.S. and S.A. verified the underlying data.

Data sharing statement

Data may be requested at www.elspac.cz .

Declaration of interests

The authors declare no conflicts of interest.

Acknowledgements

The authors of this study wish to thank the participating families as well as the gynaecologists, paediatricians, school heads, and class teachers who took part in the project. Our thanks also go to Dr. Lubomír Kukla, Ph.D., ELSPAC national coordinator 1990–2012, and the entire ELSPAC team. The authors of this study (i.e. not the ELSPAC Scientific Council) are responsible for the contents of this publication. The ELSPAC-CZ study was funded by the Ministry of Education, Youth and Sports of the Czech Republic and European Structural and Investment Funds (CETOCOEN PLUS project: CZ.02.1.01/0.0/0.0/15_003/0000469 and the RECETOX Research Infrastructures: LM2015051 and CZ.02.1.01/0.0/0.0/16_013/0001761). This analysis was funded in part by the Bill & Melinda Gates Foundation (OPP1140262). The views and opinions expressed in this paper are those of the authors and do not reflect the official position of any of the organizations for which the authors work.

Supplementary material associated with this article can be found in the online version at doi: 10.1016/j.eclinm.2022.101627 .

Appendix. Supplementary materials

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Home » Social Justice » Issues related to children » Gender bias against girl child » Key findings of the report in India

• One in three girls missing globally due to sex selection, both pre- and post-natal, is from India, i.e. 46 million out of the total 142 million.
• India has the highest rate of excess female deaths at 13.5 per 1,000 female births or one in nine deaths of females below the age of 5 due to postnatal sex selection.
• In India, around 460,000 girls went missing at birth, which means they were not born due to sex-selection biases, each year between 2013 and 2017.
• India (40%) along with China (50%) account for around 90% of the estimated 1.2 million girls lost annually to female foeticide.
• One in nine females below the age of 5 die due to postnatal sex selection.
• It tends to be higher among wealthy families, but percolates down to lower-income families over time, as sex selection technologies become more accessible and affordable.
• The skewed ratio causes the number of prospective grooms to outnumber prospective brides, which further results in human trafficking for marriage as well as child marriages.
• However, the positive news is according to the report, advances in India have contributed to a decline in child marriages in South Asia. This corroborates the NFHS data which had said that child marriage in India fell from 47% in 2005-’06 to 26.8% in 2015-’16.

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Girl-Child Discrimination in India: Examining a Declining Child Sex Ratio

Simi Mehta and Anshula Mehta

Women are seen as nurturers and the providers of emotional caretaking, and men are considered providers of economic support. Despite India’s reputation for respecting women and treating woman as goddesses, the practice of female foeticide through sex selective abortion continues unabated. This is despite the Pre-Conception and Pre-Natal Diagnostic Techniques Act (PCPNDT), 1994.

The 2011 Census revealed the number of girls per 1000 boys was 914. Inevitably, there has been a decline in the child sex ratio since the turn of the century. Astonishingly, urban India is performing worse than rural India. Even though India’s sex ratio is slightly better as compared to China and Pakistan, physical elimination of the women is of significant concern. The economic and non-economic disempowerment of women where women are considered as resourceless by families is the one of the main reasons for the declining child sex ratio.

Gender seems to be one of the most dominant variables that influence human development. When it comes to the right to vote, the government treats women as individuals. On the contrary, when it comes to land and property, then the right goes to the head of the household that is the male member. And this discrimination continues in every aspect. Hence, freedom of mobility, freedom to grow, making decisions for the young and older girls and addressing social gender norms are some of the important aspects of this issue.

Dr. Mitu Khurana, who passed away on 19 th March 2020, faced extreme humiliation, injustice and discrimination at all the portals of justice: from lower (family courts), high and Supreme Court of India.

Speaking at The State of Gender Equality #Gender Gaps, organized by Gender Impact Studies Center, Impact and Policy Research Institute, GenDev Center for Research and Innovation, CitiMakers Mission International and Delhi Post News, Dr Bijayalaxmi Nanda, spoke about the policy environment not only from a historical perspective but from a contemporary perspective as well, because the declining child ratio has been an issue since the 1980s.

