Gender norms as health harms: reclaiming a life course perspective on sexual and reproductive health and rights

Abstract

Despite their demographic significance and the lifetime impact of gender disparities on their health and rights, women considered older than reproductive age are excluded from most investments in global public health. While development policies linking human rights with access to sexual and reproductive healthcare have yielded progress towards improving the status of women and girls, older women have not benefited from these initiatives. Yet as women grow older, they experience a range of health conditions rooted in their reproductive biology – from ageing with fistula, to cervical and breast cancers. Current approaches to global women’s health ignore these serious conditions, harming older women through the perpetuation of gender norms that construe women’s health through a narrow reproductive lens. Meanwhile, older women are generally absent from global ageing discourse, which lacks a gender perspective, creating a dual invisibility as the field of global women’s health presumes ageing women are accounted for. Reclaiming the sexual rights framework suggested by the International Conference on Population and Development and the Beijing Platform for Action, we call for the revision of global health policies to incorporate a life course approach to women’s health as a matter of human rights.

Resumé

En dépit de leur importance démographique et de l’impact des disparités sexuelles sur leur santé et leurs droits tout au long de leur vie, les femmes qui ne sont plus jugées en âge de procréer sont exclues de la plupart des investissements en santé publique dans le monde. Alors que les politiques de développement liant les droits de l’homme à l’accès aux soins de santé sexuelle et génésique ont permis de progresser vers une amélioration de la situation des femmes et des filles, les femmes âgées n’ont pas bénéficié de ces initiatives. Pourtant, à mesure que les femmes prennent de l’âge, elles connaissent une série de pathologies ancrées dans leur biologie procréative – depuis le vieillissement avec une fistule, jusqu’aux cancers du col de l’utérus et du sein. Actuellement, les approches internationales de la santé des femmes ignorent ces pathologies graves, ce qui lèse les femmes âgées par la perpétuation de normes sexuelles qui interprètent la santé féminine dans une optique génésique étroite. Dans le même temps, les femmes âgées sont en général absentes du discours international sur le vieillissement, auquel une perspective sexospécifique fait défaut, créant ainsi une double invisibilité, puisque le domaine de la santé des femmes dans le monde suppose que les femmes vieillissantes sont prises en compte. Revendiquant le cadre de droits sexuels proposé par la Conférence internationale sur la population et le développement et le Programme d’action de Beijing, nous demandons la révision des politiques internationales de santé pour y inclure une approche des droits fondamentaux des femmes axée sur le parcours de vie.

Resumen

A pesar de su importancia demográfica y el impacto de las disparidades de género en su salud y derechos a lo largo de su vida, las mujeres consideradas mayores que aquéllas en edad reproductiva son excluidas de la mayoría de las inversiones en salud pública mundial. Aunque las políticas de desarrollo que vinculan los derechos humanos con el acceso a los servicios de salud sexual y reproductiva han logrado avances hacia mejorar la condición jurídica y social de mujeres y niñas, las mujeres mayores no se han beneficiado de estas iniciativas. Sin embargo, a medida que las mujeres envejecen, experimentan una variedad de problemas de salud arraigados en su biología reproductiva: desde envejecimiento con fístula, hasta cáncer cervical y cáncer de mama. Los enfoques actuales en salud global de la mujer hacen caso omiso de estos graves problemas, lo cual perjudica a las mujeres mayores al perpetuar normas de género que interpretan la salud de la mujer desde una estrecha perspectiva de la salud reproductiva. Mientras tanto, las mujeres mayores generalmente están ausentes del discurso mundial sobre el envejecimiento, que carece de una perspectiva de género, lo cual crea doble invisibilidad ya que el campo de salud global de la mujer supone que las mujeres que envejecen son incluidas. Reclamando el marco de derechos sexuales sugerido por la Conferencia Internacional sobre la Población y el Desarrollo y la Plataforma de Acción de Beijing, hacemos un llamado a modificar las políticas de salud global para incorporar un enfoque de ciclo de vida con relación a los derechos humanos de las mujeres.

