T.K. Sundari Ravindran
THE term ‘gender’ is often used as synonymous with ‘sex’, male and female. Though the two are indeed synonymous according to English language dictionaries, the term ‘gender’ has over the past three decades evolved into a concept different from ‘sex’. Ann Oakley and others used the term gender in the 1970s to describe those characteristics of men and women which are socially determined, as against ‘sex’ which describes biologically determined characteristics. This distinction between sex and gender provides a useful analytical tool for focusing attention on differences between women and men which are socially constructed.
Many of the differences in men’s and women’s roles and responsibilities, norms and values guiding appropriate behaviour and access to and control over resources, have less to do with the fact that they were born male or female or that women alone can be impregnated and bear children, and more with how society expects women and men to behave. These in turn are derived from patriarchal ideology – a system of ideas based on a belief in inherent male superiority. This ideology typically includes the belief that male control over property is ‘the natural order of things’.
What do we mean by ‘engendering’ health or a gender perspective on health? The very term suggests that it is not the same as focusing on women’s health, or even more narrowly on health conditions exclusively experienced by women as a consequence of their biology.
Traditional frameworks for analysing women’s health have often concentrated on the childbearing years, and especially with health problems related to pregnancy and childbearing. Besides their special health needs that are different from those of men due to biological differences, women are also exposed to all the health problems that affect men throughout their lifecycle. Thus malaria, tuberculosis, occupational and environmental health hazards – all these impact women’s health needs too. In fact, since infections such as malaria and hepatitis become life-threatening conditions for women during pregnancy, they are issues of special concern.
A gendered perspective on health includes, besides examining differences in health needs, looking at differences between women and men in risk factors and determinants, severity and duration, differences in perceptions of illness, in access to and utilisation of health services, and in health outcomes. ‘When considering the differences between women and men (in health status), there is a tendency to emphasize biological or sex differences as explanatory factors of well-being and illness. A gender approach in health, while not excluding biological factors, considers the critical roles that social and cultural factors and power relations between women and men play in promoting and protecting or impeding health.’1
Why do we advocate engendering health? Few would disagree with the view that health is a product of the physical and social environment in which we live and act, which is in turn affected by the global and local environment: social, cultural, economic and political. It is also widely acknowledged on the basis of studies conducted in diverse settings that inequalities in health across population groups arise largely as a consequence of differences in social and economic status and differential access to power and resources. The heaviest burden of ill-health is borne by those who are most deprived, not just economically, but also in terms of capability, such as literacy levels and access to information.
Substantial evidence exists to indicate that in almost all societies women and men have differing roles and responsibilities within the family and in society, experience different social realities, and enjoy unequal access to and control over resources. It therefore follows that gender is an important social determinant of health. Gender differences are observed in every stratum of society, and within every social group, across different castes, races, ethnic or religious groups.
Men and women perform different tasks and occupy different social, and often different physical, spaces. The sexual division of labour within the household, and labour market segregation by sex into predominantly male and female jobs, expose men and women to varying health risks. For example, the responsibility for cooking exposes poor women and girls to smoke from cooking fuels. Studies show that a pollutant released indoors is 1000 times more likely to reach people’s lungs since it is released at close proximity than a pollutant released outdoors. Thus, the division of labour by sex, a social construct, makes women more vulnerable to chronic respiratory disorders including chronic obstructive pulmonary disease, with fatal consequences.2 Men would in turn be more exposed to risks related to activities and tasks that are by convention male, such as mining.
Differences in the way society values men and women, and accepted norms of male and female behaviour influence risk of developing specific health problems as well as health outcomes. Studies have indicated that preference for sons and the undervaluation of daughters skew the investment in feeding and health care. This has potentially serious negative health consequences for girls, including avoidable mortality. On the other hand, social expectations about male behaviour may expose boys to a greater risk of accidents, and to the adverse health consequences of smoking and alcohol use.
