Adolescents’ perceptions of gendered influences on mental health: Results from a 13-country qualitative study

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Fine, Abigail Harrison, Natalie A. Rykiel, Matilde Maddaleno Herrera This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6717615/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: A growing body of research supports the influence of gender norms on adolescent mental health globally. There is a lack of qualitative studies, however, that elicit adolescents’ own perspectives on these issues across diverse cross-cultural environments. The current study seeks to address these gaps through a qualitative exploration of gendered influences on mental health among adolescents living in 13 countries. Methods: A total of 71 focus group discussions (FGDs) with adolescents aged 12-19 years were conducted between February and June of 2021. Countries were selected to ensure geographic, economic, and cultural diversity, and included: Belgium, Chile, China, the Democratic Republic of the Congo, Egypt, Indonesia, Jamaica, Jordan, Kenya, Malawi, Sweden, Switzerland, and the United States. Within each country, FGDs were stratified by sex and age. FGDs were recorded, transcribed verbatim, and translated into English for inductive thematic analysis. Results: While adolescents’ reflections underscored the role of gender norms in influencing mental health, it was apparent that there are important gender differences in the nature of this relationship. According to participants, restrictive norms frequently expose girls to greater scrutiny and control, discriminatory treatment, damaging beauty standards, and gender-based violence, which have deleterious impacts on their mental health. For boys, participants highlighted emotional suppression as a central aspect of masculinity and discussed links between masculine norms and risky health behaviors. Conclusions: Across a diverse group of countries, findings suggest the need for adolescent mental health prevention and promotion strategies that focus on shifting harmful gender norms during this critical developmental period. Psychology Epidemiology Adolescents Gender norms Masculinity Femininity Mental health Qualitative study Implications and Contribution Focus group discussions with adolescents across 13 countries revealed variations in the influence of gender norms, both intrinsic and extrinsic, on adolescent boys’ and girls’ mental health. Broad representation across low-, middle-, and high-income countries implies the importance of developing gender-transformative interventions to improve adolescent mental health outcomes globally. Introduction Adolescence (ages 10-19) is a critical developmental period characterized by rapid biological, cognitive, social, and emotional changes [1,2]. These co-occurring changes make adolescents particularly vulnerable to the emergence of mental health problems, including depression, anxiety, substance abuse, conduct disorders, eating disorders, and suicidal behaviors [3,4]. Indeed, mental health problems affect up to 20% of adolescents worldwide, and represent a leading cause of health-related disability among this age group [5,6]. With approximately half of lifetime mental health problems manifesting prior to age 14 [7], psychosocial maladjustment in adolescence can give rise to impairment throughout the life course [2,4]. As such, drivers of mental health problems during this sensitive period of development are vital targets for preventive interventions. Adolescence also marks the emergence of persistent gender inequalities in mental health [8]. Around the world, girls have been identified as demonstrating more internalizing symptoms (e.g., depression, anxiety) as compared to boys, although the size of this disparity has been found to vary greatly across countries [9,10]. By contrast, boys have consistently been found to exhibit greater externalizing symptoms (e.g., aggression, substance use, conduct problems) [8]. While this gender divide is well-established, the underlying interplay between biological (i.e., sex-related) and social (i.e. gender-related) processes that give rise to this disparity is poorly understood. Emerging evidence suggests that gender norms may play a critical role by influencing both the development and expression of mental health problems among adolescents globally [11–13]. Gender norms can be defined as the “often unspoken rules that govern the attributes and behaviors that are valued and considered acceptable for men, women, and gender minorities” in a given culture [14]. These norms appear to solidify in adolescence, leading boys and girls to engage with and reenact different social scripts that are likely to inform gender disparities in health outcomes throughout the life course [11,15,16]. A growing body of research supports the influence of gender norms on adolescent mental health globally [17]. For adolescent boys, normative values around masculinity in many settings encourage harmful behaviors such as aggression, delinquency, and substance use [18,19], and may help explain an outsized prevalence of behavioral disorders when compared to girls [2]. Further, masculine norms emphasizing strength and invulnerability can impede adolescents from expressing and seeking help for emotional distress [13,20]. This may contribute to more severe subsequent mental health outcomes [21,22]. Indeed, a recent systematic review found that adherence to masculine norms was generally associated with poor mental health (including stress, depression, and anxiety) among adolescent boys, with the included qualitative studies emphasizing the role of emotional restriction in exacerbating these mental health consequences [23]. For adolescent girls, entrenched gender norms may contribute to discrimination, restricted opportunities, and increased exposure to gender-based violence, sexual and reproductive health risks, and early marriage [12]. These gender-specific risk factors can produce immense psychological distress, leading to elevated rates of depression, anxiety, and attempted suicide among girls when compared to boys [12,24,25]. In addition, there is some evidence for the relationship between adherence to feminine norms and the development of eating disorders in adolescence, fueled by body dissatisfaction [26,27]. It is important to note, however, that findings in this area have been decidedly mixed [28]. Notably, existing evidence related to these issues is predominantly from high-income countries (HICs), even though most of the world’s adolescents live in low- and middle-income countries (LMICs). For instance, a systematic review of longitudinal studies of gendered drivers of suicide in adolescence identified 67 manuscripts, only five of which were from LMICs [24]. It is also important to note that quantitative global surveys have historically approached this issue through an examination of sex differences as opposed to the empirical measurement of gender norms, thus limiting conclusions around sociocultural influences on mental health [29]. Finally, there is a lack of qualitative studies that seek to elicit adolescents’ own perspectives on these issues across diverse cultural environments. The current study seeks to address these gaps in evidence through a qualitative exploration of gendered influences on mental health among adolescents living in 13 countries spanning five continents, including both LMICs and HICs. While a wide range of topics were covered in the initial research, this analysis focuses on adolescents’ perceptions of the ways in which gender norms contribute to the development of mental health problems in adolescence, and the extent to which this is different for girls and boys living in diverse settings globally. Methods Participants and Procedures This study uses qualitative data collected in conjunction with and commissioned by the United Nations Children’s Fund (UNICEF) 2021 State of the World’s Children Report . Detailed methods have been described elsewhere [30]. In brief, 71 focus group discussion (FGDs) with adolescents were conducted by partner organizations in 13 countries: Belgium, Chile, China, the Democratic Republic of the Congo (DRC), Egypt, Indonesia, Jamaica, Jordan, Kenya, Malawi, Sweden, Switzerland, and the United States. Each country hosted a minimum of four FGDs equally divided by sex and age such that there were at least two younger (ages 12-15) and two older (ages 16-19) FGDs held separately with boys and girls. Prior to data collection, all country partners obtained ethical approval from their local ethical review boards. Johns Hopkins University (JHU), the coordinating partner, waived ethical review. Across participating countries, FGDs were held between February and June 2021; depending on local COVID-19 restrictions at the time, FGDs were either held in-person or online. All FGDs were implemented using a comparable FGD guide which was developed collaboratively by UNICEF, JHU, and country partners. FGDs lasted between 60 and 90 minutes, and were conducted in local languages by experienced researchers who had participated in an online training conducted by JHU prior to commencing data collection. FGDs were audio-recorded and transcribed verbatim, and field notes were written immediately after each session. Data Analysis Transcribed audio-recordings and typed field notes were translated into English for analysis. These qualitative data were coded using an inductive thematic analysis approach [31]. Analysis began with a process of open coding, with lines of data examined and labeled based on their thematic content. Initial codes were compared, grouped into categories, and organized into a preliminary codebook. This codebook was further refined throughout the data analysis process, with two JHU analysts working to apply it to the full set of qualitative data . Coded data with relevance to gender norms and mental health were subsequently reanalyzed by the study’s authors. Two qualitative analysis software programs – ATLAS.ti (Version 9.1) [32] and MAXQDA 2022 [33] – were used to help organize and analyze the data. Results Across participating countries, adolescents discussed important gender differences in the nature of the relationship between gender norms and mental health. In the section that follows, emergent themes have been organized according to these gender differences. Gendered Influences on Girls Standards of femininity. Adolescents around the world reflected on the ways in which standards of femininity governed conduct among girls. Participants listed a range of idealized feminine traits – including being “fragile,” “delicate,” “gentle,” “quiet,” “sensitive,” and “beautiful” – and described strong external pressure to conform to these traits. Several participants also expressed that girls faced greater scrutiny around adherence to gender norms, and more limitations on associated behaviors, compared to boys their age. We're told we have to be like this, like this, like this. While the boys, well… It's like they're doing whatever they want. (Older girl, Belgium) Interestingly, some participants suggested these feminine norms could serve as a protective factor against