Indian Journal of Community Medicine

Introduction

India has made considerable progress in the social and economic spheres during the last century. Life expectancy, infant mortality, and litreracy rates have improved. However, progress in the area of sexual and reproductive health has been slow. HIV epidemic is steadily spreading from high risk to low risk population, maternal mortality rate continues to be high and sex ratio is declining in many states. Traditional ideologies of masculinity/femininity often push men and women ot unsafe sexual behaviors. A .culture of silence. about women's health problems still prevails which often restricts women's access to health care.

Men and women have dissimilar rates of different diseases, and seek medical care differently and in differing amounts, is well known. Do gender differentials in health indicators call for attention? Are these differentials determined by sexual differences only or are there other variables that mediate these differences? Can health professionals help in reducing these gaps? These are some of the questions that often perplex health professionals. Understanding of gender is a prerequisite to recognize the basis of existing gaps in health and health seeking behavior of men and women so that health service providers can effectively address gender inequality in health.

What is gender?

Girls and boys are born unaware of the manners and ways, i.e., how they should look, dress, speak, behave, think or react. Their manners are constructed into masculine and feminine or gendered as men and women, through the process of socialization (Fig.), i.e., informal education, which makes them acceptable in the society and prepares them for their gender roles. Gender role refers to a determined pattern of behavior in terms of rights, duties, obligations and responsibilities assigned to women and men in a given society, Gender roles differ from one society to another, from one place to other and also over different periods of time.

Fig. 1:

Gender role expectations stem from the idea that certain qualities, behavior characteristics, and needs are .natural. for men, while certain other qualities are .natural. for women and therefore men have a natural right to enjoy different status than women. As man is usually the head of the household, the breadwinner and the decision maker; and since most men are playing these roles it is considered .natural. that the lineage of the family is after the name of the man. The institutions of marriage, family and religion play an important role in making gender roles seem .natural. though gender is not natural or biological. People are born female or male but learn to be girls and boys who grow into women and men. They are taught what are the appropriate behavior, attitudes, roles, and activities for them and how they should relate to each other. This learned behavior makes up gender identity and determines gender roles whereas sexual characteristics that differentiate male and female anatomically and physiologically are determined in the womb at the moment of conceptin. Sex refers to differentiation while gender establishes a hierarchy between men & women.

In general, the institutionalization of men's power over women within the economy, the polity, the houshold, and the heterosexual relations makes women powerless and convinces them about their own inferiority to men. By demanding certain sterotyped '.appropriate' roles and behavior (women is to adjust with the man for the harmony in the home); by denying control even over their own bodies and labor; by limiting access to resources; and by restricting the opportunities to participate in decsions which affect their lives, women have been systematically pushed into subordination.

The discourses of masculinity also perform a function in naturalization of men's power. The masculine/feminine quality rests on and supports a whole set of dual associations that contrast the powerful male with the powerless female: hard/ soft, active/passive, productive/reproductive, warrior/nurturer. Such associations ease men's and restrain women's access to and control over political, economic and cultural power. These different forms of control often result in perpetuation of the subordination of women. women's subordination is reflected both in women's condition (like their lower level of health, income and education), as well as in their decision making power, and control over resources).

Is Gender a determinant of Health?

In Indian society, health status of men and women differs greatly. It is reflected in the higher mortality rate in women throughout the lifecycle as is represented by their adverse sex ratio.These gaps in the health status are thought to arise due to the disparities in the education and income of men and women, which is not true. The gross domestic product in Vietnam, Mangolia and Tazakhistan is lower than India but they have higher life expectancy of women (Table I). Similarly, maternal mortality rate is lower in the countries having more poverty than India, e.g.Vietnam has the real GDP per capita of US$ 1,860 and maternal mortality rate of 160 as compared to India having real GDP per capita of US$ 2,248 and maternal mortality rate of 407. Even within India, state comparisons show higher maternal mortality rates in some states despite the higher education level of women (Table II). Relatively richer states of Panjab and Haryana have low sex ratio of 847 and 861 for every 1,000 men. On the other hand Orissa the poorest state has 972 women for every 1,000 men.This suggests that poverty, poor female literacy and participation of women in workforce are not the only determinants of poor health and nutritional status of women but there are more complex issues such as gender that need to be considered while analyzing determinants of health inequality. Masculine/feminine attributes and attitudes imposed by the social structure need to be examined as determinants for the existing gender gaps in health and nutirtion. Both women and men are sufferer of such attitudes.

