Trigger warning: This section of reading covers topics which may be triggering or upsetting to readers, including gender-based violence, sexual violence and sexual coercion.

Start with the basics: Sex and gender, not the same

Sex and gender are often used interchangeably, but the two concepts are very different. Let’s begin our discussion about gender as a determinant of health by differentiating sex from gender.

For the purpose of this course, we will adopt the following definitions, which will constitute a basis to better understand women’s, men’s and transgender people’s concerns and experiences, including health.

OK, so what are we referring to when we talk about a person’s sex?

“Sex” refers to the physical differences between people who are male, female, or intersex. A person typically has their sex assigned at birth based on physiological characteristics, including their genitalia and chromosome composition.  From the time that sex is assigned, an individual’s sex becomes a social and legal fact.

Council of Europe, 2021

OK, so then what is gender?

While sex is a biological characteristic, gender is a social and cultural concept. You will often hear that ‘gender is socially constructed.’ 

Gender refers to the cultural roles, behaviors, activities and attributes expected of people based on their [biological] sex.

CDC, 2019

Gender is often described using the terms woman, man and non-binary (not identifying strongly with either gender), though individuals may define their gender in other ways as well. 

Gender norms, roles and relations vary from society to society and evolve over time. They are often upheld and reproduced in the values, legislation, education systems, religion, media and other institutions of the society in which they exist.

When individuals or groups do not “fit” established gender norms they often face stigma, discriminatory practices or social exclusion – all of which adversely affect health. Gender is also hierarchical and often reflects unequal relations of power, producing inequalities that intersect with other social and economic inequalities. (World Health Organization, 2011)‎. 

Gender identity refers to the gender to which persons feel they belong, which may or may not be the same as the sex they were assigned at birth. It refers to each person’s deeply felt internal and individual experience of gender and includes the personal sense of body and other expressions, such as dress, speech and mannerisms.

Council of Europe, 2018

In many (though not all) cultures, individuals are assigned a gender at birth based on their biological sex (primarily the genitals they are born with). For example, an individual born with a penis in the United States would in most cultural circumstances be referred to as a boy or man from birth using he/him pronouns. However, this person might decide at a young or older age that they are more comfortable living in the world using she/her pronouns and adopting different behaviors or ways of presenting themselves socially than the dominant cultural definition of a man. 

Gender roles will be defined differently by different cultures and by different individuals.

Even as we are emphasizing that sex and gender are not the same concept and should not be used interchangeably, you will see that much of the medical, Public and Global Health literature often do use the terms ‘men and women’ when they are actually referring to ‘males and females.’ As you read through this section keep this in mind — sometimes as you are reading about ‘women’, for example, the text might actually be referring to females as a biological sex.

The intersection of sex and gender for health outcomes

Sex and gender interact in complex ways to affect health outcomes. 

As we discussed in a previous section of reading, there are both biological and social determinants of health. When we talk about gender as a determinant of health, we must look at how biological determinants of health such as sex intersect with social determinants of health — such as gender. The health outcomes related to gender as a determinant of health sit at this intersection of biology (sex) and social context (gender).

Sex (male or female) can affect disease risk, progression and outcomes through genetic (e.g. function of X and Y chromosomes), cellular and physiological (e.g. hormonal) pathways. These pathways can produce differences in susceptibility to disease, progression of disease, treatment and health outcomes, and are likely to vary over the life-course.  

For example, data shows that males experience more severe COVID-19 outcomes in terms of hospitalizations and deaths than females.  This is, in part, explained by higher quantities of an enzyme found in males, which binds to the SARS-COV2 virus. In another example, we know that breast cancer is about 100 times more common in females than males (though males can develop breast cancer) (American Cancer Society, n.d.). While females generally tend to have more breast cells than men, the main risk factor for cancer for females is higher production of the hormones estrogen and progesterone (American Cancer Society, n.d.). These are examples of biological determinants of health related to sex.

While biology is an important determinant of health, we have discussed in detail in this course how structural and social determinants are also important considerations in understanding health outcomes. Gender norms (man, woman, non-binary or other gender identities), socialization, roles, differentials in power relations and  access to and control over resources are all structural and social factors which contribute to health outcomes.

Gender norms are social principles that govern the behavior of girls, boys, women, and men in society and restrict their gender identity into what is considered to be appropriate. Gender norms are neither static nor universal and change over time. Some norms are positive, for example, the norm that children shouldn’t smoke. Other norms lead to inequality.

Save the Children, 2021

For example, data show that men’s increased risk of acquiring SARS-COV2 is also linked to their lower rates of handwashing, higher rates of smoking and alcohol misuse and, related to that – higher comorbidities for severe COVID-19 symptoms as compared to women (WHO, 2021). Studies have also shown that in some contexts women are more likely to seek out health services, especially preventive health services, for physical and mental health concerns than men (Thompson et al, 2016, ). In some socio-cultural contexts, mothers were more likely to seek out more expensive healthcare services for boy newborns than girl newborns (Willis et al, 2009; Ismail et al, 2019). These are examples of social determinants of health related to gender.

We will revisit these and other examples in more detail as we move through this section. While the topic of ‘gender as a determinant of health’ applies to women, men and trans-identifying people we will explore women’s health in this course. 

