Report of the WHO Regions for Health Network workshop on gender health, women’s health, men’s health strategy
Lugano, April 17-18, 2018
Gender-specific medicine is an important aspect of the broader and more complex subject of “gender health”, which also considers the social and environmental dynamics associated with it, and which provided a focus for the Who workshop held on 17 and 18 April 2018 in Lugano. The meeting, which was titled “Gender health, women’s health, men’s health strategy”, was organised by the Regions For Health Network, a WHO body responsible for staging initiatives that promote the development of regional health policy.
The main aim of the meeting was to develop skills and competences regarding the gender-specific approach to health; it also provided a valuable occasion for sector professionals to discuss the WHO’s main European initiatives regarding gender and health through experiences, contributions and subnational examples of the implementation of current women’s health strategies and the development of a men’s health strategy.
The main speaker, Isabel Yordi Aguirre, supervisor of the Gender and Health programme organised by the WHO European Regional Office, immediately clarified that there is still a certain amount of confusion, as well as a certain degree of resistance, regarding the concept of gender, which is often incorrectly considered simply a synonym of sex.
The gender concept and gender mainstreaming
Whereas there are no doubts that sex is determined by the biological and functional characteristics of each individual, it is not yet universally clear that gender, on the other hand, represents a cultural construction, or better, the representation and encouragement of behaviours that “cover” the biological make-up and give rise to a status of man/woman.
One substantial difference between the two concepts lies in the fact that whereas sex is difficult to modify, gender, being a product of human culture, can be modified and varies depending on the context. And like other factors, with which it interacts – such as education, employment, income and geographical area – it is an important determinant of health, for both women and men. The prevalence of certain conditions, such as obesity and lack of exercise, is influenced by gender. Consequently, any policy or strategy, not just in the health field as such, can have a diversified impact for men and women.
The achievement of equality between women and men in all areas of society, which also involves the integration of a gender prospective in policy-making, is the main objective of gender mainstreaming. The principle underlying this strategy is represented by the consideration of the differences that exist between the living situations, the needs and the interests of men and women, in all economic and social programmes and initiatives. Consequently, any programme or measure to be adopted must conform to the objective of equality between men and women, and must be evaluated on the basis of the effects it has on the gender relationship.
Gender mainstreaming is supported by a number of different instruments and methods, to be adapted to the context in question, including gender analysis, the development of equality goals, the training of the professionals involved and the use of teaching methods that are sensitive to gender specificity. These instruments can help to:
■ understand the reasons underlying a differential access to resources and to the rights of men and women;
■ assess the different impact and implications of health initiatives on men and women.
■ include the needs and necessities of women and men in the various different social and cultural contexts.
Gender mainstreaming in Europe
“Equality between man and woman is a fundamental right, a value common to the European Union and a necessary condition for the achievement of European goals in terms of growth, employment and social cohesion”. Although inequalities persist, the European Union has made considerable progress towards equality between the genders (for example, the increase in the number of women on the work market, the progress achieved in the education and training field), thanks to the legislation dedicated to the matter and by adopting a dual approach: the inclusion of the matter of gender equality in the Union’s policy (gender mainstreaming) and the adoption of specific measures for female emancipation.
Gender values, social and cultural conventions and discriminatory and/or harmful stereotypes can translate into behaviour that can have a negative influence on individuals’ health and well-being. There is significant evidence testifying to the relationship between these elements and certain health risks, such as eating disorders, lack of exercise and depressive disorders through to the extreme case of suicide.
Generally speaking, values and conventions can lead to educational and professional choices that restrict the quality of life, financial safety and independence of the female gender. The same conventions also have a negative impact on male health, leading to violence, substance abuse and poor regard for health, through to suicide.
In 2016, the member States of the WHO’s European Region adopted a strategy for the health and well-being of women, by creating links between gender, gender equality and women’s health and imposing a series of key actions for progress. The strategy was supported by a report on women’s health, which presents the key data, which were illustrated during the second part of the day by Isabel.
The strategy is based on a vision, i.e. that all girls and women should be supported in achieving their potential well-being, that their human rights must be respected and protected, their needs satisfied, and that the various countries should work, both individually and jointly, to reduce gender and socioeconomic inequalities in health. The agenda for the change involves:
■ the promotion of governance for women’s health and well-being;
■ the elimination of discriminatory values, conventions and practices that influence the health and welfare of women and girls;
■ the assessment of the impact of gender and of the other social, economic, cultural and environmental determinants;
■ the improvement of the health service’s response to women’s health and welfare.
Measuring the gender gap
In recent years, a number of different instruments have been developed that make it possible to measure the gender gap, i.e. the gap between the male gender and the female gender, especially in social and occupational contexts, and they were discussed during the workshop. One of these is the global gender gap report 2017, which has been produced by the World Economic Forum since 2006 and provides a picture of the breadth and entity of the gender gap worldwide. For each country, the index establishes a standard of the gender gap on the basis of political and economic policy, also taking into consideration education and health, to obtain a results table: first place is occupied by Iceland, which has held this position for 9 years, followed, primarily, by Nordic countries (more specifically, Norway and Finland). While these are the first three positions in the worldwide table, it is interesting to see where the G7 countries are placed. France does excellently, occupying 11th place, followed by Germany, UK, Canada, USA and, second-last, just ahead of Japan, Italy.
Another indicator used to measure gender inequality is the gender equality index, a composite indicator that measures the complex concept of gender equality and, on the basis of the EU’s policy framework, helps to monitor progress in terms of gender equality throughout the EU over time.
