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raghavan-gilbert/vw-991 2 Gender and Reproductive Behaviour p Understanding gender provides: w insights into mens and womens behaviour w relationships.

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Presentation on theme: "raghavan-gilbert/vw-991 2 Gender and Reproductive Behaviour p Understanding gender provides: w insights into mens and womens behaviour w relationships."— Presentation transcript:


2 raghavan-gilbert/vw-991

3 2 Gender and Reproductive Behaviour p Understanding gender provides: w insights into mens and womens behaviour w relationships and w reproductive decisions w These insights are crucial to communicating with and serving both men and women effectively.

4 raghavan-gilbert/vw-993 Gender and Reproductive Behaviour ZGender refers to the different roles that men and women play in society ZAlso to the rights and responsibilities that come with these roles ZGender differs from sex, which refers to the biological and physical differences between men and women

5 raghavan-gilbert/vw-994 Gender and Reproductive Behaviour p Gender roles usually taken for granted - reflected in: u family structures u household responsibilities u labour markets u schools u health care systems u laws u public policies u The influence of gender is similar in strength to religion, race, social status and wealth

6 raghavan-gilbert/vw-995 Gender and Reproductive Behaviour p Gender roles begin at birth and span a lifetime: very young boys and girls learn from their families and peers how they are expected to act u around people of the same sex u around people of the opposite sex

7 raghavan-gilbert/vw-996 In Utero Pre - Puberty Early Adolescence Late Adolescence Young Adulthood Near Old (55-64 yrs) Young Old (65-74 yrs) Oldest Old >75yrs technical advances family influences School influences peer influence peer pressure Socio cultural influence Cultural and societal pressure Community approval & Support Family support Family & Community From WOMB To TOMB The Life Cycle In RH

8 raghavan-gilbert/vw-997 GENDER PERSPECTIVES IN RH: A LIFE CYCLE MODEL In Utero E Sex selection - abortion - infanticide E Value of the girlchild G Biological vulnerability

9 raghavan-gilbert/vw-998 Pre-Puberty E Conditioning to gender roles - nutrition - education - abuse - violence - work allocation E Child Pornography E Child Prostitution G Conditioning to gender roles - nutrition - education - work allocation - domestic violence - abuse GENDER PERSPECTIVES IN RH: A LIFE CYCLE MODEL

10 raghavan-gilbert/vw-999 Puberty E Menarche E Virginity E FGM E Pregnancy E Violence G Rites of passage G Gender Role conditioning G Abuse GENDER PERSPECTIVES IN RH: A LIFE CYCLE MODEL

11 raghavan-gilbert/vw-9910 Early Teens E Hormonal Changes E Curiosity E Violence E Exploitation E Pregnancy G Gender role imprinting G peer influence G abuse GENDER PERSPECTIVES IN RH: A LIFE CYCLE MODEL

12 raghavan-gilbert/vw-9911 Late Teens E Sexual Bonding E Pregnancy E STD/HIV E Gender roles enacted E High risk behaviour E Violence and Abuse G Gender roles acted out G Sexual activity G High risk behaviour G Abuse GENDER PERSPECTIVES IN RH: A LIFE CYCLE MODEL

13 raghavan-gilbert/vw-9912 Young Adulthood E Gender Roles internalized (or questioned) E productive role (non NSA/NSA) E reproductive role - household - child minding - contraception - pregnancy/abortion - sexual - nurturing & care giving G Gender roles internalized G productive role G sexual role

14 raghavan-gilbert/vw-9913 Adulthood E Gender role entrenched - low economic power - community respect important - low legal power - domestic violence - STD/AIDS - health risks * malnutrition * maternal depletion syndrome * gynaecological morbidity, * cancer cervix and breast risks * high risk abortion and sequelae - uneven access to RH services - Use of FP services G Gender roles entrenched - productive - decision makers - little involvement in contraception - domestic violence - marital infidelity - little household/ care giving roles GENDER PERSPECTIVES IN RH: A LIFE CYCLE MODEL

15 raghavan-gilbert/vw-9914 Near Old (55-64) E Gender roles still entrenched E menopause - osteoporosis - c. v. risks - body image - depression - loneliness - care giving - gynae. cancers - lifestyle diseases - DM. HPT, CVD, cancers G Gender roles still entrenched but weakening G loss of sexual drive G less economic power G loss of health G greater dependence on caregiving of wife/females G risk of infidelity G depression GENDER PERSPECTIVES IN RH: A LIFE CYCLE MODEL

16 raghavan-gilbert/vw-9915 Old Age (65-74) E Widowed or in care giving role - social alienation - poverty - failing health G Weakening or reversal of gender roles - dependence on women for care- due to disability - lifestyle diseases - cancers - mental health GENDER PERSPECTIVES IN RH: A LIFE CYCLE MODEL

17 raghavan-gilbert/vw-9916 Oldest Old (75 years) E Mental health E Economic dependency E Cancers E Physical disability G Reversal of gender roles G Dependence of female care givers G Mental health G Cancers G Physical disability GENDER PERSPECTIVES IN RH: A LIFE CYCLE MODEL

18 raghavan-gilbert/vw-9917 Gender and Reproductive Behaviour u adolescent males experience more sexual freedom than adolescent females u Potentially harmful sexual attitudes and behaviour that can develop during youth are often difficult to change during adulthood.

