Understanding gender inequities in antimicrobial resistance: role of biology, behaviour and gender norms

Abstract

Antimicrobial resistance (AMR) poses a critical public health threat, with gendered implications that are often overlooked. Key drivers of bacterial AMR include the misuse of antibiotics, inadequate water, sanitation and hygiene infrastructure and poor infection control practices. Persistent gender discrimination exacerbates these issues, resulting in disparities in healthcare access and outcomes. This review explores how biological, sociocultural and behavioural factors contribute to the differential incidence of AMR in women. We present a conceptual framework to understand how gender norms influence antibiotic use and AMR. Differences in infection susceptibility, health-seeking behaviours, the ability to access and afford essential antibiotics and quality healthcare and appropriate diagnosis and management by healthcare providers across genders highlight the necessity for gender-sensitive approaches. Addressing gender dynamics within the health workforce and fostering inclusive policies is crucial for effectively mitigating AMR. Integrating intersectional and life course approaches into AMR mitigation strategies is essential to manage the changing health needs of women and other vulnerable groups.

Summary box.

• It is essential to recognise how individuals from different genders and marginalised groups, access, interact with and experience healthcare specifically infection-related healthcare and antibiotic use.

• Effective bacterial antimicrobial resistance (AMR) mitigation strategies require context-specific policies, that integrate gender perspectives, especially in regions with high gender inequality.

• Implementing gender-responsive and transformative policies in the health environment is essential for achieving gender parity and promoting women in leadership roles.

• Adopting intersectional and life course approaches can tailor interventions to the evolving health needs of women and other at-risk populations, contextualising the global response to AMR.

Introduction

Gender is a key understudied social determinant that influences life and health outcomes across diverse cultures and economies. Currently, in the field of health and health policy the gendered lens has largely focused on women’s reproductive and maternal health.¹ While these areas remain important, it is critical to broaden this lens and consider the health of women in their entire life course and include how health and well-being are manifested in different genders.

Bacterial antimicrobial resistance (AMR) is a cross-cutting public health threat. Universal drivers of AMR include the misuse and overuse of antibiotics; lack of access to clean water, sanitation and hygiene (WASH) infrastructure; poor infection and control for disease prevention in healthcare facilities and farms; lack of quality healthcare; self-medication and; limited access to effective antibiotics, vaccines and diagnostics.^{2 3} An increase in the prevalence of AMR is also a major cause for lack of access to effective antibiotics, which consequently may result in higher deaths caused by drug-resistant infections (DRI).⁴ These drivers of AMR are impacted by inequities within and across countries.⁵ Current policies to mitigate AMR do not account for context-specific disadvantages driven by gender and sociocultural factors.⁵ While there is an increasing focus on better understanding how and why biological sex and/or gender may influence AMR, there remains a lack of evidence on this topic to help inform public health policy and interventions.⁶

The emerging evidence on the gendered drivers and impact of AMR, is predominantly from high-income countries (HICs). According to a meta-analysis of 11 studies, covering mostly HICs, women are 27% more likely to receive an antibiotic prescription in their lifetime compared with men.⁷ In low- and middle-income countries (LMICs) where the burden of AMR and DRIs is highest, gender discrimination and lack of investment in progressive and inclusive policies limits women’s access to healthcare services, antibiotics and vaccines.^{8 9} The intersection of gender with other power structures such as race, religion, caste, income further accentuates women’s burden of AMR.¹⁰ In this narrative review, using current evidence we provide a conceptual framework for how biological, behavioural and social norms may make women more vulnerable to AMR through their life course, calling for the importance of a gendered lens to AMR research and mitigation strategies.