Patriarchal norms which deny women the right to make decisions regarding their sexuality and reproduction expose them to avoidable risks of morbidity and mortality, be it through sexually transmitted infection resulting from coercive sex, or death from septic abortion because access to safe abortion has been denied by state legislation. The practice of unsafe sex by large sections of men who are aware of the health risks cannot be explained except in terms of gender norms of acceptable and/or desirable male sexual behaviour.
Because men and women are conditioned to adhere to prevailing gender norms, their perceptions and definitions of health and ill-health are likely to vary, as is their health seeking behaviour. Women may not recognise the symptoms of a health problem, not treat it as serious or warranting medical help, and more commonly, not perceive themselves as entitled to invest in their well-being.
Finally, because women and men do not have equal access to and control over resources such as money, transport and time, and because the decision-making power within the family is unequal with men enjoying privileges that women are denied, women’s access to health services is restricted. They may be allowed to decide on seeking medical care for their children, but may need the permission of their husbands or significant elders within the family to seek health care for themselves. Restrictions on women’s physical mobility, common in many parts of India, often makes it imperative for women to be accompanied to a health facility by a male family member.
In many instances, biologically determined differences between women and men interact with socially constructed behaviour to the disadvantage of women. This is best illustrated in the case of sexually transmitted infections. Women are biologically more susceptible to contracting a sexually transmitted infection than men. This is because of the shape of the vagina and a greater mucosal surface exposed to a greater quantity of pathogens during sexual intercourse, since the quantity of seminal fluid is far greater than the vaginal fluid involved. Further, women with a sexually transmitted infection are more likely to be asymptomatic and therefore less likely to seek treatment. Untreated and undiagnosed sexually transmitted infections are the cause of chronic infections and numerous long term complications suffered by women, including infertility and cervical cancer.
There are other factors which compound women’s vulnerability because of the way society expects women and men to behave. For a majority of women, high risk activity can simply mean being married. Social norms which accept extra-marital and pre-marital sexual relationships in men as ‘normal’, and women’s inability to negotiate safe sex practices with their partners, are factors that make it difficult for women to protect themselves from sexually transmitted infections. A study of STD (sexually transmitted diseases) clinic patients in India (1992) indicated that a third of the women, all in monogamous married relationships, were infected by their husbands, while the majority of the male patients were infected by commercial sex workers and casual sexual partners. Not a single man was infected by his wife.3 Men’s unwillingness to use condoms further accentuates women’s risk. For example, in a study of the prevalence of and risk factors for HIV infection in Tamil Nadu, India (1994-1995) covering a population of about 97,000, less than 2% of married men were found to be condom users.4 The stigma attached to visiting an STD clinic together with other barriers such as lack of time, money and decision-making power discourages women from seeking treatment.
To summarise, both ‘sex’ and ‘gender’ differences between women and men, and the many ways in which the two are intertwined, contribute to differences in health risks, health seeking behaviour, access to and utilisation of health services and health outcomes between the two groups. Research, policy and services aiming to improve the health status of a population will have to examine, understand and address these differences.
One of the biggest obstacles to better engendered health policies and services is the limited availability of information on sex and gender differences in health status. Engendering health information would imply the collection and dissemination of data on differences between males and females in (among others) health outcomes such as mortality, morbidity and undernutrition; causes of morbidity and mortality; specific population groups who are most affected (e.g., age, socio-economic or ethnic groups); and recognition of health problems and utilisation of health services.
Probing the reasons why there are observed differences between men and women in health outcomes, determinants of health status and in health seeking behaviour, calls for engendering health research. It would imply asking questions such as:
* Are women and men at differential risk of exposure to infection or different in terms of vulnerability? Are these caused by ‘sex’ differences or ‘gender’ roles and norms? Do these also affect the rates of progression from infection to disease, (and/or) severity of illness experienced and the duration of the illness? Are they at differential risk of recurrent infection?
* Do gender norms differentially influence women’s and men’s ability to recognise health problems, their access to health services and their ability to successfully complete treatment?
* Are there differences in the treatment received at health facilities by women and men? Do these contribute to differential health outcomes?
