INTRODUCTION TO CONCEPTS AND TOOLS IN GENDER, FIGHTS DEVELOPMENT, AND HEALTH
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- INTRODUCTION TO CONCEPTS AND TOOLS IN GENDER, FIGHTS DEVELOPMENT, AND HEALTH
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Essential Readings
Compiled for
Short Course on
Gendered Research in Health
Baroda, March 6-18, 2006
Module 1
Introduction to Concepts and Tools in
Gender, Rights, Development, and Health
Women’s Health Training Research and Advocacy Cell
Women’s Studies Research Centre
The Mahraja Sayajirao University of Baroda
Vadodara
Contents
Page
Session 1: Patriarchy
Understanding Gender
Kamla Bhasin
1
Gender and Objectivity in Medicine
Barbara Ehrenreich
45
The 'Declining Significance' or the 'Changing Forms' of Patriarchy?
Sylvia Walby
49
'So you row, do you? You don't look like a rower.' An account of medical students'
experience of sexism
Sandra Nicholson
57
It Goes Without Saying: Voices of Women Medical Students
64
Sessions 2 and 3: What is Gender? Social Construction of Masculinity and
Femininity
Do Men Matter? New Horizons in Gender and Development
80
Men, Masculinities and Development: Broadening our Work towards Gender Equality
Alan Grieg, Michael Kimmel and James Lang
89
Masculinity, Femininity and Servitude: Domestic Workers in Calcutta in the Late
Twentieth Century
Raka Ray
124
How to Build a Man
Anne Fausto
141
Session 4: Locating Gender inequalities in Class and Caste
Daughters of Independence: Gender, Caste and Class in India
Joanna Liddle and Rama Joshi
146
Session 5: Concept of Development
Gender and Development: Concepts and Definitions
Hazel Reeves and Sally Baden
Third World Policy Approaches to Women in Development
Caroline Moser
203
The Meaning of Women's Empowerment: New Concepts from Action
Srilatha Batliwala
216
a
Page
Session 6: Health as a Development and Gender Issue
Maternal Deaths in an Indian Hospital: A Decade of No Change?
Vinaya Pendse
216
Genders, Sexes, and Health: What are the Connections — and Why does it Matter?
Nancy Krieger
236
In Sickness and in Health
Lesley Doyal
242
Explaining Urban-Rural Variations in Health: A Review of Interactions between
Individual and Environment
Robert A. Verheij
255
Sessions 7 and 8: What are Rights? Applying the Rights Approach to Health
Fundamental Rights (From Part III of the Constitution of India)
268
Universal Declaration of Human Rights
272
The Right of the Highest Attainable Standard of Health, General Comment 14
278
Right to Health in International Documents
298
Convention on the Elimination of All Forms of Discrimination Against Women
300
Sexual Rights
TARSHI
315
A Summary of the National Population Policy and the State Population Policies of
Uttar Pradesh, Madhya Pradesh, Rajasthan, Maharashtra and Andhra Pradesh
Leela Sami
317
Anti-people State Population Policies
Mohan Rao
322
Women's Perspective on Population Policies; Feminist Critique of Population Policies;
Population Policy Statement for Gujarat
Renu Khanna
324
Advancing Safe Motherhood Through Human Rights
World Health Organisation
330
Safe Motherhood: A Matter of Human Rights and Social Justice (Factsheet)
Family Care International and the Safe Motherhood Inter-Agency Group
359
A Human Rights-based Approach to Programming for Maternal Mortality Reduction
in a South Asian Context A review of Literature
UNICEF
364
Hi
Recommended Readings*
Session 1: Patriarchy
Manjrekar, N. and Shah, T. (2000). Orientation Course in Women's Studies. Course Readings, Week 4.
Vadodara: Women’s Studies Research Centre (WSRC).
Iyengar, K. (n.d.) Review ofMedical Textbooks of Obstetrics and Gynaecology. Unpublished manuscript.
Komaromy, M., Bindman, A. B., Haber, R. J., and Sande, Merle, A. (1993, February 4). Sexual Harrassment
in Medical Training. The New England Journal of Medicine, 328, pp. 322-326.
Sessions 2 and 3: What is Gender? Social Construction of Masculinity and Femininity
Geetha, V. (2002). Understanding GewtZer.Theorising Feminism Series. New Delhi: Stree.
Dixon-Woods, M. Regan, J., Robertson, N., Young, B., Cordle, C. (2002). Teaching and Learning about
Human Sexuality in Undergraduate Medical Education. Medical Education, 36, pp. 432-440.
Guha, S. (1998). From Dais to Doctors: The Medicalisation of Childbirth in Colonial India. In L. Lingam
(Ed.), Understanding Women’s Health Issues - A Reader. New Delhi: Kali for Women, pp. 145-160.
Session 4: Locating Gender inequalities in Class and Caste
Oxaal, Z. and Baden, S. (1997, October). Gender and Empowerment: Definitions, Approaches and
Implications for Policy. BRIDGE (development - gender). Report No 40. Brighton, UK: Institute of
Development Studies, pp. 1-6.
Session 5: Concept of Development
Sen, G. and Grown, C. (1987). Development Crises and Alternative Visions. Chapter 1: Gender and Class in
Development Experience. New York: Monthly Review Press, pp. 23-49.
Session 6: Health as a Development and Gender Issue
Health Canada. (2003). Exploring Concepts of Gender and Health. Ontario: Women’s Health Bureau, Health
Canada.
Courtenay, W. H. (2000). Constructions of masculinity and their influence on men's well-being: a theory of
gender and health. Social Science and Medicine, 50, pp. 1385-1401.
Ballantyne, P. J. (1999). The social determinants of health: A contribution to the analysis of gender
differences in health and illness. Scandinavian Journal of Public Health, 27, pp. 290-295.
Swaminathan, P. (2002). Women, Work and Health. Issues for Consideration. In R. Khanna, M. Shiva, and
Gopalan, S. (Eds.), Towards Comprehensive Women’s Health Programmes and Policy. Baroda: SAHAJ for
WAH! pp. 442-459.
Sessions 7 and 8: What are Rights? Applying the Rights Approach to Health
Correa, S. and Petchesky, R. (1994, March). Reproductive and Sexual Rights: A Feminist Perspective. In G.
Sen, A. Germain, and L. Chen (Eds.), Population Policies Reconsidered - Health, Empowerment and Rights.
Harvard Series on Population and International Health, pp. 107-123.
Correa, S. (n.d.). From Reproductive Health to Sexual Rights: Achievements and Future Challenges.
* Note: Readings are available with WOHTRAC and have been put on display. You may photocopy them at cost (60
paise per page). You are requested to fill the requisition form before 4.00 pm every day and the photocopies will be
provided to you the following day in the morning.
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A Ithough we have known the word gender in
JTjL grammar, obviously it is being used differently now.
Can you explain this new meaning ?
Understanding Gender
I
First published in 2000
Second impression 2000
Kali for Women
Bl/8 Hauz Khas
New Delhi-110 016
*"T^he word gender is now being used sociologically or as a con
JL ceptual category, and it has been given a very specific meaning.
In its new incarnation gender refers to the socio-cultural
definition of man and woman, the way societies distinguish
men and women and assign them social roles. It is used as an
analytical tool to understand social realities with regard to women
and men.
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The distinction between sex and gender was introduced to deal
with the general tendency to attribute women’s subordination to
their anatomy. For ages it was believed that the different
characteristics, roles and status accorded to women and men in
society, are determined by biology (i.e., sex), that they are natural,
and therefore not changeable.
©Kamla Bhasin, 2000
ISBN 81-86706-21-6
Design & Graphics:Bindia Thapar
'•
Printed at Pauls Press, E44/11 Okhla Phase II,
New Delhi-110 020
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In a way women, and women’s bodies, were and are held
responsible for their subordinate status in society. Once this is
accepted as natural, there is obviously no need to address the
gender inequalities and injustice which exist in society.
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The concept of gender enables us to state that sex is one thing.
but gender is quite another.
Everyone is born male or female, and our sex can be determined
simply by looking at our genitalia.
But every culture has its ways of valuing girls and boys and
assigning them different roles, responses and attributes.
All the social and cultural “packaging” that is done for girls and
boys from birth onwards is “gendering”.
Each society slowly transforms a male or female into a man or a
woman, into masculine and feminine, with different qualities,
behaviour patterns, roles, responsibilities, rights and expectations.
Unlike sex, which is biological, the
gender identities of women and
men are psychologically and
socially — which means his
torically and culturally —
determined.
Ann Oakley, who was
among the first few feminist:
scholars to use this concept,
says the following: “‘Gender’
is a matter of culture, it refers
to the social classification of
men and women into ‘masculine’
and ‘feminine’.” That people are male or female can usually be
judged by referring to biological evidence. That they are masculine
or feminine cannot be judged in the same way: the criteria are
cultural, differing with time and place. The constancy of sex
must be admitted, but so also must the variability of
gender.” 1 She concludes that gender has no biological origin,
that the connections between sex and gender are not really
‘natural’ at all.
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2
Let us see the main differences between these two terms.
SEX
GENDER
Sex is natural
Gender is socio-cultural and it
is man-made.
Sex is biological. It refers to
visible differences in genitalia
and related differences in
procreative function.
Gender is socio-cultural and it
refers to masculine and femi
nine qualities, behaviour
patterns, roles and responsibili
ties, etc.
Sex is constant, it remains the
same everywhere.
Gender is variable, it changes
from time to time, culture to
culture, even family to family.
Sex is natural.
Gender can be changed.
Sex cannot be changed.
Gender is socje-cultural and it
refers to masculine and femi
nine qualities, behaviour
patterns, roles and responsibili
ties, etc.
T Tow docs one translate gender into South Asian
JL JL languages ?
^T^his is indeed a problem. While English has two different words
X — sex and gender — most South Asian languages have only
one word - “linga” used for both sex and gender. To distinguish
' between them we have found two words to qualify linga. For sex
we say “praakritik lingd' or natural/biological sex, and for gender
“saamaajik lingd' or social sex. In fact this definition often works
3
better than “sex” and “gender” because the terms themselves
contain the definition, and so no further explanations are required.
ut isn’t gender closely related to our sex ? Aren’t the
roles and behaviour assigned to women and men
based on their sexual differences ?
Z^Anly to some extent. Because of their bodies women, but not
V_-/all women, bear children, feed them and menstruate; but
other than this there is nothing they do that men cannot do or that
men can do and women cannot. Bearing children does not mean
that only women can or should look after them. Men can just as
well do the caring. So just having male or female bodies does not
necessarily have to determine our characteristics, roles, or destinies.
But in reality it is quite difficult to establish what is natural and
what is socially constructedbecause as soon as a child is born
families and society begin the process of gendering. In many South
Asian cultures the birth of a son is celebrated, the birth of a
daughter is bemoaned; sons are showered with love, respect, better
food and better health care. Boys are encouraged to be tough and
outgoing, girls are encouraged to be demure and home-bound.
There is nothing in a girl’s body which stops her from wearing
shorts, or climbing trees or riding bicycles, and there is nothing in
a boy’s body which stops him from playing with dolls, looking after
younger siblings or helping with cooking or cleaning the house. All
these differences are gender differences and they are created by
society. Proof of the fact that gender is a cultural and social
attribute rather than a natural one, is that it keeps changing — over
time, in different places and among different social groups. For
example a middle class girl may be confined to the home or school
while a tribal girl may roam around in the jungles freely, taking the
animals for grazing, or climbing trees for fruits, leaves or branches.
They are both girls but they develop very different capabilities,
aspirations and dreams, inspite of the fact that their bodies are the
same.
Similarly, in many families girls
were traditionally not sent to
school or allowed to go out .
of the house after they were <■
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10 or 11, and were often
married at puberty. But now
things have changed. So too, the
education, roles and responsibili
ties of men ha^e changed, although perhaps not as much. This is
what is meant when we say that gender is variable; it is or may be
different in different families or communities and at different times
in the same family.
Even our bodies can be shaped or changed by us, society or culture.
We can change the size, shape and strength of our bodies through
training, use, disuse, misuse or abuse. Obvious examples are bodies
.of male and female wrestlers, body-builders, athletes, dancers, yoga
practitioners and so on.
Similarly, women’s bodies are such that they can procreate, but we
can now choose whether to have children, how many to have and
at what intervals to have them. Reproduction is not inevitable in
the same way for women as it is for female animals.
If o/ wcwuuv (%vkv cock/,
cxw/ a/ Rnzw/,
becxxu^c/ cv wovKzxyi/ doe^vt' cook/ vviZh/ Ke^
w&wib'l
What follows from this is that the different status women and men
enjoy in society is indeed socially and culturally determined; it is
man-made, nature has very little to do with it. It is gender not. sex
which has determined that, (almost) everywhere, women as a group
are considered inferior to men. They enjoy fewer rights, control
fewer resources, work longer hours than men but their work is
5
4
either undervalued, or underpaid. They face systemic violence at
the hands of men and society; and they have little decision-making
power in social, economic and political institutions.
"No social order in history has extended, distorted
and used the natural difference between the sexes as
brutally and systematically as ours. This order first
transformed natural sex into a social artificial
gender, made 'men' out of men, and 'women' out of
women — in fact, turned 'men' into the 'human
race' and women into simply a sex as such ... And
finally, having created these differences, it declares
them to be 'natural' again, in order to render them
economically exploitable." Claudia von Werlhof2
Every society prescribes different norms for girls and boys, women
and men, which determine almost every aspect of their lives, and
their futures. Let’s just look at the more obvious ones.
Dress
Girls and boys, women and men dress differently in most
societies. In some places this difference may be minimal, at others
very stark. In some communities women are made to cover their
bodies from top to toe, including their faces. The mode of \dress
can and does influence the mobility, sense of freedom and dignity
of people.
Attributes
In most societies women are expected to have and
perfect qualities such as gendeness, caring, nurtur
ing and obedience; men are expected to be strong,
self-confident, competitive and rational. Vasanth
Kannabiran, an Indian feminist, once said in a
gender training, “Rearing of children is supposed
to be as natural, as inherent to a woman as giving
birth to children. . . And it is not just in relation to
the children we produce; it is assumed that love or
6
motherhood is sitting in me waiting to flow out like a stream to
anybody who needs it. We become eternal mothers. So I mother
my child, other people’s children, my husband, my brothers, my
sisters, my father who actually calls me ‘my little mother’ ! To
everyone I become a mother by extension. You are expected to
overflow with a motherly feeling towards the entire universe. And
this is supposed to be natural! Not work at all. It is something you
do as easily as breathing, eating or sleeping.” 3
Roles and responsibilities
Men are considered to be the heads of households, bread-winners,
owners and managers of property, and active in politics, religion,
business and the professions. Women, on the other hand are
expected and trained to bear and look after children, to nurse the
infirm and old, do all household work, and so on. This determines
their education or lack of it, preparation for employment, nature
of employment, etc. However, the degree of differentiation
between male and female roles varies widely. Sometimes the rules
are merely preferential, and very litde anxiety is shown by either
sex over temporary role,reversals.
"Cora du Bois reports that in Alor, although there
are distinctions between the economic roles of the
sexes, it is not thought unhealthy for anyone to take
on the other sex's work — rather they are admired
for possessing a supplementary skill. The women
control the subsistence economy and the men
occupy themselves with financial deals, but many
men are passionate horticulturists and many women
have financial skills. In some cultures, on the other
hand, where horticulture is defined as a female
pursuit, a proclivity for it in a man is regarded as
proof of sexual deviation. In yet others, a special
category may even be created for females who excel
in pursuits assigned to both sexes." Ann Oakley 4
7
Other societies impose rigid sex roles. The
Mundurucu Indians of Central Brazil, again
according to Ann Oakley, are an example of a
society in which the polarisation of sex roles and
sex groupings has become a primary social element.
The physical and social separation of the sexes is
virtually complete: men and boys live in men's
houses separate from females. Each sex group,
(with the exception of small children) interacts
only within itself, and antagonism between
the two is shown on many ritual and other
occasions. The sexual polarity pervades not
only economic tasks and social roles, but the
area of personality as well, where it takes the form
of a concern with dominance and submission.
Anxiety about people's ability to stay within
the prescribed sex roles and personality types, and
about the real and imaginary desire to transcend
them, is expressed in many pieces of folklore
and ritual." 5
To the outsider, western societies seem to have
very little gender differentiation, but as Ann
Oakley points out, “In western societies
today, sex is an organising principle of
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social structure, and despite popular belief
to the contrary, it plays a great part in
determining social roles. So it is not surpris
ing to find that, as among the Mundurucu, a
great deal of anxiety in western culture has its roots in the demands
made by gender roles. Psychiatrists tell us that a great deal of our
security as adults comes from staying within the boundaries of
these roles — we must stay within them if mental health is to be
preserved.” 6
8
Z^ould some of these differences arise because girls
V^/and women are biologically weaker ?
A ctually, biologically speaking men are the weaker sex and
_/”Vthe Y chromosome (found only in men) is responsible for
many handicaps.
A list given by Ashley Montagu in his book The Hatural Superiority
of Women contains 62 specific disorders due largely or wholly to
sex-linked genes and found mostly in males. “About half of
them are serious, and include haemophilia (failure of the blood-clotting mechanism), mistral stenosis (a heart deformity) and
some forms of mental deficiency. . . At every stage of life,
beginning with conception, more genetic males die ..than genetic
females. More males than females are produced and the two
facts of greater mortality and greater production seem to go hand
in hand.”
Although X and Y sperms appear to be
produced in equal numbers, between 120 and 150
males are conceived to every 100 females. By the
time of birth the ratio of males to females has
dropped to about 106:100 in the US (whites only)
and in Britain to about 98:100. More males than
females are miscarried or stillborn, and more males
than females die of birth trauma; 54% more males
than females die of birth injuries and 18% more of
congenital malformations.
"In fact the life expectation of the female at birth is
almost universally higher than that of the male. In
Britain, life expectation at birth is 74.8 years for
females, but 68.1 for males; in China it is 65.6 and
61.3 respectively; in Brazil, 45.5 and 41.8. 1
9
Ann Oakley provides ample data from research studies to show
that men are much more susceptible to infectious diseases and
mortality. According to her this susceptibility “has been
directly connected with the difference in chromosomal make-up
between male and female. Genes controlling the mechanisms by
which the body withstands infection are transmitted via the X
chromosome. . . the male’s higher susceptibility has a distinct
biochemical basis.” 8
In South Asia however the biological superiority of women
has been overshadowed by the social and cultural inferiority
imposed on them and today, in almost every area, women lag
behind men.
Aristotle called the male principle active, and the
female, passive. For him a female was a "mutilated
male", someone who does not have a soul. In his
view the biological inferiority of a woman also
makes her inferior in her capacities, her ability to
reason and therefore to make decisions. Because the
male is superior and the female inferior, men are
born to rule and women born to be ruled Aristotle
said "The courage of a man is shown in command
ing, of a woman in obeying." s
Sigmund Freud stated that for women "anatomy
is destiny". Freud's normal human was male, the
female was a deviant human being, lacking a penis,
and her entire psychology supposedly centred
around the struggle to compensate for this defi
ciency.
And here's what Mr.Darwin had to say about
women:
"Woman seems to differ from man in mental
disposition, chiefly in her greater tenderness and
10
less selfishness... It is generally admitted that with
women the powers of intuition, or rapid perception,
and perhaps of imitation, are more strongly marked
than in men; but some, at least, of these faculties
are characteristic of the lower races, and therefore
of a past and lower state of civilisation." 10
A re you saying that biological differences between
jijLwomen and men are of no consequence at all ? That
the fact that women produce children has nothing to do
with the roles they are assigned in society ?
T^Te are not denying that there are some biological differences
W between males and females, but the fact that gender roles
vary so much between cultures shows that they cannot be based
on or explained away by sex alone. We should remember a simple
rule of science — variables (gender roles) cannot be explained
by constants (genitalia and chromosomes or sex). If biology
alone determined our roles, every woman in the world should be
cooking, washing and sewing but this is clearly not the case because
most professional cooks, launderers and tailors are men.
What we are saying is that
_
neither sex nor nature is
Q?
responsible for the unjustifiable inequalities that exist
r
between women and men. Like
the inequalities between castes, classes and
races, these too are man made; they are historical constructs and
therefore they can be questioned, challenged and changed. A
woman may well have children but that should be no reason for
her inferiority and subordination; nor should it determine her
education, training or job opportunities. Why should having
different bodies and different functions lead to inequality ? You do
not have to be the same to be equal, to have equal rights and
opportunities.
11
Maria Mies, a feminist activist and scholar writes
in The Social Origins of the Sexual Division of
Labour
.. male-ness and female-ness are not biological
givens, but rather the result of a long historical
process. In each historic epoch male-ness and
female-ness are differently defined, the definition
depending on the principal mode of production in
those epochs. . . Therefore, men women develop a
qualitatively different relationship to their own
bodies. Thus in matristic societies, female-ness was
interpreted as the social paradigm of all productiv
ity, as the main active principle in the production
of life. All women were defined as 'mothers'. But
'mothers' then had a different meaning. Under
capitalist conditions all women are socially defined
as housewives (all men as breadwinners), and
motherhood has become part and parcel of this
housewife-syndrome. The distinction between the
earlier, matristic definition of female-ness and the
modern one is that the latter has been emptied of all
active, creative, productive (i.e. human) quali
ties."11
Tf this is so can you tell us how society turns males
JLand females into masculine and feminine beings ?
^■T^his happens through a process of socialisation or gendering;
1 an on-going process within families and society.
All of us know that a new-born baby is not only immediately
classified by sex, it is also assigned a gender. We have already seen
how in some cultures even the welcome given to a new-born child
is different. This is followed by the difference with which they are
addressed, handled, treated and clothed and, through this regula
tion, taught how they should behave to be part of the society they
12
are born into. This is called socialisation. The specific process of
socialisation which teaches children their gender roles is also called
gendering or gender indoctrination. Different social mecha
nisms teach children masculinity and femininity of personality and
make them internalise behaviour, attitudes and roles.
According to Ruth Hardey, socialisation takes place through four
processes, namely, manipulation, canalisation, verbal appellation
and activity exposure, explained below. All four processes are
normally differentiated by sex and all are features of the child’s
socialisation from birth on.12
By manipulation or moulding is meant the way you handle a
child. It has been noted that boys are treated as strong,
autonomous beings right from the beginning. In some cultures
mothers fuss with the baby girl’s hair, dress her in a feminine
fashion and tell her how pretty she is. These physical, experiences
of early childhood are very important in shaping the self
perception of girls and boys.
The second process, canalisation involves directing the
attention of male and female children to objects or aspects
of objects. Examples of this are giving girls dolls or pots and pans
to play with, and encouraging boys to play with guns, cars and
aircraft. In working class homes in South Asia
girls don’t play with pots and pans, they are
made to start cleaning real pots and pans,
and real homes, looking after real babies
while they are still very young; whereas boys are
sent to school or made to work outside
the home. Through this kind of differential
treatment the interests of girls and boys are
channellised differently and they develop
different capabilities, attitudes, aspirations and
dreams. Familiarity with certain objects directs
their choices.
13
Verbal appellations are idso different for boys and girls. For
example, we often say, “Oh, how pretty you look” to girls and to
a boy, “You are looking big and strong.” Research studies show that
such remarks construct the self identity of girls and boys, men and
women. Children learn to think of themselves as male or female
and so to identify with other males or females. Family members
constantly transmit aspects of gender role directly in the way they
talk even to very young children, and they also convey the
importance given to each child.
The last process is that of activity exposure. Both male and
female children are exposed to traditional masculine and feminine
activities from their very childhood. Girls are asked to help their
mothers with household chores, boys to accompany their fathers
outside. In communities where the sexes are segregated, girls and
boys live in two distinct spaces and are exposed to very different
activities. It is through these processes that children imbibe the
meaning of masculine and feminine, and internalise them almost
unconsciously.
Tf this process of socialisation is an on-going one then
1 why is it that the debate between “nature” or “nurture”
still continues ? Isn’t it obvious that upbringing is
responsible for differences between girls and boys ?
