Women and health in Italy: steps taken and challenges to be faced

Carla Collicelli

CNR-CID Ethics and Italian Alliance for Sustainable Development (ASviS)

Received 21 February 2022; accepted 8 June 2022

Summary. In recent years, in light of the growing gaps in the economic and social conditions, the issue of inequalities has become increasingly topical. Each of the dimensions of the social inequalities (economic, geographic, educational, gender, health and life expectancy, ethnic and intergenerational) is linked to all the others, but there is no doubt that the lack of equality in health and access to treatment is one of the most important critical issues. In this context, the various forms of privation and discrimination affecting the female component of the population represent an important factor, to which the recent investment and planning lines following the pandemic crisis rightly dedicate some importance. The paper examines the state of the art of gender inequalities related to health and well-being, both the long-standing and the most recent ones, related to the coronavirus pandemic. At present, there is still a long way to go in order to achieve adequate levels of gender equality in the field of health and healthcare.

Keywords. Equality, gender, mental distress, denatality, pandemic.

Gender equality: an open question

The last decade has been characterized by a general improvement in the condition of women, from a social and economic point of view, throughout the advanced Western world, and also in Italy. And the opinion has spread according to which the inequity that has always existed virtually everywhere between men and women is now being overcome. But is it really so? There are numerous signs of a too weak and slow pursuit of the female component versus the male from the perspective of the main indicators of well-being, health and socio-economic condition, to which the deterioration recorded after the pandemic crisis is now to be added.

In 2018, an Ipsos study on social identity was carried out,1 according to which a third of Italian women are not satisfied with the possibility of balancing their living space with family and professional commitments; indeed, the higher the level of social and occupational commitment, the greater the frustration recorded. The woman feels alone in the face of family duties, since in the vast majority of cases she alone has to take care of the children and other fragile subjects of the family, and even when she has a personal health problem, she is forced to take care of it mostly by herself. Responsibility for family duties without the possibility of delegation affects a share between 30 and 50% of the women interviewed, while a similar share is that of women who receive some help from another family member in the performance of these functions, but to a modest extent. The cases of full responsibility assumed by the partner/spouse concern between 5 and 12% of the couples, depending on the individual case.

According to the BES of Istat* in its version relating to the year 2020 (Analysis on equitable and sustainable well-being data) the condition of women has recorded progressive, albeit slow, improvements from 2010 onwards, above all thanks to their growing presence in decision-making positions and in scientific-technological professions. After a decline in 2016, the indicator of women’s equality and empowerment indeed improved in 2019, thanks to the data on women’s skilled work, but it was still far from achieving the expected objectives. And there is no improvement in the general employment share, which even records a worsening between 2019 and 2020.

Life context has had a problematic impact on this reality for some decades, since there has been a growing weakening of the spontaneous factors of social protection of the individual, starting with family and neighborhood networks and direct participation organizations (see paragraph Propensity to procreation and denatality, below). This is creating a new immaterial poverty, often invisible and hidden, and which does not depend on economic conditions, but on existential ones.

The issue of gender equality in the debate on sustainability

The issue of gender equality has taken on particular importance in recent years, in the context of the international and national movement aimed at achieving by 2030 the sustainable development goals sanctioned in 2015 with the UN Agenda, which was signed by almost all the world’s countries. The current trends for each of the 17 goals – and among them for goal number 5 (“Achieve gender equality and the empowerment of all women and girls”), both in Europe and in Italy – are systematically monitored within the work carried out for 5 years by ASviS** (Alleanza Italiana Sviluppo Sostenibile, “Italian Alliance for Sustainable Development”), and gender equality is considered one of the pillars of the framework of sustainable development and the broadest intergenerational equality.

In this regard, the latest ASviS2 Report confirms the reported trends, attesting them through an extensive review of statistical indicators, which can also be compared at an international level. In Europe, the composite index relating to goal 5 (gender equality) shows a positive trend between 2010 and 2019 (Figure 1), mainly due to the increase in the share of women in management positions (+16.6% between 2010 and 2019) and members of national parliaments (from 24% in 2010 to 32.1% in 2019). But it is also noted that all of Europe is still far from the target quota set by the European Pact for Gender Equality (50% by 2030), and a negative trend is identified in particular for other indicators, for example for the share of women who are inactive due to healthcare responsibilities (+6.1% between 2010 and 2019), which in 2019 stood at 32.3%.