Biological factors causing gender differentials in antibiotic consumption and AMR

There are biological factors that create differences in women’s consumption of antibiotics compared with men over their life course. Exposure to antibiotic use and AMR presents a multifaceted challenge for women, particularly during critical stages of their reproductive health journey. This vulnerability is notably exacerbated in LMICs where adequate WASH facilities are often lacking, thereby amplifying the risk of women contracting antibiotic-resistant infections.^{11 12}

Starting from menstruation, women experience physiological changes that may predispose them to infections and the use of unsafe sanitary products in environments with poor sanitation increases the likelihood of exposure.¹³ However, there may be indiscriminate use of antibiotics in response to menstrual discomfort which could further contribute to the emergence of AMR. For example, a study conducted microbial in Nigeria revealed that a significant proportion of women resort to self-medication using antibiotics to alleviate menstrual cramps, highlighting the pervasive practice of inappropriate antibiotic use among women.¹⁴

Pregnancy and childbirth represent pivotal periods in a woman’s life where the risk of infections is heightened, necessitating the use of antibiotics for therapeutic and prophylactic purposes. In LMICs, where access to quality maternal healthcare is often limited, pregnant women may face challenges in receiving timely and appropriate medical interventions, increasing their susceptibility to antibiotic-resistant infections.^{15 16} Additionally, complications during childbirth, such as obstetrical fistulas or postpartum infections, may require the administration of antibiotics, further contributing to the selective pressure driving AMR.¹⁷ Further, there has been a rise in caesarean births across the globe, which could lead to a higher prophylactic use of antibiotics among women.^{18 19} Another concern that disproportionately affects pregnant women is sepsis. Evidence suggests that pregnant or postnatal women are at the highest risk of contracting sepsis in comparison to the general population.²⁰ Further, it has been estimated that approximately 11% of maternal deaths are caused due to sepsis.²¹

Similarly, women seeking abortion services in LMIC settings may encounter barriers to accessing safe and hygienic procedures, increasing the risk of post-procedural infections.²² The use of antibiotics to prevent or treat such infections is common, particularly in environments where sterile conditions cannot be guaranteed. Consequently, women undergoing abortion procedures may be at heightened risk of encountering antibiotic-resistant pathogens, perpetuating the cycle of AMR.²³

There are sex-related factors in immune response, anatomy and physiology that create differences in health outcomes between men and women.²⁴ For instance, women are usually at a higher risk of contracting urinary tract infections (UTIs).²⁵ Factors such as sexual activity, hormonal changes and anatomical differences contribute to the increased susceptibility of young women to these infections.⁶ UTIs are also highly prevalent among pregnant women.¹⁶ Studies from Zambia and Ethiopia have found a high prevalence of drug-resistant UTIs especially among pregnant women.^{26 27} In post-menopausal women, UTIs are more common, serious and recurrent.

Behavioural factors causing gender differentials in antibiotic consumption and AMR

There are behavioural differences among men and women which impact their health and economic decision-making. Existing literature on gender differences in behaviours related to decision-making suggests that men tend to be more risk-taking while women are generally considered more risk averse.²⁸ Debate is ongoing in the literature on whether these behavioural differences are due to nature/biology or nurture/conditioning.²⁹ Therefore, it is important to explore these differences in the context of decisions related to health, antibiotic consumption and how they can influence AMR.

Gender disparities in health risk behaviours often see men engaging in higher rates of alcohol, tobacco and drug use compared with women, driven by societal expectations of masculinity. This trend is compounded by cultural norms that discourage men from seeking timely healthcare interventions for substance abuse issues. Higher alcohol and drug consumption among men may lead to a higher need for antibiotic use due to weakened immune response.^{30 31} Weak immunity can increase susceptibility to infections, such as the development of respiratory infections.

Masculine ideals also promote risky sexual behaviours, such as avoiding condom use, which elevates the risk of transmission of sexually transmitted infections (STIs), including HIV between partners.³² This reluctance to seek testing and treatment for STIs further impacts women’s health, as they bear a disproportionate burden of these infections when in relationships with substance-abusing or condom-averse partners.^{32 33} Additionally, the link between masculine behaviours and violence increases women’s vulnerability, resulting in physical and psychological harm.^{32 34} This can also contribute to unintended pregnancies among women, exacerbating social, economic and health challenges.

