Implications of the Global Early Adolescent Study's Formative Research Findings for Action and for Research

Why Is Understanding Gender Norms Important to the Health and Social Well-being of Adolescents?

Adolescence is a critical life stage—a time of enormous physical, cognitive, emotional, and social development. During adolescence, boys and girls develop the ability to think abstractly and critically. They begin to form a sense of who they are and what role they want to play in the world. While parents continue to be important in their lives, adolescents transition from strong parental control in childhood to greater independence as they move through their teenage years. Meanwhile, as adolescents' social networks expand beyond their immediate families and neighborhoods, peers play a greater role in influencing their opinions, attitudes, and behaviors [1]. As boys and girls begin to establish independence, enforcement of social norms—including gender norms—by parents, peers, schools, and other community institutions becomes particularly poignant. While these changes and developments can create major opportunities for girls and boys, they also expose them to new risks. The behaviors that they adopt and the social context in which they live can set trajectories for their health and well-being as adults.

While some of these risks and behaviors are the same for both boys and girls, differences in behaviors and practices emerge in adolescence that contribute to differential patterns of morbidity and mortality. For girls, HIV/AIDS, complications associated with early pregnancy, childbearing and unsafe abortions, infectious diseases, unintentional injuries, and suicide account for significant mortality [1]. Girls are also more likely than boys to be subjected to harmful traditional practices such as child marriage that have long-standing consequences for their health. Girls are less likely to complete secondary school or have secure employment and are more likely to be exposed to intimate partner violence and sexual abuse [2], [3]. For adolescent boys, the top causes of mortality include unintentional injuries from road injuries and interpersonal violence, HIV/AIDS, suicide, and drowning [1]. Boys are also more likely than girls to engage in health-harming behaviors such as early and heavy smoking and alcohol and illicit drug use [1] and are more likely to report early and unprotected sex [4]. Finally, there is growing evidence that in settings where there is sex parity in school attendance, boys are falling behind girls in terms of education achievement [5].

Gender inequities are a key underlying determinant of the sex differentials in morbidity and mortality of adolescents and adults, particularly related to sexual and reproductive health. Gender inequities manifest in different ways, such as discriminatory laws, policies, and sociocultural practices, unequal power, or access and control over resources. At the root of inequities are gender norms, which prescribe differential status, power, access to resources, and expected behaviors (including in relationships) according to culturally appropriate expectations for males and females. While girls and boys are affected by gender norms, girls are more likely to experience the negative repercussions and outcomes of these norms.

Gender norms and attitudes, shaped in early childhood and adolescence, become entrenched over time (We distinguish “norms” as widely shared social expectations from “attitudes,” which reflect individual beliefs related to gender equality). For example, almost half of adolescents (15–19 years), including both boys and girls from a range of countries, agree that wife-beating is justified in some situations [3]. Within this context, the Global Early Adolescent Study (GEAS) was conceptualized to better understand: (1) how gender socialization (We define gender socialization as the process of learning widely shared social expectations [i.e., norms] and attitudes associated with one's sex.) occurs in early adolescence (10–14 years); (2) how gender norms and attitudes, including those related to sexuality, form in early adolescence; (3) how these evolving norms and attitudes shape health trajectories as individuals transition through adolescence into adulthood; and (4) appropriate measures and methods for research on these issues for this age group. The GEAS is being conducted in two phases. Phase 1 (2013–2016) consisted of formative research to identify domains or themes related to young adolescents' norms and attitudes and developed tools to measure changes in these norms and attitudes. Phase 2 (2017–2020) is being designed from the findings of Phase 1 and will follow cohorts of young adolescents over 3 years to understand how gender norms and attitudes evolve and influence health behaviors and outcomes. The articles presented in this supplement describe the various findings of the Phase 1 studies in eight low-, middle-, and high-income countries (Belgium, China, Ecuador, India, Kenya, Nigeria, Scotland, and the United States).

What Do We Know About Gender Socialization in Early Adolescence?

