Gender, migration and health: are there any gender-specific migration issues?

Gender, migration and health: are there any gender-specific migration issues?

Leuconoe Grazia Sisti1,2, Gianfranco Costanzo1, Umberto Moscato2

1Health Directorate, National Institute for Health, Migration and Poverty (INMP), Rome, Italy; 2Center for Global Health Research and Studies, Catholic University of the Sacred Heart, Rome, Italy

Received 21 November 2021; accepted 16 February 2022

The global health perspective – which defines as a priority the improvement of health and the achievement of equity in health for all people, worldwide1 – emphasizes the interdependence of the different determinants of health in affecting the health of individuals and communities. In this regard, the role of gender and migration is coming to the fore.

Gender – defined as the socially constructed roles, behaviors, activities and attributes that a given society considers appropriate for women and men2 – is increasingly recognized as a central aspect of migration that influences the reasons for the migration itself, the experiences made during migration, and the opportunities and resources available in the countries of destination.

Migrants of any sex and age, including those with diverse sexual orientations, gender identities and expressions, and sex characteristics (SOGIESC), often face additional migration-related challenges.

Migrant women are 135 million, nearly 50% of the global stock of international migrants.3 Being a migrant increases the risk for women and girls to experience various forms of gender-based violence (GBV), including sexual, physical, mental and economic harm in the countries of origin, transit and destination. Most of the worldwide estimated 225,000 victims of trafficking between 2003 and 2016 were women.4 In particular, the central Mediterranean route (from North Africa mostly to Italy) is known to be dangerous, with staggering levels of physical and sexual violence5 usually inflicted by traffickers but also military and security forces. Also migrants with diverse SOGIESC face high rates of discrimination, and higher risk of human trafficking and gender-based violence that, however, do not spare heterosexual migrant men and boys either.6-8 In this context – besides cultural bias that can make it harder for males to report violence – , since the majority of gender-based violence support services are provided in maternal and reproductive health clinics, this might increase the male victims’ barriers to receiving adequate support.9 Moreover, male migrants are frequently perceived as being less vulnerable than women and children, who are usually prioritized in the provision of humanitarian services and aid, thus generating the risk of neglecting or underestimating their needs.10

In host countries, migrants tend to be employed in “3D” jobs (dirty, dangerous and demeaning) with lower salaries, fewer rights and higher occupational hazards, much more frequently than national workers.11 Men are more likely than women to die or be injured at work, given that they are employed in more dangerous jobs (e.g., agriculture, farming, construction, mining, manufacturing, transportation), but also female-dominated sectors, such as domestic work, pose particular risks, including abuse and violence.12

Actually, whereas in the past women often migrated as dependent on their spouses or other family members, today they increasingly migrate alone for study or work, encouraged in part by the growing demand for gender-specific care work in the host countries (e.g., Europe and North America). In these settings, women often work in the informal economy, with limited bargaining power, no (or uncertain) contractual arrangements and only a few opportunities to claim or be guaranteed sick leave.13 In addition, if their legal status is bound to a specific employer, or if they do not hold a valid residence permit, their reporting of possible abuse and exploitation may be hindered, thus further increasing their vulnerability.14

In host countries, women may be more vulnerable than men to abuse and denial of rights, also due to economic hardship, financial dependence and legal insecurity. A recent survey in Australia found that one-third of migrant and refugee women experience domestic violence and that, among these, temporary visa holders consistently report proportionately higher levels of it.15

The lack of a systematic collection of health data reported by gender is still an issue that obstructs the production of scientific evidence in this area.

Migrant men and women are generally both healthy at departure, and do not have particularly different health conditions on arrival compared to the native population.

However, an increased risk of developing post-traumatic stress disorder (PTSD) following the exposure to traumatic events has been reported in women (twice as likely than in males),16 together with an increased risk of psychological distress, depression17 and postpartum depression,18 childhood diabetes and obesity – especially among North African female migrants – and gestational diabetes mellitus (among South Asian migrants).19,20 Depression, anxiety and PTSD are frequently recorded among migrants with diverse SOGIESC, particularly when their condition is associated with detention or living in camps, and high social isolation.21

Cultural and religious beliefs, language barriers, concerns about payment for health care services, uncertainties about the rules for accessing them, lack of communication with healthcare providers, and fear of discrimination may hinder the migrant’s adequate access to healthcare services, even when they are free. In this regard, the literature has particularly focused on health outcomes in migrant women, highlighting a higher risk of unmet sexual and reproductive health needs and adverse pregnancy outcomes – including high maternal mortality – even when they are entitled to access services.