Existing research describes the misinformation circulating among women, their partners and their communities deterring proper and consistent contraceptive use.^{35 36} In a randomised experiment carried out in the USA, it was observed that misinformation concerning the side effects and efficacy of contraception influenced women to select an option that did not most closely match their stated preferences.³⁷ This can lead to unwanted pregnancies and abortions, which may increase the risk of certain postpartum or post-abortion infections requiring antibiotics.

Women’s risk-averse behaviour could lead to women accessing healthcare facilities more than men, for both minor and major illnesses. However, in many LMIC settings, women’s low levels of education and earnings could lead to reliance on the male members in the households to accompany them to hospitals, but men’s inability to understand women’s healthcare needs may further prohibit women. A study based in Kolkata, India, found that men usually characterised women’s health issues as ‘light diseases’ or common health problems, that can be dealt with easily.³⁸ In these situations, women may rely heavily on self-medication or informal practitioners.

Gender norms causing gender differentials in antibiotic consumption/antimicrobial resistance

Norms are shared social beliefs that perpetuate inequitable power relationships. Some of the ways in which gender norms manifest in different countries lead to child marriages and son-preference, valuing of boys’ education and employment relative to girls’, exercising control over women’s financial assets, acceptability of sexual harassment and violence and limiting women’s mobility. Societal norms based on gender interact at various levels of society—household dynamics, legal frameworks and institutional policies—to negatively impact the ability of women and other non-male genders to make decisions (lack of agency). As a result, these groups experience worse health and employment outcomes compared with men.^{9 39}

Figure 1 shows a conceptual framework of how gender norms impact AMR, particularly through intermediary drivers of health and bargaining power, which in turn impact the intermediary drivers of AMR which include (1) susceptibility to infection; (2) health access, including access to affordable and quality healthcare and, (3) appropriate diagnosis and management by health providers. These intermediary drivers/indicators of AMR impact final drivers of AMR such as inadequate access to essential antibiotics, lack of appropriate diagnosis, increased misuse and overuse of antibiotics and increased resistance (figure 1).

Figure 1. Relationship between gendered social norms and AMR. The framework was conceptualised by the authors. It provides an overview of the social norms that have been associated with health and economic outcomes based on the literature⁶⁸; and links them to the drivers of AMR. The list is to be interpreted as indicative and non-exhaustive, subject to revision and update as the evidence base is strengthened. AMR, antimicrobial resistance.

Susceptibility of infection

Adverse gender norms around caregiving responsibilities, suitable education and jobs for women, increase women’s susceptibility to infection and reduce its prevention. These norms impact women’s nature of paid and unpaid work, nutrition, access to WASH facilities, access to safe and hygienic menstrual products, education and awareness, which puts them at a greater risk of contracting bacterial infections. Existing literature has shown that malnutrition is more common among women and girls.^{40 41} A potential reason for this could be that son-preference in most LMICs influences gendered child malnutrition, girls may receive less attention and breastfeeding time.^{42 43}

In terms of work, time-use data reveal that women are usually the primary caregivers in the household which requires them to be involved in cooking, animal care, children and elderly care work.⁶ In settings where cooking areas lack proper ventilation, they are at heightened risk of contracting DRIs through respiratory tract infections or pneumonia.⁴⁴ Women are more likely to be engaged in informal work in LMICs and tend to be involved in menial tasks performed at agriculture and animal husbandry sites, which may result in higher exposure to animals carrying resistant bacteria.⁴⁵ According to a recent WHO report women perform 76% of unpaid healthcare activities.⁴⁶ Even in formal work, women constitute approximately 67% of front-line healthcare workers, thus putting them at a greater risk of exposure to AMR due to their occupation.⁴⁷