Also with regard to Italy, the ASviS index relating to goal 5 shows a positive trend between 2010 and 2019, largely due to the increase in women elected to regional councils (from 2012 to 2019 the index increased from 12.9% to 21.1%) and those on the boards of directors of listed companies (from 2010 to 2019 the indicator rose from 4.5% to 36.1%).

But in 2020 the index sharply deteriorated. Female employment rate between 2019 and 2020 dropped from 53.8% to 52.7% (-1.1%, compared to a reduction in male employment rate of -0.8%), well below the EU average of 67.4% in 2019; moreover, the ratio between the employment rates of women with preschool children and those without children decreased by 0.9%, registering a value of 73.4% in 2020 (Figure 2).

As the ASviS Report notes, the impact of the pandemic has left its mark on many aspects of collective life, also affecting trends relating to the condition of women, aggravating the pre-existing structural gaps. In fact, after the pandemic, women are penalized more than men in terms of job losses and care burden, which have significantly increased due to the periods of closure of schools and the use of smart working. Life expectancy at birth decreased as a result of the pandemic for both genders and, as regards women, it declined by one year between 2019 and 2020, reaching 84.4 years of age. Even the indicators relating to female empowerment show a worsening in the last year and an increase in episodes of domestic violence.

From a political point of view, the ASviS Report highlights the attention that is paid in the National Recovery and Resilience Plan (PNRR), launched in July 2021, with respect to the female issue, attributing to the issue of equality between men and women more importance and transversality than to all the other components. Among the innovative elements contained in the Plan, the conditionality clause with respect to female and youth employment for the participation of companies in calls for tenders on PNRR projects stands out in particular: it’s the so-called Gender procurement, which in tenders favors companies that do not discriminate against women and gender certification.

At the same time, several shortcomings are highlighted, from that of a more precise definition of the gender equality goal and the measures to be implemented, to that relating to the lack of integration of European resources with national ones, to the failure to define a participatory and inclusive governance, also with regard to women, up to the failure to apply the Gender Impact Assessment ex ante for any legislative action, one of the enabling cross actions for the entire Plan.

Finally, the ASviS Report underlines the importance of the new National Strategy for Gender Equality 2021-2026, which is the first programmatic document that comprehensively addresses the issue of gender rebalancing, focusing on five strategic priorities (work, income, skills, time and power) and identifying ten transversal measures which are considered enabling. And it also formulates several proposals to try to bring the gender equality trend back on an improvement path, including that relating to the system of social and health care services and to territorial medicine, and that concerning the enhancement of the so-called “medicine of differences”,*** which – along with the attention to the male and female genders – also includes a focus on the homosexuality area.

Gender as a determinant of health

Within the broader issue of gender equality, that of inequalities in health and healthcare is of critical importance. And not only with reference to the well-being of women and social justice with respect to the female gender, but also based on the belief that the well-being and health of women are of absolute importance for the collective well-being and for the definition of a more advanced model of sustainable development, and of a society attentive to the eco-systemic balance.

Similar considerations are the basis of the analyses on gender as an essential element in the context of the so-called health determinants,3 speaking of which there is the particularly critical and negative short circuit that occurs between the discomfort of the female component of the population and other socio-economic and cultural discrimination factors, related to ethnicity, age, geography, sexual orientation or health conditions and self-sufficiency. All factors that often strongly affect access to healthcare and the quality of services, including the behavior of operators and the communication and information between operators and patients, in some cases with significant repercussions on the clinical outcomes themselves.

Gender inequalities in healthcare

Not many studies addressed the issue of gender equality with respect to health and healthcare in Italy and in the world. Those which did dealt in particular with the following aspects: the differences in per capita health expenditure, both public and out of pocket; deaths avoidable with prevention and therapies; life expectancy at birth; access to innovative treatments and therapies; presence of services on the territory; waiting times for access to treatment.