>T^he amazing thing is that many 'of us are
1 not always aware of what we are doing
to our children. In fact we may believe we
treat girls and boys differently because they
are actually different. We may not accept
that our daughters and sons develop
differendy because of the way schools,
communities and we ourselves treat them.
Children also learn these roles without
being aware of the fact that they are being moulded. If there were
no differences between girls and boys, and all girls and all boys
everywhere behaved more or less in the same way, one could argue
that gender roles are based on sex, but as we have seen that is not
the case.
Sanctions or disapproval against children and adults when they
deviate from their gender roles is another very powerful way of
making everyone conform to expected male-female behaviour. The
most common form of sanction is social ridicule.
The worst case I have come across of a backlash against women
who dared to deviate, is from in a village in Kerala. Three young
women workers saw their male colleagues go into a local pub every
day. One day they decided to do the same just for fun. That led
to all kinds of men following them and approaching them for
sexual favours. Because they had dared to walk into a place where
“good” women do not enter, they were defined as “bad”. The logic
was “If you can walk into a pub, you should be available for sexual
pleasure too.” Not being able to deal with the social ridicule and
harassment that followed two of the girls committed suicide.
In addition to social sanctions there are also “economic sanctions
and, according to Ann Oakley, the severe problems confronting
single women with children, and their economic difficulties are an
index of society’s disapproval of them. Often, families threaten or
refuse to financially support children who deviate from set norms
and practices.
Z^an you elaborate on this business of labelling
certain characteristics and qualities as masculine,
and others as feminine ?
/Certain dualities have come to be defined as male or female
V_>when they need not necessarily be either. For example:
15
14
Body
Nature
Emotion
Subject
Private
Mind
Culture
Reason
Object
Public
third world is emotional and irrational and first world rationd,
scientific, modern.
It is important to understand these connections between gender
and other hierarchies of class, caste, race, first world and third
world, etc.
With those on the left being “female”,
and the ones on the right, “male”
"Three hundred years of witch-hunting, running
parallel with the colonisation of the world, were
necessary to snatch from the women—as from
Third World peopL ■their power, their economy
and their knowledge, and to socialise them into
becoming what they are today: housewives and the
'underdeveloped'. The housewife— and with her the
'underdeveloped'—is the artificial product, result
ing from unimaginably violent development, upon
which our whole economy, law, state, science, art
and politics, the family, private property and all
modern institutions have been built. The Third
World is the 'witch' of witch-hunting days and is
the 'general-housewife', the 'world housewife' today
including Third World men. The relation between
husband and wife is repeated in the relation between
the First and the Third World." Claudia von
Werlhof 13
Not only have the two been
ranged as polar opposite, a
hierarchy has been created
between them. Mind is sup
posed to be superior to body,
and culture an improvement
on and superior to nature.
Those who are rational and
objective are valued more highly
)
than those who are subjective and
emotional. Women are the bodies, almost like nature (they breed
like animals); men are the minds, thinking, rational, acting beings
who work on nature and transform “it” into culture. Men are
therefore superior, over and above nature, they can do with nature
what they please.
Not only do women belong to the left side of the above-mentioned
dualities, the indigenous and poor are also categorised as such. This
is why tribals, forest-dwellers, small peasants and fisherfolk can, like
women, be treated with disregard by development planners. Their
forests can be cut and lands taken over without their knowledge
or consent. This is how millions of them become “development
refugees” and end up in horrible slums in urban centres to eke out
a living in the most dehumanising conditions.
Not just qualities and characteristics, but even spaces are gendered.
A pub, football stadium, street corner, tea-shop, paan shop, cinema
hall can all become, male spaces. Women normally go into them
accompanied by some men. If they cannot help going into them
alone they are expected to leave as fast as possible, if they do not
wish to get into trouble. Under no circumstances should they
consider lingering around like the men.
At the global level, the third world or the South is considered Body,
the first world, the Mind; third world is Nature, first world Culture;
Similarly the kitchen or public well is almost entirely a female space.
I am at a loss to find a social space that is exclusive to women.
17
16
f
They have no space for entertainment or work which is theirs alone.
In Dhaka some women have started a weekly ^add^ — a term
generally used for a gathering of men where they chat, eat, drink,
and enjoy themselves. Many men and some women objected to the
use of the word “adda” by women because the very concept of
l<addd' was male — not “respectable” enough for women. Words
and activities which are fine for “respectable men are not
considered good enough for “respectable” women. This is
patriarchal logic.
Even within the home, a quiet room or space might be reserved
for the man so that he is not disturbed by the rest of the household.
It has been pointed out to me in workshops that household
resources or items too, may be gendered. For example the larger
glass, chair, or bed are reserved for the (male) head of the
household. In working class homes the bicycle, radio, wrist-watch
are all for men.
Jsn’t language also gendered ?
■Tndeed it is. Language is patriarchal and therefore carries and
1 reflects gender biases and inequalities. Often men have a
vocabulary of their own which women seldom use. The most
obvious example of this is words of abuse with sexual connota
tions, commonly used by men. Although men use them without
any hesitation, they are horrified if any woman does.
Our languages are also replete with proverbs and sayings which
show women to be inferior to men; refer to them as being sinful,
mean and quarrelsome. There is an oft-repeated couplet in Hindi
which says a drum, an uneducated or low caste person and women,
all deserve to be beaten. “A woman’s heaven is in her husband’s
feet” is a proverb repeated all the time by some maulvis. In Bangla
there is a saying, “Unlucky is the man whose cow dies. Lucky is
the man whose wife dies.”
18
Then there is the use of the masculine as the standard, the norm.
‘Mankind', ‘he’ and ‘his’ are used even when the reference is to
women. Words like chairman, newsman, sportsman, one-man
show and hundreds of others are commonly used for women in
these roles — although this practice is now changing.
The language of social sciences, philosophy ami
other disciplines also continues to be patriarchal
and ignores, marginalises or misrepresents women.
The mode in which abstract thought is cast and the
language in which it is expressed are so defined as
to perpetuate women's marginality. We women
have had to express ourselves through patriarchal
thought as reflected in the very language we have
had to use. It is a language in which we are
submitted under the male pronoun and in which the
generic term for "human" is "male". Women have
had to use "dirty words" or "hidden words" to
describe our own body experiences. The vilest
insults in every language refer to parts of the female
body or to female sexuality." Gerda Lerner24
Another point worth mentioning here is that certain terms and
roles in our languages are gender ascriptive (where gender is built
in) like uncle-aunt, brother-sister, mother-father because they
indicate the gender or sex of the person. But there are
a host of others which are not gender ascriptive but
it is assumed that they refer to a man or a woman.
For example, secretary, nurse, kindergarten teacher
are assumed to refer to women whereas boss,
pilot, manager, politician, surgeon, or farmer
refer to men. These assumptions only prove that
public spaces and jobs continue to be dominated
by men. Women are few and far between,
especially in decision-making and managerial
positions.
19
XZou have used the word patriarchy so often and have
A implied that patriarchy is the cause of gender
inequalities and the subordination of women. Can you
explain this tefm?
historical period throws up its own Variations on how patriarchy
functions and how social and cultural practices differ. The broad
principles, however, remain the same i.e., men control most
economic resources and all social, economic and political institu
tions.
"Tt is important to understand patriarchy in order to understand
-Lpresent-day relations between women and men. Gender
relations are skewed because of the existence of patriarchy. In
common parlance patriarchy means male domination; the word
“patriarchy” literally means the rule of the father or the “patriarch”,
and was used originally to describe a specific type of “male
dominated family”—the large household of the patriarch which
included women, younger men, children, slaves and domestic
servants, all under the rule of this dominant male. Now it is used
more generally to refer to male domination, to the power
relationships by which men dominate women, and to characterise
a system whereby women are kept subordinate in a number of
ways. In South Asia, for example it is called pitrsatta in Hindi,
pidarshahi in Urdu and pitritontro in Bangla.
Patriarchy is both a social structure and an ideology or a belief
system according to which men are superior. Religions have played
an important role in creating and perpetuating patriarchal ideology.
They have spread notions of male superiority through stories like,
Eve was created from Adam’s rib; or man is created in the image
of God, etc. Today, media and even educational institutions spread
patriarchal ideology by showing men to be stronger in decision
making positions, and women as voracious consumers, dependent
and jealous. Ideology plays an important role in perpetuating social
systems and controlling people’s minds. For example, by reducing
women to bodies and objectifying them, media encourage violence
against. women. Ideology provides the justification for social
behaviour and socio-economic structures.
The subordination that women experience daily, regardless of the
class we might belong to, takes various forms—discrimination,
disregard, insult, control, exploitation, oppression, violence —
within the family, at the place of work, and in society. The details
may be different but the theme is the same.
Patriarchy is not the same everywhere. Its
nature can be and is different in different
S/
classes in the same society; in different
societies and in different periods in
j history. For example the experience of
patriarchy was not the same in our
r
grandmother’s time as it is today; it is
different for tribal women and for upper
caste Hindu women; for the women in the
USA and women in India. Each social system or
20
Normally the following areas of women’s lives and societies can
be said to be under patriarchal control.
Women’s productive or labour power
Women’s reproduction
Women’s sexuality
Women’s mobility
Property and other economic resources
Social, cultural and political institutions15
An analysis of the main institutions in society—the family, religion,
law, political, educational and economic institutions, media,
knowledge systems—demonstrates quite clearly that they are all
patriarchal in nature, and are the pillars of a patriarchal structure.
This well-knit and deep-rooted system makes patriarchy seem
invincible; it also makes it seem natural.
21
Under patriarchy different kinds of violence may be used to
control and subjugate women and such violence may even be
considered legitimate. In fact, feminists believe that violence against
women is not just pervasive, it is systemic in patriarchies.
All this does NOT imply that women are totally powerless or
without rights, influence and resources under patriarchy. In fact,
no unequal system can continue without the participation of the
oppressed, some of whom derive some benefits from it. This is
true of patriarchies as well. Women have risen to power, have
occasionally been in control, have wrested benefits in greater or
smaller measure. But all this does not change the fact that the
system is male-dominated — women are merely accommodated
in it in a variety of ways. To give a parallel example, in a capitalist
economy workers play a very important
role, they may even participate in
management to some extent,
but this does not mean they
are ever in control. For a
variety of complex rea
sons women also support
and perpetuate patriarchy.
Most of us have
internalised its values and
are not always free of patri
archal ideology.
In order to retain their privilege
women continually renegotiate their bargaining power, so to speak,
sometimes at the cost of other women. But it is important that
we look at the overall system and analyze the reasons for this
complicity. It is true that women often treat their sons better,
deprive their daughters of education, restrict their freedom,
mistreat daughters-in-law and so on. All this needs to be
understood in the context of the respective power and position
that men and women have in the family and in society. A rural
22
woman explained this very well. She said “Men in our families are
like the sun, they have a light of their own (they own resources,
are mobile, have the freedom to take decisions, etc.) Women are
like satellites, without any light of their own. They shine only if
and when the sun’s light touches them. This is why women have
to constantly compete with each other for a bigger share of
sunlight, because without this light there is no life.”
The appropriate way to describe male control over women is
paternalistic dominance. There is dominance but it is paternal
istic because women are provided shelter, food and security visa-vis outsiders. Paternalistic dominance has oppressive aspects, but
it also involves a set of mutual obligations and is frequently not
perceived as oppressive. This is what makes it difficult to recognize
and fight.
How liberating was national liberation?
Although national liberation movements ended the
political control by colonial powers and introduced
the principle of separation of legislative from
judicial and punitive powers, women were hot
liberated from the rule of husbands, or fathers, in
the household. Within the home men still retain
consolidated and arbitrary powers to determine the
rules, judge the performance, and punish their
wives and children. Thus men have the capacity to :
• demand sexual relations at any time;
• prevent their wives from practicing contracep
tion;
• determine how wives and daughters could and
should spend their time in domestic work, in
education, leisure or cultural activities, and
determine the terms on which they enter the
public space for employment;
23
I
• exert punitive or corrective violence against
women when they judge the rules infringed,
and not be subject to legal retribution for this;
• use and dispose of wives' earned or inherited
property; and
• buy and sell wives/daughters, or dispose of
them to meet debts or to compensate for insult
by other males.
Many of these presumptions and behaviours are
translated into relations with women in the outside
community, the workplace and political spaces. 16
"T^on’t education and overall modernisation or devel
JL7 opment bring in equality between men andwomen?
"K Tot necessarily. Very often education itself is patriarchal, it jus
tifies, perpetuates or ignores inequalities between women and
men. Any number of analyses of textbooks and children’s literature
have shown the gender bias in them, in favour of men. This bias
continues in almost all academic disciplines and is one of the main
batdes being fought by the women’s movement and women’s
studies practitioners, everywhere.
HISTORY is HIS STORY.
To get a complete picture of the world
we also need HER STORY
Even a cursory examination of societies like the UK and the USA
which have had univers;d education for a long time and are
supposed to be modern, industrialised and egalitarian, show that
gender inequalities persist in them. Men are still considered heads
of households inspite of the fact that both countries have large
numbers of female-headed households. Over 50 per cent women
in these societies experience physical violence at the hands of their
husbands, and there is a high incidence of rape and physical
24
0*
t
violence. Within the US, the Equal
Remunerations Act has still to
) be passed, and abortion is a
criminal offence in many states.
US Census Bureau figures show that
a US working woman, just out of
college, earns 75 per cent of the salary offered to the men she
studied with — and the older she gets, the further behind she finds
herself. An Associated Press analysis of census statistics released
in 1991 found that at every educational level, women earned less
than men with the same amount of schooling.
I
Ann Oakley provides statistics to show tha
t in all industrialised countries there is a marked differentiation by
gender in most, if not all, occupations. One occupation in
particular, that of a housewife, is exclusively feminine. She further
states that within industry there is a great deal of differentiation
by sex. Most women, usually between a third and two-thirds of all
working women, are concentrated in textile and clothing manufac
ture, and in food processing.
On the whole males command the majority of jobs with high
prestige, high skill and high income, and this is true throughout
the industrialised world. Of all managers of large establishments
tabulated for Britain in 1966, 87 per cent were men and 13 per cent
women. Women make up three per cent of all barristers in the
USA, four per cent in Great Britain and seven per cent in Sweden.
A mere 0.06 per cent of all engineers are female in Britain, 0.07
per cent in the USA and 3.7 per cent in France. While women in
the professions receive the same rates of pay as men, in other jobs
they do not: thus skill, prestige, financial reward and gender are
interrelated in a complex but consistent fashion. 17
Vast differences persist in higher education, too. According to Ann
Oakley, “It is at the highest levels of education that the disparity
25
patterns and so on. Gender relations are both constituted by
and help constitute these practices and ideologies in interac
tion with other structures of social hierarchy such as class,
caste, and race. They may be seen as largely socially
constructed (rather than biologically determined), and as
variable over time and place.” 19
is most marked. For every hundred people aged 20 to 24 in higher
education in 1965, there were 6.6 females in the UK, 5.3 in
Denmark, 2.3 in Switzerland and 15.2 in Bulgaria. While women
made up about two-fifths of the intake of university students in
Britain in 1967, women take less than a third of all final degrees
and only about one-ninth of all higher degrees.” These facts clearly
reflect the situation in so called advanced nations that education
is more important for a boy than it is for a girl. The subjects girls
and boys study also reflect this disparity. In the United States in
1964, 46 per cent of masters’ degrees in education were gained by
women but only 10 per cent of these in science. Of all those
studying medicine, dentistry and health in Britain in 1967, two-
Like gender, gender relations are not the same in every society,
nor historically static. They are dynamic, and change over time.
However, one can generalise and say that in most societies gender
relations are not equitable.
This understanding challenges the assumption that, within house
holds, relations between women and men are harmonious and
without conflict. In fact, there is both co-operation and conflict,
harmony and disharmony. In other words, there is politics in
gender relations. Here the term “politics” refers to the fact of
power play in any relationship. Because people are assigned
differing amounts of power, authority and control (over other
people, resources, decision-making), subtle or blatant power games
or politics taking place between genders within the family, at the
work-place and in society at large just as they do between castes,
classes and races.
thirds were men.18
These statistics from industrialised countries, capitaUst or socialist,
indicate that gender hierarchies cannot be removed by education
or development alone, if no serious attempts are made to
change patriarchal structures and attitudes.
Tf gender determines the status and role of women and
JLmen, doesn’t it also determine relationships between
men and women ?
■fndeed it does. If you assign different values to gold and silver
JLyou automatically determine the relationship between the two;
so too, does society determine the relations between men and
women. Relations based on gender are called
gender relations. “The term gender relations
refers to the relations of power between
women and men which are revealed in a
range of practices, ideas, representations,
including the division of labour, roles, and
resources between women and men, and the
ascribing to them of different abUities, atti
tudes, desires, personality traits, behavioural
I.
Theoretically gender hierarchy can mean the domination of either
gender, but in practice it almost always means a hierarchy in which
men dominate and women are dominated. A common aspect of
gender relations across cultures and throughout recent history is
the subordination of women to men. Gender relations therefore
are relations of dominance and subordination with elements
of co-operation, force and violence sustaining them. This is so
because most societies are patriarchal or male dominated. One can
also say, that in most societies, gender relations are patriarchal in
nature, they follow the rules of patriarchy — an ideology and social
system whereby men are considered superior to women, are
dominant and control most resources and social institutions.
27
26
’ : relations between women and
Not only does gender determine
it may also influence relations between men, and between
men,
women. In South Asia where gender hierarchies are particularly
uneven, gender is a very strong organising factor. In North India
for example, the social relations between the bridegroom’s father
and the bride’s father are illustrative, with the former generally
considered superior and worthy of greater respect. The brides
father is always considered to be in a lower, subservient position
merely because he is the father of a girl.
Examples of gender often determining relations between two
women are those between a mother-in-law and daughter-in-law
(saas-bahu)-, between a woman and her brother’s wife (bhabh,) or
husband’s sister {nanad); or relations between the two mothers-inlaw. In all these, the women who are connected to the bridegroom
automatically occupy a superior status to those who are related to
the bride.
Thomas von Aquinas, an otherwise intelligent and
god-fearing Christian leader who lived in Germany
some three hundred years ago, said women are like
weeds, they grow so fast because they are of little
worth. (Men of course are the main crop, the cash
crop in today's world !)
Tb'
eqiAcd/ t'o wicw
ywrHiat exactly do you mean by politics within the
W family and women’s bargaining power being
negotiated all the time ?
W1
28
seen that all members of a household do
have already
have the same access to resources, services and
opportunities. Based on these inequalities, sev
eral social scientists see the family as a place of
bargaining and contestation, where power is
negotiated. The well-known economist,
Amartya Sen, calls this a co-operation and
conflict model. Bina Agarwal, a feminist
economist, has developed this concept further,
and according to her the household/family is
a complex matrix of relationships in which
there is ongoing negotiation, subject to con
straints set by gender, age, type of relationship
and “undisputed traditions”. Gender interac
tions within the family as well as in the
community, market and state contain elements of co-operation and
conflict. Two parties agree to cooperate when such co-operation
leaves them better off than non-co-operation.
Bina Agarwal maintains that a rural person’s bargaining power will
depend on his/her fall-back position, which in turn depends on
five factors, in particular.
• private ownership and control over assets, especially arable land
• access to employment and other income-earning means
• access to communal resources such as village commons and
forests
• access to traditional external social support systems
• access to support from the state or from NGOs
“These five factors impinge directly on a person’s ability to fulfil
subsistence needs outside the family. The premise here is that the
greater a person’s ability to physically survive outside the family,
the greater would be her/his bargaining power (at least in relation
to resource sharing for subsistence) within the family. Inequalities
among family members in respect of these factors would place
some members in a weaker bargaining position relative to theirs.
Gender is one such basis of inequality, age another.” 20
29
I
exploited classes. In order to punish rebellious poor
peasants and landless labourers, landlords and
police are not satisfied with beating up men and.
burning their huts; in many cases they also rape
their women. Why? Obviously, these rapes are not,
as is often believed, a kind of safety valve for the
repressed sexual urges of the rapists. In fact, these
acts have nothing to do with sexuality as such,
neither are the targets the women as such, but
rather the men of the poor classes. Women are seen
as the only property that the pauperised men still
possess. The rape of their women teaches poor men
the lesson that their status is one of absolute
powerlessness and propertylessness. This sexual
aggression on the part of landlords and police
against poor women is a weapon with which to beat
the men of the propertyless classes and to stabilise
the existing or newly emerging power relations in
the countryside. Class rule and the oppression of
women are here closely interwoven. He who owns
the land owns the women of the land." Maria
Mies21
To give just one example: women’s income-earning capacity, when
realised, places them in a stronger bargaining position vis-a-vis
other members of the household, especially if their income is for
the family’s survival. Similarly, their access to or control over
resources like land, money, or other assets reduces their dependent
status, and enables them to negotiate a better status within the
family.
1" Yqw do our other identities like religion, caste and class
A 1 affect gender and gender relations?
A 11 of us have multiple identities. For example, in addition to
xXbeing a woman, a person may be Hindu, middle class, upper
or lower caste, married, etc. Gender interacts with the other
identities, impacts and is impacted by social and economic factors,
as well as by ethnicity, race, age and marital status. In society all
women are not subordinate to all men. For instance, a rich woman
because of her class affiliation, is in a position to dominate the men
who work for her as domestic help. In this case a woman’s class
is more important than her gender. In other cases, a “lower” caste/
class woman may be doubly exploited by an
upper caste/class man. In some communities
in India, for example, a lower caste bride is
obliged to spend her first night as a married
woman with the upper class landlord.
Similarly there may be differences between people belonging to
different races or ethnic groups. “Upper” caste women generally
face more restrictions on their mobility than “lower” caste women
because they have to preserve caste purity and superiority.
Generally speaking, “upper” castes are much more male dominated
or patriarchal because they are concerned about caste purity as well
as patrimony or controlling property. This is why “upper” caste
families impose restrictions of dress and mobility on their women,
thereby controlling women’s sexuality. Because “lower” castes have
no purity to safeguard their women are not similarly restrained.
The existence of separate personal laws based on different
religions also affects gender relations. Muslim Personal Law for
example, allows polygamy and unilateral divorce for men; Christian
Law does not recognise adultery by a man as cause for divorce;
the Hindu Code does not allow adoption of children by parents
of two different religions, and so on. And all religious laws favour
men in matters relating to property rights and inheritance.
There is also a difference between the social, economic and political
status of men and women belonging to different classes. Those of
"Sexual exploitation mainly in the form of rape, is
a means used by the ruling classes to discipline the
30
31
I-
the bourgeoisie or propertied classes have greater access to
economic resources, education and information; they control
social, economic and religious institutions in a way that people
belonging to the working classes do not. There are differences
between the roles, responsibilities and privileges of bourgeois
women and working class women. Engels noted an important
difference between bourgeois and working class women: the
former in his analysis, does not work outside the family, she is
totally dependent on her husband, she is property herself. Her only
function is to produce heirs. The working class woman, on the
other hand, has already broken her oppression by being a worker
and hence attaining some economic independence.
Working class women also do not observe purdah or sex
segregation, because they are obliged to enter public spaces to
make a living. It has been observed that small farming
households discourage their women from working outside
the home when their economic condition improves. Women
who remain within the household, being dependent, or in seclusion
are considered a symbol of social status in many patriarchal
societies.
c
an you explain what is meant by the term “gender
division of labour”?
ender division of labour or sexual division of labour, refers
xj’to the allocation of different roles, responsibilities, and
tasks to women and men based on societal ideas of what men
and women should do and are capable of doing. Different
tasks and responsibilities are assigned to girls and boys, women and
men according to their sex-gender roles, and not necessarily
according to their individual preferences or capabilities. All
work/activities can be divided into three categories—productive,
reproductive and community work/activities. Let us examine each
of these for a “gender division of labour”.
32
PRODUCTION refers to that activity which
produces goods and services for consump
tion and trade. All work done in factories,
offices and farms, falls into this category,
and it is only these activities that are
counted as economic and included in the
Gross National Product of countries.