WASH is a crucial intervention in mitigating AMR, especially in LMICs and inadequate WASH disproportionately impacts women.⁴⁸ Women with limited economic resources, education and access to WASH are more likely to be exposed to enteric pathogens through contaminated water.⁴⁴ In South Asian countries like India and Nepal where menstruation still remains a taboo subject, women often resort to using unsafe menstrual products such as cloth and may be isolated from their households during their menstrual period due to being labelled as ‘dirty’.^{49 50} Poor WASH facilities coupled with limited access to menstrual products may also increase the risk of urogenital infections.^{44 51}

Access to affordable and quality healthcare

Son-preference and gender norms that place restrictions on women’s physical mobility, ownership and control of physical and financial assets influence women’s participation in decision-making and their bargaining power. This impacts women’s access to health and lowers their access to affordable and quality healthcare, resulting in reduced access to essential antibiotics. A preference for boys over girls can lead to families prioritising healthcare, immunisation and treatment for male children.⁵² Health data from Mali shows that boys are more likely to finish their antibiotic course in comparison to girls.⁵³ Studies based in India show significant disparity in immunisation rates between girls and boy.⁵⁴ Almost two out of five women in India reported needing to seek permission from family members for travelling to pharmacies and hospitals.⁵⁵ Evidence from Bangladesh shows that there are wider gender disparities in access to pharmacies in rural areas.⁵⁶

Norms surrounding women’s paid and unpaid labour, job characteristics and motherhood can also impact their access to prompt and accurate medical diagnoses.⁹ The double burden of paid and unpaid work leaves no time for women to seek timely and accurate diagnoses. Many women find themselves predominantly engaged in informal employment with limited job stability and inadequate access to health insurance.⁵⁷ In addition, women and girls do not make decisions about their health based only on their own self-interest but are influenced by the interests and expectations of their families and communities.³⁶ Cultural expectations tied to motherhood might restrict women from seeking medical attention for non-maternal health concerns.³⁶

There are norms about suitable jobs for women and norms that prohibit women from participating in the workforce and more easily accessing the healthcare system. Only 53% of adult women participate in the labour force globally, compared with 80% of men.⁵⁸ There is evidence that women’s lack of earned income and prevalent patrilocal family structures leading to co-residence with parents-in-law reduces their nutrition and bargaining power at home.⁵⁹

Appropriate diagnosis and management by health providers

Gender-biased health systems, lack of adequate representation of women in the medical field and inadequate research on women’s health can lead to unintended gender-bias in patient care and over prescription of antibiotics to women. For instance, 72% of the physicians working in countries across Africa are men.⁴⁴ As a result, women may have fewer tools to negotiate risk reduction interventions.⁴⁴ For example, a study based in Sweden and the USA revealed that being women was correlated with a higher likelihood of inappropriate prescribing for viral respiratory tract infections, viral bronchitis, viral pneumonia, influenza or pleurisy.⁶⁰ In general, women’s health remains severely underfunded, suffers from insufficient research addressing them and women remain under-represented in clinical trials.⁶¹

There is also evidence that doctor–patient gender concordance plays a role in healthcare delivery and outcomes. A study in the Netherlands found that female general practitioners (GPs) prescribed less antibiotics, especially to female patients, while prescriptions by male GPs did not vary by patient gender, after controlling for comorbidities and patient age in both cases.⁶² This evidence underscores the importance of gender dynamics in healthcare, suggesting that increasing the representation of female healthcare providers may lead to improved healthcare delivery and outcomes, especially for women. It also highlights the need for further training and awareness among male providers to address potential biases in treatment.

The lack of diagnostic infrastructure, combined with insufficient research into women’s health issues, contributes to gender differences in AMR. A study from several African countries underscores this disparity, revealing that gonorrhoea symptoms differ between men and women, with women frequently being misdiagnosed.⁶³ This misdiagnosis, arising from inadequate screening/testing from doctors, as well as discomfort and shame from patients can result in the prescription of incorrect antibiotics, leading to increased treatment failure.

