Antecedents
The chapter's emphasis on gender differentials and inequalities in health rather than on women's absolute health conditions reflects the evolution of thinking on women and health issues. (Annex 10.A charts these advances in the past two decades, highlighting milestones and influential publications.) In the 1960s and 1970s, the field of international women's health issues emerged from and was influenced by an interest in women's fertility behavior as a means of curbing population growth and by an interest in maternal and child health to improve child welfare, with little or no attention paid to mothers (McNamara 1981; Rosenfield and Maine 1985). Much of the work in the 1980s sought to bring a woman-centered perspective into population and maternal and child health programs. This focus included awareness of how women's lower status in society affected health delivery and health-seeking behaviors and how women's time burdens in poor households affected child health. The issues raised included the quality of care in health and family-planning programs and the nature of women's work and its impact on child survival and health (Bruce 1990; Leslie 1988). Reducing maternal mortality became a major development objective (Herz and Measham 1987).
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The 1994 United Nations International Conference on Population and Development in Cairo placed women's reproductive health and rights at the center of the population and development debate, and the United Nations Women's Conference in Beijing the following year reinforced the importance of women's empowerment and of a gender perspective in health. Along with the global burden-of-disease effort, researchers estimated the loss of women's healthy years of life caused by gender violence (Heise, Pitanguy, and Germain 1994), and gender was identified as central to women's risk of and treatment for HIV/AIDS (Gupta 2000; Mann 1993). The World Health Organization analyzed how differences between women and men in access to and control over resources determine differential exposure to risk and access to the benefits of health technology and care (WHO 1998). After more than two decades almost solely devoted to maternal and reproductive health issues, attention expanded to cover a range of women's health issues unrelated to reproduction and to identify and correct gender differentials and inequities in health (Sen, George, and Ostlin 2002). These new emphases complemented renewed interest in health inequities and their reduction in the field of international health (see, for instance, Evans and others 2001).
Framework
Both sex and gender matter in health. We use the term sex to describe differences between men and women that are primarily biological in origin and that may be genetic or phenotypic. By contrast, we use the term gender to describe differences that are primarily caused by social conditions or cultural and religious beliefs and norms regarding the sexes. Structural gender inequalities that place women in a subordinate position to men underlie and contribute to gender differentials in disease (Sen, George, and Ostlin 2002). A gender perspective addresses differences between men's health and women's health that arise from this lower position and the consequent unequal power relationship between the sexes. Sex and gender can act alone, independently, or interactively in determining differentials in the burden of disease (Krieger 2003). Some women's excess health burdens, such as uterine cancer, are based almost solely on biology. At the other end of the continuum, some women's excess health burdens, such as injuries from domestic fires or domestic abuse, are solely gender based.
However, in most cases sex and gender interact to determine women's disease burdens. Two salient examples are depressive disorders and HIV/AIDS. Women are twice as likely as men to become depressed, and genetics and hormones influence the risk of depression. However, genes and sex hormones cannot entirely explain women's excess burdens, and gender factors play an important role (WHO 2000). HIV infection rates among teenage girls are 5 to 16 times higher than among teenage boys in Sub-Saharan Africa. This earlier age of HIV exposure for girls is partly explained by the greater biological efficiency of male-to-female transmission and partly by girls' lack of knowledge, opportunities, and bargaining power in sexual relations that make them prime victims of the rapid spread of the disease.
Existing knowledge about the interplay between sex and gender in determining disease is imperfect and evolving (Krieger 2003; Pinn 2003). This chapter groups women's excess health burdens from diseases into the following four broad categories:
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diseases specific to women (that is, where biology plays a major role in the disease)
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diseases related to women's average greater longevity (where both sex and gender tend to play important roles)
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diseases that result from the interaction of sex and gender
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diseases that are predominantly gender based (that is, that result from specific behavioral, social, and cultural factors associated with women's condition).