One very important issue dealt with during the workshop regarded men’s health and well-being. In recent years, these two aspects have received growing attention in the WHO European Region (which includes, amongst its 53 countries also Russia, the former USSR countries and the Balkans), due primarily to the high premature mortality rate amongst men, particularly in the Eastern part of the Region. Life expectancy at birth amongst the men in the Region’s countries varied between 62.2 and 81.3 years in 2015, whereas healthy life expectancy varied between 56.6 and 71.8 years. Although the premature mortality rates are gradually improving, the differences between the Eastern and the Western parts of the Region are still high. Health inequalities also exist within the individual countries and between groups of men from different socioeconomic backgrounds.
In order to deal in a systematic way with all the factors that generate these important differences, the WHO’s European Regional Office is developing a specific men’s health strategy. The main aims are:
■ to reduce premature mortality amongst men for non-transmissible diseases and intentional and non-intentional lesions;
■ to reduce the inequalities in terms of physical and mental health and well-being between men of all ages, both between and within the Region’s countries;
■ to improve gender equality, through changes in structures and policy that involve men in certain key areas, including self-care, fatherhood, unpaid caregiving, the prevention of violence and sexual and reproductive health.
Men are behind, compared to women, when it comes to health. They die younger, although the life expectancy gap has closed in certain countries. And whereas heart disease amongst women has received a certain amount of attention in recent years, the fact remains that many men start to have heart attacks and strokes about a decade earlier than women. Every year, the number of suicides amongst males is far higher than amongst females, as is the number of men who dies from alcohol-related deaths.
Some of these inequalities can probably be explained by biological differences: it is widely believed that men suffer from heart disease at a younger age than women because they do not enjoy the protective effects of oestrogen, the female sex hormone. Health insurance cover and access to healthcare can be other factors to consider: indeed, in the United States, the percentage of people without health insurance is higher amongst men than amongst women.
The scientific literature published in recent years has shown that men are far more propense than women to behave in a way that puts their health at risk. More men smoke and drink excessively than women, they do not use seat belts and they skip screening appointments.
Why do men behave like this? One school of thought points its finger at gender roles and how men are supposed to act. The underlying idea is that men act recklessly, they do not heed health advice and are reluctant to seek medical assistance because they conform to male ideals. Some surveys have shown that higher masculinity indices are associated with lower health behaviour scores. Prevention campaigns have played a significant part, because they do not take into account the different attitude of men and women with regard to health promotion messages. Many health promotion messages (for example, a diet that is rich in fruit and vegetables) transmitted by female characters or with concepts associated with weight loss – and that are, therefore, generally speaking, closer to the female universe – are likely to exclude men from their target audience.
Some men are reluctant to seek medical assistance due to certain male ideals regarding the tolerance of pain. However, if access to health services were to be presented as a way to maintain and regain another aspect of their masculinity – for example, being able to compete or work again – men might seek a medical consultation more often.
We therefore have to make health and medical care culturally sensitive and individualised according to gender, with high gains in terms of men’s health.
There is mounting evidence supporting a gender-specific approach in the promotion of the health of men and women, boys and girls. The influence of gender conventions and roles on risk factors and its relationship with decisive socioeconomic, cultural and environmental factors of health throughout life is high and should be taken into consideration by the politicians responsible for it. The gender equality agenda calls for policy and actions that involve men and women in the transformation of roles and conventions for better health for all.
Herforshe and Barbershop initiatives
Lastly, attention turned to stressing the importance of involving men in achieving gender equality objectives, by providing a number of recently-promoted initiatives as examples.
In September 2014, the United Nations office in New York provided the venue for a special event to launch the HeForShe solidarity campaign in favour of equality, created by the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women), the UN body that works to foster the growth and development of women’s condition and their participation in public life. The aim of the campaign was to involve boys and men in the prevention of discrimination against women, based on the idea that gender equality is a question that affects everyone on a social, economic and political level. The campaign aimed to involve men and boys in a movement that was initially conceived as a mission by women for women and that set the target of involving 100,000 men, a target that was met in just 3 days. Former US president Barak Obama and current president Donald Trump are just two of the male personalities that have taken part in the initiative. The promotion of gender equality in the male population has attracted vast media coverage and has led to the launch of other important initiatives such as Barbershop.
Women have driven the gender equality movement for decades and although it is essential that men join in the effort, it is also necessary that this proactive involvement is the result of a profound reflection, in order to promote women’s existing commitments and leadership.
In line with this outlook, and based on decades of work dedicated to women’s rights, the barbershop concept was developed jointly by the governments of Iceland and Suriname, in order to involve men and recruit them as partners in the promotion of gender equality.
Why the name barbershop? “Barber’s shops are known as a safe place in which men can talk openly and can express their ideas, just like in a gym changing room.” These were the words of Iceland’s foreign minister, Gudlaugur Thor Thordarson, promoter of the first Barbershop conference, held at the United Nations headquarters in January 2015. The event was a success and saw the participation of over 500 people: it was the first time that male representatives of high-level institutions met with the sole purpose of having a sincere discussion regarding gender equality.
However, the progress towards gender equality is hampered by the unequal power relationships between men and women. Overcoming this barrier requires not merely laws and policy, but also a change of attitude and behaviour. The “barbershop” concept looks to innovative ways for men to activate and motivate other men to deal with discriminatory stereotypes of masculinity. It identifies the ways on which men talk about gender equality in a safe and comfortable environment and deals with the way in which male leaders can carry this dialogue forward.
Regional Epidemiology Service (SER), Veneto Regional Authority