KEYSTONE / Module 2 / Slideshow 1 / Gender, Equity, and Social Justice in Health

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Inaugural KEYSTONE Course on Health Policy and Systems Research 2015

Gender, Equity and Social Justice in Health

GENDER, EQUITY AND SOCIAL JUSTICE IN HEALTH

Aditi IyerGender and Health Equity Project

Indian Institute of Management Bangalore

LEARNING OBJECTIVES

• To unpack what ‘gender’, ‘equity’ and ‘social justice’ mean and how they relate to each other

• To understand why and how these terms matter for HPSR

Gender - a major source of injustice

GENDER = SEX?

Sex?

Gender?

GENDER = SEX?Sex = Biology

Chromosome-linked anatomical & physiological differences derived from sex karyotypes 46, XX female, 46, XY male.

Some individuals (intersex) have other karyotypes with added or missing sex chromosomes: 47,XYY; 47,XXY; 47,XXX; 45,X.

Inherited sex chromosomes cannot change, but other aspects of biology (sex hormones, reproductive organs, secondary characteristics) can change through puberty, menopause

through (1) individual actions and (2) environmental factors (Sen, Ostlin, George 2007)

GENDER = SEX?

Sex = Biology

Gender?

GENDER = SEX?

Sex = Biology

Gender = socially defined relationships of power between men and women

GENDER SYSTEMS• Structural inequalities marked by unequal access for

women and men to material and nonmaterial resources and their control over these. [e.g., income, assets, sources of credit; voice & say in decision making, time, etc.]

• Unequal access and control form the basis for defining and distinguishing male and female behaviours, expectations, roles and relations between and among women and men. [e.g., divisions of labour, mobility, notions of masculinity & femininity, etc.]

• Unequal power relations are socially legitimised through cultural norms & values and internalised by individuals through socialisation

(Sen, George, Ostlin 2002)

GENDER SYSTEMS• Gender also refers to a complex array of structures,

practices, and behaviours that define social institutions other than the family: communities, economies and states.

• Gender systems change over time and place.

• Social movements for sexual rights, in particular the lesbian/gay/bisexual/transgender (LGBT) movement, have challenged feminist movements to be more inclusive and to recognise sexual and gender orientation as an important source of discrimination, bias, violence and challenge to health.

WHAT ABOUT BOYS AND MEN?

• Gender inequality is also harmful to boys and men, despite the many tangible benefits it gives them through resources, power, authority and control.

• These benefits to men do not come without a cost to their own emotional and psychological health, often translated into risky and unhealthy behaviours, and reduced longevity (Sen, Ostlin, George 2007).

WHY DOES GENDER MATTER?

• Allows us to understand how inequality / bias is reproduced

• Allows us to see how social institutions, norms & values justify, define and maintain unequal power relations.

• Gender with other axes of power determines (1) who is valued for what; (2) who decides; (3) who does what; (4) who has what.

• Determines whether people’s needs are acknowledged, whether they have voice or a modicum of control over their lives and health, and whether they can realize their rights (Sen, Ostlin, George 2007)

GENDER AS INTERSECTIONAL• Gender interacts with other axes of power - economic class,

religion, caste, ethnicity, age, life stage. Gender modifies the experience of economic class, caste, etc. and vice versa. [e.g., “poverty of poor men”]

• One’s position on each axis brings a unique set of advantages and disadvantages. Those in the middle of a social spectrum (e.g., non-poor women, poor men) are able to leverage the advantages that emanate from one axis to overcome the disadvantages inherent in another axis (Sen and Iyer, 2012).

• This intersectionality mostly shapes the constellation of social factors that build around the biological determinants of health. [e.g., “weathering” (Geronimus 1992, 1996), “rationing” (Sen, Iyer, George 2007)].

SEX OR GENDER: WHY BOTHER?

• Some health outcomes occur mainly due to sex (i.e., biology)-linked vulnerability [e.g., Higher prevalence of short stature and gonadal dysgenesis among women with Turner’s syndrome compared with unaffected women (Krieger 2003); risk of haemophilia, vulnerability to testicular & prostrate cancers, respiratory-related causes of death in newborns (Snow 2010).

• Some health outcomes stem mainly from the gender system: from gendered divisions of labour, gendered leisure activities & ways of coping with stress, responsibility for caring, of low value. [e.g., Greater risk of death by drowning or road accidents among men, greater risk of death by burning or ebola among women (Snow 2010); higher prevalence of HIV/AIDS due to needle-stick injury among female healthcare workers (Krieger 2003)]

• Some health outcomes occur due to a combination of sex and gendered causes. [E.g., Heightened female risk for blindness due to untreated cataract (Snow 2010), earlier age of HIV infection among women compared with heterosexual men in the US (Krieger 2003)]

• Separating inequalities that are socially determined from those which stem mainly from biology is essential if equity-oriented strategies are to work.