Sex and gender have a much wider influence on disease than is usually acknowledged. They influence the etiology, diagnosis, progression, prevention, treatment, and health outcomes of disease as well as health-seeking behaviors and exposure to risk. Whereas sex plays a bigger role in the etiology, onset, and progression of disease, gender and its consequences influence differential risks, symptom recognition, severity of disease, access to and quality of care, and compliance with care. In addition, poverty and social exclusion because of race and ethnicity interact with sex and gender and contribute to women's excess disease burdens in ways that are largely unexplored to date (Breen 2002).
Factors that influence gender differentials in relation to the risk of disease include (a) biological (genetic, physiological, and hormonal) differences between the sexes; (b) women's longer life expectancy; (c) nature and rate of change of women's labor force participation compared with men's participation; (d) women's differential access to social protection mechanisms (health and social insurance); (e) cultural norms, religious beliefs, and family arrangements and behaviors determining gender roles and gender hierarchy in society; (f) gender differences in educational attainment; (g) income differences between the genders resulting from the interaction of all the previous factors; and (h) interactions between race, ethnicity, income, and gender.
Women's overall underutilization of health services has been well documented. For instance, even though women in India report more illness than men, hospital records show that men receive more treatment (World Bank 1996); in Thailand, men are six times more likely than women to seek clinical treatment for malaria, a disease that affects women and men similarly (Hanson 2002); and in Brazil, the Dominican Republic, Jamaica, Paraguay, and Peru, low-income women underuse health services (Levine, Glassman, and Schneidman 2001).
Three groups of factors influence this underuse of health services. The first group is service factors, such as accessibility; affordability (money and time costs); and appropriateness or adequacy, including friendliness, of the health and social infrastructure for meeting women's needs. The second group is user factors, which include social constraints, such as restrictions on women's mobility and women's average lower incomes and greater time burdens than men's; asymmetric information about health needs and rights and the availability of services, which disproportionately affects poor women; and marital status, family roles, and work conditions affecting access and use. The third group is institutional factors, including men's decision-making power and control over health budgets and facilities, which affect local perceptions of illness and norms concerning treatment, and stigmatization and discrimination in health settings, which affect women among the poor and women of minority ethnic and racial groups.
Context
The global demographic dynamic, a product of the interplay of nature and nurture, biology and society, helps determine gender differentials in health. In 2001, the world's population, an estimated 6.2 billion, was 50.3 percent male and 49.7 percent female. The surplus male population was concentrated in the developing countries, whereas the developed countries had a higher proportion of women, primarily in the older age groups (WHO 2001).
In the developed countries, the number of women age 80 and older was more than double the number of men in the same age group. This female advantage in longevity helps shape a gender paradox in health outcomes worldwide: on average, males live shorter but healthier lives than females. Even though more boys are born than girls, gender differences in mortality eventually change the sex balance in populations so that by age 30 or so women start outliving men, and the absolute female advantage in survivability increases with age (Kinsella and Gist 1998). Therefore, differences in life expectancy at birth by gender, using 2000 data, vary in favor of females, ranging from one year in the low-income countries of South Asia and Sub-Saharan Africa to seven years in Europe and Central Asia and nine years in the middle-income countries of Latin America and the Caribbean.
Overall, however, women have higher morbidity than men. Murray and Evans (2003) find that in relation to expected lost healthy years at birth, whereas men lose 7.8 years over their lifetimes as a result of poor health, women lose 10.2 years. In other words, women spend about 15 percent of their lives in unhealthy conditions and men spend just 12 percent. Therefore, living longer lives should not be taken to indicate better health for women. Women live less healthy lives and are saddled with higher morbidity in part because they outlive men (Verbrugge 1989). Supporting the less healthy lives assertion, women up to age 65 reported worse health status in virtually all 64 household surveys from 46 countries (Sadana and others 2000). Because of these differences in morbidity, the concept of healthy adjusted life expectancy at birth describes differences in health conditions between males and females better than the concept of life expectancy at birth.