As regards life expectancy at birth, at European level women live six years longer than men (84 years versus 78), but 33% of women, compared to 28% of men, do not consider themselves to be in good health. The number of healthy life years has most recently increased for men in 19 member states and for women in 15 member states. The biggest gains were observed in Cyprus (+5.4 for women and +4.4 for men) and Italy (+4.5 for women and +5 for men) (Sources: Eurostat and Istat).

As for Italy, the advantage of women in terms of life expectancy is particularly evident, but data shows that the gap in mortality rates has tended to narrow for some time, and that health and life expectancy have improved in the last “pre-COVID” years more for men than for women (Tables 1 and 2).

And also in terms of obesity (Figure 3) and cardiovascular conditions (Tables 3 and 4), where traditionally females’ advantage was evident, the situation slowly tends to rebalance.

With respect to obesity, there is still a strong difference between male and female rates. The trend illustrated in the graph shows a decline in the male rate and an increase in the female rate. With the advent of the pandemic then, the positive evolution of recent years suffered a decrease, as we said, which is completely canceling – in the North and, partially, in the other areas of the country – the expected earnings in years of life accrued in the last decade.

But health inequalities in terms of gender are particularly evident when it comes to equality of access to care. A particularly authoritative source, from this point of view, is EIGE (European Institute for Gender Equality), which calculates gender equality at European level on the basis of six main domains (work, money, knowledge, time, power and health) and two additional ones (violence against women and intersectional inequalities). In its 2019 Report, EIGE notes that, “despite the results obtained in the past decades and the measures taken by the Commission... progress towards effective equality is very slow”. The European Union is closer to gender equality in the sectors of health (88.1 points out of 100) and income (80.4 points) than in that of economic and political power (51.9 points). Unmet health needs in Europe are higher for single mothers and fathers (6% and 8%, respectively) and women and men with disabilities (8% and 7%, respectively).4

In Italy, according to Istat, the situation of delays and the renunciation of necessary healthcare services due to the waiting lists is particularly critical, involving 13.2% of men and 18.4% of women in 2015. Due to transport, delays and renunciation issues, again in 2015, they affected 4.1% of men and 5.7% of women. Due to economic reasons, delays and renunciations, they affected 10.1% of men and 13.8% of women for at least one service, 5.5% of men and 8.4% of women for medical examinations and treatment, and 3.7% of men and 5.2% of women for prescribed medications. Provisional data relating to the last two years indicate an aggravation of this situation following the pandemic event and the bed saturation in many hospitals.

The issue of caregiving and the caring role of women

A particular, albeit not secondary, aspect of female hardships in the healthcare sector concerns the care and assistance that women provide, both in their family and within the extended family network, to the sick and disabled. Interesting evidence from this point of view was found by FAVO (Federazione Associazioni Volontariato Oncologico, “Federation of Voluntary Oncological Associations”) which, with its XI Report on the condition of cancer patients of 2019,5,6 initiated a broad analysis of the economic and social costs of cancer for patients and their families, conducted through a survey carried out in 2018 on 1,289 patients and 1,205 caregivers.7,8 With that first contribution, an initial reporting was proposed with respect to the most important and general aspects – in terms of magnitude and qualitative characteristics – of the costs and socio-economic distress caused by the oncological condition.

The following Report9 analyzed the working and social conditions of the caregivers of cancer patients, whom the survey revealed to be 57% female and 43% male, with the vast majority between 35 and 65 years of age. Sixty point two percent of them live with the patient, and 22.2% live very close to them. The activities that the caregiver carries out to assist the sick are varied, and range from transport (94.4% of cases) to moral and psychological support (77.1%), to the relationship with the care team (70.3%), the management of daily activities (53.5%), external duties (52.0%), support for compliance with the prescriptions (45.1%) and economic support (33.3%), relations with others caregivers and carers (17.5%), personal care and hygiene (16.0%).