Although both women and men are in
volved in productive activities the gender
division of labour prevails. Men do jobs which
are more skilled and better paid. Often women’s
productive activities are an extension of the work they do
at home. In the agricultural sector, women’s productive work is not
reflected in economic accounting because it is considered an
extension of their household work. Women’s productive activities
are given less importance and less value. Women are the last to be
hired because of the patriarchal notion that men are the main
breadwinners and are heads of households. Therefore, male
employment is given greater emphasis and priority.
REPRODUCTION is of two kinds — biological and social.
Biological reproduction refers to giving birth to new human beings,
an activity which only women can perform. Social reproduction
refers to all the caring and nurturing activities necessary to ensure
human survival and maintenance. Reproductive activities, thus, are
those activities which reproduce human labour. Caring of children,
cooking, feeding, washing, cleaning, nursing and other household
activities fall in this category. Although they are necessary for
human survival they are neither considered work, nor an economic
activity and hence are invisible, unrecognised and unpaid. Repro
ductive work is carried out mainly by women and girls across the
world.
COMMUNITY work refers to all those activities necessary to run
and organize community life. Governance, the organisation of and
participation in social and cultural festivals, social services and
33
233 I
facilities Eke roads, schools, health care, etc. are all
community activities. Both men and women partici
pate in these but, again, according to prescribed
norms which define “male” activities and “female”
activities.
i
Gender division of labour, therefore, operates not only
in reproductive activities within the household but in
productive and community activities as weU, most of which take
place outside the household. The gender division of labour is now
considered a key concept to understand how gender inequabties or
asymmetries are kept in place and reconstituted.
I
In time this division leads to a gender division of skiUs. Men and
women, boys and girls learn and master only those skills considered
appropriate to their gender roles. Thus, different skills and
aptitudes are created in women and men, girls and boys, and are
then ascribed solely to one or the other.
Gender division of labour also leads to hierarchies and inequalities
because men and women’s labour is not valued or rewarded equally.
Even now, equal pay for equal work is not the norm in most
countries; housework is unpaid; and women are the first to be fired
when recession hits the workplace.
The allocation of certain tasks to men and women in productive
processes (specially in household production) also leads to issues
of command and control over resources and the products of
labour. Thus, because of a gender division of labour, men assume
control over land; technology; credit; cash from the sale of
products, and so on. Normally, women produce for subsistence and
men for exchange or cash.
Like gender and gender relations, the gender division of labour is
also not the same everywhere. It is specific to culture, location and
time. To challenge the gender division of labour in society means
challenging what being a "man” or a “woman” in a society entails.
34
CO
Women's productive and reproductive work is
generally not assigned much economic value.
According to the UNDP Human Development
Report of 1995 the invisible and unpaid work
contributed by women, annually, is worth US $ 11
trillion.
"The husband has 'the queen of the commodities' i.e.
money, in his pocket, but the wife is not paid for her
work. The husband must give her only board and
lodging, as he would also have to do for a slave. The
housewife's working hours, conditions of work,
holidays, leisure are not settled by contract; the
marriage contract is not comparable to an employ
ment contract. There is no right to strike, no sisterly
organisation of housewives; they are instead ,
individualised and atomised. They enjoy no social
security on the basis of their work as housewives,
nor are they protected by law from the despotism
and violence of their husbands. In the home nobody
ensures the observance of human rights, hence they
are a private affair, which allegedly do not concern
the public even when there is no guarantee of
physical safety.
The wife must serve, and above all, obey the
husband; he can demand this in a court of law. In
short the housewife is an unpaid worker, at the
disposal of her husband, round the clock, all her life;
even more, her whole person is at his disposal,
including her sexuality and child-bearing capacity,
her psyche and feelings, She is at the same time
slave and serf who is compelled to do all the work
that her husband and children need, including
demonstrating love even when she does not feel any.
Here one works out of love and love becomes work.
35
f
The situation may not always be intolerable, but it
is impossible to predict that it will not become so."
Claudia von Werlhof22
Irrespective of class or caste women do in the family what
“shudras” or “menial” workers do in society. Within every
household women are the “shudras” and men the “twice-born” or
“upper castes”. Women are the providers of services, even in
bourgeois or upper caste households. Like the “shudras” therefore,
women are considered “unclean”, “impure”, unfit for the superior
pursuits of religion and spirituality, education, etc. Because menial
jobs are not considered important or of much value, women’s work
is totally unpaid and unrecognised when performed at home, and
underpaid when performed outside.
Women’s work outside the home is often an extension of their
work in the family. For example, a large number of women work
as kindergarten and primary school teachers or nurses and
airhostesses. Jobs which entail authority, power and control are
considered men’s jobs and jobs involving caring, nurturing,
servicing are seen as women’s jobs. Women are subservient at
home, they continue to be subservient outside. Men are in a
position of power and control at home, they continue to be in
similar positions in the outside world. Men are better educated and
better trained and they do not have to carry the double burden of
work, so their professional graph rises much higher than that of
women.
"Everything that women do must bear fruit and be
gratis, like the air we breathe. This applies not only
to producing and rearing children, but also to the
sundry housework and wage labour, the emotional
care bestowed on colleagues, the friendliness, sub
missiveness, being-always-at-others-disposal, heal
ing-all-wounds, being sexually-usable, the-puttingeverything-again-in-order, the sense of responsibil36
i
ity and self-sacrifice, frugality and
unpretentiousness, the renunciation in favour of
others, the putting-up-with and helping-out-in-allmatters, withdrawing-oneself and being-invisible
and always-there, the passive being-available and
the active 'pulling-the-cart-out-of-the-mud', the
endurance and the discipline of a soldier. All this
makes up the feminine work capacity." Claudia von
Werlhof23
" When the Taliban leadership takes over in
Afghanistan, the first instruction they issue is that
men should wear skull caps and grow beards while
women should cover themselves and remain in
doors. Women are prohibited from working or using
public baths. It is interesting to see the connection
between a new political regime and the gender
regime that comes into force and the way a gender
division of labour is reinforced. The sexual division
of labour therefore is not a structure in its own
right. It is part of a system of production,
consumption and distribution, which is structured
by gender." Vasanth Kannabiran 24
The gender division of labour is responsible for statistics like:
globally, women hold only 14 per cent senior management
positions (UNDP Human Development Report, 1995); the ratio
between women’s salaries and men’s salaries in the US continues
to be 3:5 and this has not changed in the last one hundred years.
Seventy per cent of the world’s poorest and illiterate people are
women.
According to Maria Mies,
we should no longer look
at the sexual division of
labor as a problem within the
37
family, but rather as a structural problem of society as a whole. The
hierarchical division of labour between men and women and its
dynamics form an integral part of dominant production relations,
i.e., the class relations of a particular period and of society and the
broader national and international division of labour.25
According to Joan Kelly, a feminist historian, we should look at
property relations and women’s relationship to work as the basic
determinant of the sexual division of labour and sexual order. The
more the domestic and public domains are differentiated, the more
work and, hence, property are of two clearly distinguishable kinds.
There is production for subsistence and production for exchange,
and this is what influences the sexual division of labour.
T") ut most people consider this gender division of
JU labour natural. Because women give birth to chil
dren and breast-feed them, aren’t they better equipped
for caring and nurturing activities ?
XZour use of the term “better equipped” is interesting. Women
J_ are indeed equipped with a uterus and a pair of breasts but
they have no extra equipment for caring, cleaning or looking after;
therefore it is not “natural” for them to be looking after everyone.
And, let us not forget that men manage to sweep and clean and
wash and cook when these activities are paid for, so the reasons
for doing or not doing reproductive work cannot be biological or
natural.
But because people want to believe that present gender relations
and the gender division of labour are “natural”, based on women’s
biology, they find it difficult to think beyond bodies. It’s also very
convenient to reduce everything to nature because then you don’t
need to question or challenge patriarchal privilege. You wash your
hands off all responsibility. So often in gender workshops we have
observed that men get extremely upset, agitated and belligerent
38
O
j
when we demonstrate that gender is socially constructed, that
gender relations and the gender division of
labour are not natural. They had a beginning
✓
and therefore can have an end. The
challenge of feminism and the political
work of the women’s movement is to
/
—-r
work towards an end to inequality based
on biological difference. It is possible
— though still not common —to
find examples in many societies where these
so-called “natural “ differences and division of
labour have been changed.
Z"^ould some of this division of labour be the result
V>of social conditioning because women are confined
to the household and men deal with the outside world ?
J'T^his is an important but complex question, and it is not easy
X to provide a straightforward answer. First we need to
understand the dichotomy between the private and public domains.
Women are expected to remain in the private domain while men
function in the public, while also controlling the private. Before the
industrial revolution, however, this separation between the two was
not so marked. Most production took place within the household
and all members participated in it. Everyone was a “breadwinner”.
The household was the site of both reproduction and production.
There was co-operation and complementarity between men
and women. Women’s skills, knowledge and their ability to
reproduce the next generation were highly valued because they
were indispensable for survival. In many ways this old order was
gynocentric (woman-centred). Because of the important role
women played in the household economy in colonial America the
word “husband-woman” (the woman who managed, looked after,
controlled or husbanded the affairs of the household) was
commonly used.
39
The advent of the market economy and industrialisation dramati
cally upset the unity between private and public, the harmony
between nature and human beings. Production was no longer a
matter of subsistence alone — it was also intended for the market
and for profit. Gradually production moved out of the household
and into factories, commercial farms, and so on, and the market
rather than nature became the controlling force in the lives of
ordinary people.
The “economic man” moved out of the household and the
“domestic woman” remained in it. Boys went to schools and
universities to acquire knowledge and skills for operating in the
outside world, while girls remained at home, acquiring skills for the
“domestic” world.
"It was not only women's productive skills which
gave her importance in the old order. She knew the
herbs that healed, the songs to soothe a feverish
child, the precautions to be taken during pregnancy.
If she was exceptionally skilled, she became a
midwife, herbal healer, or 'wise woman' whose fame
might spread from house to house and village to
village. And all women were expected to have
learned, from their mothers and grandmothers, the
skills of raising children, healing common illnesses,
nursing the sick." Barbara Ehrenreich and Deidre
English 26
What happened in Europe as a result of marketisation and
industrialisation has also happened in South Asia. Here too,
production moved out of the household, as did education.
Earlier most people picked up knowledge and acquired their
production skills in the household, and girls and boys both got
educated at home in skills and activities which were necessary for
survival.
40
Among tribals, forest dwellers and peasants living
in remote areas of South Asia, even now production
takes place largely within the household. Their
economy is still primarily a subsistence economy;
surplus production is exchanged with items not
produced by the household, in the local market.
Women and men share householding activities and
there is little or no distinction between the public
and private spheres. Compared to other classes and
communities there is not much inequality between
men and women either. Slowly these communities
are also getting “integrated” into the market economy and
becoming more “patriarchal” than they used to be.
"Because of changes in the mode of production the
home ceases to be viewed as a centre of economic
production and comes to be seen rather as a refuge
from economic production, 'a haven from the
heartless world', a 'utopian retreat from the city'.
Reproduction remains in the family, production
moves out. Household management loses its public
character. It no longer concerns society. It becomes
a private service and as Engels said, the wife
becomes the head servant, excluded from participa
tion in social production." Alison M.Jaggar 27
The distinction between the “public” and the “private’-’ opens up
new horizons and opportunities for men, but limits the place and
functions of women. In a way, this is the end of the gynocentric
order. Another consequence of the separation between the public
and the private is the relative seclusion and isolation of women
which follows. Women get excluded from society and separated
from other women and men.
"The traditional productive skills of women —
textile manufacture, garment manufacture, food
41
processing — passed into the factory system.
Women of the working class might follow their old
labour into the new industrial world, but they
would no longer command the productive process.
They would forget the old skills. In time, even the
quintessentially feminine activity of healing would
be transformed into a commodity and swept into the
Market. The home-made herbal tonic is replaced by
the chemical products of multinational drug firms;
midwives are replaced by surgeons." Barbara
Ehrenreich and Deidre English 28
T) ut has this separation between “public” and
JL> “private” sharpened the inequalities between men
and women ?
XT'es it has. With the separation of the two, a hierarchy devel
1 oped between them. The private or domestic sphere lost all
economic, political and historical significance and became less and
less important. That which does not enter the market is not
considered “work”, those who do not operate in it
have no economic worth. Because women
remained in the economically insignificant house
hold, they lost their centrality, their value. Men’s
work became more important, the differences
between women and men kept increasing, patri
archy became more powerful. From being
gynocentric, households — and of course the public
arena — became androcentric (male centred) and
androcratic (male-ruled).
Gyne = Greek for woman
Andros = Greek for man
Gynecology = Science of psychological functions
42
t
ti
and diseases of women
Gynocentric = Woman-centred
Androcentric = Man-centred
Gynarchy = government by females
Gynocracy = women’s rule
Androcracy - men’s rule
Gynelatory = worship of women
Gynocide = killing of women
Gynophobia = aversion to or fear of women
Androgyny = presence of male and female charac
teristics in the same person
The basic values which govern the domestic and public spheres
have also been sharply divided; in fact one can almost say they are
opposed to each other. While in the private sphere love, caring,
selflessness, understanding are appreciated, the public sphere
requires and valorises competition, ambition, aggression, individu
alism. Women are expected to provide a haven for men at home,
away from the ruthlessness of the market place.
Religion-based morality and values do not anymore have a place
in economics, science or technology. Barbara Ehrenreich and
Deirdre English have described this rupture very well: “This new
ordering of the world is not to be imagined as a mere
compartmentalisation along some neutral dividing line. The two
spheres stand, in respect to the basic values, opposed to each other,
and the line between them is charged with moral tension. In its
most fundamental operations the market defies centuries of
religious morality which (in principle, at least) exalted altruism and
selflessness while it condemned covetousness and greed. In the
Old Order commerce was tainted with dishonour, and lending
money at interest was denounced as usury. But the market which
imbibed the new order dismisses all moral categories with cold
indifference. Profits can only be won by some at the price of
poverty for others, and there is no room for human affection,
generosity, or loyalty...”
43
held and a communal household is the focal point of both
domestic and social life. It is in societies where production for
exchange is slight and where private property and class inequality
are not developed that sex inequalities are least evident. Women
continue to be active producers all the way up the scale but* they
steadily lose control over property, products and themselves, as
surplus increases, private property develops and the communal
household becomes a private economic unit, a family (extended or
nuclear) represented by a man. The family itself, the sphere of
women’s activities, is in turn subordinated to a broader social and
public order governed by a state — which tends to be the domain
of men. This is the general pattern presented by historical or
civilised societies.” 29
TJrom what you have said so far it seems that the
Jr greater the separation between the private and
public spheres, the lower the status of women. Is this
true ?
A ccording to many feminist historians (and according to
/vFngels), this seems to be the case. Women have a more equal
status in societies where production takes place within the
household and where there is little separation between the domestic
and public spheres. But this private-public dichotomy is basically
based on two different modes of production and economic
systems in which women play very different roles. Therefore, in
reality it is women’s relationship to work and property which
determines their status. Socialist feminists are of the opinion that
women’s secondary status in history can be traced to economics,
inasmuch as women as a group have had a distinctive relation to
production and property in almost all societies. The personal and
psychological consequences of secondary status can be seen to
flow from this special relationship to work.
According to Joan Kelly, “Although what constitutes ‘domestic’ and
‘public’ varies from culture to culture and lines of demarcation are
differently drawn, a consistent pattern emerges when societies are
placed on a scale where, at one end, familial and public activities
are fairly merged and, at the other,
domestic and public activities are
sharply differentiated. Where
familial activities coincide with
public or social ones, the
status of women is compara
ble or even superior to that
of men. This pattern is very
much in agreement with
Engels’ ideas, because in such
situations the means of subsist
ence and production are commonly
TXoes this separation between private and public
JLz serve to conceal what happens inside the family,
and make it difficult to challenge inequalities and
conflicts within the household ?
T> efinitely. In fact it has been argued by many political thinkers
1 J (and their followers) that the State should have no say in the
“private” realm. The home and relations between family members,
it is argued, should be exempt from government regulation.
Everything that happens within the four walls of the house is
considered a personal matter and no outside intervention is
encouraged. Glaring inequalities and grave assaults on women are
thus allowed to continue. Wife-battering, marital rape, rape of girls
by fathers or other male relations, mental and physical torture of
girls and women, and general deprivation experienced by girls have,
till recently, remained invisible, ttndiscussed and unchallenged.
■
J
L
The divide between the domestic and public spheres also creates
problems for women who take up jobs outside the home. These
demand from them independence, mobility, competitiveness and
long hours of work; the family demands the opposite —
45
44
|
••
subservience, service, co-operation. Scores of working women
have talked about these almost irreconcilable demands and the
physical and emotional tensions and stress they lead to. The role
of a good wife and an effective boss are difficult to combine. No
such demand is made on men, to combine the role of a good
husband and an effective boss.
>■
Feminists have critiqued and challenged this strict division of the
private and the public, because they believe it encourages male
dominance and increases inequalities. It is to challenge this duality
that the feminist movement coined and popularised the slogan,
“The personal is the political”. It brought to the notice of the
public the domestic sphere where women face different kinds of
subjugation and oppression.
NO /AOPE %[N([ ABOUT DO/AffTK ViOLEH(E!
T s there a difference between the different terms used
JLfor women’s subordinate position — terms like
oppression, exploitation, subordination ?
A Ithough these terms are often used loosely and interchange
JTXably, there are differences between them. But first I would like
to point out that terms like gender oppression and gender
subordination only state that there is oppression or subordination
on the basis of gender. They do not specify which gender is
oppressed or subordinated. Stricdy speaking, gender oppression
does not only actually mean wom
en’s oppression; although, because
women are generally the ones
< who are subordinate, it is assumed
1
that gender oppression and gender
subordination refers to them.
46
i
■
The term exploitation is now normally used in a Marxian sense,
and it means economic exploitation or extraction of surplus.
Women’s exploitation thus means that they are made to. provide
economic services at low or no rates at all, and the exploiters derive
economic or material benefits from this exploitative relationship.
Oppression is commonly used for women’s subordinate position,
or their domination by men. In general the term refers to a
historical and structurally institutionalised system of rights whereby
one group benefits at the expense of another. The term implies
forceful subordination and it has been used to describe the subject
conditions of individuals and of groups as in “class oppression ,
“caste oppression” or “racial oppression”.
Subordination means being placed below or ranked in an inferior
position to someone else, or being subject to the control or
authority of another. The term “women’s” subordination refers to
the inferior position of women, their lack of access to resources
and decision-making, etc., and to the patriarchal domination that
women are subjected to in most societies.
Not all feminists find the term “oppression” appropriate.
According to Gerda Lerner it “inadequately describes paternalis
tic dominance, which while it has oppressive aspects, also involves
a set of mutual obligations and is frequently not perceived as
oppressive...
“.. . The word ‘oppression’ focuses on a wrong; it is
subjective in that it represents the consciousness of the subject
group that they have been wronged. The word implies a power
struggle; defeat resulting in the dominance of one group over the
other. Women, more than any other group, have collaborated in
their own subordination through their acceptance of the sex
gender system. They have internalised the values that subordinate
them to such an extent that they voluntarily pass them on to their
children. Some women have been ‘oppressed’ in-one aspect of their
lives by fathers or husbands, while they themselves have held power
47
x
Gender and Development
over other women and men. Such complexities become invisible
when the term ‘oppression’ is used to describe the condition of
women as a group.”30
Lerner feels that the use of “subordination of women” has distinct
advantages. “Subordination does not have the connotation of evil
intent on the part of the dominant; it allows for the possibility of
collusion between him and the subordinate. It includes the
possibility of voluntary acceptance of subordinate status in
exchange for protection and privilege, a condition wLich charac
terises so much of the historical experience of women. I will use
the term ‘paternalistic dominance’ for this relation. ‘Subordination’
encompasses other relations in addition to ‘paternalistic domi
nance’ and has the additional advantages over ‘oppression’ of being
neutral as to the causes of subordination. The complex sex/gender
relations of men and women over five millennia cannot be ascribed
to a simple cause — the greed for power of men. It is therefore
better to use fairly value-free terms in order to enable us to describe
the various and varied sex/gender relations, which were con
structed by both men and women in different times and different
places.”31
The term deprivation is sometimes used to express women’s
situation but it is inappropriate because it hides the existence of
power relations. Deprivation is the observed absence of preroga
tives and privileges. It focuses attention on that which is denied,
not on those who do the denying. Deprivation can be caused by
a single individual, groups of people, institutions, natural condi
tions and disasters, ill health and many other causes.
Since women’s situation varies from society to society and at
different times in history, one can use different terms to suit the
situation one is describing.
48
\V7hy has gender become so important in development issues and debates?
■
r
Z^vver the last 10-15 years gender and development has indeed
been discussed a great deal. There have been scores ■ of
conferences, trainings and workshops on the subject. Women s, or
gender, concerns were brought to bear on development issues
when it started becoming clear that planned development efforts,
which were meant to improve the lives of whole communities, were
either not helping women, or were actually harming them in many
ways. Around the end of the 1960s and early 1970s (mainly) women
researchers in different parts of the world started pointing to the
neglect of women in development planning. Similar things had
been observed earlier about the lack of participation and further
marginalisation of the poor in this process. Planners assumed that
development programmes would automatically benefit all members
of communities, but this assumption was found to be invalid
almost everywhere. In the 1950s when the newly independent
countries began planned development, their model was the west.
It was thought that industrialisation and modern agriculture would
usher in growth and development, and the focus was on
industrialists, landowners, rich farmers and entrepreneurs. Govern
ments of developing countries were “betting on the strong”,
assuming that the benefits of development1would
------ “trickle down”
to the poor majorities, and gradually whole commu
nities would prosper. Little attention was paid to
the income-poor and to women. Women’s contri
bution to the household and to the economy was
neither recognised nor valued.
During the First United Nations’ Decade, 19601970, it became clear that the benefits of develop
ment were not reaching the poor majority. There
was evidence of underemployment, food shortages
49
and further polarisation between the rich and the poor. As a result
of these findings and the pressure from below, the goals of
development and the means for their achievement were re
examined during the Second Development Decade, 1970- 80. In
countries like India and Bangladesh, NGOs working in rural areas
pointed out the lack of participation by the poor and women in
development programmes. This is when concepts like peoples
participation”, a “bottom-up approach , redistribution with
growth” and so on were debated, and the “basic-needs approach ,
accompanied by anti-poverty programmes, introduced.
In much the same way, it was discovered that even when a
household benefits from development programmes, it does not
follow that women in the household will benefit equally or benefit
at all. Studies done from a feminist, perspective — i.e., one which
is guided by women’s interests and concerns and aims to transform
hierarchical gender relations and make them equal — in different
parts of the world — provided data and evidence to show that
gender-blind development plans had generally ignored women,
their perspectives, needs and interests. This neglect meant that
existing inequalities between women and men were not addressed,
and second, women’s action and potential contribution to and
participation in the development process was ignored. Conse
quently, women were further marginalised and disempowered.
It was there for all to see that women were not given access to
educational and training opportunities, technology did not liberate
them from drudgery, and prejudice and misconceptions persisted.
ould you please give some examples to explain these
points.
A Imo st everywhere in the world women have been farmers and
JLXproducers of food. Despite this, our planners, decision
makers and communicators have persistently refused to recognise
their contribution. The very language of these gentlemen (and
50
ladies) betrays their discriminatory perceptions. Thus while
referring to farmers they invariably use masculine pronouns like
“men” and “he”.
Development programmes leading to marginalization of women
The result of these blinkers vis-a-vis women was, and still is, that
in planning for agriculture and rural development, women have
been neglected and further marginalised. Most training, informa
tion and credit for agriculture, horticulture and animal husbandry
have been given to male farmers, inspite of the major contribution
of women to these activities. Extension programmes have been run
almost exclusively by men, for men. By contrast income generating
activities for women have remained conventional: sewing, embroi
dery, papad and pickle making, which have generated little income
but many myths about what is feminine and masculine.
Agricultural development has normally and almost entirely been
“manned” by men, right from decision-making to implementation.
For example the massive and expensive Training and Visit projects
for agriculture extension in India, planned and funded by the World
Bank in the 1980s, totally ignored or bypassed women. Similarly,
a report on media support for big reforesution programmes in
Nepal did not mention women even once. Women have not even
been involved in projects related to reforestation, water supply,
grain storage or other activities which are managed primarily by,
and are of critical concern to them.
