Gender Matters WHO’s Gender Policy and the importance of gender in health interventions and research

WHO’s Gender Policy “...WHO will, as a matter of policy and good public health practice, integrate gender considerations in all facets of its work.” “…integration of gender considerations, that is gender mainstreaming, must become standard practice in all policies and programmes.” “…all programmes will be expected to collect disaggregated data by sex, review and reflect on the gender aspects of their respective areas of work, and initiate work to develop content- specific materials.”

Definition of Terms “Sex” refers to the biological and physiological characteristics of male and female animals: genitalia, reproductive organs, chromosomal complement, hormonal environment, etc. “Gender” refers to the socially constructed roles, rights, responsibilities, possibilities, and limitations that, in a given society, are assigned to men and women -- in other words, to what is considered “masculine” and “feminine” in a given time and place

Blindness Source: Abou-Gareeb, I., et al., “Gender and blindness: a meta-analysis of population-based prevalence surveys”, Ophthalmic Epidemiology 8(1), 2001,

Approximate # of blind people -- developed countries, China, India, and Africa (millions)

Approximate # of blind people -- developed countries, China, India, and Africa -- by sex (millions)

Higher prevalence of blindness among women: Why? Greater lifespans of women  greater burden of degenerative blindness. But more women are blind at all ages. Must be another explanation. Differential mortality among blind men/women? No.

Higher prevalence of blindness among women: Why? Women suffer from more trachoma than men, due to their gender-specific childcare activities -- but, again, the difference is too small to account for the overall difference in incidence. Most likely explanation? Differential use of eye-care services due to differences in gender roles and behaviors.

Change in blindness prevalence (%) with improvements in eye care - Guangdong, China

So.... One of the quickest ways to reduce overall levels of blindness, and thus move toward Vision 2020 goals, may be to increase women’s access to and utilization of eye- care services -- through projects that address the gender realities of the intervention area.

Lung Cancer Source: WHO/IARC, “CancerMondial: Worldwide Cancer Mortality Statistics”, last update: June 2002

Age-Standardized Mortality Rate (25-85+), Lung Cancer, Germany

Trend in Age-Standardized Mortality Rate (25-85+), Lung Cancer, Germany

Gender helps explain the differing trends Men seem to have begun hearing health-based warnings about cigarette smoking. For women, though, smoking appears to have a gender significance -- that is to say, it is a marker of having arrived in the male world of power, action, strength control, importance, as well as, for many women, a way to “stay thin” -- that is, to maintain traditional feminine attractiveness. This gender significance works against health-based warnings about smoking Tobacco companies exploit this significance, promoting women’s association of cigarettes with glamour and power.

Different Questions for Different Interventions: For men: What has worked to bring smoking and lung cancer down? How can this trend be continued and amplified? For women: How can the power of smoking, as a gendered marker of arrival in the world of power and prestige and a convenient way of staying “feminine” looking, be countered, so that women can make sensible decisions about smoking and health?

HIV/AIDS Source: UNAIDS, Report on the Global HIV/AIDS Epidemic 2002, Geneva, 2002

Approximate # of adults living with HIV/AIDS, worldwide -- by sex (millions)

Similar prevalence -- but varying strategies, because, for example: Prevention: Men can use a condom w/o a partner’s cooperation -- women can’t. Women often are not free to refuse sex; men usually are. Testing: Women often risk physical abuse and abandonment if they report a positive HIV test -- men generally don’t. Treatment: Women, not men, must take PMTCT drugs -- but often men, not women, have financial and other forms of control over whether women are able to take them.

Violence Source: WHO, World Report on Violence and Health, Geneva, 2002.

Death Rates Per 100,000 Population for Various Forms of Violence

But.... Women: >“One of the most common forms of violence against women is that performed by a husband or male partner.” Men: >“... are much more likely to be attacked by a stranger or an acquaintance than by someone within their close circle of relationships.”

% of Total Murders Committed by Opposite-Sex Intimate Partners - Various Studies

So -- To reduce the male murder rate, a focus on “public” murders -- murders by acquaintances, murders by strangers, murders taking place in connection with other crimes -- will be most important. To reduce the female murder rate, a focus on murders by intimate partners could have a major impact.

But that’s not all Murder is not like other diseases, in that it has a human perpetrator. Much as any other disease prevention effort must focus both on the infected person and on the agent of infection, attempts to reduce murder rates must focus on murderers as well as murdered people. How does a gender focus inform attempts to address the perpetrators of murder?

WHO’s Answer -- ???? Crime statistics reveal that most violent crime is committed by males Yet WHO’s recently released World report on violence and health does not highlight sex or gender as a possible risk factor for committing violence Gender distribution,violent crime arrests, USA, 2000 Source: Crime in the United States 2000; Federal Bureau of Investigation; Washington, DC; 2001

WHO’s Answer -- ???? Looking at the numbers, isn’t it at least plausible that differential socialization, or possibly even differences in biology, tend to make males more prone to use violence than females? Given this, wouldn’t at least some discussion of this possibility be in order when discussing risk factors for violent behavior? Evidently, the utility of gender-aware thinking still needs reinforcement -- even at WHO!

To Wrap Up: We have looked at: –A condition with many origins that significantly disables a large number of people (blindness) –A major, non-infectious, chronic killer (lung cancer) –A major infectious disease (HIV/AIDS) –A major health problem with mostly social roots (violence)

To Wrap Up: We have seen: –A condition which disproportionately affects women, even though there would be no a priori reason to expect that it would (blindness) –A disease which disproportionately affects men, but for which men and women exhibit very different trends over time - and which may, by implication, require different interventions for the two sexes (lung cancer) –A disease which affects men and women about the same amount, in the aggregate, but which has very different implications for each (HIV/AIDS) –A problem which affects men and women at different rates and in different ways, but which is also perpetrated by one sex more than the other.

The message? Looking at health with a gender perspective teaches us about factors that give rise to and sustain disease and disability -- factors that we might not notice without a gender perspective. Knowing about these factors helps us to better fight disease and disability. In WHO’s work -- Gender matters.