19 raghavan-gilbert/vw-9918 Gender and Reproductive Behaviour p Traditional male and female gender roles: w deter couples from discussing sexual matters w condone risky sexual behaviour w ultimately contribute to poor reproductive health among both men and women

20 raghavan-gilbert/vw-9919 Gender and Reproductive Behaviour p Programmes can encourage men to adopt positive gender roles and be: Y supportive husbands, and Y caring fathers

21 raghavan-gilbert/vw-9920 Gender and Reproductive Behaviour Health care providers, policy- makers, and donors recognize: v the direct connection between men and womens gender roles v their reproductive health v the effect that inequities in gender roles have on womens well being

22 raghavan-gilbert/vw-9921 Understanding Gender wgender roles and gender norms are culturally specific and thus vary tremendously around the world. w however, men and women differ substantially from each other in power, status and freedom. wmen have more power than women in all societies

23 raghavan-gilbert/vw-9922 Understanding Gender o Power is a broad concept that describes the ability or freedom of individuals to make decisions and behave as they choose a persons access to resources and ability to control them.

24 raghavan-gilbert/vw-9923 Understanding Gender Two types of power help to describe the inequities in male and female gender roles - power to and power over k Power to describes the ability of individuals to control their own lives and to use resources for their own benefit k Power over means that individuals can assert their wishes, even in the face of opposition, and force others to act in ways that they may not want to

25 raghavan-gilbert/vw-9924 Understanding Gender F Calls for changes in gender roles, and hence behaviour, often touch emotional and political nerves F such change is perceived as threatening F is part of the global trend toward equality and justice F studying how gender affects reproductive behaviour is necessary for improving reproductive health for all

26 raghavan-gilbert/vw-9925 Understanding Gender pDifferences in power between men and women are not absolute or universal. Some poor, illiterate, unemployed, or homosexual men have little power and few resources pWomens gender roles do give them some power but is more limited and influenced by: wher culture wage wincome and education

27 raghavan-gilbert/vw-9926 Understanding Gender j Type of marriage j A womans power to make decisions increases with her level of education also with her husbands level of education j younger women who marry older men have less power gender roles are changing toward more equality for younger men and women in some cultures

28 raghavan-gilbert/vw-9927 How Gender Roles Affect Reproductive Behaviour z Gender has a powerful influence on reproductive decision-making and behaviour z men are the primary decision-makers about sexual activity, fertility, and contraceptive use

29 raghavan-gilbert/vw-9928 How Gender Roles Affect Reproductive Behaviour p Men are often called gatekeepers and have many power roles husbands fathers uncles religious leaders doctors policy-makers and local and national leaders

30 raghavan-gilbert/vw-9929 Little is known about how gender roles affect these decisions to: w practice family planning w choose when and how to have sexual relations w engage in extramarital sexual relations w use condoms to prevent STDs w breastfeed w seek prenatal care How Gender Roles Affect Reproductive Behaviour

31 raghavan-gilbert/vw-9930 Gender is just one of many other factors such as: w Education level w family pressures w social expectations w socio-economic status w exposure to mass media w personal experience w expectations for the future w religion p Consequently, no two couples decision-making environments are identical How Gender Roles Affect Reproductive Behaviour

32 raghavan-gilbert/vw-9931 Traditional gender roles can jeopardize the reproductive health of both women and men. wInequities in power make women more vulnerable to mens risky sexual behaviour and irresponsible decisions. wGender roles can be unhealthy for men too Gender Roles Can Harm Reproductive Health

33 raghavan-gilbert/vw-9932 qWomen have difficulty communicating about sex or RH, because of their gender roles qWomen may submit to men because they are afraid of retaliation. qMale gender roles can contribute to men contracting and transmitting STDs Gender Roles Can Harm Reproductive Health

34 raghavan-gilbert/vw-9933 b Male gender roles harm mens health as well as womens. b Mens control over reproductive decision- making may be weakening traditional gender roles are starting to change with social opportunities for women power is being redistributed Gender Roles Can Harm Reproductive Health