What is more, we find that most technology has been given to and
is controlled by men, while women continue to do the more
tedious, repetitive and back-breaking tasks. Commercialisation of
agriculture has led to greater control of cash and family resources
by men, even when, often, women do the work.
In the Eighties a review of eleven major rural development projects
in Nepal showed that the productive roles of women were
completely ignored because of distorted concepts of housewife ,
51
“head of household”, and “economic” activity. In most of these
projects, new farming technologies and machinery were made
available only to men and applied only to male tasks, such as
ploughing. When mechanisation was introduced for a female task
such as husking or milling, it was transformed into men’s work.
This happened with the introduction of mechanised milling for
high yielding rice varieties in Indonesia and Bangladesh. As a result,
in one stroke large numbers of women were deprived of whatever
little they were earning earlier.
Women have also been excluded from owning or controlling land,
the most crucial productive resource in agricultural economies. An
FAO study has pointed out that traditional systems of land tenure
often allowed women to grow food for themselves, their children
and extended families, without recourse to formal land ownership.
Some land reform programmes, however, have given titles
to land to individual men with the result that women ., , ,•
may no longer have access to or control over it. At
the same time the new owner may decide to sell
rather than cultivate the land, taking it out of use
for producing food for local consumption.
Because land deeds are made out in the names of
men they become the legal heads of household. As
such it is only they who are entided to receive
loans, participate in government schemes, become
members of co-operatives, etc. This is so even in
places like the hills of UP in India where most agricultural work
is done by women because of male migration to the cities. It is
the same story when it comes to training.
An analysis of many irrigation resetdement schemes like the
Mahaveli Scheme in Sri Lanka, the Muda Scheme in Malaysia, and
the Mwea Scheme in Kenya shows that they were planned with a
nuclear family (a male head and a female housewife-helper) in mind,
ignoring existing customary practices which gave women relative
autonomy as producers in these communities.
52
Feminist researchers have pointed out that in the Mahaveli Scheme
in Sri Lanka married women were not entitled to plots of land, and
because the family was asked to name only one heir, this was usually
the son. Thus, contrary to Sinhala customary law and practice of
bilateral inheritance whereby both sons and daughters have a'right
to the family paddy land, and where married women too have
independant and unalienable land ownership rights, in the scheme
villages, wives were considered to be dependants. Again, because
they were not given land titles, women had litde access to
agricultural extension information, institutional credit and co
operative membership. Thus women were marginalised and
disempowered in new ways.
Extension trainings too, it has been found, neglected women,
and cultural attitudes further discourage contact between women
and male extension agents. For example, in one area of north - west
Bangladesh, women traditionally selected seeds for planting.
When a new variety of high yielding wheat was introduced the
results were disappointing; it was found that women were choosing
wrong seeds because the extension programme had been directed
only at men.
Thus the experience of different parts of the world shows that
women have been pushed out of mainstream agriculture in the
name of “development”. Earlier, men and women were equal
partners in agriculture. Their knowledge, contribution, and partici
pation in decision-making were more or less the same. Gradually,
male farmers were singled out for attention by male “ developers”;
they got machines to lighten their burden and to increase efficiency;
they were made members of co-operatives and development
committees. Cash-crops delivered cash into the hands of men.
Commercialisation of agriculture also marginalised women because
markets, banks and trading centres are “public” spaces and thus
beyond the reach of most women.
Other areas of economic activity provided similar insights. For
example, in India it has been found that as a result of
53
mechanisation and modernisation women lost their jobs in the
textile industry where they had been employed in large numbers.
This economic marginalization has led to women’s social
marginalization and to a lowering of their status. This may be one
reason why, for example, dowry, and female infanticide and
foeticide in India have spread to areas and communities in which
they did not exist earlier. This may also be one of the main reasons
for the continuing decline in the female-male ratio in South Asia.
Economic redundance seems to have lowered the chances of
women’s survival.
f Y" ow would you characterise such a development
JL JL paradigm from a feminist perspective ?
■A 4"any socialist feminist researchers have gathered enough
j_VJLevidence to show that monetisation and the commercialisa
tion of production have led to the marginalization of women and
the poor. Capital accumulation makes it possible for some people
to accumulate more and more even as others lose control over land
and other resources. The only thing they control is their labour
power, but the value of their labour is not determined by them.
In fact, Engels has said quite categorically that it was private
property that led to the creation of class and gender hierarchies.
According to him the need to control women came along with the
emergence of private property. Male control over women’s
reproduction and sexuality made for the world historic defeat of
the mother right. Further, the position of bourgeois women is
much worse than that of working class women because bourgeois
women themselves are property, they are merely the carriers and
producers of heirs.
Economists Amartya Sen and Jean Dreze came to similar
conclusions from their research on Female Male Ratios (FMR) in
India.32 They show, first, how since 1901 the FMR for the whole
of India has been going down systematically. Second, they show
that generally figures are higher among poor, illiterate working
classes and castes.
In 1901 lower caste chamars in UP had an FMR of 986 compared
with 937 for the state population as a whole. By 1981 the FMR
was more or less the same among Scheduled Castes and Tribes and
other castes This is because the SCs and STs of UP are today more
like the ‘higher’ castes, which means they have also begun to
practice the patriarchal neglect of women thereby reducing their
chances of survival. In other words these figures prove that the
patriarchal norms of higher castes are spreading to others.
This process. Sen and Dreze say, is particularly strong when the
disadvantaged castes experience upward economic mobility. It is
quite shocking and bewildering to be told by them, that higher
levels of poverty tend to go with higher FMRs. It is in fact,
plausible that the parmership aspect of gender relations is stronger
in poorer households, where survival depends on effective co
operation, than among privileged households where women tend
to have a more dependent and symbolic position.
Veronika Bennholdt-Thomsen, a German feminist scholar presents
a similar hypothesis. She writes that the appalling situation of the
majority of Third World women is not a remnant of archaic
systems of patriarchy, or a sign of backwardness and underdevel
opment; on the contrary, it is a product of modern development.
According to her, the housewife as we know her today, emerged
in the First World during the 19th century. She is the result of a
protracted historical process comparable with and closely related
to that 6f proletariatization. Bennholdt-Thomsen terms this
process ‘domestication’ or ‘housewifisation’ and she goes on to say
that as soon as the modern money and commodity economy gains
hold, women find themselves relegated to the unpaid or lowest paid
spheres of work. In particular, women cease to be able to live
...........
autonomously with their
children in
i a world which runs on the
they have such restricted access. Growing
money to which
'
55
54
*
propertylessness forces them to submit to dependence on men,
and relations between men and women stop being co-operative.
Based on these objective circumstances, they necessarily become
hierarchical. She says since money and social esteem in modern
society are closely related, those whose access to money is severely
limited are also denied esteem.33
Maria Mies, who studied rural women in India in the ‘70s, writes:
‘The most brutal forms of violence and of sexist terror are to be
found in areas where agriculture has been rapidly ‘developed’ in
recent years, where new forms of wealth appeared,’ where cinemas,
alcohol, television and other new consumer goods were introduced
as indicators of ‘modernisation’.”34
These statistics and insights should make all those involved with
“development” sit up and rethink. They remind us that economic
progress by itself does not necessarily reduce gender inequalities.
In fact, capitalist economic growth may actually lead to an
intensification of gender bias. Punjab and Haryana, two of the
most economically advanced states of India, with their FMRs of
882 and 865 respectively (as against the Indian average of 927), are
good illustrations of this point.
Achieving greater gender equality involves a process of active social
change which may have no obvious link with economic growth.
A number of studies have shown that the extent of anti-female
bias is substantially reduced by various factors
that give women more voice and agency
J
within the family. These are primarily
education and the ability to earn an
yC__
independent income through paid
>
employment. The latter makes for
women getting greater exposure,
more respect, more bargaining power
and better chances of survival.35
56
ave these researches and insights made any
difference to development planning and pro
grammes?
XT’es, they have. Some planners and decision-makers realised that
1 ignoring or neglecting women was harming not just women
but entire communities and nations, because women, after all are
half the human race. To influence member governments the
United Nations organised a major global conference on Women
and Development in 1975 in Mexico, declared 1975-85 to be the
Decade of Women, and formulated declarations and plans of
action which were endorsed by many member governments.
Literally hundreds of other conferences and meetings were
organised in different parts of the world to discuss how to integrate
women into development. So, on the one hand there was pressure
from below — i.e., the demands of the women’s movement for
equality, justice and development -— and on the other there was
pressure from above — i.e., global declarations, UN charters, and
so on. The result was that many governments set up women’s
ministries, departments or commissions with the task of generating
data and qualitative information on women, to monitor and
evaluate the impact of development programmes on them, and to
integrate women’s concerns in development planning. Womens
contribution to production and to society in general and their
specific needs were now recognised and discussed. To some extent,
the purdah of neglect and disregard was lifted and women became
somewhat visible. Many governments agreed to provide annual
reports to the UN Commission on the Status of Women on
progress made by them towards gender equality.
However, as Saskia Wieringa points out, “Despite the attention
paid to issues of women and development in the last decades,
actual progress has been uneven and piecemeal, both under
conditions of economic decline and of economic growth.” In a
United Nations Report of 1991, the Secretary General at that time,
Perez de Cueller, noted that “It is clear from these data and
57
indicators that although there have been some improvements for
women over the past twenty years, the majority still lag far behind
men in power, wealth and opportunity. The HDR 1993 shows that
womenfthe world’s largest excluded group from development’), are
frequendy shut out from positions of power, are much less likely
to be literate than men, and have many fewer job opportunities:
in the (developing) countries for which relevant data are available
the female human development index is only 60 per cent that of
males.” Some recent work has also stressed the link between the
gender gap in development and violence against women.36
T Tave gender relations become more equal in South
AjlAsia ?
Tt is not easy to give a clear-cut answer to this question. The issue
JLis complex and cannot be generalised for all societies or
countries. In some ways women have definitely gained. Today they
have more rights (right to vote or to inherit, for example); more
opportunities (for education, training, jobs, travel); and more
participation in political decision-making. There is also much
greater awareness about women’s oppression and the need to tackle
it systematically. Women themselves are much more articulate and
organised for change. But there are other ways in which women
seem to be worse off.
In Sri Lanka, for instance, where the statistics for female life
expectancy and literacy were quite impressive, the situation has
deteriorated over the last 10-15 years. In India, Bangladesh and
Pakistan the sex ratio continues to become more adverse for
women. In 1901 the female-male ratio in undivided India was 975
women to 1000 men. In 1991 in Bangladesh it was 940, in India
927 and in Pakistan 910. Today 74 million women and girls are
“missing” in South Asia. This means many more women and girls
are being “killed” today than 90 years ago by patriarchal neglect,
discrimination and violence. These figures prove that the situation
of women and girls has been worsening inspite, or perhaps because
58
of, “development”. In most of South Asia, while women are being
provided with more opportunities, and there is more awareness and
articulation of gender issues, we find a resurgence of patriarchies.
Religious fanaticism of all kinds has meant more restrictions for
women. In Pakistan, for example, progressive family laws have been
replaced by the anti-women Hudood Ordinance; in Bangladesh,
fundamentalists have been attacking emerging women’s groups and
NGOs working for the empowerment of women. Right-wing
Hindu groups in India are busy reviving patriarchal role-models.
Market fundamentalists are spreading pornography and demeaning
images of women with incredible speed. Beauty contests, which
had been discredited and more or less disappeared,
are back with a vengeance along with globalisation
and liberalisation. The incidence of violence
against women has increased sharply. Economic
hardships are leading to increasing discrimina
tion against women. For example, in India, the
practice of female infanticide has reached
villages in South India where it had never existed;
and dowry is being practised by communities which
neither gave nor took dowry earlier. The figures with
regard to women’s participation in politics continue to be appalling,
in spite of the fact that four of our seven South Asian countries
have had women heads of state. No South Asian country has had
more than a handful of women members of parliament since
Independence.
Examining the changes in the patriarchal system in Britain, Sylvia
Walby makes observations which seem to be applicable to South
Asia as well. She says: “There have been changes both in the degree
and form of patriarchy in Britain. It has seen a movement from
a private to a public form of patriarchy over the last century. Private
patriarchy i$ based upon household production as the main site of
women’s oppression. Public patriarchy is based principally in public
sites such as employment and the state. The household does not
cease to be a patriarchal structure in the public form but it is no
longer the chief site. In private patriarchy expropriation of
59
women’s labour takes place primarily by individual patriarchs, in
public patriarchy it is collective.”
On the question of whether there has been progress or regress in
women’s position, she says, “Patriarchy is not a historical constant.
Modifications in gender relations over the last century or so have
been interpreted variously as progress, regress and involving no
overall change. Liberals typically define them as progress; Marxists
as regress followed by stasis, and radical feminists as embracing no
significant change.”37
arlier everyone talked of “women in development”.
How did this change to “gender and development”?
Tnitially most people talked about integrating women into devel
JLopment. This has been called the Women in Development
(WID) approach, which aimed at meeting women’s basic needs and
making use of women’s traditional skills and abilities for achieving
the goals of development. However, it was found that WID
policies and programmes did not address the subordination and
oppression of women, nor did they question the anti-poor biases
of development thinking and programmes.
It was in the '80s that the focus shifted from women to gender,
and from welfare, basic needs and efficiency approaches to a
women’s empowerment approach, which seeks to address the
patriarchal system at the root of women’s subordination. It was
argued that looking only at women is neither problemfree nor adequate. Focusing on women made it
appear as if women were the problem, as if
something was wrong with them, and that if that
something was corrected, things would improve.
Later it was pointed out that to improve women’s
condition and status and to make them partners in
development, it was essential to understand the
60
causes of women’s subordination; to examine the social system
(patriarchy) which keeps women oppressed and subordinate. The
concept of gender emphasised that the problem was not with
women but with the socio-cultural definition given to women and
men, which determined their rights and responsibilities, their work
and spaces and so on. Women are what they are because of a social
system, and it is the social system and its definition which need
to be changed to improve women’s status. Looking at gender
requires looking at men as well, because women cannot be
understood in isolation. It requires an examination of how gender
is constructed and perpetuated in different societies, it means
looking at gender relations, the gender division of labour and
gender hierarchies. And, importantly, it requires looking at and
addressing power in gender relations.
"The increasing recognition that development is not
gender-neutral was accompanied by a conceptual
shift from 'women' to 'gender'. The concept of
gender emerged as a way of distinguishing biologi
cal difference and socially constructed inequality,
while the concept ofgender relations sought to shift
attention away from looking at women and men as
isolated categories to looking at the social relation
ships through which they were mutually consti
tuted as unequal social categories. Gender relations
are an aspect of broader social relations and, like all
social relations, are constituted through rules,
norms and practices by which resources are allo
cated, tasks and responsibilities are assigned, value
is given and power is mobilised. Gender relations
take account of the central issues of power and
hierarchy within the family and society." Madhu
Sarin38
Although not all “gender experts” do so, we believe the following
points need to be stressed when talking of gender and develop
ment.
61
Differences between men and women’s achievements and partici
pation are a result of socially constructed gender roles rather than
of biological difference.
What needs scrutiny and change is not just women but gender
relations and gender divisions of labour.
Changing the condition, position and roles of
women requires a corresponding change in the
condition, position and roles of men. The two
are inter-connected and there is a relationship
of power between them.
. <1/.
To change women’s position it is necessary to
challenge patriarchal structures and ideologies.
Because of gender- subordination women con
tinue to require special attention.
Gender relations and hierarchies cannot be studied in isolation.
They have to be understood in the context of caste, class and race
and north-south relations.
It is now widely recognised that women must be empowered and
that the systems and ideologies which keep them subordinate,
dismantled. Women must be equal partners in decision-making in all
institutions and at all levels, and they must be subjects, not objects,
or just beneficiaries of development policies and programmes.
These changes in the thinking on women and development have
been analysed, categorised and labelled (mainly) by women
researchers and academics.Approaches followed during the last
three decades have been labelled WID, WAD and GAD. These
labels try to capture trends which were set in motion from the
ground up by millions of women and men all over the world who
were dissatisfied with the treatment meted out to the majority of
the world’s population, and to', nature, by insensitive analysts,
62
planners and policy makers. For the majority, their concern is not
more “progress” but survival. In the ‘80s and the ‘90s Structural
Adjustment Programmes, globalization and privatisation have
further squeezed the poor who have lost even the little control they
had over the natural resources on which they subsisted. Instead of
the majority controlling the natural wealth of the world a handful
of companies, motivated purely by profit and power, control and
exploit it. In most countries of the world the poor are worse off
today than they were in the ‘60s. So much for “planned
development”.
During the last two decades 1.6 billion people living
in about 100 countries have experienced a decline
in their per capita income.
Growth can, and has become for many, jobless,
voiceless, rootless and futureless. UNDP Human
Development Report, 1996.
People’s organisations and movements (like the women’s, environ
ment, human rights and NGO movements) have been questioning
development thinking, challenging hierarchies of caste, class, race
and gender, and they have been trying to create alternative thinking
and practices. One of these has been to reconceptualise women
in development. Maxine Molyneux, a feminist researcher, pointed
out that after the revolution in Nicaragua, efforts were made to
meet women’s practical gender needs but their strategic interests
were not addressed. Hence although the condition of women
changed, their position vis-a-vis men did not. Similar insights from
different parts of the world led to the formulation of useful
concepts like condition, position, practical gender needs,
strategic gender interests, subordination, empowerment,
autonomy, and so on.
Condition of women is their material state in
terms of their nutritional level, health, access to
63
basic needs, education, and this can be improved by
providing food, health services, education, etc.
Position of women is their placement or status in
society in relation to men. To assess the position we
need to look at the social relations of gender or
relations of power between women and men. To
improve women's position the existing norms,
structure and power relations between women and
men have to be changed.
Practical Gender Needs (PGNs) are related to the
condition of women. They are easily identifiable
(food, clean water, medicines, housing) and they are
related to the existing gender division of labour. For
example women say they need water, fuel andfodder
because it is they who look after their children, the
household and domestic animals. Because fulfilling
women's PGNs does not change the existing power
relations no one feels threatened by activities and
programmes aimed at meeting PGNs.
Stategic Gender Interests (SGIs) are related to
women's subordinate position in society and their
desire to change the existing hierarchical gender
relations and make them more equal. SGIs can be
pursued by women organising, getting into deci
sion-making positions, changing discriminatory
practices, norms and rules in order to transform
gender relations. Activities which promote women's
SGIs are education, consciousness-raising, mobilis
ing and organizing, developing leadership and
management skills, etc. Such activities are often
resisted because they challenge male domination
and demand long-term changes in gender relations.
But these categories are often very fluid. The
condition of women can be changed in such a way
64
that it leads to changes in their position and
transforms gender relations.
asier said than done! How do you actually change
age-old ideas, attitudes and behaviour patterns?
How do you redistribute power between women and
men?
Tndeed it is not easy to change all this, especially power relations.
JLOrganisations that are supposed to plan and bring about change
are themselves very patriarchal, be they government departments
or non-government organisations/ Even
women’s organisations and women
are not free of patriarchal thinking
because they are products of the
same culture^Massive changes are
required in thinking, in organisa
tional structures and policies, in
planning and implementing devel
opment programmes, for real social
change to take place. I
Large numbers of women and men all over the world have made
different kinds of efforts at different levels to change patriarchal
thinking, attitudes, structures and organisations. To give just a few
examples:
/• School curricula have been analysed and made more gender sen^sitive.j
sitive.A
• Patriarchal biases in media have been highlighted and laws, regu
lations and guidelines prepared to weed out sexism from media
and make them reflect women’s contribution, needs and aspira
tions.
• Laws have been scrutinised and made more gender sensitive.
• Women’s studies centres have been instituted to prepare women
65
and men who can conduct gender sensitive research; to analyse
social, economic and political issues from the perspective of
women.
• Attempts have been made to make national censuses gender sen
sitive and obtain sex-differentiated data which would make it pos
sible to prepare gender- transformative plans.
• Hundreds of workshops and trainings have been conducted for
planners, managers, trainers, field-level workers, government and
non-government, to help them understand gender disparities, sen
sitise them to gender issues, and. instil a commitment to gender
equality. Such workshops have also been conducted with police
personnel, media persons, members of the judiciary, elected rep
resentatives of people and other public servants.
• Guidelines, check-lists, frameworks have been prepared to ana
lyse plans and programmes to make them gender sensitive and
gender transformative.
• Special units, cells, departments and commissions have been set
up by NGOs, governments and the UN to plan and monitor
progress towards equality. By 1985,90 per cent of member coun
tries had established an institutional body or system for promot
ing the status of women.
• Women’s organisations have emerged in almost every country to
work on a range of gender issues. Women’s publishing, film
making, art, architecture, newspapers and magazines have flour
ished in many countries.
Some governments, UN organisations and NGOs have made
special efforts to recruit women and train them for senior
positions; and to make organisations, their policies, rules and work
culture more women-friendly. Special gender indicators have been
developed to measure the success of programmes aimed at
women’s empowerment and gender equality.
For making development more gender sensitive,
government policies now increasingly emphasise
qualitative inputs, focusing on inculcating self
confidence among women; generating awareness
, 66
about their rights; and training them for economic
activity and employment. Efforts to improve wom
en's access to critical inputs and productive re
sources such as land, houses and trees through joint
or individual titles have been expanded to include
support through credit (or small scale capital),
marketing, training in skills/ management and
technology. Developing women's organisations is
now accepted as an effective strategy for promoting
women's empowerment.
f
The most well-known initiative of the Government
of India to promote gender equality in the political
sphere is the 73rd Amendment, reserving one-third
of elected seats in local government for women.
Through this measure, an estimated one million
women could emerge as leaders at the grassroots
level in rural areas alone, 75,000 of them being
chairpersons. The Government of India has also
drafted a national policy for the empowerment of
women. Reservation of one-third seats for them,
even in Parliament and state legislatures, is being
debated.59
exactly do gender sensitivity and gender
sensitisation mean?
W se„
T^Xifferent people mean different things by these
_L/words. The simple meaning of gender sen.
sitivity is acknowledging that women are subordinated in most societies, and that this subordiuation is harmful not only for women and girls, but
also for men and boys and the entire society. It
means being aware of why men and women behave
differently, and understanding their needs and concerns.
67
It also means understanding the implications and impact of
different policies and programmes on women and men. In
planning, gender sensitivity implies making plans which will not
only not ignore and further marginalise women, but will take care
of women’s special needs and make efforts to involve and empower
women. In short to transform gender relations.
not just women’s issues, they are social issues. It is unfortunate
that for much too long only women and their organisations have
been concerned with them. But it is heartening to see that
some sensitive men are also taking up these issues now and
starting groups like “Men Against Rape” or “Men Against Violence
Against Women”.
According to feminist gender trainers, gender sensitivity means not
only understanding but also challenging patriarchy and other inter
connected hierarchies like those of caste, class, race and northa
south. We believe gender sensitization is necessary
at all levels in all organisations. Acknowledging
die feminist slogan “Personal is Political”, we
believe gender sensitization begins with each
one of us, our families and organisations. It
requires not only an intellectual understanding
of concepts like gender and patriarchy but
using this understanding to transform our own
ways of thinking and behaving. Understanding
alone does not change social relations and social
realities, what changes society is people’s behaviour and actions. In
other words gender sensitivity requires internalising our under
standing and applying these insights to our behaviour. Transform
ing gender relations means demolishing the separation between
theory and practice, personal and public, objective and subjective,
rational and emotional. Gender sensitivity does not only mean'
“main (man) streaming” women, it means examining the main
stream from a feminist perspective. If it is patriarchal, unjust and
unsustainable then women need to challenge and change it, instead
of joining it.
Gender sensitivity and gender justice definitely require women’s
equal participation in organisations and in decision-making
processes but in addition they require a transformation in the
practices and cultures of organisations. For example, while many
NGOs are recruiting more women, their organisational culture
continues to be male, and at times even hostile towards women.
