Please note: This archive was last updated in 2005.

RHO archives : Topics : Gender and Sexual Health

Overview/Lessons Learned

Introduction

Sex and gender both shape women's health needs. Sex or biological differences between women and men, such as childbearing, breast cancer, and menopause, create unique health issues for women. They also lead to male-female differentials in depression, cardiovascular disease, and other health problems. Gender or sociocultural differences between women and men place other burdens on women's health. The roles, rights, responsibilities, and status assigned to women by society leave women vulnerable to unwanted and unprotected sexual intercourse, poor nutrition, and physical and mental abuse; they also limit women's access to health care.

The importance of sex and gender in women's health was emphasized at two United Nations conferences: the 1994 International Conference on Population and Development in Cairo (www.unfpa.org/icpd/icpd.htm) and the 1995 World Conference on Women in Beijing (www.un.org/womenwatch/daw/beijing/platform). These conferences broadened the definition of health to encompass women's physical, emotional, and social well-being and placed health in the larger context of women's social, political, and economic life. They encouraged reproductive health programs in developing countries to take a more holistic approach to women's health by:

  • Examining the gender issues that underlie health problems.
  • Addressing women's health needs throughout the life span.
  • Viewing sexuality as a positive part of a woman's life.

Five years later, the ICPD+5 process documented only limited progress toward these objectives (www.unfpa.org/icpd5/meetings/hague_forum/reports/back_paper.htm). Lack of consensus on gender concepts and strategies, limited data, and inadequate funding have hampered efforts to integrate a gender perspective into health and development efforts. Despite efforts to broaden services and become sensitive to the social context in which women live, reproductive health programs and policies often pay inadequate attention to the social, economic, political, psychological, and sexual dimensions of women's health and well-being.

However, governments renewed their commitment to the Beijing platform at the UN's Women 2000 Conference (www.un.org/womenwatch/confer/beijing5) and also recognized the emergence of new issues in the five years since the Beijing conference. These include the way gender shapes the transmission and impact of serious diseases, such as HIV/AIDS, malaria, and tuberculosis, and the extension of the concept of gender-based violence to include marital rape, honor killings, and racially motivated violence.

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Health consequences of gender

Gender has important consequences for women's health: an estimated 94 million girls and women are “missing” worldwide because discriminatory treatment ultimately increases mortality (Klasen and Wink 2002). The negative impact of gender begins at or even before birth when a preference for sons may put baby girls at risk of infanticide—or with new ultrasound technology, at risk of sex-selective abortion. In some societies, girls receive less and worse food than boys, a disparity which continues throughout their lives. As they reach adolescence, girls may be subjected to female genital mutilation and suffer its adverse health consequences (see RHO's Harmful Health Practices and Adolescent Reproductive Health sections). Throughout childhood and adolescence, girls also are more likely than boys to be sexually abused by family members, friends, teachers, or other male authority figures. Severe abuse may leave girls with long-lasting psychological problems and predispose them to risky sexual behavior later in life. Adolescent girls also may be pressured into having sex at an early age by arranged marriages, by older men offering gifts, and by adolescent boys trying to fulfill masculine roles.

After marriage, women's low status continues to limit their ability to control their own lives, including their fertility and their access to health care. In communities where having a large family is a woman's only way to improve her social status and where being childless is grounds for divorce or abandonment, women may feel pressured to have many, closely spaced children despite the toll it takes on their health. Gender roles give men primary authority over sex and reproductive health decisions. Double standards on sexuality deny women the ability to refuse sex or negotiate condom use, and at the same time encourage men to have multiple sexual partners. As a result, women cannot protect themselves against unwanted pregnancies, STIs, and their adverse health consequences (see RHO Reproductive Tract Infections).

Gender disparities in health care exacerbate women's problems. The allocation of a family's resources, including access to health care, depends as much on family members' status as on their needs. In some parts of the world, families are slow to recognize when girls and women have health problems, delay seeking treatment for them, and spend less on their medicines. Health care systems also suffer from gender biases: providers may treat female patients with disrespect; physicians view women's bodies and the reproductive process as potential medical problems; researchers exclude female subjects from clinical studies and focus on male complaints; and women are excluded from health policy-making and planning.

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Violence against women

Cultural definitions of manhood and masculinity contribute to another common health problem for women: violence. Gender-based violence includes physical, mental, sexual, verbal, and psychological abuse. Most violence against women is carried out by their husbands or partners, although organized violence against women as a weapon of warfare is of growing concern (see RHO's Refugee Reproductive Health section). Domestic abuse is routine and socially accepted in many parts of the world: studies in more than three dozen countries have found that from one-tenth to more than one-half of women have been beaten by a male partner. "Honor killings" take the lives of hundreds of women in Islamic countries each year, as family members murder girls and women believed to have shamed their families by real or imaginary sexual misconduct. The World Bank has estimated that, among women of reproductive age, domestic violence and rape account for 5-16 percent of healthy years of life lost to death and disability (DALYs ), depending on the region.