Role of gender as a social determinant of health: A framework

Gendered Structural Determinants

Structural Processes ↔ Social/Gender Stratification

Discriminatory values, norms, practices and

behaviours (A)

Differential exposures and vulnerabilities to diseases, disabilities and injuries (B)

Biases in health systems (C)

Biases in health research (D)

HealthOutcomes

Social and Economic Consequences

Structural causes

Intermediaryfactors

Consequences

From Sen, Ostlin and George’s (2007) Report of the Women and Gender Equity Knowledge Network to the WHO Commission on the Social Determinants of Health

EQUALITY VERSUS EQUITY• Equality refers to sameness. • Equity is concerned with fairness; with the removal of bias

and the injustice and inequality that results from it.• While equality is considered the basis for gender justice or

equity in spheres such as education, this position does not extend to gender justice or equity in health because of the confounding influence of biology.

• Equality of health outcomes can in fact be a marker for gender injustice because it may indicate that women’s particular biology-linked needs are not adequately recognised (Sen, George, Ostlin 2002)

GENDER EQUITY IN HEALTH• Sen, George, Ostlin (2002) outline 2 principles of gender equity in

health: (1) “Where genuine biological difference clearly interacts with social determinants to define different needs and experiences for women and men in health, gender equity may require qualitatively different treatment that is sensitive to these needs” (e.g. maternal health services); (2) “Where no plausible biological reason exists for different health outcomes …… recognition that (these) differences are maintained by social discrimination requires that health equity measures focus on policies that encourage equal outcomes. This may require different treatment to overcome historical discrimination”.

• Differences in health needs between women and men (due to biological and historical differences) does not naturally lead to or justify different or unequal social status or rights in just societies.

LEARNING OBJECTIVES

• To unpack what ‘gender’, ‘equity’ and ‘social justice’ mean and how they relate to each other

• To understand why and how these terms matter for HPSR

WHY DOES GENDER EQUITY & JUSTICE MATTER FOR HEALTH

SYSTEMS?• Health systems must respond equitably to health needs if they are to be just

• Health systems can serve as social agents that reflect and reproduce gender bias among healthcare workers and in their interactions with patients and communities

• A consideration for gender equity in HPSR would provide a lens to (1) understand how (and why) health systems enshrine inequity and (2) identify ways in which health systems can become more equitable and just.

WHERE DOES GENDER BIAS CREEP INTO HEALTH

SYSTEMS?• Norms, values and clinical practices imparted via formal and informal learning in medical/nursing school

• Gendered divisions of labour within healthcare organisations• Routine care: The gendered politics of recognition & acknowledgement of

health needs, routine practices that can be harmful and abusive, provider-patient relationships that can make patients lose trust and opt out of services, consideration for gender in medical advice given to women suffering from NCDs

• Provider-induced demand for non-essential healthcare services in market driven health systems

• Accountability of health workers and organisations to sexual & reproductive health services

• Gender analysis in the planning and provision of health care

TYPOLOGIES OF HEALTH SYSTEMS

• Gender blind: one that ignores gender [e.g. ?]• Gender exploitative: one that consolidates gender

bias or male monopoly in decision making [e.g. ?]• Gender accommodative: one that facilitates

women’s access services/allows them to do their roles or duties without altering or questioning the inequality underlying them [e.g. ?]

• Gender transformative: one that challenges gender norms and inequalities [e.g. ?]

EQUITY IN HPSR• Ask the right questions• Examples of questions that build on concepts at the core of

the gender system: the gender division of labour (“who does what?”); access to and control over resources (“who has what?”); how social norms define affirm or stigmatise gender identities (“who is valued for what”); how authority is distributed between women and men (“who decides?”).

• Grapple with power and inequality while designing studies: definitions and choice of variables; study design; sampling strategies; choice of respondents (voices of disempowered persons); power in the research process

REFERENCESGeronimus, A. T. (1992), “The weathering hypothesis and the health of African-American women and infants: evidence and speculations”. Ethnicity and Disease, 2 (3), 207-21.

Geronimus, A. T. (1996), “Black/white differences in the relationship of maternal age to birthweight: a population-based test of the weathering hypothesis”, Social Science and Medicine, 42 (4): 589-97.

Iyer, A., G. Sen and A. George (2007), “The dynamics of gender and class in access to health care: evidence from rural Karnataka, India”, International Journal of Health Services, 37 (3): 537–554.

Krieger, N. (2003), “Genders, sexes, and health: what are the connections—and why does it matter?”, International Journal of Epidemiology, 32: 652–657.

Sen, G. and A. Iyer (2012), “Who gains, who loses and how: Leveraging gender and class intersections to secure health entitlements”, Social Science and Medicine 72: 1802-1811.

Sen, G., A. George and P. Ostlin (Eds.) (2002), Engendering International Health: The Challenge of Equity, Cambridge: The MIT Press.

Sen, G., P. Ostlin and A. George (2007), “Gender inequity in health: Why it exists and how we can change it”,Final report of the Women and Gender Equity Knowledge Network to the WHO Commission on the Social Determinants of Health.

Snow, R. (2010), “The social body: Gender and the burden of disease” in G. Sen and P. Ostlin (Eds.), Gender equity in health: The shifting frontiers of evidence and action, New York: Routledge, 47-69.

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