Please note: This archive was last updated in 2005.

RHO archives : Topics : Gender and Sexual Health

Key Issues

This section provides summaries of research issues in sexual health and gender that are relevant to the developing world. Click article references to read abstracts on the Gender and Sexual Health bibliography page.

For additional information (including bibliography items, program example, and links to resources), see RHO's Special Focus: Gender, Human Rights, and Reproductive Health. Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

Gender and women's health

Research in developing countries has identified multiple links between the social status of women and their health throughout the life cycle (Doyal 2000). A strong preference for sons in some parts of the world leads to sex selective abortion, female infanticide, and limited access to health care for girls; the result is higher child mortality for girls than boys (Arnold 1997; Kapur 1995; Khanna et al. 2003; Li et al. 2004; Pandey et al. 2002). (See RHO's Harmful Health Practices section for more information about sex-selective practices.) The low status and social vulnerability of women also contributes to female genital mutilation (FGM), poor nutrition, overwork, stress, higher rates of sickness and maternal mortality, and limited access to health care (Arnold 1997; Avotri and Walters 1999; Barnett 1997; Currie and Weisenberg 2003; Dey 1998; Fikree and Pasha 2004; Finkler 2001; McDonough and Walters 2001; Santow 1995; Zurayk et al. 1997). An estimated 97 million women are “missing” worldwide, due to excess mortality associated with gender discrimination (Klasen and Wink 2002).

Because different standards are applied to men's and women's sexual behavior, women often have little say in their sexual lives and are left vulnerable to unwanted pregnancies and sexually transmitted infections (STIs), including HIV/AIDS (PATH/Outlook 1998; UNFPA 2000). Gender-based stigma associated with STIs and other reproductive tract infections may even discourage women from seeking treatment (Go et al. 2002). Increasingly, public health experts recognize that women's low status is accelerating the AIDS epidemic and that the fight against HIV/AIDS requires attention to be paid to underlying gender issues (du Guerny et al. 1993; Whelan/UNAIDS 1999). (See RHO’s HIV/AIDS section for more information.) Gender can affect the spread and course of nonsexual infectious illnesses such as malaria and exposure to environmental hazards (WHO 1998).

There is a statistical association between some measures of women's status and female life expectancy and maternal mortality (Shen and Williamson 1999; Williamson et al. 1997). However, other data suggest that women's economic position is equally or more important for their health than their social status (Defo 1997; Zaidi 1996). Increasingly, analysts are viewing women's myriad health disadvantages as human rights violations that demand a broad legal and social response (Ashford 2001; HRP 1999; Murphy and Ringheim 2001). Distinguishing between sex and gender and investigating the impact each one has on health is becoming a priority for medical research (Doyal 2004; Institute of Medicine 2001; Krieger 2003).

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Violence against women

Violence of all kinds has become a global public health priority (Krug et al. 2002). Despite the fact that gender-based violence is routinely underreported, studies around the world consistently find high levels of domestic abuse and rape (Coker et al. 1998; Kishor and Johnson 2004; Klevens 2001; Nasir and Hyder 2002; Watts and Zimmerman 2002), which frequently continue into pregnancy (Castro et al. 2003; Guo et al. 2004; Peedicayil et al. 2004; Sahin and Sahin 2003). In some areas, gender-based violence also manifests itself in high rates of female suicide and homicide (Ahmed et al. 2004; Jutla and Heimbach 2004). Reports on the incidence of gender-based violence will become more complete as researchers learn how to encourage the disclosure of violence by assuring womens safety, minimizing distress, and offering referrals (Ellsberg et al. 2001; Ellsberg and Heise 2002).

Violence has serious health effects on women and children. These include physical injuries, chronic gynecological and central nervous system problems, psychological distress and stress-related symptoms, unwanted pregnancies, miscarriages, low birth-weight infants, STIs, and HIV/AIDS, all of which burden the health care system (Asling-Monemi et al. 2003; Campbell 2002; Coker et al. 2002; Dunkle et al. 2004; Fischbach et al. 1997; Heise 1993; Heise et al. 1994; Jejeebhoy 1998; Valladares et al. 2002). Even psychological violence leads to physical health problems (Coker et al. 2000). Sexual coercion also contributes to the spread of HIV/AIDS and other sexually transmitted infections among women (Maman et al. 2000; Martin et al. 1999), including cervical cancer (Coker et al. 2000).