Table I: Female life expectancy at birth and real GDP per capita in select countries.

Table II: Female literacy rate, Per capita state domestic product and MMR in selected states of India

HIV epidemic has uncovered the connections between health and gender inequality. Of the estimated 30 million people infected with HIV, about 17 million are men. Cultural constructionist accounts of masculinity often identify 'risk taking' as a key element of masculine performances. For example, a recent report from UNAIDS challenges harmful concepts of masculinity and contends that changing many commonly held attitudes and behaviors including the way adult men look at risk and sexuality and how boys are socialized to become men, must be part of the effort to curb the AIDS epidemic. Broadly speaking, men are expected to be physically strong, emotionally robust, daring, and virile. Some of these expectations translate into attitudes and behaviors that endanger the health and wellbeing of men and their sexual partners. HIV prevention work has therefore addressed HIV risk-taking behavior as a facet or demonstration of masculine identity. Deconstructing the need for this demonstration and highlighting of masculine identity. Deconstructing the need for this demonstration and highlighting the pressures on men to 'perform' their masculinity through risk-taking have created a space for men to be more conscious of the reason for and consequences of their own sexual behavior.

Focusing on risk as the mediating term between masculinity and poor public health, however, threatens to decontextualize gender from the issues of sexuality and power relations more generally. Pleasure and desire are less often identified as mediating terms, and yet the power and privilege of men in their relations with women often translate into a sense of entitlement to express their desire and seek pleasure in their heterosexual relations with other women. Arguably, it is men's assertion of their entitlement to pleasure, and the demonstration of power that underpins this assertion that helps to explain the effects of masculinity on sexual health of men and women. Thus gender must be considered as a determinant of health just like caste, class, ethnicity etc. Gender inequality not only explains causes of ill-health but also the health care seeking behavior of men and women in a given society.

Gender awareness and gender sensitization

Women's health and nutritional status has consequences not only for the women themselves but also for the well being of their children (particularly girls), and the functioning of households. Similarly the unsafe sexual practices of men resulting from masculinity values not only affect their life but also the life of their wives and even the life of their children. Therefore, health professionals must use gender anlysis tools to understand effects of gender on health so as to take appropriate actions to bridge the gender gaps.

Gender analysis is the systematic examination of the roles, relations, and the processes that focus on the imbalance of power, wealth, workload opportunities and constraints as experienced by women and men in a given community. Gender analysis looks at the activities and the roles of men and women, i.e., who does what (gender division of labour), who has what (access to and control over resources), who needs what etcetra. It identifies the existing gender gaps or disparties and reveals whether programs are widening or narrowing these gaps, i.e., how health programs and policies have different impact on women and men?

Gender gaps/disparity is a measure of gender inequality in any socio-economic indicator, e.g. employment, education, health, ownership of property, income. Gender gaps result from the inequality in decision-making leading on to unequal access to resources for women and girls as compared to the men and boys. Systematic gender discrimination exists where it is part of the social system and runs through all aspects of life at family, community and institutional level.

Being aware of gender is different from being gender sensitive. Gender awareness means knowing about the gender roles of women and men and understanding that these roles are assigned by the society through the socialization process and are responsible for the unequal power relations among them. Whereas gender sensitization means a process that not only makes one aware of gender but also engages him/ her actively in bridging existing gender gaps within a specific community or institution. The power relations between men and women, the division of labour, the needs and wants, the constrainst and opportunities must be considered while working on any of the development issues including health.

'Think of gender like putting on new glasses,' says Barbara Barnet. "You see the same reality, but your focus on it differently. Be sensitive that men and women have different needs and you can make a difference in responding to their needs.... by improving dialogue between men and women, by improving negotiating skills. There is not a quick recipe to add gender. The main thing is to be sensitive that not only biology impacts on health, there are social issues as well."