developing mental health problems by contributing to the social acceptability of expressing and seeking help for emotional distress among girls. It is worth noting, however, that this sentiment was more strongly voiced by boys rather than girls themselves. Society dictates that a girl can sit and cry and relate all her feelings and that's okay because you are a female…society tells us that the girls are the ones who are supposed to talk about their feelings and be emotional. (Older boy, Jamaica) Pressures on appearance. One of the most consistent themes across countries was the deleterious impacts of feminine beauty standards on girls’ mental health. Around the world, participants described both internal and external pressures placed on every aspect of girls’ appearance – their body type, weight, features, skin color, clothing – and most agreed that these pressures were much more intense than those experienced by boys. Several adolescents also reflected on the increasing sexual objectification experienced by girls as they went through puberty. [There’s] this incredible, incredible pressure on appearance that exists….it's not okay to just be mediocre…and not like be super beautiful. (Older girl, Sweden) They do not see us as women but as objects. (Older girl, Chile) Adolescents across participating countries detailed the ways in which contending with beauty standards and sexual objectification contributed to feelings of anxiety, insecurity, and low self-esteem among girls. Several adolescents also highlighted how these factors could drive girls towards disordered eating. Notably, these mental health challenges were described as being intensified by social media’s glorification of girls and women with “ideal” bodies. I think [girls’] problems are mainly regarding their insecurities…thinking that they’re not pretty, they’re not beautiful. (Older girl, Indonesia) So there’s like a specific body type that society has told us we are all to look like and for girls who don’t have that body type, it leads to lots of things like eating disorders…especially with social media these days, you see that body image and when you don’t have it, it breaks down a lot of people’s confidence. (Younger girl, Jamaica) Participants from diverse contexts also reflected on the fine line that girls frequently navigate in their appearance and their struggle to find a balance: if they dressed too conservatively, they were seen as unattractive or unfeminine, but if they dressed in something that was too “tight,” “revealing,” or “attention-grabbing,” they were seen as promiscuous or targets for harassment. We are always being judged. We dress in…workout clothes, basic pants: “Well, you could dress in a more feminine way!” When you dress in a feminine way: “Don’t forget you are going to school!”…And then, when we…dress a bit better…we are told, “Be careful not to wear things off the shoulder, it can’t be too tight.” (Older girl, Belgium) Inequitable gender norms. Across many participating countries, adolescents also discussed the impacts of restrictive and inequitable gender norms within their specific cultural contexts. Particularly in Middle Eastern and African settings, a common theme related to traditional community values which privileged male dominance and control, and the ways in which contending with these values could contribute to immense distress among girls. I wish to work and have my own independent personality and I don’t want to depend on my family in everything or to get married to someone who wants to control me as he wishes...I wish to live a different way but the society and the whole world is surrounding me with something I don’t know, and I feel disabled. (Older girl, Egypt) Participants in these settings illustrated the ways in which inequitable gender norms were commonly enforced within adolescents’ families, contributing to a lack of agency and autonomy among girls. Specifically, they discussed the discriminatory treatment of girls compared to boys, which included heightened control, restricted freedoms, diminished attention, little consideration of their opinions, and a greater emphasis on domestic chores. Girls are concerned about [discrimination], the fact that the father cares more about the boys than the girl. The mother also cares about the boys more than the girl. (Younger girl, Jordan) Before going to school I do so much housework and often my brothers don’t do anything. (Older girl, DRC) Within families, another important issue in these settings related to the devaluation of girls’ education. A number of participants described how parents would discourage their daughters from attending school due to the belief that girls’ continued education did not benefit (and may even detract from) their marriageability. In some cases, adolescent girls also described being pushed into early marriage at which point they were forced to drop out of school. The girl loves her studies and is interested in her studies more [than marrying early]. [But her parents] tell her to leave school because in the end, “You will be in your husband’s house. Girls are created to marry and work.” (Younger girl, Jordan) There are some parents that tell girls not go to school because they will get married to rich husbands...They are told that they will not take care of the family, that they will be the responsibility of the man. (Younger girl, Malawi) More broadly, girls around the world discussed both threatened and experienced gender-based violence across their family, school, and community environments, as well as the damaging psychological impacts of such violence. This issue is covered in depth in a separate analysis based on the same data [34]. Gendered Influences on Boys Standards of masculinity. While it was clear that gender norms operate differently for boys compared to girls, participants emphasized their equally powerful role in impacting boys’ mental health. Across participating countries, adolescents discussed largely consistent cultural norms of masculinity which prioritized strength, independence, and stoicism. Common descriptors included: “strong,” “tough,” “proud,” “dependable,” “don’t need any help,” “man of the house,” “shouldn’t show emotions,” and “cannot cry.” Many boys expressed powerful anxieties related to violating these norms, including fears that they would be disparaged or harassed due to being perceived as “weak,” “vulnerable,” “soft,” “feminine,” or “gay.” We all have problems, but guys are supposed to be like robots and people think we can’t have feelings. (Older boy, United States) There is the notion that boys must be tough, and if he complains or if he opens up, he would be...mocked...[as] weak. (Older boy, Indonesia) Society tells us that as long as you are born with a penis, then you’re not supposed to be expressive. Real men don't cry…that is something that fathers instill, fathers and mothers alike. Especially in Jamaica, they don't want you to grow up as no “chi-chi boy” [homosexual]. (Older boy, Jamaica) Risky health behaviors. Around the world, participants illustrated the pathways through which masculine gender norms could drive boys towards risky health behaviors. For instance, many adolescents suggested that boys were more likely than girls to use drugs or alcohol, and several mentioned external pressures from male peers or family members who encouraged substance use as part of “being a man.” Friends are also giving [alcohol] to one another and saying, “Drink a little, don’t be a woman.” (Younger boy, Egypt) Regarding drugs…there is such a large drug culture around, like in guy groups, that it's like, test different things and do things. (Older boy, Sweden) Adolescents also emphasized the normalization of violent and aggressive behaviors among boys. Across diverse settings, adolescents described the ways in which such behaviors were acceptably employed as a means of proving their masculinity, resolving interpersonal conflicts, or defending themselves or others. [Boys] need to show that they are strong, and they know how to protect...It’s really for themselves that they go out with [a weapon]...It’s really to show, “Well, I am a man, I can fight!” (Older girl, Belgium) A lot of guys around my age they tend to be violent, and when they are around their friends everybody want to prove that they are the baddest…they hurt the weaker ones, those who cannot protect themselves, just to gain some form of clout. (Older boy, Jamaica) Increased financial pressure. Another commonly voiced sentiment was the internal pressure that many boys experience to earn money and provide for their families in order to show that they are the “man of the house.” Around the world, boys highlighted deep-seated stress and anxiety regarding achieving financial stability and independence, as well as negative mental health outcomes among those who were unable to do so. From my experience, it is what males are most likely worried about: success. Right? We have been growing up with the ideology that when we as men grow up, we must be successful in order to support our women and our kids. (Older boy, Jamaica) When a young man can't find work he falls into depression…you prefer to sit alone and isolate yourself, and you [are] frustrated and you do not have hope. (Older boy, Egypt) Alongside these internal pressures, several participants also described the external pressure from boys’ families to contribute financially from a young age. Notably, this arose most frequently in African settings. It happens that both parents reach a point that they are completely broke and have no money…You are the only boy and now they see you as a man…so they would require you to go and get a job…The entire family is looking to you to provide. (Older boy, Kenya) Consequences of limited emotional expression. Across countries, it was clear that one of the most damaging impacts of gender norms on boys’ mental health related to severe constraints on expressing feelings and seeking help for emotional distress. As mentioned above, the notion that “boys don’t cry” was a common refrain around the world, and many adolescents suggested that such masculine stereotypes drove boys’ silence and isolation when experiencing distress. Participants illustrated the ways in which such emotional repression could exacerbate mental health problems among boys, “festering” and “eating” at them. I think the worst, worst defense that a man can have is... keeping things [to himself]…That's why we’re the biggest suicide statistic out there, because we don't have…a method of venting...in the end we end up repressing ourselves more. (Older boy, Chile) Mental health is more dangerous in boys than girls because boys cannot talk about it and...well, they close themselves off, they never speak of it, and after a while it starts to eat at them. (Younger boy, Switzerland) Aligned with the normalization of risky health behaviors, a number of adolescents also suggested that in the absence of other help-seeking options, boys commonly turn to violent or aggressive behaviors as a means of coping with stress, anger, and frustration. Similarly, boys were described as frequently turning to drugs or alcohol as a way of “escaping from their problems.” The