Ethnographic research shows that violence against women may be difficult to combat because it is so deeply rooted in some cultures (Anderson et al. 2000; Go et al. 2003; Hindin 2003; Kulwicki 2002; Olavarrieta et al. 1996). Risk factors associated with violence include social norms concerning violence and gender roles; socio-demographic characteristics such as limited education and higher parity; and individual behavior and history, such as alcohol use and exposure to violence as a child (Hindin and Adair 2002; Jewkes et al. 2002; Koenig et al. 2004; Koenig et al. 2003; Martin et al. 2002). Broader economic changes that increase male unemployment and alter gender roles also may affect levels of violence (Narayan et al. 2000).

Initiatives against gender-based violence take many forms, including police and judicial reforms, legislative initiatives, community mobilization to encourage behavior change, and the reorientation of health services (Epstein 1998; IGWG 2002; Spindel et al. 2000; Stewart 1996). The most effective approach is integrated and multi-level: in the short term it provides services for victims and punishes perpetrators, while in the long term it addresses the social and economic determinants of violence (Gordon and Crehan 2000; UNICEF 2000). Prevention strategies also need to focus on empowering women and raising their status, combating norms of violence, and reducing poverty and alcohol consumption (Jewkes 2002). Thus, PAHO's integrated strategy to address gender-based violence, which was developed and tested in Central Amercia, operates at four different levels: the community, the clinic, the health sector, and the macro or political level (Velzeboer et al. 2003).

Reproductive health and family planning providers are in a unique position to identify and offer help to the victims of violence during routine health care visits (Asher et al. 2001; IGWG 2002; Moore 1999; IPPF 2000; PATH 2002; Taket et al. 2003). While many experts support regular screening for domestic violence, critics point out that: providers may be too overstretched to take on another task (Garcia-Moreno 2002); good evidence for the benefits of screening and other interventions is lacking (Ramsay et al. 2002; Wathen and MacMillan 2003); and screening may have negative as well as positive consequences (Chang 2003). Lack of support from health care providers may encourage women to endure abuse rather than change their situation (Ellsberg et al. 2000; Ellsberg et al. 2001). Even assuming providers are sympathetic to the victims of violence, without training they may not know how to respond and may even exacerbate a woman's situation (PAHO 1999; Peltzer et al. 2003). Training is critical to give providers the technical skills they need to identify, treat, and refer victims of violence; to overcome the biases they share with the larger society and help them confront their own experiences of violence; and to ensure that they do not inadvertently put battered women at risk of further violence (Heise 1996; Heise et al. 1999; Hesperian Foundation 1998; Kim and Motsei 2002).

Yet one-time training has not proven sufficient to ensure consistent screening of women for violence (Davidson et al. 2001). Ongoing and comprehensive interventions are needed to ensure that the work environment enables providers to apply their training and that providers identify and treat abused women appropriately (Jacobs and Jewkes 2002; McCaw et al. 2001). Providers need guidelines, screening tools, and continuing reinforcement as well as the knowledge that help is available for women who disclose violence (Coker et al. 2000; DAvolio et al. 2001; Guedes et al. 2002; Kimberg 2001; SAT 2001; Waalens, et al. 2000). Having a domestic violence coordinator at the clinic who can support and monitor providers efforts is also helpful (Zacharay et al,. 2002). Family planning and reproductive health clinics must be prepared to meet the special reproductive health needs of victims of violence, including access to emergency contraception and abortion services, psychological counseling, the documentation of abuse, and safe shelter for women and their children (Blaney 1998; Hyman 1996). In some regions, access to HIV prophylaxis after rape also is essential (Kim et al. 2003). New research exploring domestic violence from the woman's point of view is designed to help managers design appropriate and acceptable services (Jacobs and Suleman 1999; Shrader and Sagot 2000), keeping available resources in mind (UNFPA 2001). For insights into providing services to the victims of violence, see the program examples from Mexico, South Africa, Venezuela, and Zimbabwe.