In many instances, assumptions about gender roles contribute to the invisibility of some health problems suffered by women. For example, gender ideology reinforces the notion that women’s work at home is ‘not real work’. As a consequence, classical definitions of occupational health do not include the health impact on women of their domestic and childbearing and rearing roles, although globally women dedicate an important part of their lives to it. Engendering health information would require a framework which explicitly takes into consideration women’s multifarious roles in production, reproduction and community activities.
Engendering health research also means the adoption of methodologies which have an adequate representation of both sexes, so that sex/gender specific analysis of data is possible; ensuring that women are adequately represented as respondents in the case of household surveys; eliminating or minimising bias arising from differential costs and benefits to men and women from participating in the study, and so on.
Health policies are often ‘gender blind’. They make references to general categories such as ‘communities’ or ‘the rural poor’, without making any distinctions by gender. In effect, they are implicitly male biased. The invisibility of women in occupational health is a good example of why gender based differences need to be explicitly considered in examining health issues and formulating policies.
Engendering health policies is different from the adoption of a ‘women’s health policy’. It refers to the development of health policies that address not only women’s special needs but also the health needs they share with men, taking into account gender differences in aspects such as health risks, determinants of health, and health seeking behaviour.
For example, an engendered health policy would recognise spousal violence as a gender related health problem to which women are disproportionately more exposed because of social norms sanctioning male aggression and their right to control women. It would examine environmental health hazards separately for men and women, and devise programmes to prevent and control exposure accordingly. It would provide for active tuberculosis case-finding to minimise under-reporting of infection in women, and examine whether or not women’s biological differences contribute to their greater vulnerability to the infection, or to its consequences. Such a health policy would examine and correct gender disparities in human resources within the health sector and gender biases perpetuated by medical education.
More importantly, in the case of health issues which are specific to women, an engendered health policy would go beyond merely providing a technical service. It would address this ‘practical’ need of women in a way that challenges existing gender roles and stereotypes transforming women’s situation with respect to men. A ‘safe motherhood’ policy, for instance, would not assume either that women alone are responsible for childcare, or that they have access to the resources to ensure their own as well as their child’s well-being. It would be designed with an awareness that women often do not have a say in whether and when to get pregnant. It would acknowledge that many pregnancies are unwanted or ill-timed from the woman’s point of view, and would provide women with the option of safe pregnancy termination. Indeed, the policy would not even be called safe motherhood policy, but a safer pregnancy policy, allowing for the possibility of safe pregnancy termination.
In other words, an engendered health policy would also seek to transform existing gender relations in a more democratic direction by redistributing more evenly the division of resources, responsibilities and power between women and men.
A gender aware health policy would not be blind to other forms of social inequities, and treat women or men as homogenous groups. It would be based on the understanding that women and men are divided along class, caste, religious, ethnic lines, and ensure that the poorer and marginalised sections are not implicitly excluded. This is especially important in an era of cuts in the health sector budgets and decentralisation. Inter-regional disparities may be further accentuated if wealthier regions are able to mobilise more funds than poorer ones. Public health facilities in the poorer regions would be especially hit hard, and preventive care may receive reduced funding. This would give rise to a dependence on health services in the private sector, placing the poorer sections at a disadvantage and widening health inequities. A gender aware policy evolved in this context would explicitly consider gender disparities within the poorer and marginalised groups and design strategies that would help meet the needs of poor women.
What this implies is that the process of policy-making itself would be grassroots up, involving large scale moblisation at the grassroot level. Experiences from countries such as South Africa show that gender aware policies which evolve through this process reflect the priorities of the poorest and most vulnerable groups in society. A few informed feminists negotiating with the bureaucracy, without prior consultation with women from various sectors of society, would not be the way to go.
Another issue to bear in mind is that it is not sufficient to design a gender aware policy in the health sector alone, if policies in other areas that have a bearing on health – all development policies for that matter – are gender blind, with an implicit male bias.
While engendering health policies is in itself a complex process, translating these into programmes is a far more challenging task. Examples of policies which are progressive on paper but inadequately implemented are numerous everywhere in the world. This appears to be especially true of gender aware policies which ‘evaporate’ even by the time that a policy statement begins to spell out concrete programme interventions, and almost completely disappear when they get to the stage of implementation.