35 raghavan-gilbert/vw-9934 D Couple, or spousal, communication can be a crucial step toward increasing mens participation in reproductive health D Communication enables husbands and wives to know each others attitudes toward family planning and contraceptive use D Communication also can encourage shared decision-making and more equitable gender roles Improving Reproductive Health

36 raghavan-gilbert/vw-9935 s Research suggests that a complex web of social and cultural factors impede such discussions s In many societies sex is a taboo subject for men and women to discuss s Afraid of rejection by a sex partner s Womens inferior status and lack of power limit couple communication Obstacles to Couple Communication

37 raghavan-gilbert/vw-9936 n Womens status and communication. n Wide gap in education between the couple n Low Educational level of the couple Obstacles to Couple Communication

38 raghavan-gilbert/vw-9937 i Better-educated women can communicate more easily with their husbands. i Education may also increase a womans earning capacity - and thus her leverage in house-hold decision making. i A woman who has some economic power more likely to discuss family planning with her husband. Obstacles to Couple Communication

39 raghavan-gilbert/vw-9938 k The type of marriage - whether free choice, arranged, or polygymous - also affects the relative power of a woman k The age of a woman at first marriage relates to her ability to communicate Obstacles to Couple Communication

40 raghavan-gilbert/vw-9939 m Being male or being female has a major effect on an individuals health and well- being m Combination of their biological sex, the gendered nature of cultural, economic and social lives put individuals at risk of developing some health problems while protecting them from others Gender and Risk

41 raghavan-gilbert/vw-9940 X The subsequent effect of these health problems on the individuals will also be influenced by their gender roles and their sex X The natural course of a disease may be different in women and men X women and men themselves often respond differently to illness Gender and Risk

42 raghavan-gilbert/vw-9941 k society responds differently to sick males and sick females k women and men: may respond differently to treatment may have different access to health care be treated differently by health providers. Gender and Risk

43 raghavan-gilbert/vw-9942 p Infectious Diseases Differences are a function of the interaction between biological factors and gender roles and relations w Biological factors vary between the sexes and influence susceptibility and immunity to diseases Gender and Risk

44 raghavan-gilbert/vw-9943 w Gender roles and relations influence: the degree of exposure to the relevant vectors w The access and control of the resources needed to protect women and men Gender and Risk

45 raghavan-gilbert/vw-9944 w Differences between female and male prevalence and incidence rates are difficult to measure since cases in women are more likely to be undetected. Gender and Risk

46 raghavan-gilbert/vw-9945 Even when diseases are shared by both sexes, they may have: n different manifestations or natural histories in women and men n differences in the severity of their consequences Gender and Risk

47 raghavan-gilbert/vw-9946 For example, malaria: Z biologically, womens immunity is compromised during pregnancy making them more likely to become infected during this period Z implies differential severity of the consequences during her lifetime Gender and Risk

48 raghavan-gilbert/vw-9947 r Malaria during pregnancy is an important cause of maternal mortality, spontaneous abortion and stillbirths r Particularly during pregnancy, malaria contributes significantly to the development of chronic anemia Biological differences between the sexes can produce different health outcomes among women and men when exposed to the same environmental hazard. Gender and Risk

49 raghavan-gilbert/vw-9948 pHow and where women and men carry out their daily activities will expose women and men to disease differentially: k women in seclusion k womens more extensive clothing k domestic labour k water-related domestic work Gender and Risk

50 raghavan-gilbert/vw-9949 p Tuberculosis (TB) wOfficial figures show that twice as many male cases of TB as female cases wAt young ages, the prevalence of infection in boys and girls is similar, but a higher prevalence has been found in men of older ages Gender and Risk

51 raghavan-gilbert/vw-9950 b propensity to develop disease after infection with Mycobacterium tuberculosis may be greater among women of reproductive age than among men of the same age. Gender and Risk

52 raghavan-gilbert/vw-9951 k Care of dependants may also increase womens risk of contracting particular diseases k Considerable evidence exists that indicate women are hampered in their use of health services by: lack of transport Gender and Risk

53 raghavan-gilbert/vw-9952 p inadequate resources p their husbands refusal to grant permission p reluctance to expose themselves to health care providers p Gender differences in illness behaviour and in societal responses to female and male patients often cause women to come later for care Gender and Risk

54 raghavan-gilbert/vw-9953 pHIV/AIDS and Other Sexually Diseases usexually transmitted diseases (STDs) continue to be a major cause of distress, disability and sometimes death of both sexes uHIV/AIDS in particular, is continuing to spread, killing millions of women and men in the prime of their lives Gender and Risk