Women’s Health

What do we mean by ‘Women’s Health’?

Gender has implications for health across the course of every person’s life. Gender can influence a person’s experiences of crises and emergency situations, their exposure to diseases and their access to healthcare, water, hygiene and sanitation.

Gender as a determinant of health functions very differently for men, women and individuals with other gender identities. Between men and women, however, gender inequality disproportionately affects women and girls. People who identify as transgender also have very specific determinants of health, experiences of discrimination and health needs accessing the care that they need. 

Sexual and Reproductive Health and Rights

The Committee on Economic, Social and Cultural Rights (CESCR) and the Committee on the Elimination of Discrimination against Women (CEDAW) have both clearly indicated that women’s right to health includes their sexual and reproductive health.

This means that States have obligations to respect, protect and fulfill rights related to women’s sexual and reproductive health. The Special Rapporteur on the right to health maintains that women are entitled to reproductive health care services, and goods and facilities that are:

• available in adequate numbers;
• accessible physically and economically;
• accessible without discrimination; and
• of good quality (UN, 2006).

Despite these obligations, violations of women’s sexual and reproductive health and rights are frequent. These take many forms, including:

• denial of access to services that only women require;
• poor quality services;
• subjecting women’s access to services to third party authorization;
• forced sterilization, forced virginity examinations, and forced abortion, without women’s prior consent;
• female genital mutilation (FGM) [author’s note: including FGM/C in this list of human rights violations is very loaded within the global community; please see section below on FGM/C for more context]; and
• early marriage.

Causes and consequences of sexual and reproductive health violations

Violations of women’s sexual and reproductive health and rights are often due to deeply ingrained beliefs and societal values pertaining to women’s sexuality. Patriarchal concepts of women’s roles within the family mean that women are often valued based on their ability to have children. Early marriage and pregnancy, or repeated pregnancies spaced too closely together—often as the result of efforts to produce male offspring because of the preference for sons—has a devastating impact on women’s health with sometimes fatal consequences. 

Examining Key Issues in Women’s Health: A Global Perspective

The breadth and depth of women’s health challenges is too great to completely explore in this space. However, there are a number of women’s health challenges which are especially prioritized in the field of global health. We explore a selection of these issues below.

To learn more about these and other priority issues for Women’s Health visit the World Health Organization’s page here.

Maternal Mortality

(NOTE: Excerpts from this section attributed to Roser and Ritche, 2013)

Reducing maternal mortality is one of the highest priorities on the Global Health agenda. 

Maternal Death is defined as a female death related to pregnancy and childbirth or within the first 42 days of termination of pregnancy.

WHO, 2021b

Despite these fantastic gains, too many women are still dying from pregnancy-related causes.

The biggest tragedy is that most maternal deaths are preventable, even in resource-poor settings.

The WHO estimates that everyday in 2017, approximately 810 women died from preventable causes related to pregnancy and childbirth — that equals 295,000 women who died in 2017 alone (2019).

As the map below clearly shows, 94% of all of these maternal deaths occur in low and middle income countries (WHO, 2019). 

Play the animated graph to see where improvements in maternal mortality ratios were made from 2000-2017.

Women in high income countries have a 1 in 5,400 lifetime risk of dying from a maternal death while women in low income countries have a 1 in 45 risk of dying from a maternal death (WHO et al 2019b). 

To understand the figure and statistics below, think in terms of the lottery. If you have a 1 in 45 chance of winning the lottery and your friend has a 1 in 5,400 chance of winning the lottery, which one of you has a higher chance of winning? You do, because 1 in 45 is a much higher chance than 1 in 5,400.

Unfortunately in the example of global maternal death, we are not talking about winning. We are talking about women dying of mostly preventable causes. Therefore, as you read the statistics below, women in regions with the lower denominator (the denominators in the examples above are 45 and 5,400) have a higher chance of dying a maternal death in their lifetime.

Given your Global Health knowledge, does this distribution of maternal deaths between countries look like a health inequality or a health inequity? 

If you said ‘health inequity’, you are correct. The fact that almost all maternal deaths globally occur in low- and middle-income countries from preventable causes is unjust, unfair and avoidable — our definition of inequity.

Watch the following short videos to learn more about the leading causes of maternal mortality as well as the steps low- and middle-income countries are taking to reduce the burden of this health disparity.

Note that some statistics in the videos are slightly outdated (ie In the past 99% of maternal deaths occurred in low- and middle-income countries. That percentage has now reduced to 94%).

Maternal mortality: not just a ‘third world’ problem

While almost all maternal deaths globally occur in low- and middle-income countries, some high income countries still have maternal mortality rates which are unacceptably high. The United States, for example, has one of the highest maternal mortality rates among high income countries in the world.

By now in the semester you should be able to identify this grossly uneven distribution of maternal mortality by race and ethnicity in the United States as a health inequity.

The following video clips uncover the inequities in maternal mortality in the United States in more detail. While all videos are recommended, we ask that you watch at least two of the four clips — one on maternal mortality of Black Americans and one on maternal mortality of Native Americans and Alaskan Natives.

