Gender, referring to the psychological, behavioral and sociocultural aspects associated with sex [1
], is an important determinant for mental health outcomes and care. Several studies have revealed gender differences in terms of prevalence and clinical presentation for various mental health problems in children and adolescents such as eating disorders, anxiety disorders, conduct problems, and attention-deficit/hyperactivity disorder (ADHD) [2
]. For example, internalizing problems such as anxiety disorders occur more often among girls than boys [4
], whereas externalizing problems such as conduct problems are more common in boys than in girls [5
]. Furthermore, there are gender differences regarding coping strategies, symptomatology and medication [6
]. There are also gender differences in child and adolescent mental health care regarding the frequency of service use [10
], the age at referral [11
], as well as in the willingness to use mental health care [12
]: Compared to girls, boys are referred at a younger age [10
], whereas girls are more likely to obtain treatment in early adulthood [11
]. Furthermore, adolescent boys are less willing to use mental health services than girls [12
]. For various mental health problems, such as depressive symptoms [13
], substance use/abuse [15
] or eating disorders [16
], different risk and protective factors have been identified for girls and boys. Additionally, research on the etiology of mental health problems points towards the existence of gender-specific processes in their development [17
]. For example, rumination seems to contribute to the development of depression in girls, but not in boys [18
In addition to this predominantly binary (girls vs. boys) and heteronormative view of gender differences, existing research demonstrates that transgender, gender variant or non-binary youth experience mental health problems, such as depression, suicidality and eating disorders, at an elevated rate compared to the general population [19
]. Sexual and gender minorities (SGM), an umbrella term for individuals who do not identify as heterosexual or cisgender (e.g., transgender), face high levels of stigmatization and discrimination, and often adverse mental health outcomes [22
Mental health problems emerging in these early life stages account for a large proportion of the global burden of disease [23
], have economic long-term consequences [24
], and often persist into adulthood [25
]. Additionally, research suggests that the persistence differs by gender, for instance, girls show a more persistent course of mood and anxiety disorders than boys [25
]. In summary, there are several gender differences in mental health outcomes and care. Hence, considering gender aspects in child and adolescent mental health care is crucial for developing effective programs and thereby addressing gender-related mental health disparities early.
Programs that acknowledge gender roles and norms and consider and account for specific gender-related needs can be described as “gender-specific” [27
]. Furthermore, heteronormativity is an important gender-related aspect that should be addressed in gender-specific care [28
], highlighting the need to consider not only aspects related to gender (e.g., female, transgender, etc.) but also to sexual identity (e.g., heterosexual, bisexual, etc.). Rationales for gender-specific interventions comprise (1) responding to gender-specific psychological aspects (e.g., gender-related needs and experiences), (2) providing a safe space and a supportive, empowering environment, (3) assuming a greater effectiveness of gender-specific compared to gender-non-specific interventions, and (4) thereby addressing gender disparities and contributing to the achievement of social justice [29
]. Importantly, approaches that address one sex without addressing gender-specific aspects (mere single-sex interventions) are non-gender-specific programs [28
Child and adolescent mental health care programs can also vary in the timing of intervention. A common distinction is made between prevention (before the onset of any disorder, focus on reducing risk factors and enhancing protective factors) and treatment programs (treating an already existing disorder) [30
]. There are universal programs (targeting a whole population) and selective programs (targeting individuals or subgroups with a significantly higher risk of developing mental health problems) [31
The development of gender-specific prevention programs for substance abuse began when substance abuse among girls increased in the mid-1990s, and studies showed that girls did not benefit from existing programs [15
]. A frequently addressed gender-specific aspect of these early programs was the focus on family relationships (a specific risk factor for girls) [15
]. At this same time, the first gender-specific aggression interventions for girls were developed [32
]. These treatment programs often focused on the different expression of aggression in girls vs. boys (relational vs. physical aggression) [32
Despite these early developments, there are a few reviews of gender-specific child and adolescent mental health care for certain disorders (e.g., substance use/abuse [15
]), settings (e.g., school [32
]), and populations (e.g., SGM [33
]). However, a comprehensive review of gender-specific child and adolescent mental health care programs, without focusing on one specific mental health problem, setting, or population is lacking to better understand how their implementation and effectiveness might differ. Therefore, the purpose of this systematic review is to provide an overview of gender-specific child and adolescent mental health care by collating and critically appraising the existing research. It aims (1) to summarize and evaluate various gender-specific mental health care programs, (2) to identify the gender-specific aspects commonly addressed in these programs and (3) to synthesize their effectiveness, in order to derive implications for clinicians and health care providers. Further objectives are to identify gaps in knowledge and research, in order to make recommendations for future research.