55 raghavan-gilbert/vw-9954 Z AIDS is becoming an increasingly female affair Z Heterosexual transmission is now dominant in most parts of the world Of the estimated 5.8 million HIV infections that occurred in 1997, nearly half were in women Women now account 42% of the people living with HIV Gender and Risk

56 raghavan-gilbert/vw-9955 This increase in the number of HIV positive women reflects: z their greater biological vulnerability to the disease z a consequence of the social constructions of female and male sexuality z profound inequalities that characterise many heterosexual relationships Gender and Risk

57 raghavan-gilbert/vw-9956 n Biologically, the risk of HIV infection during unprotected vaginal intercourse is two to four times higher for women than men. women have a bigger surface area of mucosa exposed to their partners sexual secretions during intercourse Semen also contains a higher concentration of HIV than vaginal secretions Gender and Risk

58 raghavan-gilbert/vw-9957 p semen can stay in the vagina for hours after intercourse p co-existing STDs, increase the risk of HIV infection by three to four times (and in some cases five to six times) p women are biologically more vulnerable p 50-80% of STDs in women have no symptoms or have symptoms that cannot easily be recognised p are too ashamed to visit a doctor Gender and Risk

59 raghavan-gilbert/vw-9958 Z This biological vulnerability is too often reinforced by socially constructed constraints on womens ability to protect themselves Z Heterosexual encounters are socially shaped with certain modes of behaviour seen as appropriate for each sex Gender and Risk

60 raghavan-gilbert/vw-9959 w men be the initiators w be perceived powerful w be seen as risk-takers (not afraid) w Many women find the heterosexual relationship a difficult one in which to negotiate a strategy for their own safety. Gender and Risk

61 raghavan-gilbert/vw-9960 In many societies sex continues to be defined primarily in terms of male desire with women perceived as passive recipients _ women may find it difficult to express their own needs _ find it difficult to assert their wish for safer sex _ find it difficult to negotiate for their partners fidelity or no sex Gender and Risk

62 raghavan-gilbert/vw-9961 For many women, their economic and social security is dependent on the support of a male partner mfear of abandonment can be a powerful force mdiscrimination against divorced or separated women and their children Gender and Risk

63 raghavan-gilbert/vw-9962 pno legal right to refuse conjugal sex pthe threat of physical violence or abuse many women will prefer to risk unsafe sex in the face of more immediate threats to the well-being of themselves and their children Gender and Risk

64 raghavan-gilbert/vw-9963 i If a woman does become infected with HIV or with any other STD, gender inequalities may affect the progression of the illness and possibly her survival chances. i The exclusion of women from many research studies on HIV/AIDS has had the additional effect of prolonging the male bias in research. Gender and Risk

65 raghavan-gilbert/vw-9964 q The combination of unequal access to care and the gender gap in medical knowledge contributes to a situation where women in both rich and poor countries have a shorter life expectancy than men after a diagnosis of AIDS Gender and Risk

66 raghavan-gilbert/vw-9965 p Violence and Injuries Intentional and non-intentional injuries are among the major causes of morbidity and mortality for both women and men at all ages and across all societies. men are more likely than women: y to die in car accidents y to suffer death or disability as a result of occupational hazards. Gender and Risk

67 raghavan-gilbert/vw-9966 W Although women have lower rates of unintentional injuries overall, they are more likely than men to suffer injuries at home because of their domestic responsibilities. Intentional injuries: W more common among men W directly connected to masculine behaviour, risk-taking, aggression and the consumption of drugs and alcohol. Gender and Risk

68 raghavan-gilbert/vw-9967 Gender and Risk Health consequences of gender-based violence Non-fatal Outcomes Physical health consequences p STDs p Injury p Unwanted pregnancy p Miscarriage p Chronic pelvic pain

69 raghavan-gilbert/vw-9968 p Headaches p Gynaecological problems p Alcohol/drug abuse p Asthma p Irritable bowel syndrome p Injurious health behaviours (smoking, unprotected sex)

70 raghavan-gilbert/vw-9969 Mental health consequences n Post-traumatic stress disorder n Depression n Anxiety n Sexual dysfunction n Eating disorders n Multiple personality disorder n Obsessive-compulsive disorder

71 raghavan-gilbert/vw-9970 Fatal Outcomes r HIV/AIDS r Suicide r Homicide


73 raghavan-gilbert/vw-9972 p Due to pathological/psychopathological disorder – conjugal paranoia – delusions of sexual spousal infidelity – intermittent explosive disorders (temporal lobe epilepsy, post episode amnesia – borderline personality disorder Issue: Since person is perceived to be sick, he is then absolved from the wrong doing 1. PSYCHOPATHOLOGICAL MODEL

74 raghavan-gilbert/vw-9973 p Using violence as beneficial to the maintenance of family structure The process of socialisation especially of males Men socialised into aggression for problem solving and demonstrating authority Women socialised to submit to male authority Encouraged to develop character traits that complement male headship of the family Sociological perspectives on deviance i.e. abusive individuals are deviants brought about by an unfulfilled childhood, lack of attention, exposure to violence etc.