As you watch these videos, which historical, structural and social determinants of health can you identify that impact Black and Native Americans’ birth experiences and higher risks of maternal mortality in the United States?

Pay special attention to the effects of institutional and internalized racism of medical providers and the medical system in the United States that affect racialized and systematically marginalized pregnant people. 

Why are women dying?

The Leading Causes of Maternal Mortality Globally

Women die as a result of complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy and most are preventable or treatable. Other complications may exist before pregnancy but are worsened during pregnancy, especially if not managed as part of the woman’s care.

Remember, a maternal death can occur during pregnancy, during or immediately after childbirth or in the period following child birth (typically considered up to 6 weeks or 42 days, referred to as the postpartum period).

The major complications that account for nearly 75% of all maternal deaths are:

• Severe bleeding also referred to as hemorrhage (mostly bleeding after childbirth)
• Infections also referred to as sepsis (usually after childbirth)
• High blood pressure during pregnancy (also referred to as hypertensive disorders including pre-eclampsia and eclampsia)
• Complications from delivery and
• Unsafe abortion.

The remainder are caused by or associated with infections such as malaria or related to chronic conditions like cardiac diseases or diabetes. 

The graph below charts the decline in maternal deaths by cause from 1990 to 2016. Note in particular the significant drop in number and percentage of maternal death by hemorrhage.

This pie chart gives another visual of the leading causes of maternal deaths.

Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. All women need access to high quality care in pregnancy, and during and after childbirth. Maternal health and newborn health are closely linked. It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for the mother as well as for the baby. 

Severe bleeding or ‘hemorrhage’ after birth can kill a healthy woman within hours if she is unattended. Injecting oxytocics immediately after childbirth effectively reduces the risk of bleeding.

Infection or ‘sepsis’ after childbirth can be eliminated if good hygiene is practiced and if early signs of infection are recognized and treated in a timely manner.

Pre-eclampsia should be detected and appropriately managed before the onset of convulsions (eclampsia) and other life-threatening complications. Administering drugs such as magnesium sulfate for pre-eclampsia can lower a woman’s risk of developing eclampsia (WHO, 2019a).

Unsafe abortion specifically is explored in further detail in a section below. An abortion is considered unsafe when it is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both (WHO, 2020a).

Why do women not get the care they need while pregnant, giving birth or in the post-partum period?

Poor women in remote areas are the least likely to receive adequate health care. This is especially true for regions with low numbers of skilled health workers, such as sub-Saharan Africa and South Asia (WHO, 2019a). 

The latest available data suggest that in most high income and upper middle income countries, more than 90% of all births benefit from the presence of a trained midwife, doctor or nurse. However, fewer than half of all births in several low income and lower-middle-income countries are assisted by such skilled health personnel.

The main factors that prevent women from receiving or seeking care during pregnancy and childbirth are:

• Poverty
• Distance to facilities
• Lack of information
• Inadequate and poor quality services
• Cultural beliefs and practices (WHO, 2019a).

Also think back to the clips you watched about maternal mortality in the United States — think of other historical, structural and social determinants of health such as racism and discrimination in their different forms which affect pregnant individuals around the world in different contexts.

To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at both health system and societal levels (WHO, 2019a).

Adolescent pregnancy and early (or child) marriage

Note: The following section is adapted from WHO: Adolescent Pregnancy (2020b) 

Every year, an estimated 21 million girls aged 15–19 years in developing regions become pregnant and approximately 12 million of them give birth. 

At least 777,000 births occur to adolescent girls younger than 15 years in developing countries each year. 

For example, the national adolescent birth rate among girls in 2019 in the United States was 16.7. However, in Arkansas the rate was 30 births per 1,000 girls aged 15-19 while in New Hampshire this rate was only 6.6 births per 1,000 girls aged 15-19 (Power to Decide, 2021).

While the estimated global adolescent fertility rate has declined, the actual number of child births to adolescents has not, due to the large – and in some parts of the world, growing – population of young women in the 15–19 age group. The largest number of adolescent births occur in Eastern Asia (95,153) and Western Africa (70,423).

Causes of Adolescent Pregnancy

Adolescent pregnancies are a global problem occurring in high-, middle-, and low-income countries. 

Around the world, however, adolescent pregnancies are more likely to occur in marginalized communities, commonly driven by:

• Poverty
• Lack of education and
• Lack of employment opportunities for girls themselves and their families.

Several factors contribute to adolescent pregnancies and births. 

In many societies, girls are under pressure to marry and bear children early.

In least developed countries, at least 39% of girls marry before they are 18 years of age and 12% before the age of 15. 

Additionally, adolescents may lack the agency or autonomy to ensure the correct and consistent use of a contraceptive method.  

An additional cause of unintended pregnancy is sexual violence, which is widespread with more than a third of girls in some countries reporting that their first sexual encounter was coerced (against their will, without their permission).

Sexual violence is defined as any sexual act, attempt to obtain a sexual act,unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.

Krug et al, 2002

Health Consequences of Adolescent Pregnancy

Early pregnancies among adolescents have major health consequences for adolescent mothers and their babies. 

Pregnancy and childbirth complications are the leading cause of death among girls aged 15–19 years globally, with low- and middle-income countries accounting for 99% of global maternal deaths of women aged 15–49 years.