majority of the violent behaviors for males is because they have no one to talk to and they don't know how to handle their stress. (Older boy, Jamaica) When you are using drugs, it’s because you are stressed so you are trying to forget those bad feelings...when you use them, you kind of forget about your worries. (Older boy, Kenya) Discussion Findings from this qualitative study across 13 countries emphasize the consequences of gender norms on adolescent mental health in diverse global contexts. This aligns with a growing body of evidence among young people worldwide, which has drawn attention to the myriad ways in which gender norms can drive exposure to key mental health risk factors [14], dictate socially acceptable expressions of distress [35,36], and govern specific coping strategies and help-seeking behaviors [37,38]. These findings are particularly important given that adolescence is a period in which gender norms become more firmly internalized and patterns of related behaviors are established [11,15]. As such, there is a clear impetus for preventive interventions that target the links between gender norms and mental health during this critical developmental period. While adolescents’ reflections underscored the role of gender norms in influencing mental health, it was apparent that there are important gender differences regulating this relationship. Specifically, findings suggest that for adolescent girls, this pathway is largely indirect. According to participants, restrictive and patriarchal norms frequently expose girls to different risks as compared to their male peers, including greater scrutiny and control, discriminatory treatment, damaging beauty standards, and gender-based violence. These risks, in turn, have deleterious impacts on girls’ mental health and well-being. These findings reflect and unify those that have previously been identified across largely siloed research – for instance, in studies focused solely on dating violence [39], early marriage [40], or body image [41] – which have established the many health-related harms for adolescent girls stemming from inequitable gender norms. Together, they speak to the multifaceted impacts of the gender system on girls’ mental health, with gender norms operating through layered socioecological environments to produce gender disparities in mental health during adolescence and throughout the life course [14]. For adolescent boys, by contrast, findings suggest that gender norms have more of a direct impact on mental health. Most prominently, adolescents across countries discussed emotional suppression as a central aspect of masculinity, with immense social and emotional consequences for those seen as violating this norm. This is not a surprising finding: a substantial body of research has highlighted restrictive emotionality as a stereotypical masculine trait worldwide [13,42,43], and it has been included as a key component of scales designed to measure adherence to masculine norms [44,45]. Further, a number of quantitative studies drawing on such scales have documented associations between restrictive emotionality and a range of negative mental health outcomes among adolescent boys, including low self-esteem, stress, anxiety, depression, and suicidal behaviors [23,46,47]. The present study furthers such research by suggesting that a key pathway towards more severe mental health problems for adolescent boys is the exacerbation of distress that results from emotional suppression. This has arisen as an important theme across several prior qualitative studies [48,49], and underscores the importance of building skills around greater emotional expression and communication among boys as a central strategy for mental health promotion, prevention, and treatment efforts. In addition, our findings stress boys’ reliance on behavioral outlets – including both substance use and aggression – in the absence of socially acceptable emotional expression. This is particularly noteworthy in combination with adolescents’ emphasis on both of these risky health behaviors as components of “being a man” across a number of settings. Again, many existing studies have linked the endorsement of traditional masculine norms in adolescence with drug use [50], alcohol use [51], and violence [52]. These associations are frequently raised as an important contributing factor towards excess behavioral disorders among boys when compared to girls [2]. What is striking in this study, however, are adolescents’ perceptions of the ways in which these normative masculine behaviors can emerge from underlying states of distress. This aligns with a growing body of research, focused largely on adults, which has made the case for “male-type depression” or “externalizing depression” characterized by symptoms such as anger, aggression, substance abuse, and risk-taking [35,53–55]. Findings from the current study stress the need to extend this research into adolescent populations to better understand both universal and culturally bound manifestations of distress among boys around the world. This study also highlighted important cross-cultural nuances in the relationship between gender norms and mental health. While masculine norms appeared largely consistent across the included countries, there was notably less universality in terms of feminine norms. Girls in Middle Eastern and African settings highlighted unique struggles arising from contending with restrictive gender norms across family, school, and community environments. These patterns reflect worldwide trends: according to the Gender Inequality Index, while global gender inequality has generally decreased over the past three decades, substantial geographic disparities remain, with the countries included in the current study ranging from low inequality in Sweden (0.023) to high inequality in the DRC (0.601) [56]. While evidence in this area is still emerging, research has suggested that there are complex mental health ramifications to these trends. For instance, studies among adolescents have documented associations between greater gender equality at the national level and higher life satisfaction [57] and lower suicidal ideation [58] for both boys and girls. By contrast, however, one large cross-national investigation of 566,829 adolescents across 73 countries found that while girls consistently reported poorer mental health compared to boys, greater national gender equality was in fact associated with larger gender disparities in mental health [9]. In explaining this finding, the authors hypothesized that as countries become increasingly gender equal, girls’ mental health may suffer due to their expectations outpacing their experiences of equality. Our findings provide additional support for this hypothesis, with girls in both Jordan and Egypt highlighting the distress produced by the friction between their personal desires for freedom, autonomy, and educational attainment and their families’ and communities’ adherence to traditional norms. Overall, adolescents’ descriptions of gender norms’ influences on mental health speak to the multi-level nature of these pathways: gender norms are defined within communities, enforced within families and peer groups, and engrained within individuals, with interactive impacts on adolescent mental health and well-being. This suggests the need for multi-level adolescent mental health prevention and promotion strategies that incorporate a targeted focus on shifting harmful gender norms during this critical developmental period. Importantly, over the past two decades, growing global recognition around the influence of gender norms in shaping health throughout the life course has spurred researchers and practitioners to move beyond “gender-neutral” programming towards that which is “gender-transformative” [59]. In alignment with the Sustainable Development Goals, which include achieving gender equality as a stand-alone goal [60], gender-transformative interventions seek to achieve outcomes through “fostering critical examination of gender norms and dynamics, strengthening or creating systems that support gender equality, strengthening or creating equitable gender norms and dynamics, and changing inequitable gender norms and dynamics” [61]. In their recent systematic review focused on gender transformative interventions targeting health among young people globally, Levy et al. identified 59 existing programs which were predominantly focused on sexual reproductive health, violence, or HIV [62]. Notably, only four of the identified programs assessed mental health – and none targeted mental health as a primary outcome. This clear gap in evidence, alongside the findings from the current study, strongly reinforces the need to develop and evaluate gender-transformative mental health interventions for adolescents around the world. These findings should be interpreted considering several limitations. First, data analysis was conducted on the English translations of original language transcripts, increasing the possibility of misinterpretation. Second, despite an effort to include a large and varied group of countries, results cannot be considered transferable either within countries or across other settings. Third, given the study’s broad focus on adolescent mental health, there are a number of gender norms-related themes which were not explored in depth across FGDs and therefore lacked sufficient saturation for inclusion in this analysis. For example, while one FGD in Belgium included a brief discussion of the stress generated by adolescent girls feeling the need to prove themselves above boys in both education and work environments, this was not a topic that was explicitly addressed in other FGDs. Future qualitative studies should build upon the findings from the current analysis to better target nuances in adolescents’ perceptions of the ways in which gender norms drive gender disparities in mental health. Despite these limitations, the current study’s strengths lie in its inclusion of the voices of adolescents across diverse geographic, economic, and cultural settings. To our knowledge, this is the largest existing cross-country qualitative study focused on adolescent mental health – as well as one of the few qualitative studies to explore complexities in the relationship between gender norms and mental health in adolescence. Overall, our findings highlight the mental health costs that both girls and boys around the world pay because of restrictive and inequitable gender norms. While the recent global emphasis on gender transformative programming is promising [59,62], it is clear that such work must expand to include the nuanced ways in which the gender system contributes to mental health disparities among adolescents around the world. Abbreviations LMICs low- and middle-income countries HICs high-income countries UNICEF United Nations Children’s Fund FGD focus group discussion DRC Democratic Republic of the Congo JHU Johns Hopkins University Declarations Funding Information: This work was supported by Wellcome Trust through a contract with UNICEF Headquarters for the preparation of the 2021 State of the World’s Children Report, On My Mind: Promoting, protecting