75 raghavan-gilbert/vw-9974 NESTED FRAMEWORK INTERACTIONIST EXPLANATION A) Personal B) Microsystem C) Exosystem D) Macrosystem

76 raghavan-gilbert/vw-9975 p Interactionist Explanation Personal Individuals developmental experiences shapes his response domestic violence experience physical abuse (especially in women) sexual abuse

77 raghavan-gilbert/vw-9976 PROGRAMME INTERVENTIONS 1. Self Help Groups Self esteem Personal empowerment 2. Programmes for aggressors

78 raghavan-gilbert/vw-9977 p Interactionist Explanation Microsystem interpersonal/family structure male dominance in family male control of wealth marital conflict; power relationships, patterns of communication use of alcohol

79 raghavan-gilbert/vw-9978 Interactionist Explanation Exosystem institutional social structure for dealing with stressful events p unemployment p low socio-economic status p (physical) isolation of woman p delinquent peers p lack of welfare service support

80 raghavan-gilbert/vw-9979 p Strengthen Health System Improvement of information system to identify to assist and to refer on gender-based abuse PROGRAMME INTERVENTIONS

81 raghavan-gilbert/vw-9980 p Interactionist Explanation Macrosystem broad sets of cultural beliefs and values masculinity linked to dominance/honor rigid gender roles male ownership of women approval of physical chastisement of women machismo (cultural ethos that condones violence as a means of settling of disputes)

82 raghavan-gilbert/vw-9981 p Legal Reform (paradox of reporting) – analysis of laws – strengthen legal reform – provide safe alternative Disseminate results include and use mass media

83 raghavan-gilbert/vw CRITICAL PATH APPROACH p Traces path that battered women take in finding a response to a problem of violence against women (VAW) –Violence - Physical, sexual and psychological –Damages self esteem, identity, and development of the woman to gain information about the paths taken to seek care and solutions to learn from women themselves what their perceptions of the response they received as they searched for help to gain insights into the preconceptions and responses of service providers in relation to violence against women to formulate interventions, together with the community actors, that identify the obstacles identified in the study and strengthen a coordinated response

84 raghavan-gilbert/vw THE PATRIARCHY FRAMEWORK p Examines the entire fabric of society –Patriarchy is defined as a set of beliefs and values which lays down the supposedly proper relations between men and women, between women and women, and between men and men –Looks beyond the individual, family and interpersonal relations –Shows how cultural values, social institutions and mechanisms to legitimize and maintain: male power over women male use of power inside and outside the home mens work is of more value, more significance, more pay male violence upon women comes from the exercise of male power male desire to maintain that power

85 raghavan-gilbert/vw-9984 REPRODUCTIVE HEALTH CONSEQUENCES -Implications for Clinical Practice- u There are still large gaps in the education and training of health care providers u The problems of violence can not be fully dealt with in the medical setting u Spousal violence is considered one of the most important causes of injuries among women, more important than car accidents, for instance u Violence may be a more common problem for pregnant women than pre- eclampsia, gestational diabetes and placenta previa, conditions for which pregnant women are routinely screened and evaluated u In order to increase knowledge and skills in the area of violence against women, all RH providers should be offered special training in violence against women u Collaboration should be established between reproductive health services and services outside the hospital/clinic u Models of best practice within the health care system should be developed. Adapted from WHO/FIGO VAW Congress - Schei 1997

86 raghavan-gilbert/vw-9985 REPRODUCTIVE HEALTH AND GENDER- BASED VIOLENCE p The programmatic concerns of UNFPA about gender-based violence and activities undertaken to address these concerns: p Studies focusing on male participation in reproductive health and their subsequent evaluation are needed in order to demonstrate the impact of this approach. p Adolescent reproductive health programmes and parent education programmes are successful and necessary initiatives. p Inclusion of emergency contraception for the management of unwanted pregnancy and the development of psychosocial support services for victims is effective in conflict and refugee situations. p Strategies to eradicate gender inequalities are fundamental to addressing reproductive health problems. p Gender-based violence, is among other things, a means of structuring power relations not only between men and women but also between men. p Guidelines and protocols should be developed to assist physicians and other health staff to address the issue of partner violence. p Specific training in emergent and chronic care for physical and mental aspects of therapy as well as prophylactic care against genital infections and pregnancy is recommended for all Reproductive Health providers. Adapted from: WHO/FIGO Congress - Gardiner 1997