Adolescent mothers aged 10–19 years face higher risks of eclampsia, puerperal endometritis [infection of the uterus] and systemic infections than women aged 20–24 years. Babies born to mothers under 20 years of age face higher risks of low birth weight, preterm delivery and severe neonatal conditions. 

Social and Economic Consequences of Adolescent Pregnancy

Social consequences for unmarried pregnant adolescents may include stigma, rejection or violence by partners, parents and peers. Girls who become pregnant before the age of 18 years are more likely to experience violence within a marriage or partnership. Adolescent pregnancy and childbearing often leads girls to drop out of school, which may jeopardize girls’ future education and employment opportunities (WHO, 2020b).

The video clips below detail the risks for, causes of and challenges facing young mothers and parents in two different settings globally: Romania, the Philippines and Nigeria.

Watch at least two of the three following clips. As you watch, what risk factors and causes of high adolescent pregnancy do you learn about in each setting? 

Which similarities and differences do you note between the causes and challenges of adolescent pregnancy in the different contexts?

Reflect on the structural and social determinants of health that put young women in different contexts at risk for adolescent pregnancy.

How is becoming pregnant at a young age a social determinant of health in and of itself for young women and girls? 

Unsafe abortion

Note: The following section is adapted from WHO: Preventing Unsafe Abortion (2020a). 

As we learned above, unsafe abortion is one of the leading causes of maternal mortality globally.

When completed by a trained provider in sanitary and safe conditions with the appropriation equipment and medication, abortion is one of the safest medical procedures in the world. Mortality rates for safe abortion are less than 1 death per 100,000 procedures performed (Raymond and Grimes, 2012). In the United States, this means that safe abortion is safer for women than childbirth (Raymond and Grimes, 2012). This also means that in 2017 alone, between 14,000-39,000 women’s lives globally could have been saved if they had had access to safe abortion services.

Abortion is a highly politicized issue in a number of countries around the world. In some contexts women and their providers can be criminalized for requesting or performing an abortion, even in the cases of rape or incest. However, even in countries where abortion is illegal or criminalized, individuals with financial means can often find a provider to perform a safe abortion. Systematically marginalized people will have more difficulties obtaining safe abortion. This disparity in access to safe abortion is a health inequity.

In other countries — such as almost all European countries, China, Nepal and Ethiopia to name just a few — access to safe abortion services is considered health care and a human right. In  many countries, anyone can obtain a safe abortion for free from the government on demand.

Abortions are safe when they are carried out with a method that is recommended by WHO and that is appropriate to the pregnancy duration, and when the person carrying out the abortion has the necessary skills. Such abortions can be done using tablets (medical abortion) or a simple outpatient surgical procedure.

WHO, 2020a

An abortion is unsafe when it is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. The people, skills, and medical standards considered safe in the provision of induced abortions are different for medical abortion (which is performed with drugs alone), and surgical abortion (which is performed with a manual or electric aspirator). Skills and medical standards required for safe abortion also vary depending upon the duration of the pregnancy and evolving scientific advances.

WHO, 2020a

Between 2015-2019, it is estimated that 73.3 million abortions (safe and unsafe) occurred worldwide each year. 

Almost all of these unsafe abortions took place in developing countries. Estimates from 2012 indicate that in developing countries alone, an estimated 7 million women per year were treated in hospital facilities for complications of unsafe abortion.

Unsafe abortion can include procedures carried out by untrained/ non-medically trained or licensed individuals and procedures in unsanitary conditions without appropriate medication including anesthesia and anti-biotics. Unsafe procedures can include ingesting dangerous substances or herbs and insertion of foreign bodies into the vagina and uterus.

Women, including adolescents, with unwanted pregnancies often resort to unsafe abortion when they cannot access safe abortion. 

Barriers to accessing safe abortion include:

• Restrictive laws
• Poor availability of services
• High cost
• Stigma
• Health providers’ refusal to perform abortion if abortion goes against their personal beliefs or is against the law in their country of practice
• Unnecessary legal or health system requirements, such as mandatory waiting periods, mandatory counselling, provision of misleading information, third-party authorization, and medically unnecessary tests that delay care.

Who is at risk for unsafe abortion?

Any woman with an unwanted pregnancy who cannot access safe abortion is at risk of unsafe abortion. Women living in low-income countries and poor women are more likely to have an unsafe abortion. Deaths and injuries are higher when unsafe abortion is performed later in pregnancy. The rate of unsafe abortions is higher where access to effective contraception and safe abortion is limited or unavailable.

Complications of unsafe abortion requiring emergency care

Following unsafe abortion, women may experience a range of harms that affect their quality of life and well-being, with some women experiencing life-threatening complications. The major life-threatening complications resulting from the least safe abortions are haemorrhage, infection, and injury to the genital tract and internal organs. 

Access to treatment for abortion complications

Health-care providers are obligated to provide life-saving medical care to any woman who suffers abortion-related complications, including treatment of complications from unsafe abortion, regardless of the legal grounds for abortion. However, in some cases, treatment of abortion complications is administered only on the condition that the woman provides information about the person(s) who performed the illegal abortion. 

