Background: Climatic changes are threatening rural livelihoods in East Africa. Evidence suggests that climate change adaptation in this context might reproduce inequitable intra-household gender relations and that adaptation may be more effective when women are involved in meaningful ways. Hence, a nuanced understanding of the gendered nature of intra-household adaptation decision-making is essential for gender-responsive research, policy-making and practice.Objective: This qualitative systematic review aimed to investigate how gender relations influence decision-making concerning climate change adaptation in rural East African households and how decisions about climate change adaptation influence intra-household gender dynamics, in turn.Methods: Applying qualitative meta-synthesis principles, systematic searches were conducted in 8 databases and supplemented with comprehensive hand searches. 3,662 unique hits were screened using predetermined inclusion criteria, leading to a final sample of 21 papers. Relevant findings of these studies were synthesised using inductive thematic coding, memoing and thematic analysis.Results: While men tended to be the primary decision-makers, women exercised some decision-making power in traditionally female domains and in female-headed households. Women’s and men’s roles in intra-household adaptation decision-making appeared to be influenced by a plethora of interconnected factors, including gender norms, gendered divisions of labour and access, ownership and control over resources. Intra-household adaptation seemed to impact the dynamics between male and female household members. The pathways of this influence were complex, and the ultimate outcomes for men and women remained unclear.Discussion: We discuss our findings with reference to theoretical literature on gender-transformative approaches in development and adaptation and previous research concerning the gendered nature of CCA in East Africa. We then discuss implications for gender-responsive adaptation interventions.