Phase 1 of the GEAS was guided by a systematic review [6] on the factors that shape gender attitudes in early adolescence. The review highlighted five key themes:

• 1.Puberty is a critical time in the life course when pre-existing gender socialization becomes further crystalized;
• 2.Unequal gender norms and attitudes are widespread across geographic and socio-cultural settings, with similarities and differences across contexts;
• 3.Societal expectations of boys and girls differ, and so do their own gender attitudes;
• 4.Race, ethnicity, class, and immigrant status influence gender norms and attitudes;
• 5.Peers and parents are key in shaping the gender norms and attitudes of young adolescents.

Findings from the GEAS formative research presented in this supplement not only echo those of the global evidence review by Kaagesten et al. [6], but also provide a rich narrative that elaborates how gender norms and attitudes play out in the lives of young adolescents, their peers, and their families in a number of countries.

Puberty is a critical time in the life course when pre-existing gender norms and attitudes becomes further crystalized

The global review showed that unequal gender norms and attitudes develop early in life, often intensifying with the onset of puberty. In all sites, the GEAS formative research showed that gender socialization occurs early in life; girls and boys (10–14 years) expressed different gender attitudes. They described how their own and others' expectations of their gender roles had changed since childhood. They also recounted how social expectations influenced behavior, permitted activities, and opportunities available to them. The articles in this supplement highlight how parents' expectations for appropriate behavior and their interactions with their children (including discipline) change in early adolescence and differ based on the sex of the adolescent.

Unequal gender norms and attitudes are widespread across geographic and sociocultural settings, with similarities and differences across contexts

The global review by Kaagesten et al. showed that regardless of the sociocultural or economic context, unequal gender norms are widespread, even if they manifest differently in different settings. The articles in this supplement provide a rich narrative of similarities both in and across settings, as well as differences in specific contexts. For example, as articles by Yu et al., Basu et al., and Al-Attar et al. show that parents' educational and career expectations for their boys and girls are more equitable in Shanghai (China), Baltimore (United States), and Ghent (Belgium) than in New Delhi (India) and Assiut (Egypt). Furthermore, in some settings, different emphases are placed on reinforcing certain gender norms for girls. For instance, in Shanghai, more attention is placed on girls displaying appropriate behavior than on insisting that they wear traditionally appropriate clothing such as dresses and skirts (Yu et al.). In New Delhi, on the other hand, norms reinforce both appropriate behavior and appropriate clothing for girls (Basu et al.). And while girls in Baltimore and Ghent reported that parents were more likely to tolerate romantic relationships for their sons than for their daughters, both boys and girls in Nairobi (Kenya) reported that their parents did not want them to be in a romantic relationship.

Societal expectations of boys and girls differ as do their own gender attitudes

Kaagesten's review showed that societal expectations of adolescent boys and girls are different, as are boys' and girls' gender attitudes. Similarly, the GEAS formative research showed that gender norms reinforce different expectations for boys and girls. For example, across all study sites, boys are encouraged to be tough, strong, and brave and to demonstrate heterosexual prowess. Girls are taught to be nice, polite, and submissive and to accentuate their physical beauty while maintaining their modesty. Norms dictating appropriate dress codes for girls are common across all settings, reflecting beliefs about modesty for girls. However, increasingly, freedom in girls' attire is more tolerated in Shanghai, Ghent, and Baltimore than in New Delhi and Assiut. Across all sites, boys and girls reported that norms are enforced by sanctions (for example, teasing by peers) for behaviors that lie outside accepted gender norms. Also, across all settings, adolescence brings more freedom and autonomy for boys, whereas for girls, the world shrinks and their experiences become increasingly controlled and restricted. This is underscored by the findings from Assiut, Nairobi, and New Delhi, where girls' participation in the public sphere decreases on the grounds that they need protection and that family honor depends on their sexual behavior (Al-Attar et al., Basu et al., and Bello et al.).