The practice of extracting confessions from women seeking emergency medical care as a result of illegal abortion puts women’s lives at risk. The legal requirement for doctors and other health-care personnel to report cases of women who have undergone abortion, delays care and increases the risks to women’s health and lives. UN human rights standards call on countries to provide immediate and unconditional treatment to anyone seeking emergency medical care.

Prevention and control

Unsafe abortion can be prevented through:

• Comprehensive sexuality education;
• Prevention of unintended pregnancy through use of effective contraception, including emergency contraception; and
• Provision of safe, legal abortion.

Optional but highly recommended video from MSF Doctor on experiences in the field with unsafe abortion:

In addition, deaths and disability from unsafe abortion can be reduced through the timely provision of emergency treatment of complications or post abortion care (PAC). 

Post abortion care (PAC) consists of emergency treatment for complications related to spontaneous or induced aboritson, family planning and birth spacing counseling, and provision of family planning methods for the prevention of further mistimed or unplanned pregnancies that may resutl in repeat induced abortions (Postabortion Care, n.d.). 

In countries where medical abortion is illegal or criminalized, health providers are allowed to offer PAC to women but not abortion services. Therefore, if a woman comes to a clinic having attempted an abortion that is unsuccessful — the fetus is still viable — then health providers are left with difficult decisions. They can face fines, jail time and revoking of their medical licenses if they are thought to be providing abortion services.

Female Genital Cutting (FGC)

Note: Parts of this section adapted from WHO: Female Genital Mutilation (2020c) https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation; other resources as noted.

Female genital cutting (FGC) – also referred to as female genital mutilation (FGM) – is one of the most highly charged Women’s Health topics in the field of Global Health. 

Female genital cutting (FGC) — also referred to as female genital mutilation (FGM) —  involves the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons.

WHO, 2020c

FGC is mostly carried out on young girls between infancy and age 15, though it can sometimes be carried out on adult women. More than 200 million girls and women alive today have undergone some form of FGC in 30 countries in Africa, the Middle East and Asia where the practice is concentrated.

Traditional circumcisers usually perform this procedure on women and girls. Traditional circumcisers also often play other central roles in communities such as attending childbirths. In many settings, health care providers perform FGC/M due to the belief that the procedure is safer when medicalized. This is referred to as the medicalization of FGC. The World Health Organization is opposed to health care providers performing FGC.

The medicalization of female genital cutting refers to situations in which FGC is practiced by any category of health provider, whether in a public or private clinic, at home or elsewhere.

UNFPA, 2018

FGC is classified into 4 major types.

Type 1:  this is the partial or total removal of the clitoral glans (the external and visible part of the clitoris, which is a sensitive part of the female genitals), and/or the prepuce/ clitoral hood (the fold of skin surrounding the clitoral glans).

Type 2:  this is the partial or total removal of the clitoral glans and the labia minora (the inner folds of the vulva), with or without removal of the labia majora (the outer folds of skin of the vulva ).

Type 3: Also known as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoral prepuce/clitoral hood and glans (Type I FGM).

Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

De-infibulation refers to the practice of cutting open the sealed vaginal opening of a woman who has been infibulated, which is often necessary for improving health and well-being as well as to allow intercourse or to facilitate childbirth (WHO, 2020c).

While you can see from the image below that ethnic and cultural groups which practice FGC are mostly located on the continent of Africa, the practice also takes place in other regions of the world including high-income countries such as the United States, Canada, Australia and countries across Europe.

Immediate complications from this procedure can include:

• Severe pain
• Excessive bleeding (haemorrhage)
• Genital tissue swelling
• Fever
• Infections e.g., tetanus
• Urinary problems
• Wound healing problems
• Injury to surrounding genital tissue
• Shock
• Death.

Long-term complications can include:

• Urinary problems (painful urination, urinary tract infections);
• Vaginal problems (discharge, itching, bacterial vaginosis and other infections);
• Menstrual problems (painful menstruations, difficulty in passing menstrual blood, etc.);
• Scar tissue and keloid;
• Sexual problems (pain during intercourse, decreased satisfaction, etc.);
• Increased risk of childbirth complications (difficult delivery, excessive bleeding, caesarean section, need to resuscitate the baby, etc.) and newborn deaths;
• Need for later surgeries: for example, the sealing or narrowing of the vaginal opening (Type 3) may lead to the practice of cutting open the sealed vagina later to allow for sexual intercourse and childbirth (deinfibulation). Sometimes genital tissue is stitched again several times, including after childbirth, hence the woman goes through repeated opening and closing procedures, further increasing both immediate and long-term risks;
• Psychological problems (depression, anxiety, post-traumatic stress disorder, low self-esteem, etc.).

The reasons why female genital cuttings are performed vary from one region to another as well as over time, and include a mix of sociocultural factors within families and communities. 

