As health systems researchers and policymakers we need to remember that the word “gender” is not synonymous with “woman.” Gender analysis is about exploring how gendered power relations (eg. norms, roles, access to resources, decision-making) affect differences in health system experiences, access, and outcomes for men, women, and people of other genders. Gender therefore affects everyone. While unequal gender relations and norms mean that women as a group are often in a more marginalized and vulnerable position, resulting in disproportionate health outcomes, gender also has a significant effect on men’s health.
The effect of gender roles and norms on men’s health
Worldwide, men’s life expectancy remains lower than women’s. Key factors contributing to this include poor health seeking behaviors of men compared to women resulting from an interplay of factors of masculinity and workforce participation that drives men to ignore health issues. In Sri Lanka, this poor health seeking behavior has manifested in lower rates of utilization of non-communicable disease screening facilities provided through healthy lifestyle centers. Making services more inclusive by extending them to workplaces can make access easier for men. Men are also more at risk of dying due to alcohol and smoking related diseases. The prevalence of use of both substances remains significantly lower among women. In Sri Lanka, for example, according to the STEPS Survey of 2015, the prevalence of current smoking among males was 29.4% and only 0.1% among females. Regarding alcohol consumption, 34.8% of males were current drinkers and only 0.5% of the females were current drinkers. It is clear that the use of these substances negatively impact on the health of men; targeted programs are necessary to provide assistance to quit their addictive behaviors. Research has shown that the top ten causes of ill-health affect men more than women.
In many contexts, the social and economic roles performed by men and women are different, and therefore the health risks they are exposed to over their life course differ. The intersection between gender, economic power, and social roles, for example, are contributing to different health outcomes between men and women. What this means is that men’s health is often more affected by working conditions, violence, and smoking, while women’s health is often more influenced by the burdens of caregiving to different generations with paid work and housekeeping.
The role of discourse in men’s health
In addition to considering how gender roles and norms affect men’s health, it is also important to consider the role of the language and how men are perceived by different actors. Actions and discourse of health service providers, managers, policy makers, and researchers, for example, can negatively affect men. Because we often fall into the trap of talking about women as victims who are acted upon, and men as agents who act, we often fail to recognize that the social forces that expose women to health risks (patriarchal gender norms that limit the possibilities for women’s agency) act equally on men, and equally constrain their choices. Even when the effect on these forces on men is recognized, the discourse fails to reflect it.
This discourse is a result of a gendered worldview in which men are afforded power and agency, but also, therefore, considered as perpetrators and risk-takers, and inappropriate subjects for sympathy, care and support. In other words, men are subject to social and cultural forces which make it difficult for them to protect themselves from risk without jeopardizing their masculine identities, but are also disadvantaged by global and national (often patriarchal) discourse that fails to consider them as victims acted upon by cultural and systemic forces. In Ghana, for example, public discourse on domestic violence often highlights men as perpetrators rather than victims. Data from the Domestic Violence and Victims Support Unit (DOVVSU), however, shows that a significant number of men have been abused by their wives. 2,807 men reported domestic abuse cases against their wives in 2015, while 3,143 reported domestic abuse in 2014 (Domestic Violence and Victims Support Unit Report, 2015).
It is important that we consider discourse in relation to how health services are provided. In South Africa, despite substantial evidence of the poor treatment outcomes of men with HIV, men are still neglected as a key-population for HIV interventions, in local and global treatment guidelines and funding opportunities. Because maternal and child health (MCH) constitutes a window of opportunity to initiate HIV testing and care, many HIV and sexual and reproductive health (SRH) services are provided in MCH contexts – contexts in which men might feel unwelcome or uncomfortable. In addition, most health services are provided by women, further alienate men who feel uncomfortable discussing sex with women. In South Africa, this phenomenon is exacerbated by the politicization of the sexuality of men (particularly black men) who, in the context of the HIV pandemic and racist social structures that are the legacy of apartheid, are considered as spreaders of disease and perpetrators of sexual violence. The vulnerabilities that are a result of these intersecting forces is further exacerbated by the poverty and inequality that affect such a large proportion of the South African population.
Health policy makers need to start considering the challenges men face in accessing care, for example by making health facilities more male friendly – distinguishing men’s SRH services from MCH services, and keeping health facilities open later so that men who work can still access them – as well as by explicitly recognising the needs and vulnerabilities of men in the discourse used in policy documents. In addition, the discourse we use matters, because it can undermine or reinforce pervasive paradigms of understanding. As health researchers, we need to be careful in the language we use, and encourage policy makers to do the same.
Note: This blog is based on an online discussion about gender in health systems with 14 members of the new cohort of the Emerging Voices. The blog presents reflections made during those discussion.