This systematic review provides an overview of gender-specific child and adolescent mental health care. It aims at summarizing and evaluating gender-specific child and adolescent mental health care programs, identifying gender-specific aspects commonly addressed in these programs and synthesizing their effectiveness.
In total, we identified 43 studies. Most interventions were conducted in school or community settings which is in line with previous research showing that most youth with mental health problems are seen in non-healthcare settings [106
]. Furthermore, nearly half of the studies assessed prevention programs. We find it intriguing that gender-specific concepts play a role in the development of preventive interventions, but less so in treatment programs. Further light should be shed on whether this is a conceptual gap or whether actual gender-specific approaches are not labeled as such in the realm of treatment.
In our review, most interventions targeted substance-related and addictive disorders as well as eating disorders. Additionally, over 70% of the studies evaluated interventions exclusively for (mostly adolescent) girls. Taken together, these findings are not surprising since girls/women have traditionally been neglected in substance treatment which has resulted in the development of female-specific treatments in the last decades [15
]. Regarding eating disorders, adolescent girls have been the focus of prevention programs for a long time because they are at particularly high risk [108
]. This trend has contributed to the exclusion of male and SGM individuals from eating disorder prevention programs even though (particularly pre-adolescent) boys and SGM individuals have high risks, too [109
]. Only two of 43 studies (one yielding a large effect, one with no effect) focused exclusively on boys, indicating a large research gap. Reasons for this research gap include the lack of awareness of male or non-female disordered eating and the emphasis in most research on anorexia nervosa, as binge eating disorders are more prevalent among males [109
]. Furthermore, the focus on a small number of mental health problems provides important directions for future research.
Gender specificity was implemented differently depending on the targeted mental health problem and population. For instance, addressing family support and minority stressors seemed to be an important aspect in treating mood disorders among SGM youth [56
], whereas eating disorder interventions mainly targeted girls’ beauty ideals and body acceptance [64
Most of the interventions addressed several gender-specific aspects, highlighting that gender-specific interventions should consider multiple factors and experiences that intersect with each other. For example, gender norms and ideals (e.g., “thin ideal”), developmental tasks (e.g., puberty and related body changes), and resulting gender-specific mental health needs (e.g., effective prevention of eating disorders) are interconnected. On the one hand, a specific gender involves not only experiences on biological, psychological, and sociocultural levels, but also individual experiences that differ in gender groups without being specifically related to gendered roles (e.g., the role of rumination in girls’ depression) [110
]. On the other hand, addressing several gender-specific aspects at once may indicate a lack of an appropriate etiological basis, otherwise required by experts in the field [32
When looking at both controlled and uncontrolled studies, as we did in the present review, our findings indicate that most gender-specific interventions led to an improvement in mental health outcomes (particularly in mood, trauma- and stressor-related, and personality disorders). However, only 29 of the 43 studies reported effect sizes and only few studies (n
= 13) yielded medium or large effects. Additionally, the outcomes regarding the effectiveness were heterogeneous and a comparison between programs was challenging because they differed in modality, duration, and setting. The studies yielded on average medium effect sizes with treatment studies yielding larger effects than universal intervention and prevention programs. This is in accordance with other reviews reporting a “hierarchy in effect sizes” for different intervention types with treatment studies yielding larger effects than prevention studies [111
]. Assuming that most participants in prevention programs or universal interventions do not have severe symptoms, a reduction of symptoms or significant effects may be harder to find in these populations. This may also partially explain why universal body image programs and eating disorder prevention programs often yielded small or no effects.