The hours dedicated to patient care are on average 40 per week, but are exceeded in most cases, reaching over 70 hours per week in 15.2% of cases. Caregivers who received financial support, or help in terms of time, from other subjects are 20.8% of the sample. For this share, aid came from parents (30.7% of cases), siblings (28.3%), children (21.5%), other relatives (19.5%), wives, husbands or cohabitants (18.3%). Only 4.4% of cases involved help from a paid caregiver or assistant, 3.6% of cases some form of public healthcare, 2.8% of cases aid from voluntary organizations and 1.6% paid healthcare professionals.

Particularly striking with respect to gender inequality is the situation of lost working days and lost jobs on the part of female caregivers compared to their male counterparts (Figure 4).

Against an average monthly loss of working days of 12.2, and a quota of caregivers who lost their jobs due to the health event occurred to the person they take care for, equal to 4.5% of the total of caregivers, Figure 4 shows the composition by sex of the different segments of the caregiver population affected by this type of economic issue. The gap between men and women, in favor of men, is very evident, in particular with regard to the most significant difficulties and the loss of a job.

Propensity to procreation and denatality

Closely related to the social and care overload that characterizes the condition of women in Italy is also the issue of denatality. The most attentive observers have been trying to draw the attention of public opinion, decision makers and stakeholders to the various factors that condition procreation and birth rates for quite some time now. To mention some of the most significant sources, we could recall the numerous and in-depth analyses carried out by the Censis Foundation since the 1990s. Censis repeatedly described a frightened and “run-down” society, characterized, as we said, by the growing weakening of the spontaneous social protection factors of the individual and the communities, starting from family and neighborhood networks and direct participation associations.10,11 A frightened society, families and individuals with a fragile identity, and a widespread uncertainty about the future, which determines a “state of perennial anxiety” that affects everyone, but in particular women, overexposed as they are to professional and domestic burdens.

This description follows the working hypotheses of many authoritative representatives of the most recent sociology tendencies, from the “liquid society” and unstable ties of Zygmund Bauman, to the “sad passions” of Elena Pulcini and Benasayag and Schmitt, to the “a-generative society” as a virus of the third millennium by Mauro Magatti, up to the numerous analyses that underline the weight of the professional and self-realization drive that produces attitudes in search of a happiness meant as the fulfillment of individual desires. In summary, it can be said that anxiety and insecurity have been growing for a long time, together with the fear of the future and the disaffection for procreation and parenthood. At the same time, a lot of evidence points to the connection between denatality on the one hand and globalization, accelerated economic development and new models of communication and technological development on the other.

On top of these questions of socio-anthropological relevance come the important issues relating to gender balance in the life of families. Many studies reveal how the woman feels alone in the face of family duties, since in the vast majority of cases she has to take care of the children and other fragile subjects of the family as the main actor, and even when she has a personal health problem, she has to take care of them mostly single-handed. For all these situations, the proportion of responsibility without the possibility of delegation concerns a share between 30 and 50% of the women interviewed, while a similar share regards women who receive some help from another family member in carrying out these functions, but to a modest extent. Depending on individual circumstances, the cases of full responsibility shared by the partner/spouse concern between 5 and 12% of couples. According to the Istat BES,**** the asymmetry of domestic duties – measured by the percentage of family workload carried out by women between 25 and 44 years old out of the total family work among couples where both partners are employed – is markedly to the disadvantage of women. And even in the northern regions, where the situation is better than in the South, an equitable distribution has not been achieved: in these regions, in the two-year period 2018/19, the percentage of family workload carried out by women between 25 and 44 years of age was still 60.9%.

As regards external aid, these are constantly decreasing, because of the weakening of the informal aid networks that has been going on for at least the last 20 years. The relatives’ network is increasingly “stretched”, the number of assisted families decreases (from 23% to 17%), financial aid increases (48% from the elderly to the young and 47% from the young to the elderly), but direct aid decreases. And it is now clear that family and gender equality policies have not yielded the expected results, at least until today.

