BY CAMILLE SACHS
Camille Sachs is a second-year International Development student from Steamboat Springs, Colorado. She is passionate about gender challenges in development and being in the mountains.
Dr. Geeta Rao Gupta, Executive Director of the 3D Program for Girls and a Senior Fellow at the United Nations Foundation, discussed the role of gender norms in healthcare during the first Development Roundtable of the 2020-21 academic year. The talk was based on the findings of The Lancet’s Series on Gender Equality, Norms, and Health, for which she was a principal co-author.
Historically, gender norms have not received much attention in the world of healthcare. However, the Sustainable Development Goals (SDGs) focus on universal health care and the equality and empowerment of women and girls has placed a renewed focus on the overlap between gender norms and healthcare. In order to achieve the goal of Universal health coverage, we first must look at the ways in which both gender and gender norms impact healthcare. Gender refers to the culturally defined roles, responsibilities, attributes, and entitlements associated with being male or female. Gender norms refer to the unspoken social rules that govern the attributes and behaviors that are valued and considered acceptable for males and females.
Within the health system, there first needs to be a clear distinction between gender and sex, which is typically overlooked. Sex differences are the biological differences that can impact the healthcare an individual requires. Separately, gender impacts the system, social position, and pathway through which healthcare is received. Furthermore, the gendered health behaviors associated with toxic masculinities and toxic femininities can have varying impacts on individual health. All of these societally-constructed differences in gender lead to barriers to access and biases within the health system. There are direct barriers to access including access to finances, distance to healthcare facilities, autonomy in decision-making, limits on mobility, and perceived stigma or fear of retribution. There are also built-in inequities in the healthcare system. The ‘care versus cure paradigm’ leaves women in ‘caring’ roles (nurses, midwives, community health workers), whereas men are generally assigned to ‘curing’ roles (physicians, surgeons, researchers). The gender bias persists to health research where women are underrepresented and understudied, and clinical trials are rarely reported by sex or gender.
Dr. Gupta argues there are three persistent myths that have reduced our ability to fully address gender norms:
Gender norms do not affect health outcomes;
Gender norms are entrenched and cannot be changed; and
Gender norms are elusive and cannot be measured.
During the roundtable, she refuted these myths and argued that there are certain levers that can be utilized to change gender norms. These include policy and legal reforms, social movements and citizen action, interactive programs with communities, and gender equitable media messages. Furthermore, she emphasized there are external shocks that cannot be controlled, but that have an outsized impact on gender norms, such as in World War II. The policy of gender mainstreaming has fallen short of its goal due to its top-down, prescriptive approach. Instead, there needs to be a focus on civil society actors and social movements to create normative change within societies.
With less than 10 years left to accomplish the SDGs, the time to act is now. The pressure from the SDGs, the growing social movements focused on women’s rights and gender equality, the activism around rights for gender minorities, and the new champions focused on harmful aspects of masculinity provide a multitude of opportunities to push for gender norm changes.
In a conversation following the roundtable, Dr. Gupta sat down with Perspectives to continue the discussion on gender norms and healthcare. The interview has been edited for clarity and length.
Perspectives: From your perspective, what is the role of gender norms in the field of international development, and how has the conversation around gender norms evolved to where it is today?
Dr. Gupta: The topic of gender norms is rarely talked about in international development. What we talk about more is gender inequality, but gender norms underlie those inequalities. Recently there has been more focus on norms, particularly in public health because of the focus on behavior change in health and the understanding that behavior is often determined by prevalent norms. Even when inequality is talked about, the rights imperative is not talked about enough.
The field of violence against women brought attention to gender norms. That is what got people talking about toxic masculinities and that, in turn, initiated the discussion on how masculinities and femininities are shaped. When I began working on HIV/AIDS in the1990s, there was not enough emphasis on norms in shaping individual behaviors and decisions. The assumption was that all individuals, women and men, had an equal ability to ask for the use of protection in a sexual interaction. In the early days of HIV prevention, we did not pay enough attention to the gender-related power imbalances that influence individual decisions of women as compared to men.