and caring for children’s mental health. Acknowledgements: This study was developed in conjunction with UNICEF’s State of the World’s Children 2021 report, On My Mind: Promoting, protecting and caring for children’s mental health . The study was initiated by UNICEF Headquarters in collaboration with the Johns Hopkins University Global Early Adolescent Study, and was made possible through partnerships with organizations across 13 countries. These include: Centre de Référence en Santé Mentale, Steunpunt Geestelijke Gezondheid, Universidad de Santiago de Chile, Shanghai Institute for Biomedical and Pharmaceutical Technologies, Kinshasa School of Public Health, Assiut University, Universitas Gadjah Mada, University of the West Indies, Terre des Hommes, African Population and Health Research Center, Kamuzu University of Health Sciences, Karolinska Institutet, Unisanté, and Institute of Women and Ethnic Studies. We are immensely grateful to the researchers and program specialists from these organizations who helped to shape the research questions and then organized, facilitated, recorded, transcribed, and translated focus group discussions with adolescents. We would also like to gratefully acknowledge support from the Wellcome Trust and from UNICEF country offices. Above all, we are thankful for the young people around the world who gave their candid insights during 71 focus groups discussions. Conflicts of Interest: The authors have no conflicts of interest to disclose. References Sawyer SM, Afifi RA, Bearinger LH, et al. Adolescence: a foundation for future health. The Lancet 2012;379:1630–40. Patton GC, Sawyer SM, Santelli JS, et al. Our future: a Lancet commission on adolescent health and wellbeing. The Lancet 2016;387:2423–78. Rapee RM, Oar EL, Johnco CJ, et al. Adolescent development and risk for the onset of social-emotional disorders: A review and conceptual model. 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Men’s Experiences of Mental Illness Stigma Across the Lifespan: A Scoping Review. Am J Mens Health 2022;16:15579883221074789. Brownhill S, Wilhelm K, Barclay L, et al. ‘Big Build’: Hidden Depression in Men. Aust N Z J Psychiatry 2005;39:921–31. Cleary A. Suicidal action, emotional expression, and the performance of masculinities. Soc Sci Med 1982 2012;74:498–505. Exner-Cortens D, Wright A, Claussen C, et al. A Systematic Review of Adolescent Masculinities and Associations with Internalizing Behavior Problems and Social Support. Am J Community Psychol 2021;68:215–31. Miranda-Mendizabal A, Castellví P, Parés-Badell O, et al. Gender differences in suicidal behavior in adolescents and young adults: systematic review and meta-analysis of longitudinal studies. Int J Public Health 2019;64:265–83. Patel V. Reducing the burden of depression in youth: what are the implications of neuroscience and genetics on policies and programs? J Adolesc Health Off Publ Soc Adolesc Med 2013;52:S36-38. Wichstrøm L. Social, psychological and physical correlates of eating problems. A study of the general adolescent population in Norway. Psychol Med 1995;25:567–79. Williams RJ, Ricciardelli LA. Negative perceptions about self-control and identification with gender-role stereotypes related to binge eating, problem drinking, and to co-morbidity among adolescents. J Adolesc Health Off Publ Soc Adolesc Med 2003;32:66–72. Mensinger JL, Bonifazi DZ, LaRosa J. Perceived Gender Role Prescriptions in Schools, the Superwoman Ideal, and Disordered Eating Among Adolescent Girls. Sex Roles 2007;57:557–68. Weber AM, Gupta R, Abdalla S, et al. Gender-related data missingness, imbalance and bias in global health surveys. BMJ Glob Health 2021;6:e007405. Fine SL, Lai J, Baack MRM, et al. Adolescents’ reflections on mental health: Key findings from a 13-country qualitative study. Under review. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101. ATLAS.ti Version 9.1. ATLAS.ti Scientific Software Development GmbH 2013. VERBI Software. MAXQDA 2020 2019. Ramaiya A, Wheeler J, Stones W, et al. Understanding adolescents’ perceptions and experiences of violence victimization and its perceived impact on mental health: a qualitative study across 13 countries Under review. Cavanagh A, Wilson CJ, Kavanagh DJ, et al. Differences in the Expression of Symptoms in Men Versus Women with Depression: A Systematic Review and Meta-analysis. Harv Rev Psychiatry 2017;25:29–38. Rice SM, Kealy D, Oliffe JL, et al. Externalizing depression symptoms among Canadian males with recent suicidal ideation: A focus on young men. Early Interv Psychiatry 2019;13:308–13. Ando S, Nishida A, Usami S, et al. Help-seeking intention for depression in early adolescents: Associated factors and sex differences. J Affect Disord 2018;238:359–65. Clark LH, Hudson JL, Rapee RM, et al. Investigating the impact of masculinity on the relationship between anxiety specific mental health literacy and mental health help-seeking in adolescent males. J Anxiety Disord 2020;76:102292. Malhi N, Oliffe JL, Bungay V, et al. Male Perpetration of Adolescent Dating Violence: A Scoping Review. Am J Mens Health 2020;14:1557988320963600. Siddiqi M, Greene ME. Mapping the Field of Child Marriage: Evidence, Gaps, and Future Directions From a Large-Scale Systematic Scoping Review, 2000–2019. J Adolesc Health 2022;70:S9–16. Spencer RA, Rehman L, Kirk SF. Understanding gender norms, nutrition, and physical activity in adolescent girls: a scoping review. Int J Behav Nutr Phys Act 2015;12:6. Addis ME, Mahalik JR. Men, masculinity, and the contexts of help seeking. Am Psychol 2003;58:5–14. Evans J, Frank B, Oliffe JL, et al. Health, Illness, Men and Masculinities (HIMM): a theoretical framework for understanding men and their health. J Mens Health 2011;8:7–15. Mahalik JR, Locke BD, Ludlow LH, et al. Development of the Conformity to Masculine Norms Inventory. Psychol Men Masculinity 2003;4:3–25. O’Neil JM, Helms BJ, Gable RK, et al. Gender-role conflict scale: College men’s fear of femininity. Sex Roles 1986;14:335–50. Jacobson CM, Marrocco F, Kleinman M, et al. Restrictive emotionality, depressive symptoms, and suicidal thoughts and behaviors among high school students. J Youth Adolesc 2011;40:656–65. Santos CE, Galligan K, Pahlke E, et al. Gender-Typed Behaviors, Achievement, and Adjustment Among Racially and Ethnically Diverse Boys During Early Adolescence. Am J Orthopsychiatry 2013;83:252–64. Wisdom JP, Rees AM, Riley KJ, et al. Adolescents’ perceptions of the gendered context of depression: “Tough” boys and objectified girls. J Ment Health Couns 2007;29:144–62. Randell E, Jerdén L, Öhman A, et al. Tough, sensitive and sincere: how adolescent boys manage masculinities and emotions. Int J Adolesc Youth 2016;21:486–98. Hemsing N, Greaves L. Gender Norms, Roles and Relations and Cannabis-Use Patterns: A Scoping Review. Int J Env Res Public Health 2020;17. Schulte MT, Ramo D, Brown SA. Gender differences in factors influencing alcohol use and drinking progression among adolescents. Clin Psychol Rev 2009;29:535–47. Baxendale S, Cross D, Johnston R. A review of the evidence on the relationship between gender and adolescents’ involvement in violent behavior. Aggress Violent Behav 2012;17:297–310. Martin LA, Neighbors HW, Griffith DM. The Experience of Symptoms of Depression in Men vs Women: Analysis of the National Comorbidity Survey Replication. JAMA Psychiatry 2013;70:1100–6. Nadeau MM, Balsan MJ, Rochlen AB. Men’s depression: Endorsed experiences and expressions. Psychol Men Masculinity 2016;17:328–35. Rice SM, Fallon BJ, Aucote HM, et al. Development and preliminary validation of the male depression risk scale: Furthering the assessment of depression in men. J Affect Disord 2013;151:950–8. United Nations Development Programme. Gender Inequality Index (GII). Available at: https://hdr.undp.org/data-center/thematic-composite-indices/gender-inequality-index#/indicies/GII. AccessedMay 31, 2023. Looze ME de, Huijts T, Stevens GWJM, et al. The Happiest Kids on Earth. Gender Equality and Adolescent Life Satisfaction in Europe and North America. J Youth Adolesc 2018;47:1073–85. Assarsson R, Petersen S, Hogberg B, et al. Gender inequality and adolescent suicide ideation across Africa, Asia, the South Pacific and Latin America - a cross-sectional study based on the Global School Health Survey (GSHS). (Special Issue: Gender and Health Inequality - intersections with other relevant axes of oppression.). Glob Health Action 2018;11:77–86. Dworkin SL, Fleming PJ, Colvin CJ. The promises and limitations of gender-transformative health programming with men: critical reflections from the field. Cult Health Sex 2015;17 Suppl 2:128. United Nations. United Nations: Gender equality and women’s empowerment. Available at: https://www.un.org/sustainabledevelopment/gender-equality/. AccessedJune 22, 2023. Interagency Gender Working Group. Gender Integration Continuum. Interagency Gender Working Group; 2019. Levy JK, Darmstadt GL, Ashby C, et al. Characteristics of successful programmes targeting gender inequality and restrictive gender norms for the health and wellbeing of children, adolescents, and young adults: a systematic review. Lancet Glob Health 2020;8:e225–36. Additional Declarations The authors declare no competing interests. Supplementary Files PreprintsAdolescentMHSupplementalFiles.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6717615","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":460060127,"identity":"82b5cd48-743f-4783-bf79-2833b4b410f9","order_by":0,"name":"Shoshanna L. 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Broad representation across low-, middle-, and high-income countries implies the importance of developing gender-transformative interventions to improve adolescent mental health outcomes globally.\u0026nbsp;\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eAdolescence (ages 10-19) is a critical developmental period characterized by rapid biological, cognitive, social, and emotional changes [1,2]. These co-occurring changes make adolescents particularly vulnerable to the emergence of mental health problems, including depression, anxiety, substance abuse, conduct disorders, eating disorders, and suicidal behaviors [3,4]. Indeed, mental health problems affect up to 20% of adolescents worldwide, and represent a leading cause of health-related disability among this age group [5,6]. With approximately half of lifetime mental health problems manifesting prior to age 14 [7], psychosocial maladjustment in adolescence can give rise to impairment throughout the life course [2,4]. As such, drivers of mental health problems during this sensitive period of development are vital targets for preventive interventions.