Boys and girls differ in their willingness and ability to challenge unequal gender norms. These differences vary across sociocultural settings. In the GEAS research from Ghent, Baltimore, and Shanghai, young girls challenge prevailing gender norms by playing sports and wearing attire associated with boys. Likewise, some boys in Ghent believed that it is acceptable for them to knit. In Shanghai, both boys and girls prioritized high educational aspirations for themselves. Kaagesten et al. show that adolescent boys are less motivated to challenge unequal norms that privilege them, whereas girls recognize the ways norms disadvantage them and are more willing to challenge those norms. But boys face more punitive social consequences when they do challenge unequal gender norms [6]. For example, boys in Baltimore, Shanghai, and Ghent reported being teased by peers as homosexuals when they challenged masculine expectations. Girls in these same sites embraced norms associated with femininity (such as wearing makeup) and with masculinity (such as participating in sports or wearing trousers), stating that both were acceptable for girls. These findings suggest that the participation of girls in some male activities is tolerated to a certain extent, whereas when boys engage in activities that are considered feminine, they are derided, teased, and bullied by their peers and parents.

Race, ethnicity, class, and immigrant status influence gender norms and attitudes

Kaagesten's review showed that gender attitudes vary by individual sociodemographic characteristics such as social class, location, race, ethnicity, and immigration status [6]. However, the GEAS formative research focused on specific settings (urban or periurban areas) where immigrant status or social and class differences may not be as obvious. Despite this limitation, one of the GEAS sites (i.e., Ghent) reported that race, ethnicity, and immigration status influenced adherence to unequal gender norms and the degree to which adolescents challenged prevailing gender norms. Adolescents whose parents had migrated to Belgium reported different expectations from their families related to gender than other adolescents in the same communities.

Peers and parents are key to shaping gender norms and attitudes

Kaagesten's review found strong evidence that inequitable gender norms and attitudes are reinforced by parents and peers; it also found some evidence, albeit less robust, that schools and media play a role [6]. In the GEAS formative research, peers play a common role in influencing the gender norms and attitudes of young adolescents. Discussions with friends on topics such as career aspirations, menstruation, romantic interests, and problems at home shape the way adolescents view the world, recognize expectations, and understand their roles. Adolescents from all eight sites confirm that friendships provide them with emotional and social support through common experiences, as well as social protection from other peers. On the other hand, peers patrol each other's behavior and pressure each other to conform to prevailing gender norms through teasing, bullying, and social exclusion. Another common finding across all study sites was that early adolescence brings a decrease in the social tolerance for opposite-sex friendships, prompted by parents' fear of romantic and sexual relationships. This finding was most pronounced in the data from Assiut, New Delhi, and Shanghai. In Ghent, adolescents vocalized the fear that their peers might misconstrue the nature of these friendships.

Parents' influence on the development of young adolescents' gender norms and attitudes is reaffirmed by findings in all the articles in this supplement. Across the sites, findings show that parents' want their children to assume roles that conform to the prevailing gender norms of their culture and community and reinforce these norms through instruction, encouragement, reward, regulation, discipline, punishment, and admonition. Parents and adolescents most often cited mothers as the primary source of influence, and sometimes as the main disciplinarians. However, adolescents in Delhi and Shanghai noted that fathers also play a major role in shaping gender norms and attitudes, especially for boys. Parental concern for their adolescents was a strong finding across all sites: parents fear that their children's futures and the reputations of their children and families could be harmed by nonconventional behaviors, particularly early sexual initiation.

Another area of parental concern highlighted in the GEAS formative research is their worry about the influence of peers and the increasing influence of social and mass media on their adolescents. The findings from the articles in this supplement demonstrate that many adolescents have access to media and technology. Findings from Ghent and Assiut demonstrate how social media and text messaging facilitate communication for some adolescents. Parents in Nairobi, Ile-Ife, Delhi, and Shanghai voiced concerns about the potential negative impact of media on their adolescents' sexual activity. For example, as the articles from Ile-Ife and Nairobi show, parents are concerned about their adolescents' exposure to romantic films and (in their view) inappropriate dress depicted in mass media. Findings from Baltimore, Cuenca, Edinburgh, Ghent, and Nairobi suggest that young adolescents' opinions about romantic relationships may be influenced in part by what they view in media.

How Can the Global Community Promote Gender-Equitable Norms and Attitudes in Early Adolescence?