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Trafficking in humans for forced labor

Trafficking is a highly profitable criminal business that uses force, coercion, deception, and fraud to transport people and place them in situations including forced prostitution, domestic servitude, and sweatshop labor (IHRLG 2002). It does not include people who voluntarily migrate for work and may pay smugglers to help them cross borders illegally. While the clandestine nature of trafficking makes it difficult to measure, one recent estimate concluded that 800,000 to 900,000 men, women, and children are currently being trafficked across international borders each year (U.S. Department of State 2003). Traffickers operate in every region of the world, and trafficking takes place within countries as well as across borders (Orhant 2001).

Women’s limited economic options and low status makes them especially vulnerable to trafficking. Traffickers frequently recruit women and girls with false promises of good jobs or marriages overseas. Economic pressures also may lead parents to place their children in the hands of traffickers, often under the false impression that their children will have a better life or will return once their debt is paid off. Once women and girls have arrived at their destination, traffickers may control them by imprisoning them, putting them in debt bondage, using violence, confiscating their passports, or threatening them with arrest and deportation (Orhant 2001; Pisklakova and Sinelnikov 2002). Trafficked women may find it hard to seek help if they do not speak the local language, and they may fear authorities if they lack documentation. They also may worry that their families and communities will not welcome them home because of the common misconception that trafficking is the same as prostitution.

Trafficking creates a host of health problems for women, who may endure arduous journeys to another country, high levels of violence, the trauma of realizing that they are virtually enslaved, the rigors of forced labor, and sexual exploitation (Gushalak and MacPherson 2000; Phinney 2002). The consequences include: physical injuries; mental health problems, such as depression, post-traumatic stress disorder, and substance abuse; reproductive health problems, such as STIs, HIV, unsafe abortions, complications of pregnancy, chronic pelvic pain, and other gynecological disorders; and occupational health problems, such as eye strain and back injuries (Raymond et al. 2002; Zimmerman et al. 2003). Yet trafficked women generally do not get health care because their employers prevent them or they lack the money and local knowledge to seek care or they fear being discovered and deported.

Combating trafficking requires a joint effort by legislative, judicial, law enforcement, and migration authorities along with social service organizations, working across international borders (Hynes and Raymond 2002). Health care programs and providers in countries of origin and countries of destination can contribute to the effort by:

  • Warning women about the threat of trafficking, offering them information on how to migrate safely, and educating them on safer sex.
  • Identifying women who have been trafficked, treating their health problems, and offering them help.
  • Providing long-term counseling and care to trafficked women who have returned to their home countries.
  • Referring trafficked persons for other kinds of assistance, such as shelter, food, legal services, and jobs (Budapest Declaration 2003; Orhant 2002).

These kinds of activities require specialized training for health workers, new service standards and protocols, strong outreach efforts, including public awareness campaigns, and shelters and rehabilitation centers. Anti-trafficking programs also must respect women’s rights by carefully distinguishing between trafficking and voluntary choices made by women to migrate or to engage in sex work (Costello Daly et al. 2001; Huntington 2002). If the programs fail to do so, they may exacerbate women’s health problems and reduce their access to services (Busza et al. 2004).

Child sexual abuse

Child sexual abuse frequently goes unreported and unacknowledged, making it difficult to measure its prevalence. Studies show, however, that it is widespread throughout the world, with girls 1.5 to 3 times more likely to be abused than boys. Prevalence rates around the world range from 7 to 36 percent for women and from 3 to 28 percent for men (Finklehor 1994; Heise et al. 1999). Although rates of sexual abuse rise after age 10 or 11, children may be sexually abused at very young ages. Most perpetrators are men and are known to their victims. They frequently are family members, friends, or older men in positions of authority, such as teachers (Jewkes et al. 2002; Leach 2003; Tang 2002). Many use threats or coercion to get children to cooperate and to keep silent; others offer children money or other rewards (Meursing et al. 1997). In recent years, the AIDS epidemic has contributed to the problem of child sexual abuse both by creating large numbers of orphaned girls who are especially vulnerable to exploitation, and by encouraging men to target young, HIV-negative girls for sex (Human Rights Watch 2002). Gender inequality between partners may create violent households, in which children as well as women are abused (Handwerker 1993).