Discussion

We provide a conceptual framework to understand and analyse the mechanisms through which gender norms can influence antibiotic use and AMR. Not considering gender equity when formulating AMR mitigation policies and strategies, could result in exacerbating practices that cause gendered harm. This review underscores the differences in the incidence of AMR across various segments of society. Some groups face greater risks of exposure to AMR and struggle to access or benefit from AMR information, services and treatments. For example, female migrants and women in regions with war, conflict, extreme temperatures and pollution may be at disproportionately higher risk of AMR.⁶⁴ A better understanding of the intersection of gender, race, caste and other socioeconomic identifiers on infection-related healthcare and antibiotic use is required to develop sustainable and tailored AMR solutions that meet the needs of different populations.¹⁰

Accounting for the gendered dynamics within the health environment through the enactment of gender-responsive and gender-transformative policies and regulations is imperative for improving health outcomes for women, fostering gender parity and advancing opportunities for women in leadership roles in healthcare. Embracing a multisectoral approach to policymaking and nurturing collaboration among diverse stakeholders emerges as a powerful strategy for tackling complex challenges like AMR. This entails ramping up funding for surveillance and data collection initiatives, disaggregated by sex, gender, age, occupation and other socioeconomic stratifiers.

Central to this effort is providing access to essential medications and the strengthening of healthcare systems, including diagnostic infrastructure, promoting responsible prescribing practices and investing in AMR research and interventions across both high-income countries and LMICs. There is a pressing need to expand our understanding of gender differentials in prescribing behaviours, patient prescription filling patterns, antibiotic consumption trends and the development of resistance, underpinning the urgency for further research and evidence-building in this critical domain.

Current expenditure and allocation of research funding in AMR is skewed towards technology and innovation with not enough funding allocated to better understanding the sociocultural drivers, including gender. This risks developing solutions that will not be tailored to the needs of different populations.⁵ In writing this narrative review piece, we accessed the publicly available research funding allocation of two major funders in health and considered the proportion of funding allocated to AMR and gender equity using the grant themes and titles of successful applications. Of the US$39 billion total Bill and Melinda Gates Foundation (BMGF) grants awarded since 2015, 17% have been awarded to gender equity research. Wellcome Trust (WT) while having provided more funding to AMR, has devoted 3.6% of funding to gender equity research from their total funding of £5.6 billion in the same period. It is noteworthy that 89% of BMGF and 68% of WT funding in gender equity are awarded to principal investigators in HICs (Based on author's own calculations. Data are available upon request). The majority of the funding for gender is spent on reproductive and maternal health and nutrition. This is an oversight as it only considers women’s health important in their childbearing years.

To date, 170 countries have formulated National Action Plans for AMR. Despite this widespread effort, their implementation remains notably deficient.⁶⁵ The lack of clear and actionable goals hampers progress in effectively addressing AMR on a global scale. There is a conspicuous absence of considerations pertaining to gender, equity and justice in these plans, which are vital for ensuring fairness in both the access to and availability of antimicrobial treatments.⁶⁵ The WHO introduced a strategy in 2023 known as the people-centred approach for AMR. This strategy aims to acknowledge and address the obstacles and health system barriers that individuals encounter when seeking healthcare services. It emphasises a ‘prevention approach for AMR’, which includes investments in WASH and infection prevention and control (IPC), with a particular focus on at-risk populations. Additionally, this strategy considers the needs of vulnerable groups and recognises how they may be disproportionately affected by the drivers of AMR.^{66 67}

There is much literature on the need for new antibiotics and their impact on HICs, while emerging evidence supports focusing on last mile delivery of vaccines, improving WASH, strengthening food security, enhancing infection prevention measures, strengthening existing healthcare infrastructure and providing universal healthcare in LMICs.⁵ Gender implications need to be integrated into AMR mitigation strategies globally, particularly in areas with high gender discrimination and inequality. By adopting an intersectional and life course approach, interventions aimed at combating AMR can be tailored to address the evolving health needs and challenges faced by women and at other risk populations, across different stages of life.

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

Data availability statement

Data are available upon request.