The most commonly cited reasons for performing FGC are:

• Where FGC is a social norm, the social pressure to conform to what others do and have been doing, as well as the need to be accepted socially and the fear of being rejected by the community, are strong motivations to perpetuate the practice. In some communities, FGC is almost universally performed and unquestioned.
• FGC is often considered a necessary part of raising a girl, and a way to prepare her for adulthood and marriage.
• FGC is often motivated by beliefs about what is considered acceptable sexual behaviour. It aims to ensure premarital virginity and marital fidelity. FGC is in many communities believed to reduce a woman’s libido and therefore believed to help her resist extramarital sexual acts. When a vaginal opening is covered or narrowed (Type 3), the fear of the pain of opening it, and the fear that this will be found out, is expected to further discourage extramarital sexual intercourse among women with this type of FGC.
• Where it is believed that being cut increases marriageability, FGC is more likely to be carried out.

• FGC is associated with cultural ideals of femininity and modesty, which include the notion that girls are clean and beautiful after removal of body parts that are considered unclean, unfeminine or male.
• Though no religious scripts prescribe the practice, practitioners often believe the practice has religious support.
• Religious leaders take varying positions with regard to FGC: some promote it, some consider it irrelevant to religion, and others contribute to its elimination.
• Local structures of power and authority, such as community leaders, religious leaders, circumcisers, and even some medical personnel can contribute to upholding the practice. Likewise, when informed, they can be effective advocates for abandonment of FGC.
• In most societies, where FGC is practised, it is considered a cultural tradition, which is often used as an argument for its continuation.
• In some societies, recent adoption of the practice is linked to copying the traditions of neighbouring groups. Sometimes it has started as part of a wider religious or traditional revival movement.

Critiquing the international representation of and response to FGC: a fight that is making it worse?

In this section of reading, think back to our conversations about the representation of ‘other’ cultures and contexts by western countries and institutions. 

As noted above, in discussing FGC in this way we are not as authors and scholars endorsing or advocating for the continuation of FGC. However, we are asking students to look critically at the international response to FGC. Ask yourself:

• How is the framing of FGC by the international community representing ‘other’ cultures?
• How is this representation rooted in colonialism, racism and the colonial view of ‘others’ as less than colonizing countries?
• Is the international community’s framing and fight against FGC actually working to end the practice and improve the rights, health and safety of women and girls around the world?

Since the 1990s, actors from across the international community have condemned the practice of FGC as ‘wrong’ and a violation of human rights. These actors include international NGOs, the United Nations, the WHO and governments and have campaigned to end the practice of FGC through education and laws which criminalize the practice.

However, though recent data shows that in many contexts fewer younger women are undergoing FGC than in previous generations, FGC is still prevalent in many countries throughout the world and is a practice increasing in prevalence in countries such as the United States, Canada and European nations.

There is a growing body of literature from scholars and activists in contexts where FGC is practiced and from the west which questions the effectiveness of criminalizing FGC/M and the risks of condemning the practice without understanding its deeper histories, its cultural significance and the power dynamics surrounding the debate. 

This group of scholars and activists believes that “the existing narrative on FGC has been punitive and indifferent to the historical and cultural processes that construct and inform the practice” and relies on colonial representations of ‘other’ cultures as “primitive”, “savage” and opposed to human rights  (Werunga, Reimer-Kirkham and Ewashen, 2016; Sanogo and Pusumane, 2021). 

Most importantly, despite years of strong campaigning against the practice, there is evidence that this approach to stopping FGC is actually making the practice continue underground or by medical providers (Seleina Parsitau, 2018). If parents or health professionals who perform the procedure are afraid to seek health services for their daughters if they have health complications from the procedure, laws that criminalize FGC could actually put women and girls at greater risk of long-term complications and death from the practice.

It is undebatable that there is no medical justification for this procedure and the procedure puts young girls and women at risk for a number of physical health complications, including death, as well as emotional and psychological trauma. We can accept this and agree that women and girls should not be hurt or die from avoidable causes. 

As Global Health actors we can also, however, recognize the importance of understanding the socio-cultural context of this practice in order to better address it. This includes further decolonizing narratives and representations of ‘other’ cultures by westerners from colonial times through the present day.

We unfortunately do not have enough time in this course to fully work our way through this important conversation. However, you are highly encouraged to read the optional resources listed below if you want to engage further in this dialogue and international debate.

The first video clip below offers different perspectives from individuals within a community that practices FGC. 

The second video is an example of the ways in which the international community has framed FGC. It is informative about the prevalence of the practice, however we encourage students to think about how this framing of FGC represents the cultures that continue to practice FGC. How are women and girls who undergo the practice represented? And who is doing the storytelling here?

The authors of this text also want to note that they do not support the title of this second video — The Truth about Female Genital Mutilation — as it suggests that there is one ‘true truth’ about this topic and leaves little room for discussion or contextualization. In addition, as discussed above as well, the labeling of this practice as ‘mutilation’ communicates a particular message about this practice and the women and girls who have undergone it.

One takeaway message from this reading should be that there is no one ‘truth’ about FGC/M; there are many perspectives to consider in this conversation about the practice in order to address it in a way that actually advocates for the rights, health and safety of the women and girls who live in contexts where the practice is prevalent.

As Sanogo and Pusumane wrote: “The main question is how do we establish an ethical space of listening and what do we do with marginalised voices of women who are demonized for believing in [FGC]?” (2021).

As Global Health actors we can both recognize the potential and very serious harm, including death, this practice can cause to women and girls, while also understanding how the western framing of FGC since colonial times has and continues to represent (mostly) African cultures in particular ways that justified and continue to justify the west ‘fixing’ Africa.