Efforts to incorporate gender perspective into health require focus not only on women but also on men. Gender equality is possible by changing lives of men as well as women.There is a growing recognition to examine questions of men's responsibility for women's disadvantage, as well as men's role in redressing gender inequalities. It is widely accepted that gender inequality is not a result of women's lack of integration in development, or their lack of skills, or lack of resources but root cause of the problem lies in the social structures, institutions, values and beliefs, which create and perpetuate women's subordination.

Involving men in the work on gender equality must look beyond programs targeted at men's behavior. There is a need to initiate dialogue between women and men about the structures of inequality that determine the distribution of morbidity and mortality, and the role that the politics of masculinity plays in maintaining such structures. Gender should be considered not only a women issue but as a human development and rights issue.

Gender mainstreaming

Gender mainstreaming means taking gender out of its enclave of women's work. and embedding it in a sustainable human development and human rights agenda supported by both men and women. Many organizations have some gender- specific policies in place, ranging from resource allocation to policies against sexual harassment, to hiring practices and maternal and paternal leave etc. However, less apparent structure that perpetuate discrimination such as institutional cultures should also be targeted for change. Initiatives such as gender mainstreaming capacity building programs and men's discussions group can create space for consciousness raising and self-reflection that ultimately leads to stronger, more effective and equitable organizations.

Beyond institutional policies, the discussions around gender equality and discourses of masculinity can be brought in local, regional and national policy debates. Such perspectives can deepen the understanding of the social content and outcomes of policies and highlight the need to coordinate different levels of policy. For example, surveys measuring the social and economic costs of domestic violence may influence integrated policy frameworks at the local level (among communities, schools, law enforcement agencies, and health care providers) as well as national level social, economic and labour policies.

The family, educational system and religious institutions play key role in gender socialization, and these can also act as agents of transformation. In the family, increased involvement of fathers can have powerful effects on both boys. and girls. socialization. In schools, attention to empowering girls and efforts to pay attention to the ways in which male socialization stears girls away from intellectual pursuits are vital steps. In religious institutions, spiritual leaders can act as role models who value compassion and community building over more constraining gender roles.

Understanding different forms of inequality in society such as class, ethnicity and race may help build bridges between men and women who are affected by similar disempowerment due to class, ethnic and racial discrimination. Although gender cannot by a fundamental vehicle for determining power relations in society, gender inequality works in conjuction with other power structures such as those based upon differences in ethnicity, class and race..How gender is relevant for men? It becomes clear that gender equlity is part of a broader social justice agenda for ending all sorts of inequalities that will benefit most men materially and all men psychologically/spiritually. Reflections on class, ethnicity and race, for example, also can be helpful in the context of the advancement of women by raising question such as 'which women are we talking about, rich or poor?'

Concerted actions are needed to close the large health gap between women and men. A long-standing problem requires long-term sustainable corrective actions. To address the constraints faced by men and women, opportunities need to be created not only for studying the effects of gender on health but also for finding ways of mainstreaming gender in health programs of India.

Further reading

1. Menon Sen K and Shiva Kumar. Women in India-How Free? How Equal? Report Commissioned by the Office of the United Nations Resident Coordinator in India, 2001.
2. United Naitons Population Fund, India. Briefing Kit- Population and Reproductive Health, Facts on India, July 2000.
3. Foreman M. AIDS and Men: Taking Risks or Taking Responsibility, London: Zed Books, 1999.
4. UNDP. Building Capacity for Gender Mainstreaming: UNDP.s Experience, New York: UNDP, 1998.
5. UNDP, Guidance Note on Gender Mainstreaming. 1997.
6. Greig A, Kimmel M and Lang J. Women, masculirities and development? Broadening our work towards gender equlity. UNDP/GIDP MONOGRAPH #10 May 2000.

Manmeet Kaur
Consultant (Health Economics & Process Change),
Sector Investment Programme,
Deptt. of Health Haryana, Panchkula.