Women’s health across time and space6th Australian Women’s Health ConferenceHobart, Australia

Lorraine Greaves, PhD, DUBritish Columbia Centre of Excellence for Women’s HealthCanada

Goals

1. To reflect on progress in women’s health over the past 50 years

2. To identify conceptual developments in women’s health

3. To promote understanding of policy making4. To recommend strategies going forward to

improve women’s health policy and practice

Keeping in mind four “locations”

Providers Academic researchers Policy makers Communities

Messages

There has been progress, lots of it Conceptual approaches are in constant

evolution Evidence, engagement and economics

matter in policy making We need to be more strategic to secure

our achievements

Part 1

Progress

2nd wave women’s movement

Emerging politics of women’s liberation

Consciousness-raising

Control over body Labour force

participation and pay equity

Including decades of women’s health advocacy

Over-medicalization of women Sexism & paternalism Gender-neutrality and gender-blindness Exclusion from trials Lack of women in science and medicine

http://www.ourbodiesourselves.org/book/default.asp

Feminist Women's Health Center, Oregon

Self-examination kits to avoid doctors and be self sufficient

Home birth and midwifery- avoiding hospital and reclaiming birthing

Women’s health movement identified values to underpin care

Inclusive Sensitive Respectful Empowering Accessible Comprehensive

Since 1970 in Canada

Royal Commission on the Status of Women 1970

Women’s Health Bureau, 1993 Centres of Excellence for Women’s Health

Program, 1996 Women’s Health Strategy, 1999 Gender analysis policy, 2000 Institute of Gender and Health, 2000

Some achievements in this time periodStructural changes Rapidly increasing evidence and research on sex,

gender and health Introduction of gender analysis into policy Creation of women-specific health care services

Parallel processes Infiltration of feminists into positions of influence Evolution of consciousness raising into communities

of practice and knowledge exchange Global advocacy connecting women’s status to

women’s health

Key policies were, and are, very important Institute of Medicine report (USA)

Argues importance of sex (and gender) in all pillars of health research “Every cell is sexed” (2001)

Canadian Institutes of Health Research (CIHR) Institute of Gender and Health (2000) Requires sex and gender analysis be included in all

proposals Health Canada, requires GBA of policies (audited by the

Auditor General of Canada, 2009)

National Institutes of Health (USA) NIH requires women, children and minorities be included in

all research (1993) Audited by the General Accounting Office 1999

Led to new knowledge

Newly identified disease trajectories for women

Identification of diagnostic issues Requirement for new treatment

approaches Shortcomings of rehabilitation identified Health system design is gendered Health reform is gendered

Part 2

Some theoretical and conceptual transitions

The concepts, the issues

Sex Gender Diversity

Language clarity Measurement issues Capacity (Re) training Institutionalization Knowledge transfer

Sedimentary layers of terminology and analytic frames over 30 years Sex Gender Sex and gender Sex differences Gender differences Sex differences and gender

influences Sex and gender related

factors Gender equity

Sex stratification Sex differentiation Gender (based) analysis Determinants of health Sex and gender (based)

analysis Sex, gender and diversity

(based) analysis Disparities, inequities of

health Intersectional analysis Intersectional-type analyses

Parameters of the field have evolved Health

Women’s health Gender and health Men’s health Gender and women’s health Gender and health, (including

women’s health and men’s health) Health equity Now three fields: (at least)

gender and health women’s health men’s health

Lessons? Keep women in sight Being vigilant about diluting the focus on

women Broadening the field can generate

support Continuous adult education is necessary Retain the historical values base Embrace increasing complexity of

conceptual development

Sex and gender interact

Sex: biological and physiologically related factors Metabolism, hormones, size, anatomy etc

Gender: social and cultural factors Roles Identity Relations Institutionalized gender

Osteoarthritis & Osteoporosis

Sex: Female bodies are more likely to develop osteoarthritis or osteoporosis due to differences in bone structure, bone density, and hormones (Cenci et al., 2000; Riggs, 2000).

Gender: Feminine gender roles do not encourage women to do weight-bearing exercises, which put women at risk for developing osteoarthritis and osteoporosis (Fausto-Sterling, 2005).

Cardiovascular disease

Sex: Aspirin helps prevent cardiovascular disease in men but not women due to genetics and hormones (Levin, 2005). Women may have different symptoms than men of CVD.

Gender: Women may delay seeking care for cardiovascular health problems due to cultural expectations or their multiple roles within families, which may prevent them from taking time for themselves (Rosenfeld, Lindauer, and Darney, 2005)

Cardiovascular Disease (CVD) and Diversity Substantial ethnic differences in CVD exist;

The death rate due to CVD is 69% higher in black women than white in the USA (American Heart Association, 1997).