Violence against women

Note: The following section adapted from WHO: Violence against women (2021g). https://www.who.int/news-room/fact-sheets/detail/violence-against-women

WHO estimates that globally about 1 in 3 — or 30% of women — worldwide have been subjected to either physical or sexual violence in their lifetime. Think about that for a moment: there is a good chance that for every 3 women you know, at least 1 of them has experienced or will experience violence in their lifetime. 

Violence against women is a major Public and Global Health problem, prevalent in all countries around the world, and is a violation of women’s human rights. 

The United Nations defines violence against women as any act of gender-based violence that results in, or is likely to result in, physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.

WHO, 2021g

Intimate partner violence refers to behaviour by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviours.

WHO, 2021g

Sexual violence is “any sexual act, attempt to obtain a sexual act, or other act directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting. It includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part or object, attempted rape, unwanted sexual touching and other non-contact forms.”

WHO, 2021g

Over a quarter of women aged 15-49 years who have been in a relationship have been subjected to physical and/or sexual violence by their intimate partner at least once in their lifetime (since age 15). 

As the graphic below demonstrates, violence against women is not a human rights violation that is limited to particular regions, countries or incomes — violence against women is a Global Health challenge.

Globally as many as 38% of all murders of women are committed by intimate partners. In addition to intimate partner violence, globally 6% of women report having been sexually assaulted by someone other than a partner, although data for non-partner sexual violence are more limited. 

While intimate partner and sexual violence can be perpetrated by women or men, intimate partner and sexual violence are mostly perpetrated by men against women.

Risk Factors for Intimate Partner Violence

Lockdowns during the COVID-19 pandemic and its social and economic impacts have increased the exposure of women to abusive partners and known risk factors, while limiting their access to services. Situations of humanitarian crises and displacement may exacerbate existing violence, such as by intimate partners, as well as non-partner sexual violence, and may also lead to new forms of violence against women.

Intimate partner and sexual violence is the result of factors occurring at individual, family, community and wider society levels that interact with each other to increase or reduce risk (protective). Some are associated with being a perpetrator of violence, some are associated with experiencing violence and some are associated with both.

Risk factors for both intimate partner and sexual violence include:

• lower levels of education (perpetration of sexual violence and experience of sexual violence);
• a history of exposure to child maltreatment (perpetration and experience);
• witnessing family violence (perpetration and experience);
• antisocial personality disorder (perpetration);
• harmful use of alcohol (perpetration and experience); 
• harmful masculine behaviours, including having multiple partners or attitudes that condone violence (perpetration);
• community norms that privilege or ascribe higher status to men and lower status to women; 
• low levels of women’s access to paid employment; and
• low level of gender equality (discriminatory laws, etc.).

Factors specifically associated with intimate partner violence include:

• past history of exposure to violence;
• marital discord and dissatisfaction;
• difficulties in communicating between partners; and
• male controlling behaviours towards their partners.
• Factors specifically associated with sexual violence perpetration include:
• beliefs in family honour and sexual purity;
• ideologies of male sexual entitlement; and
• weak legal sanctions for sexual violence.
• Gender inequality and norms on the acceptability of violence against women are a root cause of violence against women.

Health Consequences for Women

Intimate partner (physical, sexual and psychological) and sexual violence cause serious short- and long-term physical, mental, sexual and reproductive health problems for women. They also affect their children’s health and wellbeing. This violence leads to high social and economic costs for women, their families and societies. 

Such violence can:

• Have fatal outcomes like homicide or suicide.
• Lead to injuries, with 42% of women who experience intimate partner violence reporting an injury as a consequence of this violence.
• Lead to unintended pregnancies, induced abortions, gynaecological problems, and sexually transmitted infections, including HIV. 
• Intimate partner violence in pregnancy also increases the likelihood of miscarriage, stillbirth, pre-term delivery and low birth weight babies. 

These forms of violence can lead to depression, post-traumatic stress and other anxiety disorders, sleep difficulties, eating disorders, and suicide attempts. 

Health effects can also include:

• headaches
• pain syndromes (back pain, abdominal pain, chronic pelvic pain) 
• gastrointestinal disorders
• limited mobility and 
• poor overall health.

Sexual violence, particularly during childhood, can lead to: 

• increased smoking
• substance use, and 
• risky sexual behaviours. 

It is also associated with perpetration of violence (for males) and being a victim of violence (for females).

Further impacts: social and economic costs including costs to children

Children who grow up in families where there is violence may suffer a range of behavioural and emotional disturbances. These can also be associated with perpetrating or experiencing violence later in life.

Intimate partner violence has also been associated with higher rates of infant and child mortality and morbidity (through, for example diarrhoeal disease or malnutrition and lower immunization rates).

The social and economic costs of intimate partner and sexual violence are enormous and have ripple effects throughout society. Women may suffer isolation, inability to work, loss of wages, lack of participation in regular activities and limited ability to care for themselves and their children.

Prevention and response

There is growing evidence on what works to prevent violence against women, based on well-designed evaluations. Informed by this data, there are a range of interventions in low and high resource settings with varying degree of evidence of effectiveness to prevent violence against women. 