Trafficking is another form of violence that disproportionately affects women. Criminal organizations use coercion, fraud, and deception to transport hundreds of thousands of adults and children each year and force them into domestic servitude, prostitution, sweatshop labor, and other work. Trafficked women may endure ill treatment, sexual exploitation, or occupational hazards that threaten their health. For many, however, it is difficult to access health care because their movements are controlled by their employers, they do not speak the local language, or they fear arrest and deportation.

Violence against women has serious health repercussions that extend far beyond immediate physical injuries. Coerced sex—whether the result of domestic abuse, rape, or trafficking—leads to unwanted pregnancies, STIs (including HIV/AIDS), and gynecological problems. According to UNAIDS Director Dr. Peter Piot, gender-based violence, together with gender biases in health care systems, are accelerating the spread of the AIDS epidemic worldwide and putting young girls at the highest risk of contracting the disease. In addition, being beaten during pregnancy is associated with miscarriage, still birth, and low birth weight babies. Abuse at an early age is associated with risky behaviors later in life, including substance abuse, smoking, and sexual risk-taking. Violence also leads to mental health problems, such as depression, anxiety, post-traumatic stress disorder, and suicide.

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Sex workers

In developing countries, poor and uneducated women have few ways to support themselves, and economic need drives some women to become sex workers. The nature of their work puts sex workers at exceptionally high risk of a host of sexually transmitted infections, including syphilis, gonorrhea, chlamydia, and HIV/AIDS and their aftereffects (see RHO Reproductive Tract Infections). At the same time, their illegal status puts them at risk of violence and subjects them to high levels of stress. Most sex workers have children, who also are at risk. Low, uncertain incomes and the social stigma of their occupation frequently limit sex workers' access to adequate health care. Even when care is available, sex workers may not feel motivated to protect their health because of low self-esteem and poor prospects for the future.

The HIV/AIDS epidemic has focused the attention of the public health world on sex workers, who are frequently blamed for spreading the disease. Yet sex workers, even more than most women, have little control over their lives, including their commercial sexual transactions. Sex workers often fear male violence and must obey the dictates of brothel managers; they are in no position to negotiate safe sexual practices with their clients, nor can they negotiate condom use with their boyfriends. HIV interventions that focus on sex workers, while ignoring their clients, boyfriends, and brothel managers, are doomed to failure.

One element in the heated debate over legalizing and regulating prostitution is whether it would reduce STI transmission and increase access to health care by sex workers. Senegal, for example, requires monthly STI tests for legally registered sex workers followed by counseling and treatment if they test positive; their registration cards are revoked if they contract HIV/AIDS. The province of New South Wales, Australia, has adopted a broad array of occupational health and safety regulations for sex work since brothels were legalized in 1995.

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Health needs through the life cycle

As girls enter puberty, they face bewildering physical changes and social pressures to become sexually active. In order to make healthy decisions, all adolescents—boys and girls alike—need information about human sexuality and access to reproductive health services. Girls also must learn how to refuse unwanted sexual relations and negotiate condom use in order to protect themselves against pregnancy and STIs. (For more information, see RHO Adolescent Reproductive Health.)

As women reach childbearing age and marry, their health needs revolve around their fertility. Conventional reproductive health services help women plan when and how many children to have (see RHO Family Planning Program Issues and RHO Contraceptive Methods), minimize the risks of maternal mortality and morbidity (see RHO Safe Motherhood), prevent and treat STIs (see RHO Reproductive Tract Infections), and help infertile women conceive (see RHO Infertility). Health services for women in many developing countries have focused on family planning and safe motherhood, but women of childbearing age have other pressing reproductive health problems. Untreated, chronic gynecological problems, such as infections and uterine prolapse, affect so many women that the associated pain and other symptoms are accepted as a normal part of women's lot in life (see RHO Older Women). Fistulas, which result from obstructed labor and cause total loss of urinary or fecal control, can turn young women into social outcasts if they are not repaired.

Women also become vulnerable to mental health problems during their childbearing and child-rearing years, since most serious mental disorders begin during adolescence or early adulthood and then become chronic or recurrent problems. According to the World Health Organization (www.who.int/inf-pr-1999/en/pr99-67.html) , the burden of mental illness has been greatly underestimated: mental and neurological problems account for 11 percent of the world's disease burden and 28 percent of all years of life lived with disability. Mental illness also accounts for at least 14 percent of acute care visits in developing countries. Women are twice as likely as men to suffer from depression, which is the leading cause of disease burden for women in developing regions. Women also are at greater risk of anxiety disorders. Although biological differences may contribute to their excess risk, it seems to be women's disadvantaged social and economic position that largely accounts for sexual differentials in mental health. Social and economic factors—including violence, poverty, urbanization, and the disruption of cultural practices and traditional family roles—also contribute to the rising incidence of mental illness in developing countries.