\u003c/p\u003e\n\u003cp\u003eAdolescence also marks the emergence of persistent gender inequalities in mental health [8]. Around the world, girls have been identified as demonstrating more internalizing symptoms (e.g., depression, anxiety) as compared to boys, although the size of this disparity has been found to vary greatly across countries [9,10]. By contrast, boys have consistently been found to exhibit greater externalizing symptoms (e.g., aggression, substance use, conduct problems) [8]. While this gender divide is well-established, the underlying interplay between biological (i.e., sex-related) and social (i.e. gender-related) processes that give rise to this disparity is poorly understood. Emerging evidence suggests that \u003cem\u003egender norms\u003c/em\u003e may play a critical role by influencing both the \u003cem\u003edevelopment\u003c/em\u003e and \u003cem\u003eexpression\u003c/em\u003e of mental health problems among adolescents globally [11\u0026ndash;13]. Gender norms can be defined as the \u0026ldquo;often unspoken rules that govern the attributes and behaviors that are valued and considered acceptable for men, women, and gender minorities\u0026rdquo; in a given culture [14]. These norms appear to solidify in adolescence, leading boys and girls to engage with and reenact different social scripts that are likely to inform gender disparities in health outcomes throughout the life course [11,15,16].\u003c/p\u003e\n\u003cp\u003eA growing body of research supports the influence of gender norms on adolescent mental health globally [17]. For adolescent boys, normative values around masculinity in many settings encourage harmful behaviors such as aggression, delinquency, and substance use [18,19], and may help explain an outsized prevalence of behavioral disorders when compared to girls [2]. Further, masculine norms emphasizing strength and invulnerability can impede adolescents from expressing and seeking help for emotional distress [13,20]. This may contribute to more severe subsequent mental health outcomes [21,22]. Indeed, a recent systematic review found that adherence to masculine norms was generally associated with poor mental health (including stress, depression, and anxiety) among adolescent boys, with the included qualitative studies emphasizing the role of emotional restriction in exacerbating these mental health consequences [23].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor adolescent girls, entrenched gender norms may contribute to discrimination, restricted opportunities, and increased exposure to gender-based violence, sexual and reproductive health risks, and early marriage [12]. These gender-specific risk factors can produce immense psychological distress, leading to elevated rates of depression, anxiety, and attempted suicide among girls when compared to boys [12,24,25]. In addition, there is some evidence for the relationship between adherence to feminine norms and the development of eating disorders in adolescence, fueled by body dissatisfaction [26,27]. It is important to note, however, that findings in this area have been decidedly mixed [28].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNotably, existing evidence related to these issues is predominantly from high-income countries (HICs), even though most of the world\u0026rsquo;s adolescents live in low- and middle-income countries (LMICs). For instance, a systematic review of longitudinal studies of gendered drivers of suicide in adolescence identified 67 manuscripts, only five of which were from LMICs [24]. It is also important to note that quantitative global surveys have historically approached this issue through an examination of sex differences as opposed to the empirical measurement of gender norms, thus limiting conclusions around sociocultural influences on mental health [29]. Finally, there is a lack of qualitative studies that seek to elicit adolescents\u0026rsquo; own perspectives on these issues across diverse cultural environments.\u003c/p\u003e\n\u003cp\u003eThe current study seeks to address these gaps in evidence through a qualitative exploration of gendered influences on mental health among adolescents living in 13 countries spanning five continents, including both LMICs and HICs. While a wide range of topics were covered in the initial research, this analysis focuses on adolescents\u0026rsquo; perceptions of the ways in which gender norms contribute to the development of mental health problems in adolescence, and the extent to which this is different for girls and boys living in diverse settings globally.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants and Procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study uses qualitative data collected in conjunction with and commissioned by the United Nations Children\u0026rsquo;s Fund (UNICEF) 2021 \u003cem\u003eState of the World\u0026rsquo;s Children Report\u003c/em\u003e. Detailed methods have been described elsewhere [30]. In brief, 71 focus group discussion (FGDs) with adolescents were conducted by partner organizations in 13 countries: Belgium, Chile, China, the Democratic Republic of the Congo (DRC), Egypt, Indonesia, Jamaica, Jordan, Kenya, Malawi, Sweden, Switzerland, and the United States. Each country hosted a minimum of four FGDs equally divided by sex and age such that there were at least two younger (ages 12-15) and two older (ages 16-19) FGDs held separately with boys and girls. Prior to data collection, all country partners obtained ethical approval from their local ethical review boards. Johns Hopkins University (JHU), the coordinating partner, waived ethical review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcross participating countries, FGDs were held between February and June 2021; depending on local COVID-19 restrictions at the time, FGDs were either held in-person or online. All FGDs were implemented using a comparable FGD guide which was developed collaboratively by UNICEF, JHU, and country partners. FGDs lasted between 60 and 90 minutes, and were conducted in local languages by experienced researchers who had participated in an online training conducted by JHU prior to commencing data collection.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFGDs were audio-recorded and transcribed verbatim, and field notes were written immediately after each session.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTranscribed audio-recordings and typed field notes were translated into English for analysis. These qualitative data were coded using an inductive thematic analysis approach [31]. Analysis began with a process of open coding, with lines of data examined and labeled based on their thematic content. Initial codes were compared, grouped into categories, and organized into a preliminary codebook. This codebook was further refined throughout the data analysis process, with two JHU analysts working to apply it to the full set of qualitative data\u003cem\u003e.\u0026nbsp;\u003c/em\u003eCoded data with relevance to gender norms and mental health were subsequently reanalyzed by the study\u0026rsquo;s authors. Two qualitative analysis software programs \u0026ndash; ATLAS.ti (Version 9.1) [32] and MAXQDA 2022 [33] \u0026ndash; were used to help organize and analyze the data.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAcross participating countries, adolescents discussed important gender differences in the nature of the relationship between gender norms and mental health. In the section that follows, emergent themes have been organized according to these gender differences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGendered Influences on Girls\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStandards of femininity.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eAdolescents around the world reflected on the ways in which standards of femininity governed conduct among girls. Participants listed a range of idealized feminine traits \u0026ndash; including being \u0026ldquo;fragile,\u0026rdquo; \u0026ldquo;delicate,\u0026rdquo; \u0026ldquo;gentle,\u0026rdquo; \u0026ldquo;quiet,\u0026rdquo; \u0026ldquo;sensitive,\u0026rdquo; and \u0026ldquo;beautiful\u0026rdquo; \u0026ndash; and described strong external pressure to conform to these traits. Several participants also expressed that girls faced greater scrutiny around adherence to gender norms, and more limitations on associated behaviors, compared to boys their age. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe\u0026apos;re told we have to be like this, like this, like this. While the boys, well\u0026hellip; It\u0026apos;s like they\u0026apos;re doing whatever they want. (Older girl, Belgium)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInterestingly, some participants suggested these feminine norms could serve as a protective factor against developing mental health problems by contributing to the social acceptability of expressing and seeking help for emotional distress among girls. It is worth noting, however, that this sentiment was more strongly voiced by boys rather than girls themselves.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSociety dictates that a girl can sit and cry and relate all her feelings and that\u0026apos;s okay because you are a female\u0026hellip;society tells us that the girls are the ones who are supposed to talk about their feelings and be emotional. (Older boy, Jamaica)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePressures on appearance.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eOne of the most consistent themes across countries was the deleterious impacts of feminine beauty standards on girls\u0026rsquo; mental health. Around the world, participants described both internal and external pressures placed on every aspect of girls\u0026rsquo; appearance \u0026ndash; their body type, weight, features, skin color, clothing \u0026ndash; and most agreed that these pressures were much more intense than those experienced by boys. Several adolescents also reflected on the increasing sexual objectification experienced by girls as they went through puberty.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[There\u0026rsquo;s] this incredible, incredible pressure on appearance that exists\u0026hellip;.it\u0026apos;s not okay to just be mediocre\u0026hellip;and not like be super beautiful. (Older girl, Sweden)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThey do not see us as women but as objects. (Older girl, Chile)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdolescents across participating countries detailed the ways in which contending with beauty standards and sexual objectification contributed to feelings of anxiety, insecurity, and low self-esteem among girls. Several adolescents also highlighted how these factors could drive girls towards disordered eating. Notably, these mental health challenges were described as being intensified by social media\u0026rsquo;s glorification of girls and women with \u0026ldquo;ideal\u0026rdquo; bodies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think [girls\u0026rsquo;] problems are mainly regarding their insecurities\u0026hellip;thinking that they\u0026rsquo;re not pretty, they\u0026rsquo;re not beautiful. (Older girl, Indonesia)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo there\u0026rsquo;s like a specific body type that society has told us we are all to look like and for girls who don\u0026rsquo;t have that body type, it leads to lots of things like eating disorders\u0026hellip;especially with social media these days, you see that body image and when you don\u0026rsquo;t have it, it breaks down a lot of people\u0026rsquo;s confidence. (Younger girl, Jamaica)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants from diverse contexts also reflected on the fine line that girls frequently navigate in their appearance and their struggle to find a balance: if they dressed too conservatively, they were seen as unattractive or unfeminine, but if they dressed in something that was too \u0026ldquo;tight,\u0026rdquo; \u0026ldquo;revealing,\u0026rdquo; or \u0026ldquo;attention-grabbing,\u0026rdquo; they were seen as promiscuous or targets for harassment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe are always being judged. We dress in\u0026hellip;workout clothes, basic pants: \u0026ldquo;Well, you could dress in a more feminine way!