While there is no single or “one-size-fits-all” solution, intervention research and project evaluations point to useful steps to promote gender-equitable norms and attitudes in early adolescence.

Engage adolescents in open discussions about gender norms and attitudes that take into account their evolving cognitive capacities

The articles in this supplement and Kaagesten's review show that unequal gender norms and attitudes begin early. Early adolescence is a special time in cognitive development. Changes in brain structure and function enable boys and girls in early adolescence to begin to think abstractly and critically. This is also a time when they begin to examine—and sometimes to question—the “home truths” taught to them as children; they begin to consider who they are, and what they believe. This period of self-examination provides an important opportunity to stimulate critical thinking about their own attitudes, as well as gender norms and how these affect their own lives and the lives of others.

Stimulate critical reflection to change attitudes and norms within peer groups

Adolescents spend time with their peers, both in and out of school. The articles in this supplement and the global evidence review highlight the importance of peer relationships in shaping gender norms and attitudes. Peers share information, opinions, thoughts, and feelings. They observe what their peers wear, what they say and how they say it, and what they do. They emulate peers with whom they identify and distance themselves from those with whom they do not. These peer relationships shape adolescents and help them learn how to interact with others, deal with everyday problems, and give and receive support. The desire to fit in provides extensive motivation for young adolescents, as peer relationships reward and sanction behaviors. The stronger the adolescent feels an affiliation with his or her peer group, the stronger its influence on him or her. Based on this understanding, an increasing number of interventions use a peer-based model of critical reflection on gender norms and attitudes. Interventions that use both school- and community-based curricula to generate critical reflection on gender norms have shown that positive changes in gender attitudes are possible in a short period of time [7], [8]. However, these interventions have been less successful in changing behavioral outcomes (such as reductions in violence perpetration or victimization, sexual behavior), highlighting and demonstrating the complex relationship between individual attitudes and behaviors that are shaped by community and societal norms. One example of a peer- and school-based curriculum for promoting equitable attitudes is the Gender Equity Movement, implemented in India to encourage both boys and girls (12–14 years) to reflect on and discuss unequal gender norms and harmful practices. The intervention reported positive changes in gender attitudes [9], [10]. Other interventions that have elicited positive changes in attitudes include Choices in Nepal [11], and the Gender Roles, Equality, and Transformation project in Northern Uganda [12].

Incorporate content on gender-equitable norms in parenting interventions

Both the GEAS formative research and Kaagesten's review article show that young adolescents are still largely influenced by their parents. They look to their parents for basic needs, for information and advice, and for love and affection. They observe what their parents say and do and, consciously or otherwise, model themselves after their parents. And finally, while adolescents look to their parents for limits, they also challenge the limits that are imposed. Parents want their sons and daughters to succeed and to grow and develop into healthy and happy adults. They worry about the dangers—real or imagined—to which their sons and daughters are exposed, and they want to protect them. But often, parents lack the competencies needed to engage their sons and daughters. With growing frustration, they may use violence—and especially with boys, physical violence—to exert control. And they pass on their knowledge gaps, misconceptions, and unequal gender norms and attitudes to their children. Reviews of parenting programs suggest they focus on providing parents with information about their children's development, the challenges that they face as they grow and develop, and ways of navigating these challenges. Helping parents communicate with their children is a key focus of most programs. These reviews suggest that interventions can improve parents' abilities to connect, regulate, support, promote autonomy and role model, and reduce abuse as a way of disciplining children [13], [14], [15]. Parenting interventions that have shown some efficacy in improving parenting skills include Triple P and the Incredible Years [16], [17]. However, these interventions do not explicitly address the importance of promoting and role modeling equitable gender norms and attitudes for children. This represents a missed opportunity that must be redressed.

Change norms by working simultaneously at different levels of the ecological framework

Promoting equitable gender norms and attitudes and sustaining changes in behavior requires work at multiple levels (with individual adolescents, peers, families, communities, and societal institutions). A small number of interventions include multiple components that operate simultaneously at several levels of the ecological framework. For example, the Choices intervention in Nepal included a component aimed at increasing communication about gender inequality between parents and children at the household level (Voices). Another component was designed to generate dialogue on this subject at the community level (Promises). An evaluation of the intervention showed an improvement in adolescents' attitudes and behaviors toward sharing household tasks with their sisters, control and dominance, and girls' education [11]. More evaluations of these kinds of combined and structural interventions are needed to provide a robust evidence base on how to foster equitable gender norms and attitudes among young adolescents.