Keywords:

• life course
• older women
• sexual rights
• reproductive health
• sustainable development

Introduction

“Women’s right to the enjoyment of the highest standard of health must be secured throughout the whole life cycle [emphasis added] in equality with men.” ¹ These words form paragraph 92 of the Beijing Declaration and Platform for Action (hereafter ‘Beijing’), drafted by leaders for women’s human rights at the Fourth United Nations World Conference on Women in 1995. Last September, gender advocates in the field of global development celebrated the twentieth anniversary of Beijing as a call to action for the integration of issues impacting women and girls, including sexual and reproductive health and rights, across the 17 Global Goals forming the Sustainable Development Agenda 2030 conferred by the 70^th United Nations General Assembly. The basic right of women and girls to exercise decision-making control over their bodies through universal access to services for sexual and reproductive health is a core theme of Goals 3 and 5, which advocates successfully urged despite heavy resistance from many member states. ^2,3 Sadly, the very gender norms that almost derailed the inclusion of sexual and reproductive health and rights in the 2030 Agenda are the same limiting constructs of female sexuality and womanhood that prevail in today’s global public health and development discourse, programmes, and policies, leaving behind nearly one-quarter of the world’s women.

What do we mean by this? In 2016, women aged 50 and older comprise 23.6% of the global female population. ⁴ Despite their demographic significance, these women remain largely excluded from investments in global public health – including important action on gender-based violence and access to sexual healthcare that construes women’s health through a strictly reproductive lens. ⁵ Although Beijing underscored a life cycle approach to women’s health and rights, the reality is that, in the context of global development, women’s “right to the enjoyment of the highest standard of health” is limited to our years of reproductive functioning (at best). The arguments for this omission – characterized as a focus on younger women and girls, rather than intentional exclusion – are buttressed by compelling data points, such as: 1) the alarming incidence of new HIV infection in women and girls ages 15 to 24; 2) that reported prevalence of sexual violence is highest among women and girls between the ages of 18 and 34; and, 3) that an unacceptably high number of mothers continue to die, or become disabled, during childbirth, due to inadequate resourcing of maternal healthcare. ^6–8 While each of these distinct, yet overlapping challenges requires concerted action, investment and advocacy, at their root is a widely held normative construction of womanhood that is predicated on reproductive capacity.

We argue that a comprehensive recognition of women’s human rights must be approached through a life course perspective. In global public health, this approach acknowledges how earlier trauma and barriers to wellness, such as acquiring HIV, experiencing sexual violence, or enduring disrespect and abuse in childbirth, will impact a woman’s quality of life as she grows older. A life course perspective also engenders the awareness that many older women choose to be sexually active past their ability to have children,* and therefore continue to have sexual health needs. So long as women’s health in the context of global development is concentrated on reproductive activity, only women of a certain age cohort will have access to services and care, making the right to bodily autonomy unfilled, for it expires with the onset of infertility. In a world where girls’ bodies are prematurely sexualized and women’s reproductive capabilities policed and controlled, it comes as little surprise that ageing female bodies are rendered nearly invisible. This paper contends that the exclusion of older women in global women’s health is a consequence of prevailing gender norms. Rather than reorienting development strategies towards ageing populations, we call for the inclusion of older women in expanded investments, research and data collection, policies and programmes for reproductive and sexual healthcare.