A careful scrutiny is therefore required in every organisation, of
the language used, the jokes told, the songs sung, the comments
passed on people’s way of dressing, and so on.
Gender sensitivity also means acknowledging that AT J. issues —
economic, cultural, social or political — are women’s issues because
women represent half the human race.
Gender sensitivity also requires understanding the situation of
those women who have to combine their work at home with jobs
outside. In addition to the double burden of work, women,
specially those in management positions, face conflicting demands
on their behaviour. A woman manager is expected to be tough,
Obviously, the opposite is also true: all the so-called women’s issues
(dowry, rape, pornography, female foeticide, infanticide, etc.) are
68
Most NGOs expect their senior managers to work very long hours,
to travel and work on weekends, etc. For women who have
responsibilities at home it is not possible to live up to such
expectations and hence to fill managerial positions. Therefore,
instead of putting unnecessary pressure on women to put in
longer hours of work, NGOs need to pressurise and encourage
men to spend more time at home, and give more attention to their
roles and responsibilities as parents, marriage partners and
householders. Genuine changes in unjust gender relations can be
brought about only through concrete changes in men’s behaviour
and activities. Men can understand, appreciate and help women
only by sharing women’s endless, repetitive and thankless work
at home.
69
cool, rational, competitive, in charge; but the same woman manager
is expected to be submissive, caring, self-effacing as a wife and
mother. Male managers face no such schizophrenic situations.
relevant. For example, certain features of women’s biology may
mean that occasionally their needs are different from those of men,
most evidently, in the case of child-bearing.41
In the ultimate analysis being gender sensitive simply means being
sensitive and caring; it means being against and opposing injustice
and unfairness between men and women wherever it exists.
However, more problematic than these theoretical distinctions is
the way the concept of gender is being used today.
yVThat do you see as the problems with the “gender
■p "fas using the concept of gender contributed
1 JLsignificantly to women’s empowerment?
/Concepts are basically analytical tools or theoretical constructs
which help clarify our ideas and examine social reality in a
more systematic way. They cannot by themselves change reality,
although they may influence our perception of it and, in that sense,
construct it. Gender is simply the concept that clarifies the fact that
women and men are social categories or constructs, not merely
biological categories.
However, some feminists think that this concept has theoretical
problems. According to Maria Mies, the distinction between sex
and gender follows the well known dualistic pattern of dividing
“nature” from “culture”. For women, she says, this division has had
a long and disastrous tradition in western thought because women
have been placed alongside nature ever since the rise of modern
science. The duality between sex and gender is problematic because
human sex and sexuality have never been purely biological affairs.
Sex is as much a cultural and historical category as gender. By the
dualistic splitting up of sex and gender, by treating the one as
biological and the other as cultural, the door is again opened for
those who want to treat the sexual difference between humans as
40
a matter of our anatomy, or as matter.
Others see the need to reconsider the political and philosophical
significance of biology. According to them gender is in part
determined by sex, therefore some aspects of sex are still politically
70
▼ ▼ business” ?
TTardly a workshop, paper, article or speech on women today
1 JLis made without using the term gender. The enthusiasm for
it is so great but the understanding so little that it is being used
when it shouldn’t be or it is being misused and misinterpreted. For
example, we have heard people say “gender-ratio” instead of sex
ratio and “gender-disaggregated ” data instead of sex-disaggregated
data .
The main reason for this confusion and misuse is that most people
have not really understood what this concept means.
An elderly social worker in a remote area of
Bangladesh, when asked what type of work
he was doing, said “Aami gender kori” (I do
gender); I suppose what he meant was, he
was working for women’s development.
Terms like women’s empowerment, women’s
autonomy or women’s development are being replaced with gender
equity and equality, with each person free to interpret them the way
they want. So much so that a senior development expert once said
to me : “What is all this fuss about gender and gender sensitization.
Everyone knows what gender is, just take off everybody s clothes
and you will see gender.” The poor chap had missed the point
completely. He did not realise that our clothes tell us more about
gender than our bare bodies !
71
\V7hat are the reasons for the sudden popularity of
Vv the term ?
ender has been popularised because it allows us to talk about
Vjboth women and men and obliges us to look at relations
between them. However, many people who use the word gender
continue to talk only about women, and work only ON, FOR or
WITH women.
Many others prefer it because it is neutral, i.e., it refers to both
women and men and hence may be less threatening. It does not
antagonise men the way other terms like “women’s empowerment”
or “patriarchy” do. But for many feminists, this is precisely the
problem with this term — its neutrality. Gender or
gender relations say nothing about the nature
of these relations. Gender inequality, for
example, does not mean women are unequal
or subordinate it merely means tliat there is
inequality between the genders.
Maria Mies maintains that it is not surprising that the word has
readily been adopted by all kinds of people who may not otherwise
have much sympathy for feminism, and may even be hostile to it.
If, instead of ‘sexual violence’ we talk of ‘gender violence’, the
shock is absorbed by an abstract term, which removes the whole
issue from the realm of political commitment to that of apparently
objective discourse.
The word women’s subordination, on the other hand, does say who
is subordinated and marginalised, and who should be in focus. So
too, women’s empowerment is unambiguous.
The term “patriarchy” (which is, of course, no substitute for the
word gender, but which is used less and less by the gender wallis
and wallas) is also not neutral. It clearly and unambiguously
characterises the nature of gender relations-!.e., that men are in
control, that we live in a male-ordered world. The details and
72
particulars of the male world need to be studied carefully, but it
is clear who is in power and how that power needs to be
redistributed.
Because the term gender is neutral, it is creating a lot of confusion.
Because people have not been told what it is, why it was introduced
and how it should be used they use it to suit their own thinking
on the subject. We have innumerable men saying “ If it is a gender
cell why is there a woman incharge ?” or “Why are there no men
in gender workshops ?” or “Why are you talking of women’s
empowerment in a gender workshop ?” or “Why are there no male
gender trainers ?” Suddenly everything has to be fifty-fifty to ensure
men are not left out, and to prove we are talking of gender.
Suddenly a lot of people (mainly, but not only men) are concerned
about men being left behind or left out, men not being included
in everything. Before much justice has been achieved for women,
the threat of possible injustice against men is becoming a concern.
Thus we find that the term gender often obscures power
relationships rather than illuminating them. And it is being seen
as a sanitised, neutral category. For many gender experts, gender
is now a specialisation. It has been taken out of the living,
interconnected world. One can talk of gender in the context of
a project without mentioning patriarchy, or undersunding and
challenging the root causes of gender subordination.
Gender is also fast becoming a thing you “do” to others, specifically
to “target groups” or so-called beneficiaries. If not in theory then
in practice, the concern is often with gender at the “grass roots”
level. When gender is just a project-related concern it does not
threaten anyone. It is quite acceptable, it can be mainstreamed,
unlike struggles against patriarchy which call for dismantling
oppressive structures, institutions, attitudes. This is definitely
threatening.
This is not to deny the possibility of using gender politically, and
many feminists use it that way. But there is the real possibility of
73
the concept being used totally apolitically. However since nothing
is apolitical, it may end up being used to obscure the real issue,
i.e., patriarchal subordination. Because of this many of us in South
Asia have been very reluctant to use this concept and, even now,
use it very cautiously and only along with other concepts like
patriarchy.
Although, gender interventions in development programmes vary
widely in their understanding and purpose, the objective of most
so-called gender sensitisation modules used by official agencies and
consultants/trainers for male [and also female] policy makers,
planners and implementers is to look at gender relations in order
to enhance the effectiveness of development programmes and
policies; to involve women in development programmes in order
to tap their “productive usefulness”, to “invest” in women. Gender
equality and gender justice may not be their primary aim. These
experts seldom address the issue of power in gender relations. I
have often heard the term gender being used only to describe the
different roles and responsibilities of men and women, or the
different access and control they have to resources and decision
making. Many gender trainers do not go beyond describing the
situation, and even when they do analyse the reasons for gender
inequalities, they do not necessarily challenge them. Quite often,
they may even base their development interventions on an existing
gender division of labour.
Many gender trainers and experts treat the whole issue of gender
as a technical matter; treat it as if by using a few tools of gender
analysis gender inequalities can be removed. Such trainings and
interventions, we feel, are not only incapable of challenging gender
inequalities, they are depoliticising
the issues and making change
more difficult.
Saskia Wieringa has pointed out
how development planners are
74
searching for easy schedules, quantifiable targets and simplicity,
while addressing enormously complex situations. Instead of
demonstrating flexibility and a desire to appreciate complexity, they
are trying to bend social realities to fit their narrow frameworks.42
Wieringa maintains that fundamental questions relating to women’s
gender interests are not being asked while planning development
interventions. In the case of structural adjustment programmes,
she argues, such questions include the following: Why does
feminization of poverty occur ? Why is it that women have to do
unpaid tasks such as the care of the young, the elderly and the sick ?
Why are men not involved in these activities ? Why is it that so
many men drop out of the families they helped to -create ?
She continues, “There is a whole range of other relevant issues,
such as the imbalance between the sexes in the distribution of food,
luxury items and leisure time; the practice of invoking tradition to
prevent women from moving into new areas of life, while men in
the same circumstances are considered innovative; the lack of
attention to issues of sustainability, environmental degradation and
gender; the absence of women from the central positions in which
political and economic decisions regarding their lives are being
made; the tendency to view development as a mainly economic
process, disregarding social aspects (even though a country’s most
vital resource is its people); the fact that sexual violence is rarely
recognised as a legitimate development issue.”43
Considering the kind of “mainstream” gender work being done in
South Asia today, we also feel that instead of encouraging
commitment, flexibility, ecological and interconnected ways of
looking at social realities many “gender experts” are dishing out
very simplistic tools, frameworks and exercises.
It is not gender per se but this neutralisation of women’s issues
by a large number of “gender experts” which is cause for concern.
Discussions on women’s issues are thus being robbed of their
75
struggle aspects and of their miliuncy. This is a
problem for many other trainers who believe that
the challenge to patriarchy needs to be strength
ened, not diluted, patriarchy and patriarchal
t privilege are definitely NOT on the decline. In
fact, with the growing importance of economic
liberalisation, fundamentalism and conservatism,
patriarchy is resurgent.
While socialist feminists and eco-feminists expose
and challenge the present development paradigm
itself as patriarchal and ecologically destructive, the
attempt of many mainstream gender exercises is to increase
women’s opportunities for “empowerment” within the present
system. The relationship between patriarchy, caste, class, race, the
state, colonialism/imperialism and the environment are seldom
explored because they are defined as “political” issues !! The
assumption is that accepting these hierarchies is apolitical.
It is therefore important to challenge trends that have the potential
for depoliticising our issues. We need more clarity, commitment and
conviction in order to challenge patriarchy and hierarchies of caste,
class, religions and ethnicity in South Asia, and to make for
progressive social change. The distinctions between planners and
implementers, thinkers and doers, experts and non-experts need to
be minimised, and a much closer interaction and co-operation
between gender planning, feminist theory and the women’s
movement needs to take place. Rather than fight shy of feminism,
our programmes for women’s empowerment need to be more
clearly feminist.
ccording to you are there any issues which need to
be given more attention ?
'es, at last two issues need to be given more attention than they
have been so far, namely —
76
• Women’s access to and control over natural resources like land,
water and forests. Much more concrete action needs to be taken
at the level of policies and programmes to give women access
and control over these resources.
• Sharing of household work by men and boys.
A major reason for the subordination, lack of autonomy and illhealth among women in South Asia is the extreme burden of
household work. According to the UNDP Human Development
Report the total value of unpaid work done by women, globally,
is USD 11 trillion. Development projects have been trying to
integrate women into development, use their “human resources”
and “capital” in the service of global production; more recendy,
many people have been working towards increasing women’s
participation in governance at all levels. Yet most working class
women are already on the verge of collapse due to overwork. Why
do we hear so little about reducing women’s household responsi
bilities? Most programmes end up increasing women’s work and
responsibilities in the name of “women’s development” and
“empowerment”, but we have to accept that one reason why
women are absent from public office and senior management
positions is that they have more than full-time work at home.
Women’s roles as housewives and mothers forces them into
subordinate positions in paid employment. Since reproduction and
caring for children and families are not likely to disappear, it is
necessary to start a. parallel movement of men towards family
kitchens and homes. If we want women managers, politicians and
civil society leaders then we need more men to be mothers, care
takers, nurses and cooks. Women can exercise autonomy over their
bodies and lives only when the burden of reproductive work is
reduced.
As Maria Mies says, “Men have to share the responsibility for the
immediate production of life, for childcare, housework, the care
of the sick and the old, the relationship work, all work so far
subsumed under the term “housework”. . . This would then
immediately have the effect that men would have to spend more
77
time with children, cooking, cleaning, taking care of the sick, etc.,
and would have less time for their destructive production in
industry, less time for their destructive research, less time for their
destructive leisure-time activities, less time for their wars. Positively
put, they would regain the autonomy and wholeness of their own
bodies and minds, they would re-experience work as both a burden
and enjoyment, and finally also develop a different scale of values
altogether with regard to work. Only by doing this life-producing
and life-preserving work themselves will they be able to develop
a concept of work which transcends the exploitative, capitalist,
patriarchal concept.
. . . The processes for the liberation of women and men are inter
related. It is not possible for women in our societies to break out
of the cages of patriarchal relations, unless the men begin a
movement in the same direction. A men’s movement against
patriarchy should not be motivated by benevolent paternalism, but
by the desire to restore to themselves a sense of human dignity
and respect. How can men respect themselves if they have no
respect for women.”44
O ome people are of the opinion that “doing gender”
O requires working with women and men together, not
working only with women, or men.
T have heard these views, but I do not agree. Gender and develop
JLment does not mean you should not have separate groups of
women and men, or conduct separate workshops for them, or even
that you should have female and male trainers in every workshop.
I believe our analysis should focus on the social construction of
male and female identities and on gender relations. Such an analysis
can be done in separate groups, if that is what the situation
demands. In fact, in some communities it is necessary to have
separate meetings with women to provide them with the space to
talk and think freely, to develop bonds of solidarity and to
78
formulate common strategies. Similarly, it may be necessary to have
separate meetings and workshops with men, again to allow frank
discussions. 'Where women and men are comfortable in mixed
groups, joint workshops and meetings can be held.
Again, focusing on gender does not mean we cannot speak of
women or women’s empowerment any more. As long as gender
relations are hierarchical and women are subordinate, we
need to strengthen women’s empowerment in order to
have gender equality. It is premature to think that
\
men and women should be treated equally at all /
" \
times even before gender equality has been / •./
\
achieved. Let us not forget that we started talking k
I.-'
of gender only because inequalities between men
and women persist.
B
ut surely the gender debate is not a women versus
'men debate ?
■X To, the issue of gender equality is not one of women versus
men, nor is the conflict between all women and all men. It
is between those who believe in and want equality and those who
wish to maintain male domination. It is between belief systems and
ideologies. All of us know that there are men and women in
both these camps. There are those who accept and benefit from
patriarchy and wish to retain the status quo, and those who wish
to work.for social change. Many men are today examining their
rights and privileges, their roles and responsibilities. For the first
time masculinity, male pov^er, male sexuality, male knowledge
systems, and male ordering of social relations are on the table
for critical examination, and the examiners are both men and
women.
Therefore it is both simplistic and incorrect to think that the fight
for gender equality is a fight between women and men.
79
But there is no denying that
there is also some conflict in
the interests of men and
0
women; as women begin to
empower themselves it is likely
that this conflict will be heightened, in the
short term. But any struggle for equality will entail some
polarisation before an equitable balance is achieved.
\V7hy do gender-related issues evoke such an
W emotional, even hostile, response?
"A 4"aria Mies puts it well. She says most men and women try to
-LVJLavoid examining gender relations, because they are afraid that
if they allow themselves to become aware of the true nature of
the man-woman relationship in our societies then the family, the
last island of peace and harmony in the brutal world of money
making, power games and greed, will be destroyed. Moreover, if
they allow this issue to enter their consciousness, they will have to
admit that they themselves, women and men, are not only victims
(women) on one side and villains (men) on the other, but that they
are also accomplices in the system of exploitation and oppression
that binds women and men together. If they wish to come to a
truly free human relationship, they will have to give up their
complicity. This is not so only for men whose privileges are based
on this system, but also for women whose material existence is
bound up with it.
It is feminists who have dared to break the conspiracy of silence
about the oppressive, unequal man-woman relationship and who
want to change it. We believe that more and more people now
realise that equality between men and women is essential for
building just and peaceful relationships within families, and
communities. Women and men everywhere have to join hands to
achieve gender equality, and to create a world which is just and
peaceful for all.
80
•pVoes this imply that gender concerns in development
U go beyond integrating women iinto development ?
TXTThile some organisations only wish to add the womens
W component” to the existing institutions and systems, we
believe we need a radical transformation of patriarchal society, as
well as of the notions and practices of development, to achieve
genuine social change.
As we have already seen, development plans and projects can and
do have many anti-women (and anti-poor) biases. Instead of simply
integrating women into such plans and projects, we need to
challenge and change them. There is enough evidence today to
move that the present development paradigm with its emphasis
on economic growth, pursuit of profit and individual interests
has widened the gap between women and men, the rich and poor,
and rich and poor countries. In addition it has led to ecological
devastation. The UNDP Human Development Reports have
provided statistics from all over the world which show that the
' present form of development has forced many people to
become jobless, voiceless, ruthless, rootless and futureless
(UNDP Human Development Report 1996). Today 358 million
aires control more money than 2.5 billion poor people in the world.
The budgets of some multinational corporations are larger
than those of many national governments. This kind of polarisa
tion and centralisation of power leads to greater tensions, conflict
and violence.
A shift in development thinking will have to be accompanied by
radical changes in our organisations, and ini our social, economic
and political systems. It
L-will
-----also require a major change of values
— e.g. from self-assertion and competition to co-operation and
social justice; from expansion to conservation;
c------------ . from material
growth.
Engendering
development paradigms
acquisition to inner
one
way
of
transforming
development
as we have
and practices is
known it, and making it more equitable and beneficial for all.
81
■
■
Achieving gender equality requires looking once again at the
“masculine” and “feminine” characteristics and values (domination
- subservience, competition - co-operation, self-assertion - giving
in, exploitation - caring and nurturing) and seriously thinking:
WOMEN'S PLACE IS IN THE HOUSE.
THAT IS WHY THEY SHOULD BE IN
BOTH HOUSES OF PARLIAMENT.
• does or should development mean subordinating “feminine”
characteristics and values and valourising “masculine” values and
characteristics ?
• does gender and development mean having women enter the
public arena and behaving like men?
• does the present polarised, conflict-ridden, ecologically devas
tated world require more competition or more co-operation ?
More exploitation of nature or more caring and nurturing of
nature ? In other words, does the present-day world need more
“feminine” or “masculine” qualities ?
In fact we need to go a little further and ask whether it is correct
to label values and characteristics as feminine and masculine at all?
Aren’t these values human values? Don’t both men and women
need and develop both “masculine” and “feminine” aspects ?
Shouldn’t women and men both be rational and emotional, selfassertive and sensitive to others, entrepreneurs and home-makers,
public and domestic figures? If women are entering public spaces
and assuming responsibilities in these spaces, shouldn’t men enter
the domestic space abd assume responsibilities for child care,
nursing and home management?
82
Gender equabty requires each one of us, man and woman, to look
into ourselves and overcome our negative “male” (being aggressive,
domineering, competitive, self-centred) and “female” (being sub
us,;
missive, fearful, diffident) quabties. It also requires that all of us
and
women,
nurture
the
positive
male
and
girls and boys, men l
female qyiabties. Each one of us needs to be strong and caring,
fearless and sensitive, emotipnal and rational. We bebeve the
present-day world, which is experiencing unprecedented and
intolerable levels of violence and environmental degradation, can
be healed only through the large-scale practice of quabties like
caring and nurturing in the domestic and pubbc spheres.
At yet another level, we need to question the separation between
economics and ethics, pobtics and morabty, science and rebgion.
This separation has led to unethical economic pursuits, immoral
political power and the irresponsible and destructive use of science.
We bebeve value systems and ethics shouldn’t be peripheral to
economics, pobtics, science and technology but should constitute
their very basis and driving force. We need hobstic and ecological
ways of thinking and being. For us all these concerns are part of
our concern in engendering development. We bebeve gender and
development issues cannot be treated in narrow and mechanistic
ways. These debates cannot be bruited to how many women, how
many men, questions. In the context of our search for sustainability,
gender and development debates have to discuss the transforma
tion of the present gender, caste, class, race, north-south divisions
of labour which are totaby non-reciprocal and exploitative. We also
have to raise basic questions about the goal of development and
83
the purpose of human life. The following issues demand greater
attention than they are being given today in most gender discourses.
References and Notes
Oakley, Ann. 1985. Sex, Gentler and Society. England: Gower Publishing
Company, p.16.
von Werlhof, Claudia. 1988 A. “The Proletarian is Dead : Long Live
the Housewife”, in Maria Mies, et al, Women: The Lxtsi Colony. New
Delhi : Kali for Women, p.104.
Centre for World Solidarity 1997. Forging Links. Hyderabad.
1
• Should the objective of human effort be the production of life
and use value or merely production of things and profit ?
• Can human beings remain human if they are completely
alienated from nature and organic matter ?
• Shouldn’t communities be self-sufficient in satisfying their basic
needs to avoid blackmail and exploitation ?
• Can sustainable communities and families be established
without the autonomy of women over their own bodies and
lives, without men sharing the responsibility for the immediate
production of life, and all work so far subsumed under the term
“housework” ?
2
3
Oakley, A. op.cit., p.149.
Ibid., pp. 149-150.
Ibid., p. 150.
Oakley, A. op.cit., pp. 32-34.
Ibid., p. 36.
Ehrenreich, Barbara and Deirdre English. 1988. For Her Own Good:
50 Years of the Experts’ Advice to Women. London: Pluto Press, p. 19.
4
5
6
7
8
9
>o
>i
/
12
13
14
16
17
18
19
20
21
22
Ibid., op.cit., p. 19.
Mies, Maria. 1988 A. “Social Origins of Sexual Divisions of Labour’’,
in Women: The Last Colony, op.cit., p. 73.
Oakley, A. op.cit. pp. 174-175.
von Werlhof, C., op.cit., p. 177.
Lerner, Gerda. The Majority Finds Its Past: Placing Women in History.
Oxford and New Yorlc. Oxford University Press, p. 232.
Bhasin, Kamla. 1993. What is Patriarchy ? New Delhi: Kali for
Women.
Ashworth, Georgina. 1996. Gendered Governance: An Agendafor Change.
Gender in Development Monograph Series. New York: UNDP.
Oakley, A. op. cit, pp. 152-153.
Ibid., p. 156.
Agarwal, Bina. 1996. A Field of One’s Own. Gender and Land Rights in
South Asia. New Delhi: Cambridge University Pcess, p. 51.
Ibid., pp. 62-63.
. . .....
Mies, Maria. 1988 B. “Class Struggles and Women’s Struggles in Rural’; y
India’ 1’, in Women: The Last Colony, op.cit., p. 138.
von Werlhof, C., op.cit., p. 175.
) 1 U
84
(P
23
Ibid., p. 179.
24
Kannabiran, Vasanth. 1996. Sharing the Fish-Head: The Philosophy and
Practice of Gender Training in South Asia. New Delhi: ASPBAE/FAONGO South Asia Programme, pp. 36-37.
Mies, M. 1988 A. op.cit, p. 71.
Ehrenreich, B. and D. English, op.cit., p. 8-9.
Jaggar, M.Alison. 1993. Feminist Politics and Human Nature. New Jersey:
25
26
27
Rowman and Allenheld, pp. 144-145.
Ehrenreich, B. and D. English, op.cit., p. 11.
Kelly, Joan. 1984. Women, History and Theory. Chicago: University of
28
29
Chicago Press, pp. 10-11.
Lerner, Gerda. 1986. The Creation of Patriarcfy Oxford and New York:
3.0
Oxford University Press, p. 234.
Ibid., pp. 234-235.
.
Dreze, J. and A.Sen. 1995. India: Economic Development and Social
Opportunity. New Delhi: Oxford University Press, pp. 140-175.