Child sexual abuse can affect the physical and mental health of victims in both the short and long term, although not all victims report permanent harm. Consequences include physical injuries, STIs and HIV/AIDS, pregnancy, sexual dysfunction, depression, low self-esteem, and other psychological and social problems, including continuing vulnerability to abuse as adults (Cheasty et al. 1998; Mullen et al. 1994; Paolucci et al. 2001). Child sexual abuse also is associated with risk-taking behaviors later in life, such as unprotected sex, multiple sexual partners, and alcohol and substance abuse (Boyer and Fine 1992; Fergusson et al. 1997). Harmful consequences are reported more frequently by women than men (Rind and Tromovitsh 1997) and are more likely to occur when the abuse is severe, that is, when it involves force, penetration, incest, or repeated incidents (Kendall-Tackett et al. 1993).

The challenge for health care providers is recognizing the signs and symptoms of child sexual abuse so that they can offer appropriate medical and psychological services to victims, whether they are recently abused children or adults victimized long ago (Argent et al. 1995). In developing countries, health care providers may lack the time, training, and resources to address the problem adequately (de Villiers and Prentice 1996; Larsen et al. 1998). Community-based interventions also are important to raise awareness of child sexual abuse and advocate for legal sanctions, to teach children to recognize threatening situations and protect themselves, and to prompt children and their families to disclose abuse and request help (Krug et al. 2002; Shanler et al. 1998).

For additional information, see RHO's Adolescent Reproductive Health key issue on sexual violence and youth.

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Sex workers

Researchers have documented a high prevalence of STIs among sex workers in developing countries (Duncan et al. 1994; Lurie et al. 1995; Oshige et al. 2000) and have targeted HIV-prevention programs toward them (Van Vliet et al. 2001). Recent research suggests that sex workers also may serve as a reservoir for human papillomavirus (HPV) and thus contribute to cervical cancer rates throughout the population (Thomas et al. 2001). (Also see RHO's Cervical Cancer Prevention section.) However, sex workers' health needs go beyond the prevention and treatment of HIV/AIDS and other STIs. The work itself leads to other health problems, such as repetitive stress injuries and bladder infections, while its illegal status leaves sex workers vulnerable to violence and exploitation and creates unique psychological stresses (Alexander 1998; Farley et al. 1998; Nielson 1999; Romans et al. 2001). Sex workers also need access to family planning services (Delvaux et al. 2003).

Despite their special health needs, sex workers in many countries do not receive adequate treatment because of poverty and stigmatization (Evans et al. 1997). Although the conditions of the sex trade vary from one country to another, women in developing countries typically take up sex work for economic reasons: they have no other means to support themselves and their families (Wawer et al. 1996). Because of these economic pressures—together with a sense of powerlessness, fear of violence, and obedience to brothel managers—sex workers may have little control over sexual transactions, including the use of condoms (Campbell 2000; Carovano 1991; Cornish 2004; Pauw and Brener 2003). Sex workers who have been trafficked are in the worst situation, with no control over work conditions or over access to health care (Cwikel et al. 2003). (See the discussion of trafficking for more information.) High consumption of alcohol and drugs also may impair sex workers' ability to negotiate condom use; low self-esteem and poor expectations means they are not motivated to protect themselves from infection; and social attitudes preclude the use of condoms with boyfriends (Ford and Koetsawang 1999; Mgone et al. 2002; Varga 1997). In fact, given their difficult circumstances and the premium men are willing to pay for sex without condoms, sex workers may be making rational decisions when they choose not to use condoms or to get tested for HIV (Rao et al. 2003; Wojcicki and Malala 2001).