Rights disparities across the life course: why ageing is not gender-neutral

Across the life course, women are more likely to: be poor; experience violence; have higher rates of illiteracy and innumeracy; acquire a disability; and lack access to adequate nutrition and healthcare. ⁹ These disparities persist throughout women’s and girls’ lives and, more often than not, intensify with older age. ⁹ For example, gendered expectations of caregiving underpin women’s lesser access to remunerated employment, amounting to fewer opportunities for independent savings that must be stretched over a longer period of time into older age, as women tend to live longer than men. ¹⁰ Poverty in older age is also linked to the greater likelihood for women than men of living alone, which in turn exacerbates their risk for exploitation, violence, and abuse. ¹¹ Although the experience of ageing varies by cultural and regional contexts, the unequal conditions of older women compared to older men are rooted in gender disparities that transcend geography. Further, older women living in low- and middle-income countries comprise the majority of today’s ageing population. ¹² Despite these facts, global development discourse, research, and programming for women’s health is concentrated on younger populations considered to be at or near reproductive age, as most clearly evidenced by the 15-49 ^† age range found in globally comparable data sets monitoring issues such as GBV and HIV. Because what does not get measured does not get counted, the health status and life experiences of women aged 50 and older are absent from most foreign aid expenditures, resulting in a lack of tailored programming and policy.

Similarly, the unique concerns and experiences of older women are inadequately addressed by the small range of public health discussions on sexuality and ageing, which have been largely limited to a clinical focus on functional decline. ¹⁵ And yet, let’s be frank: older women have and enjoy sex. ^16,17 It is well-documented that, when asked, middle-aged and older women express high levels of concern and want information for their sexual health. ¹⁸ Yet, few health systems encourage the collection of this patient data, nor does public health research address this population as a priority. ¹⁹ Throughout the world, primary care providers fail to address the sexual health concerns of older women, even though they affirm a specific desire for their providers to speak to them about it. ¹⁹ Given the hesitation among researchers and practitioners to extend their work to include older populations, sexuality, sexual behaviour, and sexual health in older age is characterized in entirely medical terms, without attention to the social landscape of ageing. ^20,21 As a result, there is little recognition of how gender disparities impact the experience of growing older, eschewing the need for older women to claim a significant role in the movement to advocate for sexual and reproductive health and rights. This creates a dual invisibility for older women in development, as the field of women’s global health presupposes gender differences are addressed by the field of global ageing.

Mainstreaming a sexual rights framework in development policy will be critical to address the health and rights of older women, and although this framework is gaining traction, consensus has not been reached on full acknowledgement of sexual rights as human rights grounded in international law. While there are numerous working definitions of sexual rights, including one by the United States Government, we find the definition outlined in the World Association for Sexual Health (WAS) 2014 Declaration of Sexual Rights to be the most inclusive. ²² The Declaration comprehensively and affirmatively defines sexual rights, including reproductive rights, and the right to pursue a satisfying, safe, and pleasurable sexual life, for people of all ages, abilities, gender identities and sexual orientations.

“Beyond reproduction” but not reproductive age – how gender norms harm the health of older women

One of the chief barriers to the inclusion of older women in global public health is that “women’s health” has become virtually synonymous with maternal and child health as well as family planning. While this focus on reproduction is problematic for its clear exclusion of women who do not bear children – either by circumstance or by choice – it has also cast an influence on the treatment of other women’s health issues, bypassing older women through a normative emphasis on women and girls of reproductive age. For example, a 2005 study from the Initiative for Cardiovascular Health Research in Developing Countries underscored the urgent need to address the rising mortality of women from non-communicable diseases (NCDs). ²³ Their research on cause of death for women aged 15 and 44 across nine low- and middle-income countries demonstrated that NCDs “significantly overshadowed reproduction and HIV,” leading the study’s authors to advocate for a shift towards increasing investments in women’s health outside of maternal health and family planning. ²³ Still, by the authors’ own admission, they limited their study to only those age groups “…on which most of the conventional attention to women’s health is concentrated.” ²³ It is striking that research published with the stated goal of challenging the conventional approach to defining women’s health in reproductive terms failed to even mention women past reproductive age. Adding to this dismay is the fact that older women comprise a majority of those living with (and caring for persons with) chronic disease globally; ^‡ still, they remain unseen in the international development and health discourse.