Gender and class-linked differences

associated with CVD risk factors include: smoking, hypertension, poor nutrition, diabetes, obesity (American Heart Association, 1997), access to health care and educational attainment (Nietert, Sutherland, Keil, & Bachman, 2006).

Contracting HIV – sex and gender collide

Sex: The vagina is more susceptible to contracting sexually transmitted infections (STIs) than the penis due to physiology (Darroch and Frost, 1999)

Gender: Women can have less power in sexual relationships which puts them at a greater risk of contracting HIV (Amaro and Raj, 2000). And, women may delay seeking treatment for HIV/AIDS due to family and childcare obligations.

Our locations have evolved as well… Community

Women and girls Community

organizations Advocates Activists

Providers Health care providers Social services Hospitals Health authorities

Researchers Academics Community based

researchers Polling firms

Policy makers Government Decision makers Institutional leaders Research funding

agencies

In reality, many linkages between sectors

Community

Research

Policy

Care

In reality, common goals and movement

These sectors are overlapping sets Less distinguishable now compared to 50 years

ago Roles evolve and change over time

But, Stereotypes still dominate, and impede More synergy is required Some bridges exist, but we need to embody

these

Do these stereotypes persist?

Community

Powerless Persistent

Providers

In Silos Essential

Researchers

Theoretical Opportunistic

Policy makers

Powerful Sold out

All our different commitments need nurturingDifferent “projects” and goals for each sector

Clinical treatment Health system improvement Program design Policy design Academic research Community based research Capacity building Advocacy Knowledge translation

Part 3

Strategies for going forward in policy and practice

Our collective aims

To improve health care practices To change policies and policy making To deliver health information to women To generate support for gender analysis

and reform To generate new thinking and language To broaden the view of health To increase the evidence on women’s

health

Things to know about policy making The cycle of government

Budgets are made same time each year Internal processes are fixed Information is public Too little or too much funding?

Speed Decisions are made quickly Policy is made quickly Decision making is not public Enacting decisions may take a long time

But politics matter the most

Politicians Tensions are normal Economics will rule Ideology will surface

Public service Civil servants outlast politicians Leadership and championship matter Changing the policy making p ro c e s s is the lasting

contribution

Things to know about engagement

Network Who knows who and what position did they have

before? Who has a personal interest?

The power of reacting One individual complaint can kill an initiative One community can kill a policy Write letters, they count and are counted Critical incidents and media coverage rule

Positioning the argument

Enter the dialogue What is a ‘wicked problem’? What is a ‘killer fact’? How to exploit a ‘wedge issue’?

Link to the platform Contortion or reality? Learning the language Being ready for the next ideology

Women’s health requires evidence, engagement and economic overlay Has a tenuous position in government

Corporate memory is short Sexism tenacious

Must be renewed and refreshed continuously Personnel, politicians and deputies change

Requires vigilance Take nothing for granted

Needs economic arguments How can improving women’s health contribute? Framing women’s health in economic terms

Using the structure of government to advance women’s health

In Canada, for example GBA is required at the federal level, but not provincial Women’s health strategy is federal Federal government signs international treaties Federal government sets rights GBA was audited in 2009 by the Auditor General

A global view: Women’s health in all policies Women’s health in all policies

protect women’s property rights policies that support equal access to formal employment targeted action to encourage girls to enrol in and stay in

school health promotion to increase access of all adolescent

girls to health education measures that provide specific economic opportunities

for women measures that increase access to water, fuel and time-

saving technologies strategies to challenge gender stereotypes and change

discriminatory norms, practices and behaviours action to end all forms of violence against women building “age-friendly” environments for older women

World Health Organization, 2009

How do we need to shift our approach?

Embrace biology, in conjunction with social models of health

Social determinants don’t fully explain, or intrigue, scientists and policy makers

Science is increasingly identifying more biological issues that affect health

Epigenetics is the frontier of explanation - the interaction of environmental factors and genetic factors

Drop the binaries, and accept, embrace and teach, the fluidity of concepts

Sex, gender, (dis)ability & ‘ethnoracial’ categories are increasingly diffuse and blurry

Drop measuring “differences”, on the assumption that there is a standard

Adopt more complex views of the various factors affecting women’s health

Move into globalized views of women’s health

Contribute to better data collection

Without data, we cannot measure progress Facilitates evaluation and costing Underpins the “business case” Can be used for performance management Will get noticed, if governments collect them Expand the notion of data and evidence

Finally, be bridge-builders for women’s health

Understand each sector’s role and responsibilities, measures of success

Actively assist with other sector’s goals Cultivate mutual support across sectors Travel across sectors in your own careers Engage in 21st century consciousness-raising

Thank you

The British Columbia Centre of Excellence for Women’s Health and its activities are supported by a financial contribution from

Health Canada, through the Women’s Health Contribution Program