To overcome these and other barriers, health care programs for sex workers must understand the social and human dimensions of sex work; treat sex workers as people deserving respect rather than as the vectors of disease; look at sex workers' general well-being rather than focusing purely on STIs; and change their work environment (Basuki et al. 2002; Bhave et al. 1995; Jenkins 2000; Joesef et al. 2000; Morisky et al. 2002; Visrutaratna et al. 1995; Wolffers et al. 1999; Wolffers and van Beelen 2003; WHO 2000). Condom negotiation skills and environmental support for condom use may be key (Kerrigan et al. 2003; Wong et al. 2003). Successful interventions also involve sex workers in planning and implementation to ensure that activities meet their perceived needs, respect their decision to engage in sex work, and focus on a subset of sex workers who share the same working conditions (Ditmore 2002; Loff et al. 2003; Overs 2002). Involving sex workers has an added political benefit: it may prompt them to organize and fight for their fundamental human rights (Jayasree 2004) (see RHO’s Special Focus on Human Rights, Gender, and Reproductive Health). The deprivation, violence, and chaos that characterize many sex workers existence, however, along with their mobility, pose a challenge to interventions (Campbell and Mzaidume 2001; Ford et al. 2002; Ghys et al. 2001). Programs also may find it difficult to reach women who do not identify themselves as sex workers but routinely sell sex to supplement their regular work (Nagot et al. 2002). Two handbooks offer practical advice on designing and implementing health programs for sex workers (Europap/Tampep 1999; Overs and Longo 1997), and detailed clinical guidelines on STI programs for sex workers also are available (WHO Western Pacific 2002). To understand some of the challenges facing health programs for sex workers, see the program examples from Brazil, Ghana, and India.  

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Mental health

The Global Burden of Disease study revealed that mental health disorders have a far greater impact on public health in both developing and developed countries than previously imagined (Ustun 1999). They are also a substantial economic burden (Chisholm et al. 2000). The incidence and symptoms of mental illness vary with culture, sex, and class (Kleinman et al. 1997). Epidemiological studies in developed countries have documented higher prevalence rates of depression, anxiety, and other mental disorders among women (Dennerstein 1993). Limited evidence from developing countries confirms these patterns (Abiodun 1993; Mumford et al. 2000; Nandi et al. 2000; Pearson 1995). While it is possible that biological differences or differences in expressing distress and seeking treatment account for these sex differentials, evidence suggests that gender and social status play a key role (Astbury 1999; Del Vecchio Good 1998; Gomez and Meacham 2001; Paykel 1991; Pearson 1995); WHO 2000). For example, in India the preference for male children contributes to postnatal depression among mothers who bear girls (Patel et al. 2002); in Syria, polygamy and physical abuse are linked to womens mental distress (Maziak et al. 2002).

So far efforts to build national, community-based mental health programs in developing countries have largely failed, in part for lack of support by the government, medical professionals, and even local communities (Jacob 2001). WHOs atlas of mental health resources documents substantial shortfalls in policy making, legislation, community-level services, and government investment (Thornicraft and Maingay 2002; Project Atlas.) Practical, action-oriented research is needed to identify policies and programs that will provide access to treatments for the most common mental disorders (Abas et al. 2003; Patel 2001). One problem, for example, is that primary health care providers often lack the skills and support needed to offer mental health care (Petersen 2000). They need training and simple screening tools to diagnose and treat mental health problems and handle psychiatric emergencies (Afana et al. 2002; Reichenheim 1991; Weintraub et al. 1996). In the United States, a self-administered screening questionnaire has had good results (Spitzer et al. 2000), and trained nurses and social workers in Chile have successfully implemented a low-cost group approach to treating depression in poor women (Araya et al. 2003).

Health policy changes, judicial reforms, community support systems, and improvements in women's status also are important for improving women's mental health (Gomel 1997), as is sensitivity to gender issues in selecting the most appropriate medication for patients with mental illness (Kornstein and McEnery 2000). In settings where cultural attitudes discourage women from viewing mental distress as a medical problem requiring outside assistance, educating women and communities about mental health issues becomes essential (Aidoo and Harpham 2001; Sherbourne et al. 2001).

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Sexuality

Sexuality plays a central, but often overlooked, role in family planning and reproductive health. Research is beginning to show how people's understanding, attitudes, and behavior regarding sex and sexual relationships affect their health status and decision making (Dixon-Mueller 1993; Population Council 2001; Robinson et al. 2002; FHI 2002; Zeidenstein and Moore 1996). The number and type of clients' sexual partnerships, their sexual practices and sexual drives, and the cultural meanings of sexual attitudes and behaviors affect their vulnerability to sexually transmitted infections, including HIV/AIDS, and determine which contraceptive methods are acceptable (PATH/Outlook 1999). Indeed, sexuality—in all of its many forms and patterns—may provide a conceptual framework that is as important as gender in understanding the spread of HIV/AIDS (Dowsett 2003). At the same time, definitions of sexual health continue to evolve, with a new emphasis on sexual rights (Edwards et al. 2004).