In particular, migrant women access female cancer screening services less than native women. In Italy, it has been reported that foreign women are 40% less likely than Italian women to receive a Pap test, and 55% less likely to get a mammogram.22 They are also twice as likely as Italian women to undergo their first prenatal visit beyond the tenth week of pregnancy (the date recommended by Italian guidelines), to have higher rates of neonatal and post-neonatal mortality,23 as well as a rate of induced abortion 2-3 times higher.24

In addition, it has been estimated that today about 600,000 women and girls who have undergone female genital mutilation/cutting are living in Europe: this represents a major challenge for the healthcare systems.25 Indeed, healthcare professionals struggle to identify and manage possible clinical complications, and policy-makers are called to implement multi-sectorial policies to help prevent these practices in second-generation and first-generation migrant girls coming from countries that still implement them.

Finally, the COVID-19 pandemic has also increased the vulnerability of migrant men and women. Refugees and migrants reported a significant impact of COVID-19 on their access to work, their safety and their financial means.26 Many of them, who work in essential services, have been on the front line during this period and – with particular reference to those with non-regular employment – suffered from an increased economic insecurity, due to unprotected unemployment conditions and the absence of social security contribution schemes such as social safety nets, access to healthcare or paid family and medical leave, with the greatest impact reported for women.27

Placing the gender perspective at the center of global politics is a key priority today, as also highlighted by the Sustainable Development Goals set out in the United Nations 2030 Agenda.28

Adopting the global health perspective implies increasingly acknowledging the role of gender, also with regard to migration.

In this regard, designing and implementing gender-sensitive migration policies and pathways – that consider the diverse experiences, needs, and vulnerabilities faced by women, men and gender non-conforming individuals at all stages of migration – is therefore essential in order to advance gender equality, ensure health protection and support human rights.

References

1. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK et al. Towards a common definition of global health. Lancet. 2009;373(9679):1993-5.

2. Council of Europe. Convention on preventing and combating violence against women and domestic violence (Istanbul Convention). 2011.

3. UNDESA [Internet]. International migrant stock 2020. Available from: https://www.un.org/development/desa/pd/content/international-migrant-stock.

4. UNODC [Internet]. Global report on trafficking in persons. 2018. Available from: https://www.unodc.org/documents/data-and-analysis/glotip/2018/GLOTiP_2018_BOOK_web_small.pdf.

5. UNICEF [Internet]. Gender-based violence programme. Italy – Refugee and migrant response. April 2021. Available from: https://www.unicef.org/eca/media/16976/file/Gender-based_Violence_Programme_factsheets_-_Italy_2021.pdf.

6. IOM [Internet]. International standards on the protection of people with diverse sexual orientation, gender identity, gender expression and sex characteristics (SOGIESC) in the context of migration. 2021. Available from: https://www.iom.int/sites/g/files/tmzbdl486/files/documents/InfoNote-International-Standards-Protection-of-People-with-Diverse-SOGIESC.pdf.

7. Women’s Refugees Commission [Internet]. “More than one million pains”: sexual violence against men and boys on the central Mediterranean route to Italy. 2019. Available from: https://www.womensrefugeecommission.org/research-resources/more-than-one-million-pains-sexual-violence-against-men-and-boys-on-the-central-mediterranean-route-to-italy/.

8. INMP-NIHMP [Internet]. Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants. Technical guidance. 2020. Available from: https://www.inmp.it/eng/Publications/Books/Strategies-and-interventions-on-preventing-and-responding-to-violence-and-injuries-among-refugees-and-migrants.

9. WHO Regional Office for Europe [Internet]. Report on the health of refugees and migrants in the WHO European region: no public health without refugee and migrant health. 2018. Available from: https://www.euro.who.int/en/publications/abstracts/report-on-the-health-of-refugees-and-migrants-in-the-who-european-region-no-public-health-without-refugee-and-migrant-health-2018.