87 raghavan-gilbert/vw-9986 HEALTH CONSEQUENCES OF VIOLENCE AGAINST WOMEN: AN OVERVIEW Z Violence originates from a breakdown of social integration mechanisms, resulting in a weakening of the role of the family in socializing children, increasing relative deprivation and loss of hope for a better life Z Violence is promoted by the marginalisation of significant portions of the population, absence of mechanisms for peaceful resolutions of conflicts, and social indifference about moral bahviour Z Violence is facilitated by: drug and in particular, alcohol abuse; trivialisation of violence by mass media, and the increasing number of individuals possessing firearms in some countries Z A more holistic approach to the understanding of violence is needed in order to design more effective prevention policies and programmes Z In order to prevent violence against women, society at large must be mobilized to redefine many cultural, social, economic and political processes Adapted from: WHO/FIGO Congress - Barzelato 1997

88 raghavan-gilbert/vw-9987 m Male violence against women, particularly in the home, has many damaging consequences for womens and childrens health, including intentional injury m Male violence against women is central to the debate about gender inequalities m All acts of violence are gendered irrespective of whether the victim is female or male. Gender and Risk

89 raghavan-gilbert/vw-9988 w both sexes can be the victims of violence w they are likely to have a different relationship to the perpetrator w the type of harm inflicted varies with perpetrator and the victim Gender and Risk

90 raghavan-gilbert/vw-9989 u When women are the victims of the attack the perpetrator may be motivated: Í to demonstrate his own masculinity Í to enforce his (male) power Í to control the woman Gender and Risk

91 raghavan-gilbert/vw-9990 v in most communities, women appear to be at greatest risk from intimate male partners or other men they know v the violence girls and women experience occurs most frequently in the haven of the family v gender-based violence can lead to physical trauma, psychological distress. This trauma and resulting distress often lasts a lifetime. Gender and Risk

92 raghavan-gilbert/vw-9991 k A recent review of evidence from 40 well designed population-based studies suggested that between 25% and 50% of women around the world report being victims of physical abuse by men at some point in their lives (Heise et al., 1994) k Violence imposed on women has put it high on the agenda of womens health advocates. Gender and Risk

93 raghavan-gilbert/vw-9992 A growing consensus exists that male violence is neither an entirely biological phenomenon nor solely a product of culture. Gender and Risk

94 raghavan-gilbert/vw-9993 Z Differences in the ways in which women and men are treated by the health care system Z The various factors that can lead to inequality between the sexes, both in access to health care and also in outcomes Gender Inequalities in Health Care

95 raghavan-gilbert/vw-9994 Medical research has been a profoundly gendered activity i The topics chosen i the methods used i the subsequent data analysis all reflect a male perspective Gender Inequalities in Health Care

96 raghavan-gilbert/vw-9995 _ Problems that cause considerable distress for women have received little attention if these are not central to womens reproductive roles, e.g. incontinence, dysmenorrhea and osteoporosis _ Failure to reduce the very high mortality rates from breast cancer has also led to accusations that research into the disease is not adequately funded. Gender Inequalities in Health Care

97 raghavan-gilbert/vw-9996 k This neglect has been changing thanks to organised advocacy efforts by womens organisations. k Gender bias is evident not only in the selection of research topics but also in the design of a wide range of studies. k Researchers have ignored possible differences between the sexes in diagnostic indicators, in symptoms, in prognosis and in the relative effectiveness of different treatments. Gender Inequalities in Health Care

98 raghavan-gilbert/vw-9997 J Coronary heart disease (CHD) continues to be seen as a male disease J This is usually justified by the fact that more men than women die prematurely from CHD. However, it is also the single most important cause of death of post- menopausal women Gender Inequalities in Health Care

99 raghavan-gilbert/vw-9998 ] not enough is known about their implications to ensure gender sensitivity either in clinical treatment or in strategies for prevention ] cyclical hormonal changes make the results difficult to interpret ] female subjects may become pregnant and put the resulting foetus at risk during trials Gender Inequalities in Health Care

100 raghavan-gilbert/vw-9999 X women continue to be treated on the basis of information gathered from research in which drugs may not have been tested on female bodies, in which the precise manifestation of the disease in women may not have been studied Gender Inequalities in Health Care

101 raghavan-gilbert/vw m Womens experiences of both illness and treatment may not have been adequately explored They are not in themselves arguments for the exclusion of women Gender Inequalities in Health Care

102 raghavan-gilbert/vw Gender Differences in Access to Health Care wConsiderable evidence of gender differences in access to health care wIn the developed countries a wide range of studies show that most women use medical services more than men. Gender Inequalities in Health Care