Providers' attitudes toward sexuality also have an impact on women's health. For example, Brazilian providers' reluctance to discuss sexuality and fidelity with married women who have STIs leaves them vulnerable to re-infection by their husbands (Giffin and Lowndes 1999). Similarly, virginity exams by physicians in Islamic countries reinforce cultural controls on female sexuality (Frank et al. 1999).

Integrating sexuality and gender issues into family planning and reproductive health counseling creates many challenges (Becker et al. 1997; Moore and Helzner 1997). For example, health workers must learn how to openly discuss sex and other sensitive issues (FHI 2002; Bernhard 2002), how to take a sexual history (Andrews 2000; Presswell and Barton 2000), how to manage the sexual problems that reproductive health clients find so debilitating (Philips 2000; Ramage 1998), and how to promote sexual pleasure (Resnick 2002). In developing countries where sexuality has been integrated into family planning services, women have been willing and eager to discuss sexual issues (Abdel-Tawab 2000; also see the program example from Latin America), perhaps because so many women have sexual concerns, such as lack of desire and pain during intercourse (Nusbaum et al. 2000). Sensitively designed group discussions also can help women talk about sex and improve their sexual lives (Hesperian Foundation 2001). For a general review of sexual health issues, see Outlook, Volume 16, Number 4 (www.path.org/outlook/ html/16_4.htm#feat).

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Gender-sensitive services

Gender-sensitive services view women's health from a social as well as a biomedical perspective and respect the right of female clients to self-determination (Gijsbers van Wijk et al. 1996). Integrating gender throughout health care systems, however, requires fundamental changes, ranging from basic research and budget allocations to training and management hierarchies (Vlassoff and Garcia Moreno 2002). To make sure that gender issues are considered throughout the design, implementation, and evaluation process, health programs have been developing gender analysis and gender training tools (Baume et al. 2000; Baume et al. 2001; FHI and CIDEM 2001; HRP 1999; IPPF 2000; Doyal 1998; Newman 2003; WHO 2001.) (Also see the section below on gender analysis). Family planning managers should gather information on the realities of women's lives and their reproductive health needs, solicit women's perspectives on the services offered, and make changes accordingly (Barnett 1998; Bruce 1992). Management Sciences for Health (2001) has produced a useful how-to guide for managers on gender mainstreaming. The Interagency Gender Working Group has compiled suggested indicators to measure a program’s success in overcoming gender-based obstacles to desired health outcomes (Yinger et al. 2002).

Some reproductive health programs have become gender-conscious: they have enlarged the range of services beyond maternal and child health, fostered women's decision making, and begun to view women within the broader context of the couple and the community (Paulson 1998). Changes are also needed at the policy level. Health policies should ensure that medical research reflects women's interests and that providers respect female clients (Doyal 1998). Some also believe that, as a matter of policy, reproductive health managers should use their increased understanding of gender issues to undermine traditional gender relations and inequities rather than accommodate to them (Schuler 1998). A variety of interventions have tried to shift the balance of power in sexual relationships so that women are better able to acquire information, make decisions, and take action (Blanc 2001; Population Council and IGWG 2003).

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Gender analysis

Gender analysis is a research tool that helps policy makers and program managers appreciate the importance of gender issues in the design, implementation, and evaluation of their projects. A thorough gender analysis first examines differences in the status, social roles, and conditions of women and men in a given society, and then assesses how actual or proposed policies and programs will affect these disparities (Morris 1997; Status of Women Canada 1996; Women's Health Bureau 2003). Gender analysis can enhance a project's effectiveness and efficiency by identifying and solving problems rooted in gender inequities. It also can ensure that a project promotes gender equality.

A typical gender analysis gathers data from as many sources as possible, including quantitative data disaggregated by sex. Additional qualitative research may be conducted to help explain available data. Experts in fields as diverse as agriculture, transport, and sanitation have developed frameworks to guide the collection, organization, and analysis of information for gender analyses (ILO 2000; Miller and Razavi 1998; Vainio-Mattila 1999; FAO; World Bank). In recent years, specialized gender analysis tools have been developed for use in health care (ADB 2000; De Koning et al. 2000; PAHO 1997; Pfannenschmidt et al. 1997). These health frameworks review gender norms and look at differences in men's and women's activities, their access and control over resources, and their health profiles.

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