Raising the issue that women’s health needs to encompass more than sexual and reproductive health is an important step towards widening the scope of gender-responsive development policy. At the same time, it is crucial to maintain a focus on sexual and reproductive health so that older women (and other marginalized groups of women, such as those with disabilities, and lesbian, bisexual, and trans women), who continue to have a need for these services but are scarcely able to access care, are finally included in this agenda. This means expanding sexual and reproductive health programming and policies, guided by a sexual rights framework as an alternative to current approaches centered on strict delineations of when reproductive function starts and stops. ^§ Throughout the world, women’s bodies are not identical; as such, some women will continue to be able to bear children past “reproductive age” and therefore require care. For example, a 2013 study in Botswana found that a small percentage of women over the age of 50 continued to use family planning and some still wanted a future pregnancy, but that services targeted younger women and therefore discouraged – sometimes explicitly, through negative provider attitudes and assumptions – older women from seeking care. ¹⁹ In China, strict limits on eligibility for government-administered family planning programmes – the only healthcare accessible to most of China’s rural women – excludes women over the age of 50 from receiving free sexual and reproductive health services. Drawing an arbitrary line on when one can receive healthcare, and what for, has resulted in serious harms for Chinese women. Some cited a need for removal of intrauterine devices (IUDs) inserted when they were younger, but that they could no longer afford the services as they had aged out of state-financed care. These women have unmet needs for sexual and reproductive health services, including physical exams, and reproductive tract infection treatment. ¹⁸

It is important to remember also that most of today’s older women did not have access to comprehensive sex education in their youth. Until the 1994 International Conference on Population and Development in Cairo, the concept of teaching about sexuality, sexual behaviour, and health was not articulated as a core component of reproductive rights or policy. ²⁵ While sex education rose in prominence in the early 20^th century, it was not universally embraced and, like today, many women did not have access to programming. ²⁶ The inclusion of comprehensive sex education remains elusive in many parts of the world, with women and girls (and men and boys), particularly those in low- and middle-income countries, still left without access to information about healthy sexuality. ²⁷ What is more, high rates of illiteracy and low rates of formal school completion among older women in developing countries translate to a significant barrier for seeking sexual and reproductive health services. ^19,28 This double obstacle – the combined lack of knowledge of sexual and reproductive health issues with low levels of literacy among older women – has been shown to significantly undermine their engagement with providers. Nevertheless, though they have been deprived of the opportunity to learn about their bodies and sexuality, older women express significant interest in obtaining these services, and reproductive health systems are well-positioned to help women with their sexual life post-menopause. ^19,29

Integrating GBV with reproductive health: why a targeted approach is needed

In addition to failing to provide older women with the sexual and reproductive healthcare they require, this focus on younger women’s reproductive health can bring unintended harms to ageing women survivors of violence. Increasingly, innovations in public health have encouraged integrated service models, combining interventions for gender-based violence (GBV) with maternal health, and family planning services; ^** while these integrated services are important points of connection to care for younger women, without additional, targeted outreach, they threaten to discourage help-seeking among older women. In low-resource settings, such as rural areas in low- and middle-income countries, the only health center within miles of a woman’s home may be a maternal health clinic. If that clinic is also the only site for GBV services, it is unlikely for an older survivor to consider this setting as a source of support, for a variety of factors. In addition to provider stigma and discrimination towards older patients discouraging help-seeking, many older women (particularly those without a basic education), will see that younger women frequent the facility and view that as a sign the service is not for them. ¹⁹ This disconnect between the needs of older women experiencing violence and the availability of appropriate victim services has been well documented in high-income, western countries, ³¹ but further research is needed on the extent to which ageing survivors in low- and middle-income regions lack access to interventions based on an integrated maternal health or family planning and GBV service model. It is well-established that women aged 50 and above experience significant acts of violence, including sexual violence during conflict, ^†† and a narrow framework for women’s health that centers on reproduction risks excluding older survivors from resources for healing.