In developing countries, where there are few mental health professionals, depression, anxiety, and other mental health disorders go largely unidentified, even as sufferers request treatment for related physical symptoms. To increase treatment rates, WHO (www.who.int/inf-pr-1999/en/pr99-67.html) announced a series of global strategies for mental health in 1999. These include raising the profile of mental health on national and international political and social agendas, fighting the social stigma associated with mental disorders, shifting the emphasis in treatment to community-based services, and broadening the use of affordable and effective psychoactive drugs. Community-based services require training primary health care workers to use simple screening tools and treatment protocols to identify common mental illnesses and then to offer appropriate referrals or treatment.

As life spans increase in developing countries, more and more women are experiencing the health challenges associated with aging. When women reach menopause (generally between the ages of 45 and 55), they may need help managing its symptoms. After menopause, women face a variety of new health risks, such as breast cancer, cardiovascular disease, and osteoporosis, that may curtail their everyday activities and shorten their lives. (For more information, see RHO's Older Women section.)

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Sexuality

Sexuality underlies every aspect of reproductive health and family planning, although it is rarely addressed by service providers. Sexual drives influence clients' behavior and their decisions. For example, legitimate concerns that oral contraceptives reduce libido or that condoms interfere with sexual pleasure may discourage couples from choosing those methods. Likewise, clients may find it difficult to follow recommendations on preventing STIs and HIV/AIDS that require changes in sexual practices. Social norms, including gender roles, dictate sexual behavior to a large extent and usually leave women in a passive role.

Health care organizations need to help clients understand the links between sexuality, gender roles, and health so that they can take appropriate action. Despite concerns that such matters are too private to discuss, women in many developing countries have proven willing and eager to talk about their sexual experiences and sexual problems when given a safe and sympathetic environment. Women need basic knowledge about human sexuality and their bodies; they need help with problems such as pain during intercourse, lack of libido, and premature ejaculation; and they need support and advice on how to discuss sexual issues with their partners.

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Gender-sensitive reproductive health services

Reproductive health programs cannot isolate their services from the larger social and cultural context, because gender roles influence sexual behavior and women's health. Gender-sensitive services recognize that:

  • Social practices, such as domestic abuse and FGM, harm clients' health.
  • Many women have little control over their sexual lives and contraceptive choices.
  • Women have a right to a satisfying, as well as a safe, sex life.
  • Women's health needs extend beyond fertility issues.

To address these concerns, gender-sensitive family planning and reproductive health programs have broadened their understanding of needed services to ensure access to:

  • Information about sexuality (including the effect of contraceptive methods on sexual satisfaction), and counseling on personal sexual problems (see the program example from Latin America and the Caribbean).
  • Advice on how women can negotiate sexual matters with their partners and gain greater control over their sexual lives.
  • Sexual education and youth-friendly health services for adolescents (see the Sexwise program example and RHO's Adolescent Reproductive Health section).
  • Screening for common mental illnesses, such as depression and anxiety, followed by appropriate treatment or referrals.
  • Services (or appropriate referrals) for victims of violence and trafficking, including medical treatment, legal advice, sanctuary, and psychological counseling (see the program examples from Venezuela and Zimbabwe).
  • · community-based programs that promote social as well as individual behavior change by addressing gender issues, including sexual double standards, folk beliefs about sex and reproduction, and gender violence (see the program examples from Peru and Stepping Stones).
  • Activities that involve men in reproductive health issues and programs as clients, partners, and gatekeepers (see RHO's Men and Reproductive Health section).

Equally important for gender-sensitive services is changing provider attitudes. Providers typically operate under the false assumption that female clients have freedom of action when, in reality, they have little control over sexual encounters and contraceptive decisions. Providers also share the values and gender biases of the larger society so that, for example, they may accept wife beating, require the husband's consent for a family planning method, stigmatize trafficked women, or feel extremely uncomfortable discussing sexual functioning. In some cases, providers share the experiences of their clients (see the program example from South Africa). When, for example, providers have participated in domestic violence themselves (whether as victim or perpetrator), they may find it difficult to treat clients suffering from violence professionally.

Training can make providers more sensitive to gender issues and sexual concerns. Together with new clinical protocols and job aids, training also can give providers the knowledge and skills they need to offer more extensive services and to address clients' sexuality in a nonjudgmental way. Providers who are sensitive to gender and sexuality issues:

  • Consistently treat female clients with respect.
  • Collect information about a client's sexual partners, practices, and problems to help determine their health and family planning needs.
  • Help clients assess their STI risks.
  • Determine how much control clients have over their sexual lives and, when appropriate, suggest a contraceptive method that can be used without their partner's knowledge, offer to talk to the client's partner, or teach the client how to negotiate sexual matters.
  • Query clients about their situation, including the possibility of domestic violence and trafficking.
  • Look for signs of STIs, evidence of physical and sexual abuse, and damage from FGM during physical exams.

Managers also must learn to identify and solve gender biases that frequently permeate the delivery of reproductive health and family planning services. Common biases include the assumption that all clients are women, staff discomfort in serving clients of the opposite sex, and gender inequities in the professional relationships between staff members. Increasingly program planners and managers are using gender-analysis tools to assess gender inequities, determine how they affect women's health status and the delivery of health care, and modify health services accordingly.