“We need to engage with the idea of gendercide put forth by feminist politics not just from the point of view of violence but also from the point of view of discrimination. Through the lenses of gender biased sex selection, we are looking at the disposability and the dispensability of women and girls before they are born not just from an attitude of son preference but in terms of daughter aversion, female foeticide, sex-selective abortion and elimination of females during the pre-birth phase”, said Dr Nanda.

Though there has been a consensus around the idea that freedom of choice in reproductive matters, it is essential to map the course of one’s life amid the uncertainties that exist about its meaning, legal implications and its value.

Dr Nanda followed the discussion by talking about the state and global discourses – the idea of sex selective abortion or gender discrimination by raising three questions: first , disclosure of ‘equality vs violence’ where equality means no discrimination, no violence and all genders should be treated equally, and demographic refers to the question of correcting numbers.

The second question is of ‘crime vs justice’ where crime refers to the criminal acts of terminating female foetuses even before they are born, and justice means the substantive justice which is not just about the implementation of an act but also going beyond that. Lastly , the disclosure of ‘rights vs ethics’ where rights refer to the right to property, land, body, labour and ethics means fundamental human rights.

She also emphasised on the fact that the policy response continuum should be looked at from both the demand side as well as supply side. While talking about demand, she referred to the families that has resulted in gender discrimination. While talking about supply, she referred to the invention of new reproductive technologies by the doctors and corporate organisations which led to the implementation of the PCPNDT Act.

The most interesting fact which Dr Nanda talked about was the range of dilemma in feminist politics revolving around five questions.

• “Should we go with the law or outside the law?”, when it comes to declining child sex ratio. Some feminists emphasise on the creation of laws while others believe laws may themselves become a site of gender discrimination since they reinforce power relations and may increase bureaucratic control.
• “Whether it should be a pro-life discourse or pro-choice?”.  According to Dr Nanda’s observation via the young people, it seems that there is a pro-life disclosure, and the mother is pitted against the child. She further adds that there is a need to develop this discourse because this is what leads to a problem when it comes to feminist politics as they have engaged with this issue from a pro-choice perspective in terms of empowerment and informed choices.
• “Whether women should be seen as active agents or passive victims?”. Dr Nanda shared the example of her friend Dr Mitu Khurana (nee Khosla), who has twin daughters and was forced to go in for sex determination and then for sex selective abortion. Despite the wishes of her in-laws, she fought a legal battle against the abortion and became the first complainant under the PCPNDT Act in  2005.
• “Whether we should look at monetary incentives or rights-based approach?”. In the 2001-2011 period, there were a lot of monetary incentives with ‘ Ladli’ and ‘ Laxmi ’ schemes, where conditional cash transfers were given to the families to increase the acceptability of the girl child. While some cash transfer brought in the sense of security, their bargaining power within the community did not happen.
• “Whether it should be within the state policy or should we look at resolutions outside the state?”. Here, Dr Nanda talked about the ‘Two Child Norm’ and how these kinds of norms work against women’s rights to participate in Panchayati Raj and other places because it leads either to rejection and abandonment of women or to sex selective abortion.

Dr Nanda then highlighted the policy pathways put forth by the United Nations Population Fund UNFPA, where they say that “one needs to look at 3 A’s of tackling daughter aversion” which would make a lasting difference. First, by treating women and girls as an asset , second by enhancing their autonomy and thirdly by addressing the ageing access .

Through the talk, Dr Nanda pointed out two distinctions. One , “the binary distinction between save the girl child and not engaging with the women’s rights”, and second “the engagement with the idea of sex selection and abortion”. “It is challenging for the feminist politics to work on the selective abortion because there is an overlap over the right to abortion, but it is everyone’s responsibility to see that women and girls are not discriminated against at any level: cultural or beyond.

Dr Nanda concluded the discussion by quoting Gayatri Spivak “Strategic essentialism, where we may disagree as we live in a heterogeneous society, but we should agree on one thing which is that women should have rights over their bodies including the fact that there should not be any sex selection or gender biased sex selection.” In essence, there must be a syncretic feminist perspective with an intersectionality approach to understand the women’s issues, in present times.

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