\u0026rdquo; When you dress in a feminine way: \u0026ldquo;Don\u0026rsquo;t forget you are going to school!\u0026rdquo;\u0026hellip;And then, when we\u0026hellip;dress a bit better\u0026hellip;we are told, \u0026ldquo;Be careful not to wear things off the shoulder, it can\u0026rsquo;t be too tight.\u0026rdquo; (Older girl, Belgium)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInequitable gender norms.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eAcross many participating countries, adolescents also discussed the impacts of restrictive and inequitable gender norms within their specific cultural contexts. Particularly in Middle Eastern and African settings, a common theme related to traditional community values which privileged male dominance and control, and the ways in which contending with these values could contribute to immense distress among girls.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI wish to work and have my own independent personality and I don\u0026rsquo;t want to depend on my family in everything or to get married to someone who wants to control me as he wishes...I wish to live a different way but the society and the whole world is surrounding me with something I don\u0026rsquo;t know, and I feel disabled. (Older girl, Egypt)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants in these settings illustrated the ways in which inequitable gender norms were commonly enforced within adolescents\u0026rsquo; families, contributing to a lack of agency and autonomy among girls. Specifically, they discussed the discriminatory treatment of girls compared to boys, which included heightened control, restricted freedoms, diminished attention, little consideration of their opinions, and a greater emphasis on domestic chores.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGirls are concerned about [discrimination], the fact that the father cares more about the boys than the girl. The mother also cares about the boys more than the girl. (Younger girl, Jordan)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBefore going to school I do so much housework and often my brothers don\u0026rsquo;t do anything. (Older girl, DRC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWithin families, another important issue in these settings related to the devaluation of girls\u0026rsquo; education. A number of participants described how parents would discourage their daughters from attending school due to the belief that girls\u0026rsquo; continued education did not benefit (and may even detract from) their marriageability. In some cases, adolescent girls also described being pushed into early marriage at which point they were forced to drop out of school.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe girl loves her studies and is interested in her studies more [than marrying early]. [But her parents] tell her to leave school because in the end, \u0026ldquo;You will be in your husband\u0026rsquo;s house. Girls are created to marry and work.\u0026rdquo; (Younger girl, Jordan)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere are some parents that tell girls not go to school because they will get married to rich husbands...They are told that they will not take care of the family, that they will be the responsibility of the man. (Younger girl, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMore broadly, girls around the world discussed both threatened and experienced gender-based violence across their family, school, and community environments, as well as the damaging psychological impacts of such violence. This issue is covered in depth in a separate analysis based on the same data [34].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGendered Influences on Boys\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStandards of masculinity.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eWhile it was clear that gender norms operate differently for boys \u0026nbsp;compared to girls, participants emphasized their equally powerful role in impacting boys\u0026rsquo; mental health. Across participating countries, adolescents discussed largely consistent cultural norms of masculinity which prioritized strength, independence, and stoicism. Common descriptors included: \u0026ldquo;strong,\u0026rdquo; \u0026ldquo;tough,\u0026rdquo; \u0026ldquo;proud,\u0026rdquo; \u0026ldquo;dependable,\u0026rdquo; \u0026ldquo;don\u0026rsquo;t need any help,\u0026rdquo; \u0026ldquo;man of the house,\u0026rdquo; \u0026ldquo;shouldn\u0026rsquo;t show emotions,\u0026rdquo; and \u0026ldquo;cannot cry.\u0026rdquo; Many boys expressed powerful anxieties related to violating these norms, including fears that they would be disparaged or harassed due to being perceived as \u0026ldquo;weak,\u0026rdquo; \u0026ldquo;vulnerable,\u0026rdquo; \u0026ldquo;soft,\u0026rdquo; \u0026ldquo;feminine,\u0026rdquo; or \u0026ldquo;gay.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe all have problems, but guys are supposed to be like robots and people think we can\u0026rsquo;t have feelings. (Older boy, United States)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere is the notion that boys must be tough, and if he complains or if he opens up, he would be...mocked...[as] weak. (Older boy, Indonesia)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSociety tells us that as long as you are born with a penis, then you\u0026rsquo;re not supposed to be expressive. Real men don\u0026apos;t cry\u0026hellip;that is something that fathers instill, fathers and mothers alike. Especially in Jamaica, they don\u0026apos;t want you to grow up as no \u0026ldquo;chi-chi boy\u0026rdquo; [homosexual]. (Older boy, Jamaica)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRisky health behaviors.\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eAround the world, participants illustrated the pathways through which masculine gender norms could drive boys towards risky health behaviors. For instance, many adolescents suggested that boys were more likely than girls to use drugs or alcohol, and several mentioned external pressures from male peers or family members who encouraged substance use as part of \u0026ldquo;being a man.\u0026rdquo; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFriends are also giving [alcohol] to one another and saying, \u0026ldquo;Drink a little, don\u0026rsquo;t be a woman.\u0026rdquo; (Younger boy, Egypt)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRegarding drugs\u0026hellip;there is such a large drug culture around, like in guy groups, that it\u0026apos;s like, test different things and do things. (Older boy, Sweden)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdolescents also emphasized the normalization of violent and aggressive behaviors among boys. Across diverse settings, adolescents described the ways in which such behaviors were acceptably employed as a means of proving their masculinity, resolving interpersonal conflicts, or defending themselves or others.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[Boys] need to show that they are strong, and they know how to protect...It\u0026rsquo;s really for themselves that they go out with [a weapon]...It\u0026rsquo;s really to show, \u0026ldquo;Well, I am a man, I can fight!\u0026rdquo; (Older girl, Belgium)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA lot of guys around my age they tend to be violent, and when they are around their friends everybody want to prove that they are the baddest\u0026hellip;they hurt the weaker ones, those who cannot protect themselves, just to gain some form of clout.\u0026nbsp;(Older boy, Jamaica)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIncreased financial pressure.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eAnother commonly voiced sentiment was the internal pressure that many boys experience to earn money and provide for their families in order to show that they are the \u0026ldquo;man of the house.\u0026rdquo; Around the world, boys highlighted deep-seated stress and anxiety regarding achieving financial stability and independence, as well as negative mental health outcomes among those who were unable to do so.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFrom my experience, it is what males are most likely worried about: success. Right? We have been growing up with the ideology that when we as men grow up, we must be successful in order to support our women and our kids. (Older boy, Jamaica)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhen a young man can\u0026apos;t find work he falls into depression\u0026hellip;you prefer to sit alone and isolate yourself, and you [are] frustrated and you do not have hope. (Older boy, Egypt)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlongside these internal pressures, several participants also described the external pressure from boys\u0026rsquo; families to contribute financially from a young age. Notably, this arose most frequently in African settings.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt happens that both parents reach a point that they are completely broke and have no money\u0026hellip;You are the only boy and now they see you as a man\u0026hellip;so they would require you to go and get a job\u0026hellip;The entire family is looking to you to provide. (Older boy, Kenya)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsequences of limited emotional expression.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eAcross countries, it was clear that one of the most damaging impacts of gender norms on boys\u0026rsquo; mental health related to severe constraints on expressing feelings and seeking help for emotional distress. As mentioned above, the notion that \u0026ldquo;boys don\u0026rsquo;t cry\u0026rdquo; was a common refrain around the world, and many adolescents suggested that such masculine stereotypes drove boys\u0026rsquo; silence and isolation when experiencing distress. \u0026nbsp;Participants illustrated the ways in which such emotional repression could exacerbate mental health problems among boys, \u0026ldquo;festering\u0026rdquo; and \u0026ldquo;eating\u0026rdquo; at them.