Bennholdt-Thomsen,V. 1988. “Why Do Housewives Continue to be
Created ?” in Mies, et al, Women: The Lsst Colony, op.cit., pp. 160-161.
31
32
33
Mies. M. 1988 B. “On the Concept of Nature and Society in
34
Capitalism”, in Women: The Last Colony, p. 137.
Dreze, J. and Sen, A. 1995. op.cit., p. 199.
Wieringa, Saskia. 1994. “Women’s Interests and Empowerment:
Gender Planning Reconsidered.” Development and Change, Volume 25,
35
36
37
38
pp. 831-832.
Walby Sylvia. 1990. Theorising Patriarchy. Oxford: Basil Blackwell, p. 63.
Sarin, Madhu. 1998. ''Who is Gaining ?” Who is Losing ? New Delhi:
Society for Promotion of Wastelands Development, p. 8.
41
Ibid., p. 8.
Mies.M. 1986, pp. 22-23.
For a discussion on this see Jaggar, A. op.cit., p.22.
42
Wieringa, S. op.cit., pp. 831-832.
39
40
43
44
86
Ibid., p. 832.
Mies, M. 1986. p. 23.
I
T
Ehrenreich, B. (1974). Gender and Objectivity in Medicine. International Journal of Health Services, 4(4),
pp. 617-623
GENDER AND OBJECTIVITY IN MEDICI sTE
Barbara Ehrenreich
Medicine in the United States has been an overwhelmingly male profession since the
emergence of the modem medical profession in the late 19th century.[Historically the
exclusion of women from medical training was justified on the grounds :that females are
innately less capable of scientific objectivity than males. However, a brief examination of
gynecological theory and practice advanced by male physicians over the last 100 years
reveals that medical “science*’ has been and continues to be permeated with sex
prejudices. The direction of the bias In the medical care of women has been to reinforce
traditional social roles for women. In addition, nonobjectivity in the medical care of
women has been directly detrimental to women’s health. It is urged that medicine
discard old prejudices and develop a firmer scientific basis.
I
I
I have been asked to speak on the subject of “Women and Medicine,” but I am going
to speak instead on a subject which is much less well understood, a -subject which is so
esoteric that it has only recently begun to be a subject of critical invcs(igation-and that is
the subject of men nnd medicine.
Men were not really very important in American medicine until well into the 19th
century. Prior to that time, this country had, as had Europe, a tradition of female lay
healing. The healing occupations were open to anyone with a claim to skill, and women
entered those occupations in large numbers* serving both as midw ves and as general1
praotliionors, Many of ihoso healers wore probably Illiterate women vlio relied on skills <
passed on from mother to daughter and shared among neighbors. Bee aus>* they left few 1
written records of their work, they remain anonymous in convcntiunnl medical histories, ,
where they are usually mentioned only as a measure of the “backvardhess” of eatly .
American medicine.
.. . | ■
The 19th century was a time of great ferment in American met icine. There were
dozens of medical sects, each with Its own particular philosophy of het ling-homeopaths*
eclectics, botanists, Thomsonians-to name but a few. One sect is of jarticular interest,
because, unlike most of the others, it Was entirely male In composition. This aoct had
>f healing called
inherited from colonial times a somewhat mystical philosophy |>f
approach
to
healing
that
has
been
termed
“
heroic
’
*-probably
because
“allopathy” and an
of the heroism required of their patients. Bleeding (until the patient hinted or until the
... .................
o> _________________
__ ,(a mercury-baicd laxative)) were
pulse ceased),
blistering,
and massive doses of calomel
principal
techniques
until
the
latter
part
of
the
19th century, Uhen surgery and
their i
opium were added. This particular sect held the messianic belief that they were the only
true healers, a belief which they publicized through various verbal devices: They styled
themselves as “regular” doctors, all others being termed “irregular”! or, less politely,
This article, a seminar presentation at the Johns Hopkins University School or Hygiene and Public
Health on April 4,1974, Is based largely on the book Complaintt andDltordcri: Tht SexualPolltlct of
Slcknen, by Barbara Ehrenreich and Dclrdre English, published by the Feminist Press, Old Westbury.
New York, 1973.
■
j
International Journal of Health Services, Volume 4, Number 4, 1974
© 1975, Bay wood Publishing Co.
617
..... - BS •.
II
*15
Gender and Objectivity in Medicine / 619
fcsN 618 ./ Ehrenreich
tos■
monstrous productions inspire, especially when they aim towards a higher type thun
(heir own.
“quacks.” And when they formed their first national organization, in 1847, they named
it the American Medical Association.
would like to focus on this medical sect's theories of, and treatmenu'bf,,female
patients, especially as they evolved in the latter part of the 19th 'century^This is not
f
merely a matter of historical curiosity, for it was this group of ^doctors^and I will
henceforth accede to their claims and call them the doctors) that, shortly afterthe 19th
b?? century, did achieve a monopoly on healing and become the American medical
profession.
’
: (- • • >
S,, Their overall view of women can be stated very briefly: women were sick. More
j’.T' precisely, all aspects and phases of female reproductivity—puberty, menstruation,
O.,/pregnancy, menopause—were seen as dangerous crises requiring rest and close medical
i c attention* Dr. W. C. Taylor, in his book A Physician's Counsels to Women in Health and
Disease written in 1871 (1), gave a warning typical of his profession’s public
KV pronouncements:
r?-'- '
;
'
'• J
! '
&
I'
On the whole, however, the medical defense against female doctors was less hysterical and
more coolly “scientific”: How could a woman-that is, a “lady”—perform a' surgical
operation if she were menstruating? How could she not help but faint at the sight of
nudity in either sex?
The medical arguments against women in medicine, or, indeed, in any role outside the
home, deserve a somewhat fuller explication, if only because they illustrate the depths of
nonobjectivity which male medicine has achieved in its not-too-distant history. The basic
physiologic theory entertained by American medical men was a sort of “conservation of
energy” theory. The organs of the body were in competition for a fixed supply of energy;
any one organ, or function, could only be developed at the expense of the olhsrs. As it
applied to males, the theory was an injunction against overindulgence in sexual setivities.
If a man “spent his seed” too recklessly, he would sap the vital energies he needed for
business, medicine, and other male pursuits.
The application of the theory to females was very different. It was establi:hed that
intellectual activity would destroy a woman’s reproductive powers. In his influcn lial book
Sex in Education, Dr. Edward Clarke (3) of Harvard University argued th; I higher
education might literally cause women’s uteruses to atrophy; this theory was extremely
widespread. President Theodore Roosevelt believed it and foresaw in women’s ac missions
following
from Dr.
R.
to colleges the coming extinction of the white race. The
.....................
_ quote
.
Coleman, writing in 1889, illustrates the fervor with which 19th-century doctors
We cannot too emphatically urge the importance of regarding these monthly returns as
period* of ill health, a* days when the ordinary occupations are to be suspended or
modified.... Long walks, dancing, shopping, riding, and parties should bo avoided at
this time of month Invariably and under all circumstances.... Another reason why every
woman should look upon herself as an invalid once a month, is that the monthly flow
aggravates any existing affection of the womb and readily rekindles the expiring flames
of disease.
I should qualify this by admitting that doctors did not believe that all women were
sick. From the medical viewpoint, poor and working-class women were seen as extremely
hardy, as evidenced by the fact that they were able to work 10 to 16 hours a day in
factories and sweat shops and as household servants-whether they were pubescent,
menstruating, pregnant, or menopausal. Of course, the truth was very different. As public
health officials knew even then, the poor suffered much more than the rich from
tuberclosis and other infectious diseases and from complications of childbirth—
;
aggravated, ro doubt, by malnutrition and overwork.
What is interesting, from a scientific viewpoint, is that the doctors postulated innate
biologic differences between women of different social classes. Poor women were innately
robust and in need of almost no medical care; affluent women were innately sickly and in
i, ; need of almost constant medical attention. Now it is tempting to be cynical about a
I’ medical theory which postulates biologic differences on the basis of ability to pay for
I
medical care, and I will not resist the temptation. The theory of the innate healthiness of
the poor justified medical indifference to their problems; after all, they did not even have
Medicaid to make their problems medically “interesting.”
I
The theory of the innate sickness of affluent women served the economic interests of
!
the
_________
doctors_in two
.
ways. First, it established middle- to upper-class women as a kind of
;
‘‘client caste” to the medical profession. Recall that in the late 19th century there was
what the AMA called an “excess” of doctors, especially in the cities. A doctor could not
count on having a very large clientele to himself, so it made sense to define those women
patients he had as permanently, chronically sick. Second, the myth of female sickness
helped to discredit women as healers. In the late 19th century, feminists were demanding
female doctors for female patients, and women were literally beating on the doors of the
;
“regular” medical schools. In his presidential address to the AMA In 1871, Dr. Alfred
’
Stilld (2) was sufficiently moved by the feminist threat to state:
z
expounded the gynecologic perils of education (4):
Women beware, you are on the brink of destruction: You have hitherto been engage i in
crushing your waists; now you are attempting to cultivate your mind: You have teen
merely dancing all night in the foul air of the baU-room; now you arc beginning to spend
your mornings in study. You have been incessantly stimulating you emotions v^ith
concerts and operas, with French plays and French novels; now you are exerting jjour
_
.
.
-.u n---------- ij $cjence
understanding to leant Greek,
and. solve
propositions ,in r-.
Euclid.
DewareII
pronounces that the woman who studies is lost.
i
L.-
Certain women lock to rival men In manly iporb . . and the ilrongnilndod ape them in
al) thing*, even In dress. In doing so they may command a sort of admiration such as all
It followed from the theory that one <of the most common prescriptions tyr female
patients was total abstinence from intellectual stimulation—reading, writing,,, and
sometimes even conversation. As a young woman, Charlotte Perkins Gilman was ^confined
to months of bed rest and isolation by one of America’s most eminent gynecologists, Dr.
S. Weir Mitchell; Fortunately, she recovered from this treatment to become one of the
outstanding feminist theoreticians of her age.
j
Bed rest, however, was probably the least destructive therapy available.. Doctors
believed that all female ills stemmed ultimately from the uterus and ovaries. As Dr. M. E.
Dirix (5) wrote in 1869,
s
h
Thus, women are treated for diseases of the stomach, liver, kidneys, heart, 'ungs, etc.;
yet, in most instances, these diseases will be fiund, on due investigation, to be, in rcaljty,
no diseases at all, but merely the sympathetic reactions or the symptoms of one disease,
namely, a disease of the womb.
So, whatever a woman complained of-sorc throat, indigestion, or "nerves”—;hc ran a
good chance of being a victim of a medical assault on her reproductive and genii; I organs.
Treatments ranged from the merely bizarre to the downright sadistic. Blisters an i electric
shocks wore udininislcrcd to the vulva
“counlcriirliiinls’’ for ilio basic probb in In the
uterus. Leeches were applied to the breasts (which were seen as sympa helically
Gender and Objectivity in Medicir e / 621
620 / Ehrenreich
connected to the womb), to the vulva, and even the cervix-notwithstanding their
occasional disappearance into the uterus.
symptoms such as menopausal disorders .. . preme: .strual tension ... palpitation^ ...
G.I. disorden ... "nervous stomach" ... recunent throbbing headache. (Emphasis
added, but the ellipses are in the original.)
THE PRESENT DAY
The patient in the accompanying illustration is, of course, a woman.
The tendency of doctors to diagnose women’s ills as psychosomatic may be lucrative
cut down on the, ‘time U'
per
for drug companies and doctors (“psychosomatic” diagnoses c_.
visit yet ensure that there will be future visits, if only to renew the prescription); but they
are definitely hazardous lor
for women. I would recommend as required reading on this point
■ ..................
the article “Alleged Psychogenic
Disorders
in Womeni; A Possible Manifestation of Sexual
Prejudice,” by K. Jean and R. John Lcnnane (10).
...
Some
Some of
of the
the most
most flagrant
flagrant examples of medical nonobjectivity have surfaced over the
issue
of the birth »«..»••».
control J.....
pill. I will not detail the ugly story of ^he ^pill.’s
i&3UC W* H»V
development-from the first tests on Puerto Rican women (for efficacy only, no safety),
to the virtually unmonitored “test” on 20 million North American women. Desjiite “side
has
effects” ranging from depression to diabetes and death,
. the medical profession
• u
campaigned relentlessly against publication and distribution of full FDA warn ’infss on the
pill. “If you tell a woman she
one doctor
doetpr told a
le ’sS going
going to
IO get
gci aa headache,
Iivauavi.v, she will,
......... —
uvuiv.
(author of
Congressional hearing on the pill (11). Medical journalist Barbara Seaman (12)
u^n^or
u»
Free and Female) contrasts this massive medical Indifference to women to the doctors
panicky reactions to the recent suggestion of possible harmful effects of vasec tomy in
mice!
But I am concerned here not with the merits of the pill, but with the quallt/ of the
doctors' renctlom to the controversy. In his book for lay women, curiously entitled On
Being a Woman (1971), Dr. W. Gifford-Joncs (13) first reviews the evidence against the
pill's safety and then m«kr» the following sitiionirnl, which must bo a clmlc oxi mplo of
poor logic, untl-lntolleclualism, and Jusi plain bad grammar:
Furthermore, proving anything by statistics has always been a very risky S1™'; f°r h
well-known fact that you can prove almost anything you want by this method. In fact ts
Isicl been said there are three kinds of Iles: lies, damned lies and statistics! Yet ovjn
auumlni the finurei ire correct, it is ul»o well in remember that ill of our dally wilvlt ei
Involve some risk. Look it the slaughter on our highways and the d/ownlngs In our lak< I.
Those are major risks that are more common than the number of women | ale who de
While on the rill. I . . It's the oht . ........ . .4 "v<m r«v Vmn money i.ml you lake yn il •
Departing from the 19th century on that note, and reentering medicine in the presen
period, the subject assumes much greater significance. Today, 93 per cent of all medical
doctors are male. Virtually aU competition from other types of healers has been
Srd'ha^Lh^e^ total monopoly in th^bus^ss of hcX/fn this"^^!, the
question of the role of men in medicine becomes an extremely pressing issue We must
ask, can medical men overcome the superstitions and “old husbands tales that have
hindered the development of scientific medicine in the past? Are they capable o
objectivity? I would not presume to give a final answer, but I would like to point ou
some of our reasons for doubt on this question.
When doctors make pronouncements on “female nature,” we find them dominated by
the superstitions and folklore of the past. I have made a brief survey of books written by
(.odors for lay won ;n, and the message comes through strong and clear. Women are vain,
silly, ignorard creatures, best suited for the "trivia" of homemaking under the firm
guidance of husband and, of course, doctor. This I, Dr. Bernard Clnberg . defense of his
high fees in the introduction to his 1964 book For Women Only (6):
Gynecologists’ fees are high, ot least their patients think so, but how do they compare
with the price of a pair of shoes? Of a cocktail dress? If a patient would compile an
honest accounting of the money she wanes annually on frlppcrlos-lnchide the beau y
parlor, too, please-I’m certain that the cost of a semiannual gynecological checkup
would assume its proper modest proportion.
Or we find that palilarch of American medicine, Morris Flshbein (7) advising a husband
how to lure a recalcitrant wife in for a gynecological exam {Ask the Doctor,^19/3).
“Some women can be won over by a promise of a special treat-such as a long weekend at
a resort or a new wardrobe....” But If prejudice is thinly veiled in doctors’ books for the
public (nt least llioso I Imvo rend), no effort Is innilo to disguise It In the books doctors
write for their fellow doctors. Pauline Bart and Diana Scully, sociologists and leading
lnVP.lHK.lm. of .....In mr.llnl.m, haw m.vnyml Iwm.ly .ecu. UVmm..l..Hl.>Hl l0Mll.m.k.
‘imed ovo. Il.o h..l Un- dnc.los. Tim iollowing quale, f.om I).- Jan.osWiHs.mt
Obstetrics and Gynecology, published in 1971, is typical of their findings on the medical
view of “female nature”: “The traits that compose the core of the female personality are
feminine narcissism, masochism qnd pnssiviiy" (8).
iluine,"
I could continue. I could mention the frequently irrational and unjustified, use of
radical surgery-hysterectomies, for example-for women in this country. I could mention
ihnt branch of medicine called psychiatry, which, Insofar ai it dealt with women, hat
been llillo more than a oodifloftlion and lyurtinaltolng of inolent male pri)udl(|H. But
much of thli would be, I trust, familiar, cither from your own experience or from auch
Such notions are not limply of awteinle inten’il. UnforhinMly, they flno their way
Inio the actual practice of medicine ai It relates to women. Just as 19th-Century doclori
traced all female ills to the erratic and diseased womb (or ovaries), today’s doctors tend
to trace our ills Io the frivolous female brain. In our Informal discussions and
Investigations of women’s medical care, we have long noticed the doctors’ tendency to
diagnose our somatic complaints-nausea, chest pains, headache, or whatever-as mere
psychosomatic problems, and to dismiss them with 8 pat on the head and a prescription
for Librium. The drug companies encourage this tendency, for example, a recent ad for
“Bcllergal Spacctabs” (essentially a sedative) in the Medical World News (9), begins,
When you see the same patient over and over with functional comphints ... consider
Bel’ergal Spacetabs. Most doctors have a number of patients who complain of vague
!
recent books as Ellen Frankfort’s Vaginal Politics (14) and Phyllis Chesler’s Wo^en and
Madness (15). In lummarlzlng, I would like to offer a tentative analysis of the Issue of
men and medicine.
SUMMARY
The medical view of women-especlally of (.hose women who today ire derrandlng
better, more rational medical care-is that women are hysterical, Ignorant, and
antiscientific. But men in medicine have been, and remain, in significant areas cf their
work, barbaric, superstitious, and antiscientific.
622 / Ehrenreich
The question is, Why has this been so? 1 personally reject the obvious but facile
biologic explanation. I see no reason to believe that male healers or men in general are
innately superstitious and incapable of the objective practice of medicine. The view that
some of us are coming to is that the kinds of nonobjectivity and superstition that medical
men display when confronted by the female patient are not in any way random, as would
. be the case if mere ignorance were involved. Rather, the prevailing medical superstitions
about women always show a remarkable conformity to the prevailing cultural mythology
about the proper role of women.
In the late 19th century, the prevailing cultural norms held that genteel ladies of the
so-called better classes were to be totally idle symbols of their husbands’ wealth and
achievements. The servants who waited on them and who “manned” the factories of our
. Industrial Revolution, were, of course, never supposed to be idle, but instead capable of
ceaseless toil. The medical theory of the time supported and justified these roles. Genteel
ladies were innately “sick”; working-class women were innately “healthy.”
Today, with the demise of the servant class, even genteel women are expected to
work—to manage their own households, to raise their own children, to nurture and
entertain their husbands. Almost all women are expected, at some point in their lives, to
hold down various jobs-volunteer work (for the rich); such well-supervised “professions”
as nursing, teaching, and social work (for the middle class); clerical and less-skilled types
of blue-collar work (for everyone clse)-but definitely not leadership jobs for any of us.
The medical mythology is entirely consistent with these roles. Women are seen as
physically capable of working but mentally somewhat less than fully capable-as
evidenced, among other things, by the widespread view that most women's medical
complaints are basically due to “mental problems,” i.e. they are psychosomatic.
The “scientific” stand on contraception has also changed conveniently to suit the
times. Late 19th-century public policy was pro-natalist (for population growth, at least
among the “better” classes), hence medical science found that contraception in any form
was inherently injurious-potentially as “dangerous” as masturbation! Public policy today
tends to be anti-natalist, or opposed to population growth. Thus, medicine can find
almost no fault with any female contraceptive method that is effective, however unsafe?
To conclude, medicine as practiced by an almost entirely male profession, on women,
■ is in many respects not so much an objective “science” as it is a “scientific” disguise for
the prevailing forms of male prejudice. This is why I fed that our demand must never be
simply for “more” medical care for women. “More” is not enough when it can only mean
more prejudice, more superstition, more barbarity. In framing visions of an alternative
health care system, our demand must be for a totally new kind of medical care-care
which reflects the physiologic and social needs of its recipients, rather than the biases of
its practitioners.
Women, conscious of their own history of medical oppression, are taking the first
steps: The gynecologic self-help movement, initially persecuted as a medically
irresponsible “cult,” has grown to international proportions, offering tens of thousands of
women a revoluuonary new concept of health and healing. Midwifery, long suppressed in
the United States as “dirty” and “unscientific,” is on the rise again, challenging the
medical view of childbirth as a pathologic event. A new breed of self-assertive women is
Gender and Objectivity in Medicine / 623
entering the nursing schools, determined to be more than handmaidens to the dominant
practitioners. There arc more women in medical schools in the United Stales than Sever
before, and they arc beginning to question—not just the barriers to their own
advancement but the substance of what they are taught.
REFERENCES
1. Taylor, W. C. A Physician's Counsels Io Women in Health and Disease, pp. 284-285. W. J. Ho land
and Co., Springfield, 1971.
2. Quoted in Shryock, R. H. Medicine in America: Hisiorial Essays; p. 185. John* Hopkin* Press,
naltimorc, 1966.
3. Clarke, E. H. Sex in Education, or, a Fair Chance for the Girls. James R. Osgood and Co., Heston,
1873. Reprint edition 1972 by Arno Press, Inc.
4. Quoted in Haller, J. S., and Haller, R. M. The Physician and Sexuality In Kictorian America, p.
39. University of Illinois Press, Urbana, 1974.
5. Dirix, M. E. Woman's Complete Guide to Health, pp. 23-24. W. A. Townsend and Adams, New
York, 1869.
6. Cinberg, B. For Women Only, p. xii. Dial Press, New York, 1964.
7. Fishbein,
the Doctor, p. 144. David McKay Co., New York, 1973.
8. Quoted in Scully, D., and Bart, P. A funny thing happened on my way to the orifice: Women in
gynecology textbooks. Am. J. Social., 78: I 045-1050, 1973.
9. Medical World News, March 8, 1974.
10. Lennune, K. and Lcnnanc, R. Alleged psychogenic disorders in women: A possible manifcslition
of sexual prejudice. N. Eni(l. J. Med. 288: 288, 1973.
11. Women’s liberation and the practice of medicine. Medical World News, June 22, 1973, p. 34.
12. Seaman, B. Personal communication.
13. Gifford-Jones, W. On [icinga Woman, p. 69. Macmillan, New York, 1971.
14. Frankfort, E, I'aginalPolitics. Quadrangle Press, New York, 1972.
15. Cheslcr, P. Women and Madness. Avon Rooks, New York, 1972.
Manmcripl whmifted for publication, May 17. 1974
Direct reprint requests to:
Dr. Barbara Ehrenreich
16 Walters Avenue
Syosset, New York 1)791
I
‘ The Peronbt government of Argentina provided a recent inlcrcrling case of medical flexibility by
announcing in March a new policy of population growth. Contraceptives have been, for all practical
purposes, banned. The government announcement said that the medical justification for this
decision-thc reasons why conUaception is injurious-would be forthcoming.
0
‘DL
The ‘Declining Significance’ or the
‘Changing Forms’ of Patriarchy?
Sylvia Walby
95^
EL
3w
• • CL
pg'?
Mi 3
£3
G
INTRODUCTION
□Q-
sO
Os
3
Is patriarchy in decline? Or has it merely changed form? Whether the
development process decreases patriarchy,is the question underlying this
chapter. The answer to this question depends not only on the empirical
evidence, which is being addressed in other chapters, but on the definition
and theorization of‘patriarchy* itself. This chapter will address these theor
etical questions on ‘patriarchy* in the context of the trajectories of develop
ment and patriarchy.
The significance of gender relations in macro-historical trajectories
of development is now widely recognized (Boscrup, 1970; Elson and
Pearson, 1981; Leacock and Safa, 1986; Jayawardena, 1986; Mittcr, 1986;
Moghadam, 1992; Sen,’1984, 1987). There is now a wealth of data on
how gender relations have been changing, although the picture is still far
from complete. The task of adequately theorizing these changes in gender
relations at a marrn-lev?! necessitates adapting, refining, and building ap
propriate concepts. Existing concepts in outer mainstream analyses typic
ally insufficiently address the specificity of gender, leaving it as an empirical
question rather than a theorized phenomenon. Many of the problems
which have been identified with the use of the concept of patriarchy are
related to contingent rather than necessary features of the concept. How
ever, critics have frequently attempted to dismiss the concept of patriarchy
for problems yvhich they, incorrectly suggest are intrinsic.