In regions with customary practices regarding the treatment of widows, there are far-reaching implications for the sexual health and rights of older women that warrant a re-evaluation of integrated service models lacking additional outreach to women past reproductive age. Research on Ugandan women widowed by HIV in the Buganda community reveals that many are denied autonomy and exposed to violence through a form of levirate marriage. Following the death of their husbands, women are “passed on” to a mukuza (an appointed male guardian) pre-arranged by her spouse, assuming a subordinate role similar to that of a wife, but occupying a lower status. ³³ According to this practice, the mukuza is entitled to repayment – in the form of sex, or household labor – in exchange for his assuming financial responsibility for a widow and her children. ³³ Because of the stigma associated with widowhood resulting from HIV, these women are considered fortunate to be taken in by a mukuza; however, a widow’s submission means she has no ability to make decisions of her own, including those related to sexual and reproductive health. This is an extension of patrilineal control over such decisions throughout women’s life course. These widows’ clear need for comprehensive sexual and reproductive healthcare, including testing for HIV, ^‡‡ and support for violence and abuse, represents a blind spot in prevailing development policies for women’s health.

The harm in conflating reproductive health with reproductive function

In addition to having sexual health needs, older women continue to experience physiological changes, including those that result in death and disease, which are rooted in their reproductive biology. Frustratingly, the myopic view of reproductive health as strictly limited to reproductive capacity has resulted in the harmful neglect of significant gynecological health and related challenges for women as they age. For older women who have undergone menopause, hormonal changes contribute to an increased risk of cardiovascular disease and osteoporosis, stemming from declining ovarian function occurring during perimenopause in middle-age. ^29,34 Ageing is also associated with reproductive tissue cancers, such as breast, ovarian, and cervical cancer – the latter of which is the second most common among women in less developed regions worldwide. ³⁵ Research has shown that screening for these cancers is a serious, unmet public health need for women globally, particularly in sub-Saharan Africa, Latin America, and South Asia. ²⁹ What is striking about older women’s reproductive health issues is that their incidence and degree of severity is fundamentally linked to women’s past access or lack thereof to pre and post-natal care. ^34,29 While current international focus is on preventing maternal morbidity, the absence of a life course perspective to women’s sexual and reproductive health and rights ignores the reality that most older women did not have access to such programmes during their childbearing years.

Many other reproductive health challenges among older women are derived from gender norms aimed at the control of adolescent girls’ sexuality and later, denial of agency determining the number and spacing of pregnancies and births. For example, repeated pregnancies and obstetric trauma in younger years can result in genital prolapse, creating debilitating chronic pain for women as they age. ³⁴ Female genital mutilation/cutting (FGM/C), a harmful practice in which part or all of a woman’s or girl’s external genitals are removed, dates back to before the Common Era (B.C.E.). An estimated 200 million women and girls living today have undergone FGM/C, yet there are no systematic reviews on the health of older women who have been cut, despite the robust evidence that vulvas change as women age. ^36,37 The particular health needs of this significant population of women is completely absent in research, policy and programming.

Older women’s right to positive sexual expression and pleasure

In addition to redressing harms associated with the neglect of older women’s sexual and reproductive health, we encourage attention to the positive expressions of sexuality among women beyond reproductive age. The majority of the people who have sex do so for pleasure, not procreation, and this remains the case as women age. Though the evidence base of sexuality in older age is limited, it is known that regular sexual activity is associated with good physical and mental health among ageing populations. ³⁸ Despite this knowledge, the vast majority of research in this area has focused on dysfunction, rather than on the positive aspects and potential benefits of older women’s sexuality. ¹⁵ Providers’ treatment of sexuality among older patients, and particularly older women, continues to be hampered by stereotypes that either negate ageing female sexual agency and desire, or disparage such behaviour. ^19,17 For its clear affirmation of the right to sexual pleasure and positive sexual expression in addition to the right to be free from harm through comprehensive access to care, the sexual rights framework is a critical approach for women’s sexual and reproductive health that warrants integration into existing and future global policies in this area. ²² Given how important data is to illuminating policy gaps influencing resource allocation, and informing programming, it will be fundamental for advocates to encourage using this framework to inform sexual and reproductive health indicators in monitoring the 2030 agenda and beyond.