Perspectives: As a student of International Development, I come across a lot of work that aims to discuss gender norms, but only discusses the gender binary and the damage gender norms can have on women and girls. The Lancet series on Gender Equality, Norms, and Health is one of the only publications I have read that pays so much attention to the harms that gender norms cause both to gender minorities and to men. Why do you think the framing has historically been so focused on cis-women, and how do we push for more inclusive research in this area moving forward?
Dr. Gupta: The historical legacy of disadvantage that cis-women have faced, especially in the economic and health spheres, is what started the women’s movement. That initiated the field. I don’t think we need to defend the focus on cis-women because it is justified, but now there is a greater acceptance of the need for a focus on masculinities and the full gender continuum because gender minorities are subject to persistent discrimination and incidents of violence.
Recent social justice movements have drawn attention to the injustices faced by gender minorities. When you have masculinity and femininity defined in a rigid and hierarchical way, you create the conditions for discrimination against all those who do not squarely fall within those rigid gender categories. I think the field of gender equality will benefit from the activism for the rights of all gender identities because it questions the prescriptive and rigid way in which gender identity and gender norms are defined.
Perspectives: In your paper, you discuss three myths around gender norms that persist in the development field. Why do you think these myths persist and why is it so important that we address them?
Dr. Gupta: They persist because they maintain a power balance that benefits those who have access to power – and those are the people who are in decision-making positions. To change that power balance requires those who are negatively impacted by that power imbalance to organize and mobilize to demand their rights. In the field of health, professionals don’t acknowledge the impact of gender norms largely because they don’t know what to do about them, they don’t know enough about the interventions and evidence on how norms can be changed.
Gender mainstreaming is the approach that has been used for the past 25 years to motivate health professionals in organizations to acknowledge and rectify gender inequalities that contribute to poor health outcomes. But it hasn’t worked. To be effective, we have to be problem-solving oriented. We have to identify the specific problem we are trying to fix, understand how gender inequalities contribute to it, and then intervene to rectify those inequalities and change the gender norms that underlie them, so that the problem can be solved. We have to use the evidence that is available to demonstrate how gender norms can be changed and inequalities addressed. Those three myths persist in part because, in large measure, health professionals don’t know what to do or how to do it. It is also important to remember that when we do succeed in bringing about change, there is likely to be a backlash because we are changing the status quo – but that shouldn’t slow us down – we must keep pushing forward.
Perspectives: How has COVID-19 either reinforced or shifted the gender norms and inequalities persistent in health care systems? Do you think there are any opportunities for positive change that could come from COVID regarding gender norms?
Dr. Gupta: COVID-19 has laid bare the inequalities that characterize most societies – inequalities based on class, gender and race, for example. It has made people aware of the health consequences of those social and economic inequalities There is an opportunity for change, to build back better. I hope we take advantage of that opportunity.
There is another problem that is arising in this pandemic. When health systems get entirely diverted to deal with one health problem – in this instance, COVID-19 – then other more routine health needs that people have are not addressed. In the community where I work in India, for example, women are not getting access to routine maternal health care or menstrual hygiene management supplies because all health resources and personnel have been diverted to COVID prevention and treatment.
This is causing concern. We are likely to lose some of the progress that we made on some of these health indicators previously, but I am hopeful that because the novel corona virus has exposed other issues, we will see some progress on those issues. For example, it has revealed the extent to which women and children are vulnerable to domestic violence, the risks faced by frontline health workers who are mainly women, the implications for the economy of a lack of strong social safety nets, and the overall cost to society of vast class and gender-based inequalities. This crisis is an opportunity to build back better. We have to emerge from this pandemic into a world that is better, more equal, more just.
Perspectives: How do you hope this research will help institutions or individuals to disrupt unhealthy gender norms?
Dr. Gupta: I hope the Lancet Series will be used as a resource. The Lancet has now established a Commission on Gender and Global Health, which is a good sign! It shows that a mainstream medical journal is incorporating an analysis of gender norms into its scientific content. I hope that it will spawn more research in the future, like was undertaken by the initiative ALIGN (Advancing Learning and Innovation on Gender Norms). I hope over time more health professionals and international development experts will pay attention to the impact of rigid gender norms and gender inequalities on health and development outcomes.
Watch the full talk here.
PHOTO CREDIT: Rod Waddington licensed under CC BY-SA 2.0