10. Arsenijević J, Burtscher D, Ponthieu A, Severy N, Contenta A, Moissaing S et al. “I feel like I am less than other people”: health-related vulnerabilities of male migrants travelling alone on their journey to Europe. Soc Sci Med. 2018;209:86-94.

11. Ethical Trading Initiative [Internet]. Migrant workers. Available from: https://www.ethicaltrade.org/issues/migrant-workers.

12. Brian T. Occupational fatalities among international migrant workers: a global review of data sources. International Organization for Migration (IOM). Geneva. 2021.

13. Green O, Ayalon L. Violations of workers’ rights and exposure to work-related abuse of live-in migrant and live-out local home care workers – a preliminary study: implications for health policy and practice. Isr J Health Policy Res. 2018;7(1):32.

14. UN Women [Internet]. Women migrant workers. 2020. Available from: https://www.endvawnow.org/es/articles/1958-women-migrant-workers.html.

15. Segrave M, Keel C, Wickes R. One third of migrant and refugee women experience domestic violence, major survey reveals. The Conversation. 2021. Available from: https://theconversation.com/one-third-of-migrant-and-refugee-women-experience-domestic-violence-major-survey-reveals-163651.

16. Vallejo-Martín M, Sánchez Sancha A, Canto JM. Refugee women with a history of trauma: gender vulnerability in relation to post-traumatic stress disorder. Int J Environ Res Public Health. 2021;18(9):4806.

17. Jarallah Y, Baxter J. Gender disparities and psychological distress among humanitarian migrants in Australia: a moderating role of migration pathway. Confl Health. 2019;13:13.

18. Schmied V, Black E, Naidoo N, Dahlen HG, Liamputtong P. Migrant women’s experiences, meanings and ways of dealing with postnatal depression: a meta-ethnographic study. PLoS One. 2017;12(3):e0172385.

19. Agyemang C, van der Linden EL, Bennet L. Type 2 diabetes burden among migrants in Europe: unravelling the causal pathways. Diabetologia. 2021;64(12):2665-75.

20. Bastola K, Koponen P, Skogberg N, Gissler M, Kinnunen TI. Gestational diabetes among women of migrant origin in Finland-a population-based study. Eur J Public Health. 2021;31(4):784-789.

21. Yarwood V, Checchi F, Lau K, Zimmerman C. LGBTQI + migrants: a systematic review and conceptual framework of health, safety and wellbeing during migration. Int J Envir Res Public Health. 2022;19(2):869.

22. Petrelli A, Giorgi Rossi P, Francovich L, Giordani B, Di Napoli A, Zappa M et al. Geographical and socioeconomic differences in uptake of pap test and mammography in Italy: results from the National health interview survey. BMJ Open. 2018;8(9):e021653.

23. Petrelli A, Di Napoli A (Eds). Salute degli immigrati e disuguaglianze socioeconomiche nella popolazione residente in Italia valutate attraverso la rete degli studi longitudinali. Epidemiologia & Prevenzione. 2019;43(5-6 Suppl 1).

24. Ministero della Salute. Relazione del ministro della salute sulla attuazione della legge contenente norme per la tutela sociale della maternità e per l’interruzione volontaria della gravidanza (legge 194/78). Dati definitivi 2019 e dati preliminari 2020. 2021.

25. End FGM European Network [Internet]. FGM in Europe. Available from: https://www.endfgm.eu/female-genital-mutilation/fgm-in-europe/.

26. WHO [Internet]. Apart together survey. Preliminary overview of refugees and migrants self-reported impact of COVID-19. 2020. Available from: https://www.who.int/publications/i/item/9789240017924

27. UN Women. Policies and practice: a guide to gender-responsive implementation of the global compact for migration. 2021.

28. UN [Internet]. Sustainable development goals. Available from: https://sdgs.un.org/goals.

Conflict of interest statement: the Authors declare no conflicts of interest.

Correspondence to:

Leuconoe Grazia Sisti

Italian National Institute for Health, Migration and Poverty (INMP)

Via di San Gallicano 25/a

00153 Rome, Italy

email LeuconoeGrazia.Sisti@inmp.it