However, the results regarding the effectiveness must be interpreted cautiously due to methodological deficits for some studies including lacking control groups, small sample sizes, short-term follow-ups and poor study quality. For instance, when examining only controlled studies, the average effect size was small (d = 0.37), and 27% yielded no effects. Thus, by including uncontrolled studies (for the purpose of a comprehensive review of gender-specific programs in this field), the reported improvements may be attributed to other factors. In summary, strong causal evidence (derived from RCTs) is lacking, calling for more RCTs in this research field.
Two other limitations concern our search strategy. We did not include terms related to sex and gender (e.g., “boy”/“girl” or “transgender”) as adding these terms would have led to more than 20,000 additional results only in PubMed. With a more comprehensive search strategy, additional publications that do not include terms referring to “gender-specific” or “sex-specific” could have been detected. However, we were aware of this limitation and decided to use our search strategy primarily for two reasons: First, we wanted to know how gender-specific aspects are considered and thus also how “gender-specific” is currently understood in child and adolescent mental health care. Secondly, we conducted pilot searches to ensure that our search was specific, but not overly sensitive. These pilot searches revealed that adding sex- and gender-related terms produced a lot of noise and few relevant records. To counter this limitation, we also screened impactful reviews and reference lists. We found it intriguing that gender-specific interventions very often addressed mental health problems that are more prevalent in another gender group (e.g., female-specific interventions for substance disorders). We believe this could be symptomatic in areas in which regular interventions largely point to a specific gender group, maybe even with a gender-specific approach, but fail to label the interventions as gender-specific. These limitations might be addressed in future studies, for example by analyzing and comparing intervention manuals of single-gender and mixed-gender interventions. Additionally, we restricted our search to English and German publications due to limited language, financial and time resources. Consequently, publications in other languages were excluded and the samples of the included studies were mostly drawn from Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries—highlighting the dearth of studies from more diverse countries that impacts many different research fields [112
Another limitation resulting from time constraints is that the screening process was primarily conducted by one author, while two other authors could only screen 10–13% each in the given time. However, the authors were in constant exchange and additionally consulted with the research group.
We identified only a single study comparing a gender-specific to a non-gender-specific intervention. Consequently, this review does not allow any conclusions regarding the comparative effectiveness of gender-specific vs. non-gender-specific interventions. On the one hand, this underlines an important research gap. On the other hand, it highlights that possible superior effectiveness is not the only rationale for gender-specific care. For instance, from a consumer perspective, a safe space where youth can be empowered and supported by peers and where they can share and explore their gendered experiences is also important [113
Our review focused on gender in child and adolescent mental health care. Moreover, other social indicators, such as ethnicity and socioeconomic status, have an important impact on child and adolescent mental health outcomes and care [114
]. For this reason, we reported the ethnic/racial diversity for the included studies (Appendix B). Since these different social indicators interact with each other and shape individual experiences and health outcomes (intersectionality) [116
], future research should assess how other (intersecting) social indicators are addressed in gender-specific care.
There are many approaches to advance the research on gender-specific care derived from this review. Researchers and mental health professionals can
evaluate the effectiveness of existing gender-specific interventions;
compare the effectiveness of non-gender-specific vs. gender-specific interventions (e.g., [92
adapt existing and effective interventions to gender-specific needs (e.g., [64
develop and evaluate gender-specific interventions for other mental health problems with known gender differences (e.g., ADHD, autism);
develop and evaluate gender-specific interventions for underserved populations (e.g., [58
develop and evaluate gender-specific interventions that consider different social indicators (e.g., [60
both differentiate between gender and sex and assess sexual identities to address vulnerable SGM groups (e.g., [105
be encouraged to state to which degree an intervention that they report on is gender-specific; and
collect gender data and report gender-differentiated results in evaluation studies of interventions.
Further recommendations are directed at mental health professionals and providers who can:
teach their staff about gender-specific risk and protective factors and mental health needs (e.g., [104
sensitize each other for their own gender-stereotyped behavior or thinking.
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