With the pandemic, we have also registered negative signs with regard to natality. Already in its Annual Report 2020 – besides the statistical data that describes the situation of the low birth rate in Italy – Istat pointed out a possible link between the demographic situation, on the one hand, and the social uncertainty climate, on the other, particularly following the pandemic. According to Istat, the hypothesis of the existence of a relationship between the uncertainty and anxiety about the future produced by the pandemic and the low birth rate is more than plausible. In fact, the Report states: “In the post-COVID period, the fall in the birth rate could also undergo a further strong acceleration, there being no doubt that the increasingly demanding choice whether or not to have one (or another) child will be addressed in conditions of insecurity and difficulty, financial but not only, the duration of which is not yet known”. And the Report also mentioned in this regard the results of a simulation, according to which – following the pandemic and the related climate of uncertainty – a further 10,000 births decrease was to be expected in 2020 and 2021.

The final data relating to 2021 confirmed the predictions, as births fell further by 1.3% compared to 2020, with the decline attributed by Istat in part to the decrease in the number of fertile women (due to aging), but in notable part to reproductive choices (for at least 6,000 fewer births in 2021 alone).

Recent studies conducted by the Toniolo Institute and the Donat Cattin Foundation indicate an increase in the tendency to give renounce having children in one’s vision of the future. According to the survey by the Toniolo Institute, the failing “desire for a family” is particularly evident, especially in young women over 30 and among female graduates. As Paola Bignardi, member of the Toniolo Steering Committee, wrote, “The pandemic produced a drop in the procreative tension in a context in which relationships have been put to the test and the social and community fabric seems to be fragmented and to come apart into multiple yarns, in which each generation or category seeks the recognition of its identity and the satisfaction of its needs”. According to a similar study by the Donat Cattin Foundation, 51% of young people hope for a future without children, mainly due to work difficulties.

More generally, a recent UN study12 tried to take stock of the impact of the pandemic on women, reaching the conclusion that we have already anticipated in the previous pages, starting from the ASviS data, according to which “the modest gains obtained in the past risk being canceled”, and the inequalities that existed before the pandemic emerge from it even stronger, in particular as regards the most vulnerable groups.

With reference to the impact of the pandemic on women’s health, the UN Policy Brief points out, for example, the greater risk run by the female component of the population as predominant among health workers (on average, 70% of operators are women). And the data reported shows that, out of the total number of healthcare workers affected by COVID-19 infection in Italy (equal to 10,657 subjects at the date of publication), 66% are women. In Spain, this percentage even reaches 72% (out of 7,329 cases).

Unpaid care work also appears from the UN analysis to have increased, due to the pandemic and especially for the female component of the population.

Women and mental distress

When dealing with female differences in terms of health, the mental health area should not be overlooked. The psychological well-being of women has always been severely put to the test by the context and the conditions of life. Looking at the epidemiological data relating to psychological distress, statistics indicate, in addition to an increase in chronic diseases, often in multiple forms, also an intensification of psychological and mental distress, which occurs in particular among young people under 34 years of age and among foreigners, women, the unemployed and the citizens from the North of the country. The most common disorder appears to be depression, which, according to Istat data, involves nearly 3 million people, of whom more than half are women. But also one older adult in 5 suffers from depression, and the number of subjects who need psychiatric or psychological help is increasing, especially among the over 40s.

The loneliness of contemporary life within the city is one of the triggering causes of female psychological distress, especially in old age. Women in Italy are 51.3% of the total population, and more than 60% of the over 80s; indeed, as of January 1, 2019, in Italy there were 14,456 ultracentenarians, of which 84% were women. One third of Italian families are made of singles and the increase, in absolute terms, between 2011 and 2014 was 6.2%. Single people aged 60 and over are 17% of the total, with an increase of 7.9% in the period 2011-14. Single women aged 60 or over are three times as many as men. Consolidated data shows us that loneliness increases the risk of dementia by 40%.*****

The recent data of the already mentioned BES Report (see note *) tells us that only 35.8% of lonely people (it was 37.3% in 2019) declare themselves satisfied with their lives compared, for example, to almost half of the people living in a 4-member family; and the proportion of the very satisfied falls, especially among older single people (by 9 points among women and 10 points among men aged 55-59), but also among young women between 20 and 34 who live alone (-17 compared to 2019) and among men aged 65 and over (-4).

