Gender & Health GLHLTH 310 October 31, 2013 Melissa Watt, Ph.D. Assistant Professor, Duke Global Health Institute Coordinator, Duke CFAR Social & Behavioral Sciences Core Associate Director, MSc-Global Health

Sex vs. Gender: What matters? Gender disparities in global health Addressing gender in health programming Gender & HIV 2 Outline

SEX vs. GENDER 3

Gender is the social construction of the biological differences between men and women Gender is not “Sex” Gender is not “Women” Gender is learned, socially determined behavior

Roles, status, norms, values Responsibilities, needs, expectations GENDER THE DIVISION OF LABOUR, POWER AND RESPONSIBILITIES THE DISTRIBUTION OF RESOURCES AND REWARDS Sexuality and Sexual behavior

FAMILY RESOURCES ECONOMIC AND SOCIAL RESOURCES POLITICAL RESOURCES INFORMATION & EDUCATION TIME ACCESS TO AND CONTROL OVER: POWER AND DECISION-MAKING Gender, interacting with other variables defines:

Achieving gender equity in health implies eliminating inequalities between women and men which are unnecessary, avoidable and therefore unjust. Gender equity in health

8 Gender Inequality Poor Health POVERTY Caste Ethnicity Disability Sexual orientation

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Gender in international organizations Integrate/mainstream gender considerations in all facets of work Collect and review disaggregated data by sex Initiate work to specifically address gender inequalities Ensure gender equity in hiring

Convention on the Elimination of All Forms of Discrimination against Women (1979) Beijing Platform for Action (1995) UN Security Resolution 1325 on Women, Peace and Security (2000) Millennium Declaration / Millennium Development Goals (2000) UN guiding documents to promote gender equality

UN Millennium Development Goals Agreed by 189 countries in 2000, to be achieved by 2015!

Group work: How is this MDG related to gender and health? What are gender issues that need to be addressed and mainstreamed into this MDG? What are the gender & health issues relevant to the MDG?

GENDER and HIV 14

South Africa: HIV Prevalence by gender & age Data from Avert.org, 2008 Overall 60% of those with HIV are women

Vulnerability of HIV infection is different for men and women Two sets of reasons: – SEX: Biological and physiological reasons – GENDER: Social norms and values: risks that are socially and culturally created Gender and HIV risk

Biological and Physiological Reasons Women’s biology makes HIV transmission more efficient from a man to a woman that a woman to man. Reasons include:  There are higher concentrations of HIV in semen than in vaginal fluids  Coercive or forced sex might lead to micro lesions in the genital tract that facilitate entry of the virus.  Women often have STIs that are left untreated, which increases vulnerability to HIV Gender and HIV risk

Social Reasons: Risks Socially and Culturally Created Keeping women ignorant and passive about sex is the norm in many cultures. This greatly constrains their ability to negotiate  Safe sex  Condom use  Access to appropriate services, care and treatment Women don’t always have the power / ability to negotiate the terms of sex  Early marriages  Economic dependence  Violence / threats Gender and HIV risk

Men are also subject to social and cultural pressures that increase their susceptibility to infection and likelihood of spreading HIV  Multiple partners and sexual infidelity are condoned and often encouraged  Certain occupations tend to encourage risk taking behavior  Spending long periods away from families  Commercial sex behavior can be linked to business and peer social behaviors Vulnerability of men Gender and HIV risk

HIV prevention strategies A bstain B e faithful C ondomize

21 A bstain

22 B e faithful

23 C ondomize

Alternative HIV prevention strategies G ender relations E conomics M igration

G ender relations Individual decision making is not always possible Relationship power facilitates or hinders HIV protection behavior Property rights, literacy/education, assets shape HIV risk Sexual violence

G ender relations Intervention approaches Give women sex negotiation skills Emphasize to women: your own monogamy is not protective Intervene with men/couples: address gender norms Female-initiated methods (e.g., female condoms, microbicides) Recognize tension with desires for children

E conomics Transactional sex (both formal and informal) Economic dependence Sense of hopelessness Substance use/ addiction

E conomics Interventions Schooling for girls Training and employment for women Addiction treatment Cash transfers Money = Bargaining power = Choice

Family instability Opportunities for sexual “mixing” (migrant & partner left behind) M igration

Interventions Economic policies, rural development Multisectoral strategies: sexual and reproductive health, coupled with negotiation skills and economic empowerment Network approaches M igration

31 A bstain B e faithful C ondomize Behavior Change G ender relations E conomics M igration Social Drivers

In summary: In Global Health, GENDER MATTERS. 32