Examples of promising interventions include:

• psychosocial support and psychological  interventions for survivors of intimate partner violence
• combined economic and social empowerment programmes
• cash transfers
• working with couples to improve communication and relationship skills
• community mobilization interventions to change unequal gender norms 
• school programmes that enhance safety in schools and reduce/eliminate harsh punishment
• school programmes that include curricula that challenges gender stereotypes and promotes relationships based on equality and consent and 
• group-based participatory education with women and men to generate critical reflections about unequal gender power relationships.

To achieve lasting change, it is important to enact and enforce legislation and develop and implement policies that promote gender equality; allocate resources to prevention and response; and invest in women’s rights organizations.

Looking forward: Policy and action to advance women’s health and gender equality

In 1995, the Beijing Declaration and Platform for Action on Women during the Fourth World Conference on Women was a landmark global policy framework to promote the human rights of women and girls and gender equality (BMJ, n.d.). 

During this conference, the world affirmed that the protection of the human rights of women and girls and gender equality were and are a prerequisite for women’s health and wellbeing. Think back to some of the health challenges we discussed above; how many of the health challenges women face around the world in high-, middle- and low-income countries would be improved if women and girls could exercise their full rights and autonomy over their bodies and health?

Watch this inspiring recap of that historic conference, which solidified women and girls’ sexual and reproductive rights as inherently human rights on a global level.

Over the past 25 years there has been important progress in several areas of women’s health. However, as we explored above, gender discrimination, bias and inequalities in women’s health persist. There are also new and emerging threats to women’s health (BMF, n.d.). 

The COVID-19 pandemic is one such threat disproportionately impacting women’s health and social and economic wellbeing in the immediate and long-term (BMJ, n.d.). 

While COVID-19 mortality rates are higher among men than women, women are bearing the brunt of COVID-19’s social and economic consequences (WHO, 2021e).

At home during lockdowns, women pick up the lion’s share of unpaid care responsibilities, from childcare to looking after the sick and the elderly. Vital health and support services targeting women and girls have been severely disrupted, while reports of domestic violence have increased. Pregnant women have been specifically excluded from many treatment and vaccine trials (WHO, 2021e).

This cannot continue. Women and girls have specific and diverse health needs which must be met now, and they have equal rights to participate in, and benefit from, global recovery efforts in a post-pandemic world (WHO, 2021e).

Challenges remain for women globally and new ones continue to arise. Women often face multiple forms of discrimination and marginalization, visible in pay gaps, especially in the health workforce; the prevalence of violence against women and gender-based violence, including harassment; and limited access to opportunities such as education, employment and decision-making. Women of specific ethnic origins, women living with disabilities, trans women and migrant women face specific and unique challenges and marginalization impacting their health and wellbeing. Meaningful investment in, political commitment to and prioritization of urgent issues affecting women, their health, leadership and gender justice – like gender equality, reproductive health and violence against women – are still lacking (WHO, 2021c).

But, advances have been made in: 

• recognizing the importance of women as healthcare providers and leaders in global health;
• reducing maternal mortality worldwide and barriers women face in accessing quality health services; 
• improving understanding of how risk factors for communicable and non-communicable diseases affect women differently; 
• the development of medical abortion methods has also contributed to a reduction in the number of unsafe abortions, saving thousands of women’s lives. 

Supporting feminist movements to hold governments accountable and drive change in communities while applying a human rights-based approach is essential to continue advancing the health and well-being of women everywhere, in all their diversity.

The Women’s Health and Gender Inequalities series articulates a forward-looking agenda towards:

Supplementary Resources

1. Stefanick, M. L., & Schiebinger, L. (2020). Analysing how sex and gender interact. The Lancet, 396(10262), 1553-1554. Available at: https://bookcafe.yuntsg.com/ueditor/jsp/upload/file/20201224/1608786935844026978.pdf 

2. Gender as a Social Determinant of Health MUN: https://youtu.be/il_PPiaPiPw

3. LCGGH: Gender Equality, Norms and Health: https://youtu.be/0sHSzQw6Co4

4. The problem with sex and gender in health: Katrien Vanderheyden at TEDxUHowest:

5. The World Health Organization (WHO), the United Nations Special Programme HRP and the United Nations University International Institute for Global Health (UNU-IIGH) in partnership with the British Medical Journal (BMJ), have released a special series of papers on “Women’s Health and Gender Inequalities.”

The series celebrates and interrogates collective progress towards making the 1995 Beijing Declaration and Platform for Action on Women a reality for all women and girls everywhere, in all their diversity. As well as analyzing past successes and evidence-based strategies to advance women’s health and gender equality, the series reflects on new and emerging threats. This includes COVID-19, which has exacerbated existing inequities, with reports of rising violence against women, as well as higher adverse economic impacts caused both by increased unpaid care-giving and the fact that women work in more insecure, low-paid and informal jobs.

In addition, three episodes of The BMJ Podcast are dedicated to the special series.

Through intergenerational dialogues and between feminist advocates, researchers, health professionals, and policy makers, the podcast creates an informed and inspiring space to explore progress in several areas of women’s health but also to examine why still not one country can claim to have achieved gender equality.

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