Many of the attempts at global understanding of development do not
deal with the gender dimension (e.g. Wallerstein, 1974; Frank, 1967). There
have been a fewllgnificant attempts within the development, historical,
sociological, jind, women’s studies literature to begin to make sense of
global patterns of gender, relations :^Bpserup> 1970; Kelly, 1984; Lerner,
J986;..Mies,; 1986). .,;r
ju 1:2.
**** •'’
The substantive question of.whether the processes of development and
* of industrialization have increased or decreased gender inequality is highly
contested. On the one hand, economic development was seen to gd along
with increased educational, economic, and political participation of women
ns part of die process of modernization, The suggestion that economic
development emancipates women finds a wide resonance in the IheHture
7
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00
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I
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g
G
I
c
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20
HHITORICAL AND THBORSTICAL PBK
HCTIVES
Ih
on gender across the range of social science disciplines; across many and
various conceptions of development, economic development, moderniza
tion, and industrialization; across time and space from contemporary
Western changes to industrialization in the West to historical and contem
porary changes in newly industrializing countries.
On the other hand there has been scepticism about the extent to which
women have been able to control the proceeds of their waged labour, and
concern about issues such as die conditions under which women work,
about decreases in women’s property rights, about increased sexual ex
ploitation and effective political voice (Agarwal, 1988; Rogers, 1980; Brydon
and Chant, 1989). The issue of a backlash is relevant to both newly
industrializing countries (Afshar, 1989) and to the West (Faludi, 1992),
and die possibility of reverse is historically clear (see Koonz, 1987 on Nazi
Germany), Within Western feminist and gender theory the question of
whether this century is seeing advances has often divided between dieoretinl perspectives. 1'herc has also been an awareness that language of
progress and regress risks ethnocentric bias. Indeed so much so, diac
mart would reject die question as inherently value laden.
My concern here is to examine the different ways in which the concept
of patriarchy has been developed to address the diverse empirical issues.
'1110 concept of‘patriarchy’ has a long, complicated, and contested history.
I s^all be arguing that in revised form the concept of patriarchy is indis
pensable. However, addressing die problems diat have been raised about
sotne of die ways die term has been used is essential. The first issues are
those of definition.
||
THE DEFINITION OF ‘I’ATRIARCIIY’
F
The concept of patriarchy has bCen defined in a number of different ways,
but usually widi two similar core elements. Firstly, there is the core notion
of gender inequality. Secondly, that there is a degree of systcmaticity, in
0iat the different aspects of gender relations are connected in some way.
In order to take the debate forward it is necessary to consider the
divergences in usage and to assess the merits of die different definitions,
rfhere are three main sources of divergence and debate.
First, whether die notion of gender inequality is expressed as men’s
^domination over women, using the biological categories (e.g. Firestone,
0974), or whedier die reference is to social structures and practices (e.g.
t Hartmann, 1979). If die definition refers only to biological categories,
- tlicn die danger of biological reductionism is very strong. Since most
analysis reject die notion diat biology determines gender, it is important
that the definition of patriarchy itself makes reference to die social dimen
sion. However, it is important not to lose sight of die importance of the
If-
i
iw 1
IL
r
bh
Ir
r
THE ‘DL
JNING SIGNIFICANCE’ OF PATRIARCHY?
21
biological significr. My preferred definidon of patriarchy as a system of
social structures and practices in which men dominate, oppress, and ex
ploit women, attempts to capture die middle ground here. i
A second major issue is whedier the definition of patriarchy is tied io
the household or not. One strand of thought defines patriarchy in terms
of men’s domination over women through th^household, often including
a generational aspect in which the oldest man in a household dominates all
household members including young men (Hartmann, 1979; Moghadam,
1992; Weber, 1947). Other writers have preferred not to de the definition
of patriarchy to any particular household form, and have left open the
question as to the relationship of the household to gender inequality (Mies,
1986). Mies argues that we need to go beyond the old usage of the term
‘patriarchy’ which refers to the rule of the father, since, she argues, many
odicr categories of men (for example, male bosses) are involved in die
subordination of women. This is a key contested issue which will emerge
crucially through the debates on changes in patriarchy which I shall dis
cuss below. I shall argue that the household form of domination is a con-.-.....
dngent, not necessary, part of patriarchy, and hence should not be included
in its definition.
A third major divergence in the definition of patriarchy lies in the extern
to which writers include a dicory of patriarchy within the definition. For
instance, Hartmann (1979) stales that the chief way in which patriarchal
control is mair\tained is through die appropriation of women’s labour. Her
definition of patriarchy thus includes a theoretical relationship in which
labour is the base and other aspects of society constitute a superstructure.
(However, die base-superstructure model is softened in later work by
Harimann.) Other theorists have variously suggested male violence
(Brownmillcr, 1976), sexuality (MacKinnon, 1989) and reproduction
(Firestone, 1974), and various other areas as the basic structure. How
ever, ujliile MacKinnon sees sexuality as definitive of gender, not all the
odicrs find it necessary to build die base of patriarchy into its definition.
It is not dicorctically useful to tic the concept of patriarchy to anything
other than gender inequality. It is unnecessarily restricting, and at times
highly misleading, to tie it to either a specific household form, or to a
dominant structure, such as the economic. One of the major problems
which stems from this is the difficulty of theorizing changes in gender
relations. Yet it is vital to be able to do this. These issues are central to
the debate on patriarchy and will be discussed in detail below.
F-
SEPARATE OR FUSED SYSTEM
fy.
Since patriarchy both pre-dates and post-dates capitalism it cannot be
derivative from it. Patriarchal relations exist in feudal societies (Middleton,
1981; Lie, this volume) and they existed in pre-1989 and post-1989 Eastern
22
HISTORICAL AND THEORETICAL
.SI’ECTIVES
Europe (Einhorn. 1003). ’Flint development of capitalism nlfected patri
archal relations is clearly the case, but a change in the loi in of patriarchy
is not the same as its demise or creation.
There have been various ways of analysing the relationship between
patriarchy and capitalism, depending on the degree and form of their
engagement.
>
First, they can be considered to be so closely intertwined that they
become not merely symbiotic, but fused into one system, Eisenstein (1979)
took this position, arguing that patriarchy provides a system of control and
law and order, while capitalism provides a system of economy, in the
pursuit of profit. However, there are some logical problems here. If the
two are fused into one system it is only one, yet Eisenstein does speak of
their interrelationship as if they were two.
Second, patriarchy and capitalism can be regarded as analytically dis
tinct (Hartmann,-1979J Mitchell, 1975). Writers differ in their mode of
separation of patriarchy and capitalism. Some allocate different structures
to the different systems, while others do not. Mitchell (1975) allocates the
economic level to capitalism and the unconscious and culture to patriarchy.
Hartmann (1979) sees patriarchal relations as crucially located in the
expropriation of women’s labour by men in the two key sites, the household
and paid work, ’i’hese two forms of appropriation reinforce each other,
since women’s disadvantaged position in paid work nrnkes them vulner
able in negotiations over the domestic division of labour, while their position
in the family disadvantages diem in paid work. Thus she secs patriarchy
and capitalism as ultimately mutually reinforcing systems, even if there are
moments of tension.
Mies takes a mid-way position on die separation and integration of
patriarchy and capitalism. She notes that patriarchy long pre-dated
capitalism, and is usually In combination with another social system, for
instance feudalism. Patriarchy and capitalism are seen as very closely con
nected, but ultimately capitalism is merely anodier form of patriarchy.
Patriarchy, like capitalism, is a world system. Patriarchy is maintained by
a series of structures and practices including die family, systematic violence,
and the expropriation of women’s labour. Mies uses the term ‘capitalist
patriarchy’ to refer to the current system which maintains women’s op
pression. Cnpimlism, for Mies, is the latest form that patriarchy takes.
T hus she reverses the mure.conventional hierarchy between the two systems
and argues diat patriarchy pre-dates capitalism and has analytic priority.
She resolves the dilemma of dual-systems theory, ns to how systems of
‘patriarchy’ ami 'capitalism’ might interrelate, by theorizing capitalism as
an expression of patriarchy.
/
.< ■
Mies argues that the dependency of women in the industrialized countries
is only possible because: of the exploitation of women in nun-industrialized
countries. Mies argues that the domestication or, as she calls it, the house-
&
THE ‘D
1NING SIGNIFICANCE’ OF PATRIARCHY?
23
wifization of women in uic inciiupuiHuu capitalist nations is depends..i
upon die exploitation of die 'lliird World. The first stage is the process
of forcible colonization and the development of the luxury trade. ITic
I? second stage is the development of an internal colony, ih which women
are colonized by men in Europe. The relations within the industrialized
countries is only half the account, the other is that in the colonics and
ex-colonies,
Mies argues diat dierc has been a shift in die international division of
labour from the old one in which raw materials were exported from die
colonies for processing in the industrialized world and themmarketed
world wide, to a new intemauonal division of labour. In the new division,
f' industrial produedon is transferred to the developing countries, producing
unemployment in the industrialized countries. It .is women who^are the
new industrial producers in the Third World, and it is women who, Mies
claims, are the consumers of these items in the First World. Women arc
the cheaper labour force in the Third World since their designation as
dependent housewives enables them to be paid low wages. Women in the
First World, fired from their jobs as a result of the transfer of industry, arc
IV
die consumers.
The weakness in the account stems from problems in some of the
supporting evidence and from theoretical silences—not unexpectedly, given
the scope of the project. First, her argument that women in the First
World arc currently subject to housewifization following the transfer of
industry to the Third World is empirically incorrect. Women are entering
paid employment in greater proportions than ever before, despite having
higher unemployment rates than men in almost all Western countries bar
Britain (OECD, 1980). To be sympathetic one could note that this process
is not complete, but nevertheless the direction of change is the opposite
from that argued by Mies. Secondly, the nuclear family form was not
unique to modem capitalism. Laslett (1977) and McFarland (1978) have
shown that it is not unique and that it pre-dated the rise of capitalism, so
could not have been caused by it. Even the more intensely domesticated
version in which the women are not allowed to take outside employment
is not unique to the Victorian middle classes since it can be found among
Islamic societies, especially among their traditional urban middle and upper
classes (also, this Is changing). In short, Mies places too much explanatory
emphasis upon changes in capitalism, despite her stated interest in a world
system of patriarchy.
r.
RELATIONS BETWEEN THE DIFFERENT ASPECTS
OF PATRIARCHY
Many writers have argued that the. concept of patriarchy has insuperable
problems because it is inherently esscntialist. There are considered to be
r:
THE ‘DEI
24
HISTORICAL AND THEORETICAL PE >
IING SIGNIFICANCE’ OF PATRIARCHY?
25
c
ECTIVES
related problems of alvistoricisin, reductionism, nml inability to deal with
cultural diversity (Barrett, 1980, though see Barrett, 1990; Rowbotham,
1981; Segal, 1987). 'Phis criticism has been levelled especially against the
use of the concept of patriarchy by radical feminists, particularly those
who have focused on the issues of reproduction, sexuality, and violence,
such ns Brownmiller (1976), Daly (1978), and Firestone (1974). Here the
critique has argued that these accounts reduce women’s oppression to one
base and ultimately one which is biology, and hence that they arc essentialist (sec Segal, 1987).
ITms there are doubts ns to whether ‘patriarchy’ is an appropriate term
to grasp die complexity and diversity of patterns of gender relations (sec
. Alcoff, 1988; Barrett and Phillips, 1992; Walby, 1992). There is an argu
ment that die patterns of gender relations are too varied to justify attempts
at grasping global patterns. 'Fhis reaches its peak amongst writers of postmodemist tendency who have sometimes suggested that even the term
‘woman’, let alone ‘patriarchy’, can be inappropriately over-homogenous.
One important dimension of diis criticism has come from those who argue
diat cultural difference is insufficiently grasped by die term patriarchy, in
diat it tends to suggest that patriarchal relations are similar across ethnic
groups (Cnrby, 1982; Hooks, 1984; Yuval-Davis and Anthias, 1989).
However, these problems only arise if patriarchy is conceptualized in
the following ways. First, it is a problem if the definition refers to biological
categories as die unit of analysis. As we have seen this is not the case in
some definitions, diough it is in odicrs. Second, it is a problem if a simple
base-superstructure model is used in which one dimension of social life
determines all other aspects of gender relations. This is only true of certain
usages of the concept. In those theories which have more complex internal
models of patriarchy this problem need not occur. In dicse latter cases
dicre is no simple reduction. If these two problems are avoided then there
is no need for die concept and dieory of patriarchy to be csscntialist.
The solution to diis problem is for the system of patriarchy to be
conceptualized as being composed of several interrelated structures. At a
lower level of abstraction, within each of these structures specific patriarchal
practices can be identified which arc less deeply sedimented. Structures
are emergent properties of practices. Any specific empirical instance will
embody die effects not only of patriarchal structures, but also of capitalism
and racism (Walby, 1990).
I have argued that the system of patriarchy over the last 150 years in the
UK should be considered to be composed of six struciures: patriarchal
relations in household work, piilrinrchnl rchtiions in paid work, n patri. . archal state, male violence, patriarchal relations in sexuality, and patri
archal relations in cultural institutions.
Patriarchal relations In die household arc my first structure. It is through
these that women’s household labour is expropriated by their husbands,
J
L
I
1
I]
I
it
I5'■f
i
3-
fathers, or cohabitees. The woman may receive her maintenance in ex
change for her labour, especially when she is not also engaged in wage
labour. Of course, the nature and extent of this work varies, especially, but
not necessarily, with the wealth and income of the
fcW hUibaHd.
The second patriarchal structure within the economic level is that of
patriarchal relations within paid work. A complex of forms of patriarchal
closure within waged work excludes women from the belter iorms of work
and segregates them into worse jobs which are deemed less skilled.
The state is patriarchal as well as being capitalist ana racist. Wnile being
a site of struggle and not a monolithic entity, the state, has a systematic
bias towards patriarchal interests in its policies and attibHs.
Male violence constitutes a further structure, despite its apparently in
dividualist and diverse forni. it is behaviour rouHhely exjJentiiled by Women
from men, generating fear which has restrictive effects upon the actions of
most women. Male violence against women is effectively condoned by die
lack of state intervention against it except in extreme circumstances, al
though interpersonal violence is usually technically illegdl.
Patriarchal relations in sexuality constitute a fifth structqre. The sexual
double standard, prostitution, and pornography are WaHipIei df ^taciiccs
here*
'.
.
Patriarchal cultural institutions complete the array of structures. 4hbsc
arc significant for the generation of a variety of gcndcr-diffcrentiatcd forms
of subjectivity. This structure is composed of a set of InstitulForiS wlilcli
create die representation of women within a patriarchal gaze in a variety
of arenas, such as religion, education, and the medians ,,
.
While this model was developed within the context of the last 159 years
of UK history, with some modifications, the main^fcatu^c^^r^ globally
relevant. These would Include the reconcepiudlization of'the bdUrtdary
between the structures of patriarchal relations in paid work and in the
household in the context of agricultural and peasaHt B&bnbfHlhi where
such a boundary is not so clearly discernible.
<
J
i
CONCEPTUALIZING CHANGE
There are serious disagreements as to whether or not women’s position
has been improving with economic development. In the light of the fore
going discussion these can be divided into three types. Fifrst, there arc
disagreements over the same empirical issues. Second, thfeffc ate disagree
ments over which empirical issues arc Important and how changes in
different dimensions of women’s lives are to be weighted Id bfder to give
an overall statement as to whether there has been ah iheHillB fet decrease
in gender inequality. Third, there is disagreement over hd\V changes in
gender relations are to be conceptualized.
/
26
HISTORICAL AND THEORETICAL
ERSPECT1VES
An example of die first type of disagreement over empirical issues is
over whetiicr the workload of women in a particular society had decreased
or increased. This is obviously made difficult if the statistics arc inad
equate, but more importantly dierc may be disagreements over what may
be conliiincd wiiliin the concept ‘work’: for inslimcr, whether ‘work’ in
cludes unpaid housework, or is restricted to work which enters the money
economy. The work that women do in die domestic and informal sectors
of die economy is notoriously undercounled in official statistics (sec
Thomas, 1992), in local understandings of what counts as significant work
(Agarwal, 1.988), as well as divergent views among development ‘experts’
(Rogers, 1980). Futher, there are very considerable differences in the cx. tent to which women engage in housework, depending on class and income.
But, none die less, tills is more of an empirical dian a dicoretical question,
even though die boundaries of such concepts arc heavily theory laden.
The second type of disagreement is over die question of which aspects
of women’s lives count most towards an overall index of gender equity.
Here there is profound disagreement. A key focus is over whether paid
work intrinsically enhances a woman’s emancipation. One aspect of diis
is the question of whether paid work is more or less alienating than work
in the household. Can one aspect be balanced against another? For instance,
some writers have argued diat the development of commercialized sex in
pornography and institutiomilized prostitution is more likely with the
development of fl market economy; indeed some have argued that a sexual
counter-revolution has historically been a feature of die backlash against
women’s gains in the political and economic arenas (e.g. Jeffreys, 1985;
Millett, 1970; Fftdemian, 1981).' (However, prostitution has long pre
dated capitalism.) Wlicther or not there has been progress dicn depends
upon the ranking of the significance of the dificrcnt dimensions of women's
lives.
i.'.
r
1
r
K1’
EXPLAINING CHANGES
In many ways the question of whether paid employment liberates women
is central to many of die debates about trajectories of development and
patriarchy: The conceptual and/dicorcticnl: underpinnings to the thesis
that it docs libernte women arc interesting and all highly contested. First,
diere is the proposition that paid work is morc advantageous to the woman
than unpaid work. This often includes a second proposition, dial women
arc able to control the wages they obtain in paid work. A third and related
presumption - is that the presumed advantages that a woman gains in
employment increase die control she has in other areas of her life, such
as die domestic division of labour, and in odicr social relations, such as
access to political decision-making arenas.
IP
THE
i’
/ICL1N1NG SIGNIFICANCE’ OF PATRIARCHY?
27
. llicre is thus an implicit, if not explicit, theory of patriarchy within this
proposition diat women benefit from increased paid employment. It pre
sumes the connectedness of the different aspects of gender relations, that
is, a degree of systcmaticity. It further presumes that these operate con
sistently in the Rnme direction (rather than having an ndvcrxc impact).
Yet each of these propositions has been challenged, these challenges in
turn drawing on implicit or explicit theories of gender relations.
Is paid work better than unpaid work? Much of the recent literature on‘race’, cdinicity, and gender has queried this presumption. If the paid
work that women do is terrible, as is often the case of those women in
vulnerable positions, then it may be that domestic work is more fulfilling,
allowing greater autonomy (Hooks, 1984).
Can women control the rewards from their work? Do they get paid
themselves, or are their wages given to or controlled by dominant family
men? There arc a significant number of examples of men retaining control
of the wages of women in their families (Mark-Lawson and Witz, 1990).
Standing (1989: 1090-1) has suggested that there are seven areas where
the degree of control that women have over the rewards for paid work
need to be considered, and advocates the collection of better data. First,
control over self; for instance, as bonded labourers. Second, control over
the hours of work, such as not working longer than they would wish.
Third, control over the means of production. Fourth, control over raw
materials. Fifth, control over output, such as whether the woman is allowed
to sell her wares herself. Sixth, control over proceeds of output, especially
over whether the woman worker controls the wages which are paid, or
whether male kin or intermediaries prevent this. Seventh, control over
labour reproduction, especially over the ability to renew and enhance their
own skills.
is tiicre u positive relationship between changes in paid work and changes
in other dimensions of women’s lives? The conventional position implicitly
presumes a base-superstructure model in which the economic base deter
mines the superstructure of such things as political participation and sexual
autonomy. Such base-superstructure models have been widely criticized
when used in relation to class as well as in relation to gender, as over
simplifying complex causal interactions. Indeed some writers have argued
that we should not exclude an inverse relationship: for instance, the backlash
against women’s successes in both first-wave and second-wave Western
feminism in the arena of political and economic rights which took place
at die sexual level (Jeffreys, 1985; Millett, 1977, Faderman, 1981; Faludi,
1992).
There is a question as to what are the circumstances under which paid
work emancipates women. Historically in die West this has occurred at
diosc moments when women have also been gaining political rights. When
women won political citizenship as the result of the turn of the century
THE ‘DECLIN'
28
HISTORICAL ANO THEORETICAL t’ERSI’EC
29
whether the gap in the hourly wage rates fur men and women is greater
or lesser. However, the relative balance of oppression in household work
and paid work is a more problematic question.
It is possible for there to be a change in die form of patriarchy without
a change in its degree and vice versa.
„„,licnx ..K.vcmein, this was used l» ensure that waited work provided
wide.. .........
hoHletisotitc. ..ppoiiuniiics lor wot.wi. (Wttlby.
The ihud and Imai qitcstion involves (he very delininon ol pamarchy.
II pinriarchy is delined narrowly, then changes tn some dimensions ol
eender incqualitv will be considered irrelevant, while changes in the element
delined as key may be ■suflicient to justify a claim dint patriarchy has
_
problem widi definitions of patriarchy which locus too
ended.
T his is e[he
narrowly on men’’ss domination of women dirough the household, such as
PUBLIC AND PRIVATE PATRIARCHY
Mnnn (P86).
HIE END Ol; PATRIARCHY?
Mann (1986) has argued that patriarchy no longer exists, although there
is still gender inequality (presumably widiin die UK). This is because he
defines a patriarchal society as ’one in which power is held by male heads
of households' and where there is a 'clear separation between the public
and the."private’' spheres ©f life’ (Munn, 1986: 4 1), and these conditions
no longer hold. He suggests diat there are. three reasons lor this: die
erosion of the public/prjvalc boundary, employment trends, and the na
tion state’s welfare interventions into die household/lamily (Mann, 1986:
55). Yet he is not suggesting timt diere is not gender inequality, indeed
he suggests that it should be taken more seriously in that stratification
should be regarded as gendered. Neidier is he suggesting that there are
hoc key 'stratification nuclei’ (p. 56), nor that diere arc not significant
commonalities by gender —‘child-rearing unites almost all women’ (p. 54).
In shovt,Mann is arguing that there is still a significant amount ol
gender m^uality but, because it is not centrally determined by a maledominated household, it >s not patriarchy.
I think this is not a helpful theorization of the issues. The key element
of a definition of patriarchy is that iheic is systematically siriictuied gender
inequality. Mann accepts that this is empirically ihe case, bin denies the
application of the concept. He does this because he has defined patriarchy
as centrally linked to a male-duminaicd household. 1 diink this is a mistake.
l-ORM
3 S1 GNI I’ICANCB’ OF PATRIARCHY?
ES
AND DECREE OF PATRIARCHY
The. separation of the degree of patriarchy from its form is a crucially
necessary theoretical development. On each dimension of gender relations
it. i.S .often passible to spesify the degree of inequality between the sexes,
tOmch more dillicuW^lo this at the
die level ufW
ufSbe system
sysiciu as a whole
because of the inherently'vwlue-laden decision ns to the significance of
different aspects ol gender relations, bur instance, it is possible to state
I
i
T here have been two major forms of patriarchy in the West over the last
couple of centuries: public and private. They differ on a variety of levels;
first, in terms of the relations between the structures, and second, in the
institutional form of each structure. Further, they are differentiated by the
main form of patriarchal strategy: exclusionary in private patriarchy and
segregationist in public patriarchy. Private patriarchy is based upon house
hold production, with a patriarch controlling women individually and
directly in die relatively private sphere of the home. Public patriarchy is
based on structures odier dian the household, although this may still be
a significant patriarchal site. Radier, institutions conventionally regarded
as part of die public domain arc central in the maintenance of patriarchy.
In private patriarchy it is a man in his position as husband or father who
is die direct oppressor and beneficiary, individually and direcdy, of the
subordination of women. This does not mean that household production
is the sole patriarchal structure. Indeed it is importantly maintained by the
active exclusion of women from diese public arenas by other structures.