103 raghavan-gilbert/vw _women in many developing countries are denied these benefits. _Feminist writers argue that the normal processes of pregnancy and childbearing for instance have been turned into medical events. Gender Inequalities in Health Care

104 raghavan-gilbert/vw k Doctors treat depressed women with a pill rather than identifying underlying causes such as domestic violence or examining their living and working conditions k the most pressing concern is not too much medical attention for those who can afford it but lack of attention for those who are poor Gender Inequalities in Health Care

105 raghavan-gilbert/vw J Severe constraints on public sector spending obviously affect both sexes J in conditions of poverty it is usually women who face the greatest problems in acquiring adequate health care Gender Inequalities in Health Care

106 raghavan-gilbert/vw u less is spent on health care for women and girls in certain regions of the world this reflects both their lower social status and their lack of decision-making power. Gender Inequalities in Health Care

107 raghavan-gilbert/vw F Inequities: Reinforced in settings where customs and values deny women the right to travel alone or to be in the company of men outside their immediate family. F Where female health workers are not available treatment by a man may dishonour a woman and her family Gender Inequalities in Health Care

108 raghavan-gilbert/vw X Low self esteem limits womens ability to make demands X Embarrassment if the problem is one that the community disapproves of. X Lack of education contributes to this lack of self worth. Gender Inequalities in Health Care

109 raghavan-gilbert/vw zTraditionally, womens health services have focused on their reproductive needs, especially contraception and safe childbearing zMillions of young women and those who are post-menopausal have been denied access to any health care during periods of great need in their lives. Gender Inequalities in Health Care

110 raghavan-gilbert/vw q Are the health services women receive comparable to that of men or are there inequalities here too? q There are consistent indications that gender divisions can be a causal factor in limiting the quality of care women receive Gender Inequities in Quality Of Care

111 raghavan-gilbert/vw _ Medical knowledge is usually presented as indisputable giving women little opportunity w to participate actively in decision-making about their own bodies w reflected in failure to communicate information w lack of cultural sensitivity w disrespectful treatment which affects womens willingness to use services Gender Inequities in Quality Of Care

112 raghavan-gilbert/vw p Concern about poor quality services for women focused mostly on the inter- personal relations involved in health care Gender Inequities in Quality Of Care

113 raghavan-gilbert/vw u women and men are sometimes offered different levels of treatment for what appear to be the same clinical conditions Gender Inequalities in Health Care

114 raghavan-gilbert/vw Y Studies in UK and USA show that women are less likely than men to be offered certain diagnostic procedures on treatments for heart disease. Y Women on kidney dialysis are less likely than men of the same age to be offered transplants. Gender Inequities in Quality Of Care

115 raghavan-gilbert/vw n Many ways in which gender influences both health status and health care Conclusions

116 raghavan-gilbert/vw j gender must be placed alongside race and class as a key determinant of health and health care j concrete strategies be identified for addressing the health needs of both women and men particularly the planning of services Conclusions

117 raghavan-gilbert/vw Q Gender blindness leading both individuals and organisations to ignore the realities of gender as a key determinant of social inequality Gender Inequalities in Health Care

118 raghavan-gilbert/vw r The aim of highlighting gender in this way is to move towards a position of equality r all policies must be designed to promote equality between women and men and among women themselves. Gender Inequalities in Health Care

119 raghavan-gilbert/vw v An important distinction has been made between practical needs and strategic interests. v Womens practical needs are usually derived directly from their existing gender roles. These reflect their responsibility for the well-being of their families e.g. easy access to clean water and a regular source of income Conclusions

120 raghavan-gilbert/vw Z Most health or development initiatives are designed to meet practical needs of this kind and are often greatly valued, by the community as a result. Conclusions

121 raghavan-gilbert/vw _ Policies that reflect womens strategic interests go a step further. These policies challenge existing gender roles and stereotypes, transforming womens situation with respect to men in addition to changing their basic conditions Conclusions

122 raghavan-gilbert/vw b A reproductive health service that simply gave women the technical means to control their fertility would meet their practical needs b In order to meet their strategic needs the service would also need to: w enable women to choose between a range of contraceptive methods Conclusions

123 raghavan-gilbert/vw w identify the various strategies needed to promote their own well-being w encourage men to take responsibility Conclusions

124 raghavan-gilbert/vw X If the goal of developing gender-sensitive policies and programmes is to be achieved, this needs to be built explicitly into the original objectives Identifying Gender Concerns in the Policy Environment

125 raghavan-gilbert/vw K This will require a preliminary analysis of the context in which the policy will be operating and a clear understanding of the gender issues involved. Identifying Gender Concerns in the Policy Environment