Conclusion

The 2030 Agenda’s unprecedented recognition of women’s empowerment as a precondition for sustainable development offers an opportunity to revive the life course approach to women’s health and rights articulated decades ago. Rather than drawing boundaries between age cohorts of women and girls, the Beijing Platform for Action, and the International Conference on Population and Development, advocated a continuum of policies for maximizing women’s health and wellness across their life stages. ^1,25 While the Sustainable Development Goals have broadened conceptions of “who counts” in determining progress on gender-based violence, ^§§ targets for women’s sexual and reproductive healthcare take us a step backward by constraining indicators to access to family planning among women of reproductive age. ^2,3 The implications of this are far-reaching, and have already begun to perpetuate the exclusion of older women from emerging global public health agendas. As of writing, the World Health Assembly just voted on the “Operational plan to take forward the Global Strategy for Women’s, Children’s and Adolescents’ Health.” ³⁹ While we applaud Member States for supporting investments in this area, we are dismayed that as seemingly broad a term as “women’s health” continues to be used as a euphemism for health strictly related to reproductive function. Nowhere in this Strategy is there a mention of the reproductive health challenges that persist past women’s years of childbearing – nor any mention of older women, for that matter.

The Sustainable Development Agenda still holds great promise for extending a life course approach to women’s empowerment and health, provided Member States are to take seriously the call to “leave no one behind”, including capacity-building for inclusive data sets to inform policy, services and programmatic action. While the SDGs get many points right, we note that the lingering exclusion of adolescent girls below the age of 15 in indicators for gender-based violence and health is symbolic of the norms underlying the absence of indicators for sexual and reproductive health for older women past age 49. ^3,2 There continues to be discomfort with acknowledging sexuality outside of reproductive functioning, as manifested in the SDGs, and other avenues of global women’s health outlined earlier in this discussion. The full realization of comprehensive women’s health policies will only be possible once this discomfort is rejected, starting with alliances between advocates for the rights of girls, and stakeholders concerned with the inclusion of older women. This powerful coalition can champion the desperately-needed life course perspective in gender, health and development.

Notes

* (And/or choose to have sex with women).

† While the USAID Demographic Health Surveys (DHS) sample women ages 15-49, the World Health Organization defines reproductive age from 15-44. ^13,14

‡ Older populations have higher burdens of chronic disease; while all older adults experience similar rates of chronic disease, the greater longevity of women translates to their comprising highest overall rates of chronic disease globally. ²⁴

§ For example, the WHO definition of “reproductive age” – from 15-44, draws a somewhat arbitrary line, given that there are women and girls under the age of 15 and over the age of 44 with reproductive capabilities. ¹⁴

For example, in Guinea, USAID “will build on an existing maternal health project to decrease domestic violence by creating linkages between maternal and child health services and referrals to mission-supported legal clinics.” In India, USAID “will expand the use of mobile technology to identify and address intimate partner violence among female patients receiving family planning and prenatal care.” ³⁰

†† In the Democratic Republic of the Congo, for example, 15.5% of women seeking care for sexual violence in a South Kivu hospital between 2004 and 2008 were aged 55 and above. ³²

‡‡ In many low and middle-income countries, older persons are routinely excluded by HIV screening programmes while safe sex interventions are almost exclusively targeted to younger populations. As a result, older women, particularly those who are widowed or single, “may find it embarrassing or difficult” to procure condoms or to seek advice on safe sexual practices.” ¹⁵

§§ Goal 5 indicators 5.1.1 and 5.1.2 measure prevalence of intimate partner violence and non-partner sexual violence among women and girls aged 15 and older, respectively. ³