Following the pandemic emergency, the situation is even more critical. In 2020, 43.4% of women state that they are satisfied with their lives, compared to 45.7% of men, while 27.3% of women express themselves in positive terms about their future prospects, compared to 30.7% of men. Particularly felt is the discomfort of single elderly women, whose number is also significantly increasing, given the greater life expectancy.

According to the latest (April 27, 2021) survey of the “Stressometer” of the Study Center of the National Council of the Order of Psychologists (CNOP, Consiglio Nazionale dell’Ordine degli Psicologi), in collaboration with the Piepoli Institute, in this period 39% of the population suffer from a high level of stress. And it is confirmed that women are more stressed than men, “as if they were catalyzing all the most difficult consequences of the pandemic (like the management of the family and the children), thus suffering from very serious psychological consequences”.

With respect to the topic of the anxiety due to the pandemic, many recent researches confirm the unequivocal negative impact exerted by this health crisis on mental distress. According to the Italian Society of Psychiatry (SIP, Società Italiana di Psichiatria), in the last year there has been an increase in the cases of post-traumatic anxiety, with an estimated 300,000 new patients, in addition to the 900,000 already followed by psychiatric services. And, as explained by the WHO, “COVID-19 is increasingly associated with mental and neurological manifestations, as well as with anxiety, sleep disorders and depression”.


The socio-economic factors affecting the condition of women in Italy – and not only in Italy – emphasize the need to develop fields of research, thought and processes for resetting social and healthcare policies towards a more accurate consideration of sex and gender differences, as well as of a consequent reorganization of the therapeutic approaches.

If we consider that women in the family carry out many more functions of social support to minors and care of the home and other domestic management issues than their male partners, it’s easy to understand how much the impact of a severe chronic disease, such as cancer, can weigh on the female condition.

This raises an important issue, of particular relevance for women, which is the question of the so-called “family welfare” of our country. In the Italian social context, the family continues to play a subsidiary and complementary role to public health and social care, but social changes, the economic crisis and the aging of the population require the rethinking of adequate welfare models for the most fragile, socially deprived, lonely elderly. In actual fact, a country considered “familistic” par excellence, also according to important international scientific classifications, bases its policies for the protection of children and youth on a broad delegation to the family, and therefore mainly on the responsibility of women and mothers. In other words, the family – which is also unanimously recognized as having an important role in many aspects of well-being and social coexistence (from consumption to savings, from the education of young people to the protection of the sick and disabled, up to the redistribution of income and private assets, to name just a few of the most relevant areas) – is essentially neglected and left to itself.


* “Equitable and sustainable wellbeing”, a project launched by Istat in 2010 with the aim of evaluating the progress of society from an economic, social and environmental perspective, through ad hoc statistical indicators. Edition 2020.

** Born on February 3, 2016, on the initiative of the Unipolis Foundation and the University “Tor Vergata” of Rome to raise awareness of the importance of the 2030 Agenda for sustainable development and to mobilize in order to achieve the Sustainable Development Goals, ASviS currently brings together over 300 of the most important institutions and networks of civil society, such as organizations representing the social partners (business, trade union and third sector organizations); networks of civil society associations that concern specific Sustainable Development Goals (health, economic well-being, education, work, quality of the environment, gender equality, etc.); associations of local bodies; universities and public and private research centers, and related networks; organizations of subjects active in the worlds of culture and information; foundations and foundation networks.

*** It is on this issue that the ASviS working group on goal 5 organized the national event within the 2021 Sustainable Development Festival entitled Donne, la medicina delle differenze: salute e servizi sociosanitari integrati nel territorio, “Women, the medicine of differences: health and social and health services integrated into the territory”.

**** Equitable and sustainable well-being, see note *.

***** Confirmation comes from an unprecedented study for size and duration, conducted by experts from Florida State University (FSU) in Tallahassee, involving 12,030 individuals enrolled in the Health and Retirement Study, all people aged 50 and over. The results were disclosed in The Journals of Gerontology: B Series.13


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Conflict of interest statement: the Author declares no conflicts of interest.

Correspondence to:

Carla Collicelli

email: c.collicelli.17@gmail.com