Gender norms and obesity: Incorporating gender norms change into clinical interventions

Austin et al.’s (1) finding that gender nonconforming females had higher BMIs compared to females with gender conforming expression is an important example of how social norms can impact the health of adolescents. While prior evidence reveals that femininity is related to thinness, this is the first prospective cohort investigation to examine the association between gender expression (GE) and BMI. Austin and colleagues find that GE is a strong independent predictor of BMI in adolescence. Here, we describe the importance of appropriately assessing GE and future foci for translational work: (1) understanding possible targets/pathways between GE and obesity (gender nonconforming females → minority stress → obesity); and (2) understanding how evidence-based practices can be adapted to include gender norms.

A growing body of research on adolescent gender and sexual identity development underscores the fluidity of GE and identity during adolescence (2). Austin and colleagues add to this evidence base with the inclusion of a measure of self-perception of one’s gender. These perceptions are important, but only one dimension of how we experience gender. It is important to discern differences between how adolescents specify their own GE versus how they think others define their GE. As gender is performative (e.g., putting on make-up) and relational (dress is more feminine compared to peers), attention to contexts and settings in which youth express themselves more masculine or more feminine is needed.

Another important distinction is between GE and sexual orientation. For sexual minority youth (youth who are same sex attracted, engaging in same sex behaviors, or who identify as lesbian, gay, bisexual, or queer (LGBQ)), the intersections of GE and sexual orientation may be more complex given intense social pressures to conform to heteronormative standards of masculinity or femininity. The intersection of gender and sexual orientation may also be meaningful in capturing adolescents’ GE when measured using their perceptions of how others perceive them. In some cases, perceptions of masculinity and femininity are different within LGBQ and heterosexual communities.

Austin and colleagues’ findings point to a critical missed opportunity in interventions for obesity. No evidence-based treatments currently address or incorporate discussions of GE, gender identity, and sexual orientation. Our group has been employing novel strategies to foster conversations with youth about gender norms and hypermasculinity and have integrated critical discussions of gender norms change into violence prevention interventions (3). These conversations include asking youth to reflect on messages they hear about “being a man” or “being a woman” to understand social influences (e.g. media messages) that are consciously and unconsciously molding their perceptions of their gender identity and expression – what is called ‘gender transformative programming’ (4). To date, we have not applied this approach to obesity interventions. Clinically, novel treatment for obesity in light of these findings, could incorporate probes on femininity and masculinity, how gender norms develop (i.e. identify social influences that contribute to their perceptions of GE), how these norms affect eating and physical activity behavior, and how these beliefs may affect BMI.