Interventions in community settings or schools can be limited in terms of their reach. Radio, television, and print media have the potential to reach and influence large populations. Radio and television campaigns that target adolescents and young people include Soul City in South Africa and Sexto-Sentido in Nicaragua [18], [19]. Both present soap operas that deal with issues of sexuality, reproductive health, and gender relations. Evaluations of these large-scale programs showed some improvements in knowledge and awareness of issues related to violence, sexual relationships, and safer sex. In South Africa, Soul City showed improvements in equitable gender attitudes for a time-limited period. The impact on behavior change and sustaining changes in behavior, however, has been more limited [18] and may require combining mass media with community-based interventions.

Strengthen school-based efforts to promote equitable gender attitudes

The GEAS formative research suggests that adolescents do not perceive teachers as credible and approachable sources of advice and support on social issues. The current evidence on school-based efforts to promote equitable gender attitudes is largely drawn from comprehensive sexuality education [20], life skill–based education programs (for instance, see the earlier discussion on peer-based approaches), and, to a lesser extent, interventions around menstrual hygiene [21]. Given that primary school enrolment and school retention rates are rising in many low- and middle-income countries, schools provide an important opportunity to build equitable gender norms and attitudes. However, we need more evidence on school-based interventions, particularly whole-school approaches (encompassing curricula, training teachers, addressing sports cultures, and school policies) to promote equitable gender norms and attitudes.

Tap into the reach and influence of media and technology

The use of mobile phones has skyrocketed in many low- and middle-income countries. Adolescents have taken to this medium with enthusiasm and ease. Clearly, social media provides them with a window to the wider world. On the other hand, there is also some evidence that it is also being used to share views anonymously that reflect unequal gender attitudes and for cyber bullying [22]. Promoting messages of gender equality through mobile phones and social media has the potential to engage adolescents using a medium that they have embraced, but we need much more research in this area.

Develop measures and research methods to understand and track how gender norms evolve and to identify what works

Although Phase 1 of the GEAS illustrates how gender norms and attitudes form in early adolescence in different contexts, knowledge gaps remain. There are gaps, for example, in our understanding of the different roles that mothers and fathers play in shaping norms, or how schools, media, or structural changes in society (due to economic growth, new opportunities for women or lack thereof for young people, or migration and urbanization) are shaping gender norms among adolescents. We have few research tools and methods to measure gender norms at the community or societal level and to measure changes over time. Most existing methods largely measure individual gender attitudes as a proxy for changes in norms; however, we know that these measures do not accurately capture community-level or large-scale societal-level changes in norms. Phase I of the GEAS has contributed improved tools and data collection methods for measuring gender attitudes among young adolescents, as well as for measuring gender norms beyond individual attitudes. As the study moves forward with a longitudinal cohort study in Phase 2 of the GEAS (some sites will include an intervention research component), these tools and methods will enable us to measure changes over time and to evaluate whether interventions are, in fact, producing changes in norms beyond individual attitudes. Concurrently, we must design and evaluate multicomponent interventions for this age group that could contribute to changes in individual attitudes, as well as in group/community-level norms. We must also evaluate sustained changes in equitable norms and attitudes over time as individuals transition through adolescence into adulthood, and to capture changes in behaviors and health and well-being.

Working with young adolescents and their social networks to promote equitable gender norms is an emerging area of focus in research and programming for adolescent health and development. We continue to make progress in understanding how gender norms are shaped during adolescence, particularly in the critical early years. However, we need to continue to make efforts to better understand and respond to adolescents' needs. The GEAS formative research described in this supplement has the potential to make a valuable contribution to the field of adolescent health by enabling program implementers and researchers to design and evaluate culturally tailored and theoretically, conceptually, and empirically sound strategies to promote gender equality as a key determinant of adolescent health and well-being.