In an article entitled ‘The evaporation of policies for women’s advancement’, Longwe argues that gender aware policies run contrary to the interests of bureaucracies which are inherently patriarchal in nature. Government agencies are not and cannot be expected to be a means for redressing gender inequities because they are themselves a part of the problem and an obstacle to progress. She talks about the endless capacity of the government bureaucracy to evaporate policies for women’s advancement.5 The active involvement of the women’s movement and civil society institutions is essential, and not just to ensure that policies are engendered. Without the continued involvement and independent monitoring by these actors, gender aware policies will never be pursued but be given a quiet burial.
A number of tools have been developed for monitoring how engendered a health programme is. Some of the major questions to be asked include: Does the programme address gender differentials in health risks, health information and access to health services?
To give one example, does a malaria control programme take into account the fact that even though reported prevalence of malaria is higher among men than in women overall, malaria in pregnancy has a much higher case-fatality rate? Does it seek to gather and analyse information on malaria incidence and prevalence by sex and disaggregated into various population sub-groups so that it becomes clearer whether or not the general pattern of higher prevalence among males is true for all population subgroups? Does it seek to inform pregnant women about the risks associated with malaria in pregnancy? Does it engage in active case-finding, i.e., take samples for blood tests within the community, so that women are not under-represented among those tested and so on?
Does the programme load all responsibilities for improved health on women rather than also involving men? Does the programme add to women’s work load? For example, does the child survival programme also aim its messages at fathers? Are health education programmes conducted only for mothers, or both parents? Do nutrition programmes address themselves only to women, or expect them to spend more time in food preparation?
Does the programme perpetuate gender biases? Do fertility control programmes, for instance, actively involve men and promote male methods of contraception rather than target women and blame women for ‘high fertility’? Do strategies for the control of sexually transmitted infections focus on condom use by men rather than making women responsible for negotiating condom use with their partners, or treating commercial sex workers as ‘reservoirs of infection’?
Will the programme contribute to redressing inequities in health by gender across various sections of the population? Some examples of how this could be achieved are: correcting gender imbalances in access to health information by providing women with the information and skills that would enable them to make informed choices about their health, creating women-friendly health facilities or making health care available closer to home, and to bridge the gender gap in access to health care.
Does the programme address and help narrow gender gaps in terms of distribution of responsibilities and power among health personnel? Engendering health programmes could lead to adding to the responsibilities of female health workers at the community and health facility levels disproportionately more than their male counterparts. A conscious attempt has to be made to ensure that this does not happen, and that male health workers are also involved in the process of engendering health programmes, especially in making health prevention and promotion as much men’s business as it is women’s.
To reddress health inequities by gender requires, above all, commitment and conscious involvement of health personnel at senior levels. Of all the factors listed thus far, the patriarchal nature of the health bureaucracy and of the medical establishment would probably prove the most formidable obstacle to engendering health. This, then, would be our starting point – gender sensitisation of the medical community.
1. World Health Organization, Gender and Health: Technical paper. WHO/FRH/WHD/98.16, Geneva, 1998.
2. World Health Organization, Health and Environment in Sustainable Development: Five Years After the Earth Summit. Geneva, 1997.
3. P. Ramachandran, Women’s Vulnerability to AIDS: A Symposium in the Transmission, Prevention and Management of the Pandemic, Seminar 396, August 1992, pp. 21-25.
4. S. Solomon, N. Kumarasamy, A.K. Ganesh and R.E. Amalraj, ‘Prevalence and Risk Factors of HIV-1 and HIV-2 Infection in Urban and Rural Areas of Tamil Nadu, India’, International Journal of STD and AIDS 2, 1998-99, pp. 98-103.
5. S.H. Longwe, The Evaporation of Policies for Women’s Advancement, in N. Heyzer (ed), A Commitment to the World’s Women: Perspectives on Development for Beijing and Beyond , United Nations, New York, 1995.