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think the worst, worst defense that a man can have is... keeping things [to himself]\u0026hellip;That\u0026apos;s why we\u0026rsquo;re the biggest suicide statistic out there, because we don\u0026apos;t have\u0026hellip;a method of venting...in the end we end up repressing ourselves more. (Older boy, Chile)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMental health is more dangerous in boys than girls because boys cannot talk about it and...well, they close themselves off, they never speak of it, and after a while it starts to eat at them. (Younger boy, Switzerland)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAligned with the normalization of risky health behaviors, a number of adolescents also suggested that in the absence of other help-seeking options, boys commonly turn to violent or aggressive behaviors as a means of coping with stress, anger, and frustration. Similarly, boys were described as frequently turning to drugs or alcohol as a way of \u0026ldquo;escaping from their problems.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe majority of the violent behaviors for males is because they have no one to talk to and they don\u0026apos;t know how to handle their stress. (Older boy, Jamaica)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhen you are using drugs, it\u0026rsquo;s because you are stressed so you are trying to forget those bad feelings...when you use them, you kind of forget about your worries. (Older boy, Kenya)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFindings from this qualitative study across 13 countries emphasize the consequences of gender norms on adolescent mental health in diverse global contexts. This aligns with a growing body of evidence among young people worldwide, which has drawn attention to the myriad ways in which gender norms can drive exposure to key mental health risk factors [14], dictate socially acceptable expressions of distress [35,36], and govern specific coping strategies and help-seeking behaviors [37,38]. These findings are particularly important given that adolescence is a period in which gender norms become more firmly internalized and patterns of related behaviors are established [11,15]. As such, there is a clear impetus for preventive interventions that target the links between gender norms and mental health during this critical developmental period. \u003c/p\u003e\n\u003cp\u003eWhile adolescents\u0026rsquo; reflections underscored the role of gender norms in influencing mental health, it was apparent that there are important gender differences regulating this relationship. Specifically, findings suggest that for adolescent girls, this pathway is largely indirect. According to participants, restrictive and patriarchal norms frequently expose girls to different risks as compared to their male peers, including greater scrutiny and control, discriminatory treatment, damaging beauty standards, and gender-based violence. These risks, in turn, have deleterious impacts on girls\u0026rsquo; mental health and well-being. These findings reflect and unify those that have previously been identified across largely siloed research \u0026ndash; for instance, in studies focused solely on dating violence [39], early marriage [40], or body image [41] \u0026ndash; which have established the many health-related harms for adolescent girls stemming from inequitable gender norms. Together, they speak to the multifaceted impacts of the gender system on girls\u0026rsquo; mental health, with gender norms operating through layered socioecological environments to produce gender disparities in mental health during adolescence and throughout the life course [14]. \u003c/p\u003e\n\u003cp\u003eFor adolescent boys, by contrast, findings suggest that gender norms have more of a direct impact on mental health. Most prominently, adolescents across countries discussed emotional suppression as a central aspect of masculinity, with immense social and emotional consequences for those seen as violating this norm. This is not a surprising finding: a substantial body of research has highlighted restrictive emotionality as a stereotypical masculine trait worldwide [13,42,43], and it has been included as a key component of scales designed to measure adherence to masculine norms [44,45]. Further, a number of quantitative studies drawing on such scales have documented associations between restrictive emotionality and a range of negative mental health outcomes among adolescent boys, including low self-esteem, stress, anxiety, depression, and suicidal behaviors [23,46,47]. The present study furthers such research by suggesting that a key pathway towards more severe mental health problems for adolescent boys is the exacerbation of distress that results from emotional suppression. This has arisen as an important theme across several prior qualitative studies [48,49], and underscores the importance of building skills around greater emotional expression and communication among boys as a central strategy for mental health promotion, prevention, and treatment efforts. \u003c/p\u003e\n\u003cp\u003eIn addition, our findings stress boys\u0026rsquo; reliance on behavioral outlets \u0026ndash; including both substance use and aggression \u0026ndash; in the absence of socially acceptable emotional expression. This is particularly noteworthy in combination with adolescents\u0026rsquo; emphasis on both of these risky health behaviors as components of \u0026ldquo;being a man\u0026rdquo; across a number of settings. Again, many existing studies have linked the endorsement of traditional masculine norms in adolescence with drug use [50], alcohol use [51], and violence [52]. These associations are frequently raised as an important contributing factor towards excess behavioral disorders among boys when compared to girls [2]. What is striking in this study, however, are adolescents\u0026rsquo; perceptions of the ways in which these normative masculine behaviors can emerge from underlying states of distress. This aligns with a growing body of research, focused largely on adults, which has made the case for \u0026ldquo;male-type depression\u0026rdquo; or \u0026ldquo;externalizing depression\u0026rdquo; characterized by symptoms such as anger, aggression, substance abuse, and risk-taking [35,53\u0026ndash;55]. Findings from the current study stress the need to extend this research into adolescent populations to better understand both universal and culturally bound manifestations of distress among boys around the world. \u003c/p\u003e\n\u003cp\u003eThis study also highlighted important cross-cultural nuances in the relationship between gender norms and mental health. While masculine norms appeared largely consistent across the included countries, there was notably less universality in terms of feminine norms. Girls in Middle Eastern and African settings highlighted unique struggles arising from contending with restrictive gender norms across family, school, and community environments. These patterns reflect worldwide trends: according to the Gender Inequality Index, while global gender inequality has generally decreased over the past three decades, substantial geographic disparities remain, with the countries included in the current study ranging from low inequality in Sweden (0.023) to high inequality in the DRC (0.601) [56]. While evidence in this area is still emerging, research has suggested that there are complex mental health ramifications to these trends. For instance, studies among adolescents have documented associations between greater gender equality at the national level and higher life satisfaction [57] and lower suicidal ideation [58] for both boys and girls. By contrast, however, one large cross-national investigation of 566,829 adolescents across 73 countries found that while girls consistently reported poorer mental health compared to boys, greater national gender equality was in fact associated with larger gender disparities in mental health [9]. In explaining this finding, the authors hypothesized that as countries become increasingly gender equal, girls\u0026rsquo; mental health may suffer due to their\u003cem\u003e expectations\u003c/em\u003e outpacing their \u003cem\u003eexperiences\u003c/em\u003e of equality. Our findings provide additional support for this hypothesis, with girls in both Jordan and Egypt highlighting the distress produced by the friction between their personal desires for freedom, autonomy, and educational attainment and their families\u0026rsquo; and communities\u0026rsquo; adherence to traditional norms. \u003c/p\u003e\n\u003cp\u003eOverall, adolescents\u0026rsquo; descriptions of gender norms\u0026rsquo; influences on mental health speak to the multi-level nature of these pathways: gender norms are defined within communities, enforced within families and peer groups, and engrained within individuals, with interactive impacts on adolescent mental health and well-being. This suggests the need for multi-level adolescent mental health prevention and promotion strategies that incorporate a targeted focus on shifting harmful gender norms during this critical developmental period. Importantly, over the past two decades, growing global recognition around the influence of gender norms in shaping health throughout the life course has spurred researchers and practitioners to move beyond \u0026ldquo;gender-neutral\u0026rdquo; programming towards that which is \u0026ldquo;gender-transformative\u0026rdquo; [59]. In alignment with the Sustainable Development Goals, which include achieving gender equality as a stand-alone goal [60], gender-transformative interventions seek to achieve outcomes through \u0026ldquo;fostering critical examination of gender norms and dynamics, strengthening or creating systems that support gender equality, strengthening or creating equitable gender norms and dynamics, and changing inequitable gender norms and dynamics\u0026rdquo; [61]. In their recent systematic review focused on gender transformative interventions targeting health among young people globally, Levy et al. identified 59 existing programs which were predominantly focused on sexual reproductive health, violence, or HIV [62]. Notably, only four of the identified programs assessed mental health \u0026ndash; and none targeted mental health as a primary outcome. This clear gap in evidence, alongside the findings from the current study, strongly reinforces the need to develop and evaluate gender-transformative mental health interventions for adolescents around the world. \u003c/p\u003e\n\u003cp\u003eThese findings should be interpreted considering several limitations. First, data analysis was conducted on the English translations of original language transcripts, increasing the possibility of misinterpretation. Second, despite an effort to include a large and varied group of countries, results cannot be considered transferable either within countries or across other settings. Third, given the study\u0026rsquo;s broad focus on adolescent mental health, there are a number of gender norms-related themes which were not explored in depth across FGDs and therefore lacked sufficient saturation for inclusion in this analysis. For example, while one FGD in Belgium included a brief discussion of the stress generated by adolescent girls feeling the need to prove themselves above boys in both education and work environments, this was not a topic that was explicitly addressed in other FGDs. Future qualitative studies should build upon the findings