126 raghavan-gilbert/vw _ Do differences in the division of labour expose women and men to different kinds of health risks? _ How are any differences between women and men in the use of existing services explained? _ Are there apparent differences in the way women and men are treated or in the quality of care they receive? _ Who controls access to health-related resources? _ Do the criteria for allocation take into account the different roles and needs of women and men? Gender Inequalities in Health Care-Research Interests

127 raghavan-gilbert/vw Gender Inequalities Health Sector Reform w In most developing countries where health sector reform is being implemented, issues related to financing, resource allocation and management are of the utmost importance

128 raghavan-gilbert/vw Gender Inequalities in Health Sector Reform O of particular concern has been the implications of cost recovery for the poor O this concern has not been extended to other dimensions of vulnerability such as gender

129 raghavan-gilbert/vw Gender Inequalities in Health Sector Reform Gender is significant for two reasons: j women are found disproportionately among the most vulnerable population groups j access to and utilisation of health services are influenced by cultural and ideological factors

130 raghavan-gilbert/vw Gender Inequalities In Health Sector Reform zThe types of gender issues requiring attention is related to the six main components of health sector reform programmes.

131 raghavan-gilbert/vw Gender Issues in Health Sector Reform ¶ Improving the performance of the civil service (i.e. reducing staff, changing pay, appraisal systems). What would the impact on the gender balance and composition of staffing at different levels be? What effects would human resource policies have on relations between predominantly male health service professions, such as doctors, and those of predominantly females, such as nursing?

132 raghavan-gilbert/vw Gender Issues in Health Sector Reform · Decentralization (i.e. management systems/health care provision devolved to local government) Does decentralization improve access to health care or further marginalize vulnerable groups?

133 raghavan-gilbert/vw Gender Issues in Health Sector Reform ¸ Improving the functioning of national ministries of health (i.e. human and financial performance monitoring, prioritising and defining cost-effective interventions). What effects would human resources policies have as described in no. 1. In setting priorities, what criteria are used to determine health needs and cost-effectiveness?

134 raghavan-gilbert/vw Gender Issues in Health Sector Reform ¹ Broadening health financing options (i.e. introduction of user fees and community financing mechanisms). What are the implications of different modes of payment? Are poor women affected differently than poor men? How does cost recovery affect access to services for both sexes?

135 raghavan-gilbert/vw Gender Issues in Health Sector Reform º Introduced managed competition (i.e. establishing mechanisms for regulation, contracting with, or franchising providers in the private sector). How does managed competition affect equity and access for the most vulnerable?

136 raghavan-gilbert/vw Gender Issues in Health Sector Reform » Working with the private sector (i.e. establishing mechanisms for regulation, contracting, or franchising providers in the private sector). Are vulnerable groups more or less likely to be appropriately served by different parts of the private sector? Are womens health needs more or less likely to be met in a mixed economy of health care?

137 raghavan-gilbert/vw For example, examining the effects of decentralization - it is likely to have an adverse affect for women if steps are not taken to develop measures of equity in resource allocation and systems to measure social vulnerability because wof inter-regional inequalities wwealthier areas would be able to lure good staff wthis is likely to hit women harder

138 raghavan-gilbert/vw Z Reforms are clearly having a major impact on women both as users of services and as health workers Z If gender inequities in health are to be clearly identified, women themselves will need to be involved

139 raghavan-gilbert/vw Planning, Capacity Building, Monitoring and Evaluation w Special care has to be taken to ensure their views are heard. w discussion with the appropriate interest groups w direct consultation with potential users w a diversity of views is represented

140 raghavan-gilbert/vw Planning, Capacity Building, Monitoring and Evaluation n capacity-building programmes must be designed for both female and male workers n need to focus not just on womens issues but on the wider question of gender

141 raghavan-gilbert/vw Planning, Capacity Building, Monitoring and Evaluation W They may include broad-based gender awareness courses W more detailed briefings on gender- related topics not generally included in the medical or nursing curriculum.

142 raghavan-gilbert/vw j All policies and programmes require a clear strategy for monitoring and evaluation j Criteria for achieving this will need to be carefully constructed into and built into the planning process of the specific programme from the earliest stages

143 raghavan-gilbert/vw j Clearly identify the effects of the project or programme on women and men j directly measure how a project or programme is effective for sexes j take the necessary management decisions.

144 raghavan-gilbert/vw Key References: Gender in RH l WHO Technical Paper WHO/FRH/WHD/98/16, Gender and Health l The Battered Woman, Lenore Walker, 1979 Row & Harper NY. l ARROW: 1997 Gender and Womens Health Information Package No. 2 Kuala Lumpur Malaysia

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