from the current analysis to better target nuances in adolescents\u0026rsquo; perceptions of the ways in which gender norms drive gender disparities in mental health. \u003c/p\u003e\n\u003cp\u003eDespite these limitations, the current study\u0026rsquo;s strengths lie in its inclusion of the voices of adolescents across diverse geographic, economic, and cultural settings. To our knowledge, this is the largest existing cross-country qualitative study focused on adolescent mental health \u0026ndash; as well as one of the few qualitative studies to explore complexities in the relationship between gender norms and mental health in adolescence. Overall, our findings highlight the mental health costs that both girls and boys around the world pay because of restrictive and inequitable gender norms. While the recent global emphasis on gender transformative programming is promising [59,62], it is clear that such work must expand to include the nuanced ways in which the gender system contributes to mental health disparities among adolescents around the world. \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLMICs low- and middle-income countries\u003c/p\u003e\n\u003cp\u003eHICs high-income countries\u003c/p\u003e\n\u003cp\u003eUNICEF United Nations Children\u0026rsquo;s Fund\u003c/p\u003e\n\u003cp\u003eFGD focus group discussion\u003c/p\u003e\n\u003cp\u003eDRC Democratic Republic of the Congo \u003c/p\u003e\n\u003cp\u003eJHU Johns Hopkins University \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Information:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Wellcome Trust through a contract with UNICEF Headquarters for the preparation of the 2021 State of the World\u0026rsquo;s Children Report, \u003cem\u003eOn My Mind: Promoting, protecting and caring for children\u0026rsquo;s mental health.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was developed in conjunction with UNICEF\u0026rsquo;s \u003cem\u003eState of the World\u0026rsquo;s Children 2021\u0026nbsp;\u003c/em\u003ereport, \u003cem\u003eOn My Mind: Promoting, protecting and caring for children\u0026rsquo;s mental health\u003c/em\u003e. The study was initiated by UNICEF Headquarters in collaboration with the Johns Hopkins University Global Early Adolescent Study, and was made possible through partnerships with organizations across 13 countries. These include:\u0026nbsp;Centre de R\u0026eacute;f\u0026eacute;rence en Sant\u0026eacute; Mentale, Steunpunt Geestelijke Gezondheid, Universidad de Santiago de Chile,\u0026nbsp;Shanghai Institute for Biomedical and Pharmaceutical Technologies,\u0026nbsp;Kinshasa School of Public Health, Assiut University, Universitas Gadjah Mada, University of the West Indies, Terre des Hommes, African Population and Health Research Center, Kamuzu University of Health Sciences, Karolinska Institutet, Unisant\u0026eacute;, and Institute of Women and Ethnic Studies. We are immensely grateful to the researchers and program specialists from these organizations who helped to shape the research questions and then organized, facilitated, recorded, transcribed, and translated focus group discussions with adolescents. We would also like to gratefully acknowledge support from the Wellcome Trust and from UNICEF country offices. Above all, we are thankful for the young people around the world who gave their candid insights during 71 focus groups discussions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSawyer SM, Afifi RA, Bearinger LH, et al. Adolescence: a foundation for future health. The Lancet 2012;379:1630\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003ePatton GC, Sawyer SM, Santelli JS, et al. 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Washington, DC: Promundo-US; 2019.\u003c/li\u003e\n\u003cli\u003eMcKenzie SK, Oliffe JL, Black A, et al. Men\u0026rsquo;s Experiences of Mental Illness Stigma Across the Lifespan: A Scoping Review. Am J Mens Health 2022;16:15579883221074789.\u003c/li\u003e\n\u003cli\u003eBrownhill S, Wilhelm K, Barclay L, et al. \u0026lsquo;Big Build\u0026rsquo;: Hidden Depression in Men. Aust N Z J Psychiatry 2005;39:921\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eCleary A. Suicidal action, emotional expression, and the performance of masculinities. Soc Sci Med 1982 2012;74:498\u0026ndash;505.\u003c/li\u003e\n\u003cli\u003eExner-Cortens D, Wright A, Claussen C, et al. A Systematic Review of Adolescent Masculinities and Associations with Internalizing Behavior Problems and Social Support. Am J Community Psychol 2021;68:215\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eMiranda-Mendizabal A, Castellv\u0026iacute; P, Par\u0026eacute;s-Badell O, et al. Gender differences in suicidal behavior in adolescents and young adults: systematic review and meta-analysis of longitudinal studies. Int J Public Health 2019;64:265\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003ePatel V. Reducing the burden of depression in youth: what are the implications of neuroscience and genetics on policies and programs? J Adolesc Health Off Publ Soc Adolesc Med 2013;52:S36-38.\u003c/li\u003e\n\u003cli\u003eWichstr\u0026oslash;m L. Social, psychological and physical correlates of eating problems. A study of the general adolescent population in Norway. Psychol Med 1995;25:567\u0026ndash;79.\u003c/li\u003e\n\u003cli\u003eWilliams RJ, Ricciardelli LA. Negative perceptions about self-control and identification with gender-role stereotypes related to binge eating, problem drinking, and to co-morbidity among adolescents. J Adolesc Health Off Publ Soc Adolesc Med 2003;32:66\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eMensinger JL, Bonifazi DZ, LaRosa J. Perceived Gender Role Prescriptions in Schools, the Superwoman Ideal, and Disordered Eating Among Adolescent Girls. Sex Roles 2007;57:557\u0026ndash;68.\u003c/li\u003e\n\u003cli\u003eWeber AM, Gupta R, Abdalla S, et al. Gender-related data missingness, imbalance and bias in global health surveys. BMJ Glob Health 2021;6:e007405.\u003c/li\u003e\n\u003cli\u003eFine SL, Lai J, Baack MRM, et al. Adolescents\u0026rsquo; reflections on mental health: Key findings from a 13-country qualitative study. Under review.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77\u0026ndash;101.\u003c/li\u003e\n\u003cli\u003eATLAS.ti Version 9.1. ATLAS.ti Scientific Software Development GmbH 2013.\u003c/li\u003e\n\u003cli\u003eVERBI Software. MAXQDA 2020 2019.\u003c/li\u003e\n\u003cli\u003eRamaiya A, Wheeler J, Stones W, et al. 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Am Psychol 2003;58:5\u0026ndash;14.\u003c/li\u003e\n\u003cli\u003eEvans J, Frank B, Oliffe JL, et al. Health, Illness, Men and Masculinities (HIMM): a theoretical framework for understanding men and their health. J Mens Health 2011;8:7\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eMahalik JR, Locke BD, Ludlow LH, et al. Development of the Conformity to Masculine Norms Inventory. Psychol Men Masculinity 2003;4:3\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Neil JM, Helms BJ, Gable RK, et al. Gender-role conflict scale: College men\u0026rsquo;s fear of femininity. Sex Roles 1986;14:335\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eJacobson CM, Marrocco F, Kleinman M, et al. Restrictive emotionality, depressive symptoms, and suicidal thoughts and behaviors among high school students. J Youth Adolesc 2011;40:656\u0026ndash;65.\u003c/li\u003e\n\u003cli\u003eSantos CE, Galligan K, Pahlke E, et al. 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Cult Health Sex 2015;17 Suppl 2:128.\u003c/li\u003e\n\u003cli\u003eUnited Nations. United Nations: Gender equality and women\u0026rsquo;s empowerment. Available at: https://www.un.org/sustainabledevelopment/gender-equality/. AccessedJune 22, 2023.\u003c/li\u003e\n\u003cli\u003eInteragency Gender Working Group. Gender Integration Continuum. Interagency Gender Working Group; 2019.\u003c/li\u003e\n\u003cli\u003eLevy JK, Darmstadt GL, Ashby C, et al. Characteristics of successful programmes targeting gender inequality and restrictive gender norms for the health and wellbeing of children, adolescents, and young adults: a systematic review. Lancet Glob Health 2020;8:e225\u0026ndash;36.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Wellcome Trust","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adolescents, Gender norms, Masculinity, Femininity, Mental health, Qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-6717615/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6717615/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eA growing body of research supports the influence of gender norms on adolescent mental health globally. There is a lack of qualitative studies, however, that elicit adolescents’ own perspectives on these issues across diverse cross-cultural environments. The current study seeks to address these gaps through a qualitative exploration of gendered influences on mental health among adolescents living in 13 countries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA total of 71 focus group discussions (FGDs) with adolescents aged 12-19 years were conducted between February and June of 2021. Countries were selected to ensure geographic, economic, and cultural diversity, and included: Belgium, Chile, China, the Democratic Republic of the Congo, Egypt, Indonesia, Jamaica, Jordan, Kenya, Malawi, Sweden, Switzerland, and the United States. Within each country, FGDs were stratified by sex and age. FGDs were recorded, transcribed verbatim, and translated into English for inductive thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWhile adolescents’ reflections underscored the role of gender norms in influencing mental health, it was apparent that there are important gender differences in the nature of this relationship. According to participants, restrictive norms frequently expose girls to greater scrutiny and control, discriminatory treatment, damaging beauty standards, and gender-based violence, which have deleterious impacts on their mental health. For boys, participants highlighted emotional suppression as a central aspect of masculinity and discussed links between masculine norms and risky health behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eAcross a diverse group of countries, findings suggest the need for adolescent mental health prevention and promotion strategies that focus on shifting harmful gender norms during this critical developmental period.\u003c/p\u003e","manuscriptTitle":"Adolescents’ perceptions of gendered influences on mental health: Results from a 13-country qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-26 08:34:34","doi":"10.21203/rs.3.rs-6717615/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b2860a58-b366-4043-95dc-7e50cd66b29d","owner":[],"postedDate":"May 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":48872417,"name":"Psychology"},{"id":48872418,"name":"Epidemiology"}],"tags":[],"updatedAt":"2025-05-26T08:34:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-26 08:34:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6717615","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6717615","identity":"rs-6717615","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}