T he exclusion of women from these other spheres could not be perpetu
ated without patriarchal activity at diese levels.
Public patriarchy is a form in which women have access to both public
and private arenas. They are not barred from the public arenas, but are
mine die less subordinated within them. TTic expropriation of women is
performed more collectively than by individual patriarchs. The household
may remain a site of patriarchal oppression, but is no longer die main
place where women arc present.
In each type of patriarchy the six structures are present, but the rela
tionship between diem and tiieir relative significance is different. For in
stance, I am not arguing that in private patriarchy the only significant site
is that of the household. In the different forms there arc different relations
between die structures to maintain the system of patriarchy.
In the private system of patriarchy the exploitation of women in the
household is maintained by their non-admission to the public sphere. In
a sense the term ‘private’ for this form of patriarchy might be misleading,
in that it is the exclusion from the public which is die central causal mech
anism. Patriarchal relations outside the household are crucial in shaping
patriarchal relations within it. However, die effect is to make women’s
\
30
experience of patriarchy prlvntized,..mid the immediate bcncllciuriea arc
also located there.
■*;-k-’
1
In the public Ibnn of pniiimchy the exploitation of women takes place
at all levels, but women are not formally excluded from any. In each
institution women tire disadvantaged.
The second aspect of the difference between private and public patri
archy is the institutional form of each of'the structures. This is a move
ment from an individual to a more collective form of appropriation of
women. 1'here has also been a shift it) patriarchal strategy from exclusionary
to segregationist and subordinating.
?
r.
.. t
In the context of the UK aver the last 150 years the change within each
structure has been ns follows. Within paid work there was a shift from an
exclusionary strategy to a segregationist one, which was a movement from
attempting to exclude women from paid .work to accepting their presence
but confining them to jobs which were segregated from and graded lower
than those of men. In the household there was reduction in the confinement
of women to this sphere over a lifetime and a shift towards the state in the
main locus of control over reproduction. The major cultural institutions
ceased to exclude women, while subordinating women Within them. Sexual
controls over women significantly shifted from thq'specific control of the
husband to that of ft broader public'arena; women were; no •longer excluded
from sexual relations to tlic same cxtchtf but’subordinated within them.
Women’s exclusion from the state was replaced by tlicir subordination
within it. There afe, of course, variations, by class and ethnicity within the
UK, in these changes.
•
■<
'Hic cause of this change was feminist activity at the turn of the century
in the context of the increasing demand for female labour in an expanding
capitalist economy.
: • • r
",s
EASTERN EUROPE
.
TUB ‘DnCi.iNINO SIONIFICANCB* OP PATRIARCHY?
HISTORICAf’ANl) TIIHOHKTICAI. 1’HRSPUCTlVBS
There are sub-systems within this: for instance, pre-1989 eastern Europe
had a state-led form of public patriarchy, while die USA had a labourmarket led form of public patriarchy, with Western Europe in between
with its welfare stale and female employment participatum rates. I lowevcr,
as is becoming dear, it would be unwise to declare that women in Eastern
Europe suffered a lesser degree of patriarchy than those in die West despite
Uicir greater participation in paid work, since the degree of inequality in
die household and die size of die burden of household work appears to
'have been greater.
' .
/
The current trajectory, in Eastern Europe appears to be unhappily poised
between a shift to a market-led form of public patriarchy, and a return to
more private forms, as suggested by Moghadanfs chapter in diis volume.
31
It may be that a backlash against the- exploitation of state-led public patri
archy will lead to a more private form of patriarchy. However, the economic
shock trciiimcnt ndvociitcir by US economists may lead these countries
simply into a market-led form of public patriarchy.
)
I
CONCLUSION
?!
fi
1
The concept of patriarchy is indispensable to the macro-level analysis of
changes in gender relations. The concept needs to be developed in the
light of die legitimate criticisms of some of the early formulations. In
particular, the internal differentiation of structures within the system, and
their various combinations into different forms of .patriarchal system, is
crucial if the concept is to be able to deal appropriately with historical,
spatial, cultural, and ethnic diversity. Systematically interrelated forms of
gender inequality do not stop when the household-based form of private
' patriarchy diminishes. Rather, we see new forms. The degree of patriarchy
may change as well, but that is analytically separate from the issue of the
form, even if, contingently, in Western history, there have been some
changes in both simultaneously.
i
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* •
i
i
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I
THE ‘deci.in’
p'
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Mncillil.l., Juliht (1975), Psychoanalysis and l!eminism (I larmondsworth: Penguin).
Mmun, Swas h (1986), Common Fate, Common Bond: Women in the Global Economy
(London: Pluto Press).
Moghadam, Valentine (1992), ‘Patriarchy and the Politics of Gender in Mod
ernizing Societies: Iran, Pakistan and Afghanistan’, International Sociology, 7/1
(March): 35-53.
•••
OECD (1980), ’Wnmcn’s liinpluyiiicnl During the 1970s Recession', in A. II.
Amsden (cd.). The Ermimnies of Women and World (Harmondsworth: Penguin).
Rogers, Bahiiaha (1980), The Domestication of Wfomen: Discrimination in Developing
Societies (London: Tavistock).
Rowbotham, Sheila (1981), ‘The Trouble with “Patriarchy’”, in Feminist An
thology Collective (ed.), No Turning Back (London: Women’s Press).
Segal, Lynne (1987), Is the Future Female? Troubled Thoughts on Contemporary
Feminism (London: Virago).
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Sen, Amartya (1984), Resources, Value and Development (Oxford: Blackwell);
----- (1987), On Ethics and Economics (Oxford:
- Standard
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----- (1987), Ike
of -■
Living
(Cambric'"'
idgB^ambndge H
University
Press).
Standing, Guy (1989), ‘Globa! Feminization' through Flexible Labour’, World
Development, 17/7: 1077-95.'
■t___ 11_______________ !lt__X
Thomas, Jim (1992), lite Informal Economy (London:
Macmillan).
Walby, Sylvia (1988), ‘Gender PoliticsiandS^&Theory
and^dqalj^heory’,,Sociology, 22/2 (May):
215-32..
t
g significance’ of patriarchy?
UiS®;!;-
r
----- (1990), ■Theorisimg Patriarchy (OxfenlljBlfl^wcll). 1 r. ,,
# a
a >
•
♦
•••«
. .
! _f _ •
_______ fl
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•••••••(
i wz)> ‘iI’<iRi-fvio(iuriHRin;
nc<>ri/«iniy*vSoQini
k^unipicxiiy
—— (1992),
oRi-Modcrnluin:
’illicorizihg^Sbcini
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in Michele Barren
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.J"*h
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'>
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s,;
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Nicholson, S. (2002). ‘So you row, do you? You don’t look like a rower. ’An account of medical
students’s experience of sexism. Medical Education, 36, pp. 1057-1063
Medical students
'So you row, do you? You don't look like a rower.' An account
of medical students' experience of sexism
Sandra Nicholson
Introduction Medicine has traditionally been considered
a masculine pursuit and its undergraduate curricu
lum criticised as being inherently sexist. Oven sexism,
though diminished, still occurs and students report
offensive sexual remarks, unwanted sexual advances
and unequal learning opportunities. Sexual discrimin
ation also colludes with attitudes that promote the
stereotyping of the roles of women both in medicine
and in society itself. This study aimed to ascertain
medical students’ own experience of sexism during
undergraduate training, their understanding of these
events, what effects the events had on them and, spe
cifically, how they coped.
Methods Twelve in-depth interviews, each focusing on
a critical incident, with individual self-selecting Year 5
medical students took place. Initial qualitative analysis
of transcripts produced themes that were further
subsetted.
Results Students described situations where they felt
their learning had been jeopardised. Male students
Introduction
Criticism has been levelled at the nature of the medical
curriculum, claiming that it is inherently sexist. In
many curricula the ‘70 kg man’ is taken as the norm and
female values and anatomical diagrams are only dis
played when dealing with reproductive systems. Med
ical education devotes less time to subjects such as
domestic violence that are viewed as ‘female’.1’2
Traditionally, medicine has been thought of as a male
dominated, arena. Until the 1970s, the numbers of
female students starting undergraduate courses were
well outweighed by their male colleagues.3 Today, the
Department, of General Practice and Primary Care, Queen Mary,
University of London, UK
Correspondence: Dr Sandra Nicholson, Clinical Lecturer, Department
of General Practice and Primary Care, Queen Mary, University of
London, Medical Sciences Building, Mile End Road, London Ei
4NS, UK. Tel.: 00 44 20 7882 7942; E-mail: s.nicholson@qmul.ac.uk
© Blackwell Science Ltd
reported frequent difficulties whilst attached to obstet
ric and gynaecology firms. Students commented that
their gender did sometimes affect their relationships
with teaching staff and that affirmation from their
teachers was important. Female students coped well
with their experiences of sexism, often supporting each
other. Male students often felt resigned to being
excluded from certain learning opportunities and this
sometimes resulted in unresolved frustration.
Conclusions Developing a non-sexist undergraduate
curriculum should be prioritised. Encouraging teaching
staff to reflect on their attitudes to gender, approaches
to teaching and providing support, such as mentoring,
especially for female students frequently lacking appro
priate role models, is advised.
Keywords
education,
medical,
undergraduate/
*psychology; *sexism; adaptation, psychological;
curriculum; attitude; Great Britain.
Medical Education 2002;36:1057-1063
numbers of female consultants and GP principals have
risen significantly, but the majority of senior and
academic posts are still filled by men, raising concerns
that female students are without role models.4 The
current trend of disproportionate promotion in hospital
specialities has also led some authors to conclude that
this is due to direct or indirect discrimination.5
Sexism may be seen in open abuse or in more subtle
collusion with attitudes and behaviours that promote
the stereotyping of social roles. For example, it has been
established that stereotypical expectations can adversely
affect women’s career opportunities, as is illustrated by
the fact that more women enter specialities such as
paediatrics rather than surgery.6 It has been argued that
women are being shepherded into specialities such as
. primary care, which have been traditionally perceived
to be of lower status.n7 Typically, women, rather than
men, are perceived to bear the brunt of sexism.8
However, male students can suffer exclusion from skill
development opportunities and negative attitudes in
MEDICAL EDUCATION 2002;36:1057-1063
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Medical students’ experience ol sexism • 5 l\'.zholson
Methods
Key learning points
Sexism still exists in medical education and may be
responsible for inequalities in students’ learning
opportunities, poor relationships with teaching
staff and occasionally in much student distress.
Female students tended to cope better than male
students, using coping strategics of social support
and positive reappraisal. However, both sexes
would benefit from formal and informal support
structures, such as mentoring, to enhance their
coping strategies.
Institutional strategics to combat sexism should be
developed. Tutors should be encouraged to con
sider their own attitudes to gender and their
approaches to developing and teaching a non
sexist curriculum.
Further research to gauge the size and importance
of these issues needs to be undertaken.
certain predominantly female areas, such as obstetrics
and gynaecology.
Unfortunately, despite repeated denouncements of
medical student abuse, sexism and other forms of
discrimination in the medical literature, such unaccept
able occurrences still seem to be rife in medical
education.9 Overt sexism, though diminished in recent
years, is still prevalent in medical education. In one
study over half of students reported mistreatment
during their studies and more women than men cited
instances of public humiliation. Sexual harassment, in
terms of offensive sexual remarks and/or unwanted
sexual advances, is reported more frequently by female
students.6’10 In a letter to the Lancet it was proposed
that male students were at a disadvantage during their
final examinations as proportionately more male than
female students fail.10 Like their female peers, male
students also face discrimination.
However, the full impact of sexism on the experience
of both male and female students during their under
graduate training is not known. Students may well be
negatively affected by learning in such environments to
the extent that they then go on to develop attitudes that
may prove harmful to the care of women patients.11
Therefore, this paper describes the findings of a
qualitative study of both male and female medical
students, which aimed to ascertain students’ own
experiences of sexism during undergraduate training,
their understanding of these events, what effects the
events had on them and, specifically, how they coped.
A series of in-depth interviews were conducted between
December 1998 and August 1999 with students in their
fifth, and final year of medical school. The principal
function of these interviews was to explore students^
experiences, perceptions and how they coped with
negative learning experiences they had encountered
during their medical education to date.12 Students were
informed that the information gained through the
interviews would be used to monitor the quality of
their undergraduate courses and to assist in making
curriculum changes. Students were also informed that
the interviews were pan of a personal postgraduate
degree dissertation being undertaken by rhe inter
viewer. All students completing a particular final year
module were invited to give interviews verbally and by a
written handout, which reinforced the nature of the
interviews and their confidentiality and stated that
information about negative learning experiences was
being sought. Students who volunteered for the inter
views were therefore self-selecting. No formal ethics
committee approval was sought.
A critical incident technique was used during each
interview. The student was encouraged to describe in
detail any events that they considered to have been
negative learning experiences. These then became the
foci of the interview.13 Many students mentioned
gender issues in their descriptions of events and these
were explored further. When a student did not raise
such issues, the topic was introduced and if the
student then wished to discuss this area, it was
followed up.
A non-directive approach was used, where the
interviewee was allowed to talk at length, in his or her
own words, about what they considered the most
important aspects of the described situation. An open
interview framework was implemented in order tq
encourage students to describe events, uninterrupted,
in their own language and time. This meant that each
interview covered a list of issues, derived from informal
discussions with students, rather than setting out
specific questions.14
The number of completed interviews was limited
because the interviewer did not want to extend the
period of study into the subsequent academic year,
when the successive cohort of final year students might
possibly have had significantly different learning
experiences. From the outset, the study was planned
as a small qualitative project, which naturally had time
and cost restraints.
The authenticity of the data was enhanced by having
students explain events in their own words. It was also
© Blackwell Science Ltd
MEDICAL EDUCATION 2002;36:1057-1063
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Medical students’ experience^of sexism • S Nicholson
0
0
important to consider the context of each event in order
to maintain the validity of the data.
Following transcription of the recorded interviews,
initial qualitative analysis categorised units of data
according to emergent themes. Each theme was derived
by searching for data that had similar meaning or was
linked by a core concept. Common phrases and shared
ideas in the transcripts helped to identify the themes.
These themes with their associated data were entered
into a matrix. All recorded data were referenced by
their original interview source to facilitate further sub
analysis.1
Students of both sexes described situations where
they considered their learning had been affected by their
gender. These comments describing situations, events,
relationships and student perceptions were categorised
into the same theme. Further analysis of this reduced
data was performed by coding or assigning meaning to
units of data within this category. Data units bearing the
same code were then grouped together. This clustering
facilitated further analysis and conclusion formation.
In a cyclical process as later interviews were coded,
the coding system was revised. It became apparent that
some codes were important, with repeated themes,
whereas other codes became obsolete. It was important
that these concepts were tested out in subsequent
interviews.14 This also involved going back over some
of the original transcripts to check for consistency in
coding. Any obvious exceptions were followed up to
enhance the robustness of the emerging coding system.
Re-coding some of the earlier data ensured that the
standard of internal consistency wasdiigh. This was
important as the author was the only person completing
the coding and therefore reliability was dependent on
this internal consistency.
Attempts to collaborate or refute ‘working’ conclu
sions in later interviews and in the ongoing analysis
were* undertaken. This ensured that conclusions were
not drawn14 from isolated instances. However, due to
the size of the study some incidents were only reported
once, and where conclusions were deduced from these,
attempts were made to confirm findings with other data
sources. In particular, emerging theory was tested by
comparing conclusions with the literature.
Results
Six female and six male students were interviewed. Ten
of the 12 student interviews provided rich data descri
bing negative learning experiences that included gender
issues. Students’ descriptions of other types of negative
learning experiences and, in particular, how students
cope with them form a funher repon.
© Blackwell Science Ltd
The following categories were identified:
• learning opportunities;
• relationships with teaching staff;
• overt sexism, and
• coping strategies.
Learning opportunities
The most obvious source of sexism referred to students
feeling they had been excluded from learning oppor
tunities because of their sex.
*1 found being a bloke was a write-off...because
seeing births and stuff was impossible. I think it was
more to do with my gender than anything else.’ (Int.
2 pp.l + 4)
The difficulty for male students of obtaining per
mission to witness births and examine patients in
obstetrics and gynaecology featured repeatedly in
student comments throughout the interviews. Male
students’ comments were collaborated by their female
peers:
‘I think being a boy’s an issue if you’re doing obs and
gynae because you don’t get to see anything.’ (Int. 8
(female student) p.6)
No female student in the series of interviews des
cribed any incidents where they felt they had been
deprived of skill development opportunities.
Relationships with teaching staff
Some students considered that although they were
exposed to the same learning opportunities as each
other, their treatment by, and the relationships they
formed with, their teaching staff profoundly altered
these experiences for individual students. Students
therefore did perceive that their colleagues received
preferential treatment based on their gender:
‘...with practical things I've had more or less the same
experiences but 1 feel sometimes that the doctors
tend to talk to the males in the group and not
necessarily always the females. If I was male, I may
have been referred to more often.’ (Int. 1 p.8)
‘We were the only two girls in the group and I don't
know if it was any victimisation but we were
noticeably criticised an awful lot more.’ (Int. 3 p.l)
The above student thought that the reason for her
perceived severe treatment was that she was one of two
girls in a male-dominated group. It is noteworthy that
their teacher was also female.
MEDICAL EDUCATION 2002;36:1057-1063
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Medical students’ experience of sexism • 5 Nicholson
Data from study interviews confirms that affirmation
was important for students of both sexes:
Female students may also cope by deciding not to
engage in the arena of sexism:
‘She [the teacher] would never look at you when you
were in the room and if you were too slow presenting
a padent she would just go, “Oh, I haven’t got time
for this,” and sort of walk out, and it just made you
feel a bit hopeless. Well, it made me feel hopeless
anyway.’ (Int. 7 p.7).
‘The male surgeons have passed comments and you
think. “Well, that’s fine if you want to be like
that...let’s just get on with it.’’ (Int. 10 p.9).
Female students reported receiving more favourable
treatment than their male peers in terms of opportun
ities to learn as a result of favourable relationships
formed with teaching staff.
‘I think it's (being a girl] helped in a lot of circum
stances. It’s definitely helped in obstetrics and
gynaecology. It’s been mostly cases where men have
been excluded and we’ve been allowed to get in and
do things. I tend to think the nurses are more
sympathetic towards us.’ (Int. 10 p.8)
Overt sexism
Rare instances of overt sexism were found in the
study:
‘So you row, do you? You don’t look like a rower.*
(Int. 7 p.l 1).
This student complained that she felt she had been
treated differently from the boys on her firm who also
needed some time off to play sport.
Coping strategies
When sexism occurred, the female students who
participated in the study appeared quite capable of
dealing with it effectively and of not allowing it to
undermine their education. Female students tended to
support each other:
*We used to laugh about it because it was just silly in
the end, it was like we really couldn’t do anything
right.’ (Int. 3 p.2).
Female students may cope by actively attempting to
change or intervene in a teaching session where they
perceive they are being neglected by their teachers or
when they feel the teaching is being dominated by their
male colleagues, as illustrated by another student’s
comment:
‘I’ve butted in or tried to ask the question to get it to
turn not necessarily my way, but to get me more
involved.’(Int. 1 p.9).
Unfortunately, the male students who participated in
the study did not cope so well with being excluded from
certain types of clinical teaching. They did not have
effective coping strategies in place to attempt to achieve
their goals of assessing female patients, but instead
accepted not being able to see patients with passive
resignation. However, there was also unresolved frus
tration, anger and a sense of injustice about these
situations, which often generated an atmosphere of
bitterness and disenchantment.
Discussion
The results are from a small qualitative study that gives
an account of individual medical students’ experienc
of sexism. Although care was taken to minimise any
bias, both in obtaining data and analysing it, thereby
increasing the validity of the conclusions, this will not
ensure generalisability. What the students said was true,
but it was true for them, and pertinent to their own
situations. Therefore caution should be exercised when
drawing conclusions from such a small, focused study.
However, the results do highlight some important
points, which are powerful because of their face validity
and natural context. Further research to gauge the size
and importance of these issues needs to be undertaken.
A basic premise ensuring competency is that all
students need exposure to a wide range of clinical cases
to facilitate their learning of the basic history and
examination skills. Undoubtedly, assuring male stu
dents access to female patients is a difficult and
complex task. Obstetrics and gynaecology particularly
demonstrate the interplay between supporting patiem
autonomy by ensuring appropriate informed consent
gained before any student contact occurs, and facilita
ting adequate student experience necessary for their
learning. A variety of gender issues amongst teaching
staff, doctors, midwives and nurses also exert their
forces onto a volatile situation. Research into patient
acceptance of students in this field is scanty. A
Californian study reported high levels of acceptance
of both female and male students in an outpatient
setting. Reasons stated for refusing student involve
ment included patient privacy and discomfort with
the clinical examination.16 To overcome these difficul
ties with the nature of the intimacy of the clinical
© Blackwell Science Ltd
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Medical students’ experience of sexism • S Nicholson
examination, other studies have reported their findings
of replacing genuine patients with either simulated
patients or students themselves.17,18 However, both
cases are fraught with ethical problems. Student opin
ion is clear that it is essential that both male and female
students should have access to female patients and that
the present unequal system that male students face is
unacceptable. Contrary to the findings of this study, the
literature also reports examples of female students
suffering, such’as the women in a surgery clerkship who
reported fewer learning opportunities and less favour
able staff attitudes than their male peers.19
When students considered their relationships with
their teachers, who were usually male, they thought that
teachers felt more comfortable talking with male
students because that was more familiar to them. This
hypothesis was generated to explain why male students
may receive more teacher attention than female stu
dents and compares with other work in the area.6 In the
report The Classroom Climate: A Chilly One For Women?
the authors identified some 30 ways in which postsec
ondary female students were treated differently to their
male peers.20 It is unsurprising, therefore, that this
report concluded that women’s academic development
was likely to be affected.
However, other studies report that the majority of
students find their learning environment to be gender
neutral.21 This may be so for most students today in
most fields, but even the present small study illustrates
that this is not the case for some students in certain
areas such as medicine. The literature discusses the lack
of appropriate female role models and the open hostility
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some female senior doctors show to female medical
students.22 Unfortunately, what is not clear is why this
should occur. There is some evidence that if a teacher
experienced harsh treatment as a student herself, she
may go on to abuse students in just the same way,
isolating female students in particular in just the same
way she was.23 Certainly, female doctors graduating
two decades ago encountered more difficulties than do
today’s female graduates. It may well be that in
struggling to achieve and sustain a successful career in
medicine, female doctors develop high expectations of
their younger female successors and become antagon
istic if they are disappointed.24 Female students may
also have expectations of their senior female colleagues
in terms of support and empathy, and even positive
discrimination. If these expectations are not fulfilled,
female students may feel disheartened and let down.
Rienzi et al. reported that 10% of female and 2% of
male graduates felt they had received negative treatment
whilst at university because of their gender.21 It has been
speculated that the higher incidence of reports of such
© Blackwell Science Ltd
occurrences made by women is due to female students
having higher regard for affirmation or shaming than
their male peers.25 The results reponed indicate that
both male and female students require appropriate
feedback on their performance to reinforce correct
methods and encourage further effective learning.
The fact that different studies report varying degrees
of sexual harassment is probably a result of differences
in how this term is defined. Follet er al. found that only
10% of students in their study were offended by
behaviours that included sexist remarks or inappropri
ate humour.8 In another study, 24-3% of female
students reported that they had been subjected to
personal sexist remarks. This meant that eight times as
many women as men reported such events. Female
students also reported a significantly higher rate of
unwanted sexual advances by school personnel.6 How
ever, although instances of serious overt sexism are
rare, this does not limit its effects. Many studies have
now shown that student abuse can have a lasting
detrimental effect on students. Following the most
serious episodes, 16% of students reported that the
effects of the experience would remain with them
always.26 Student abuse in general can not only affect
students’ academic progress, but also their personal
lives, careers and, ultimately, patient care.23,24 It has
been reported that female residents more frequently use
coping strategies of social support and positive reap
praisal to deal with their experiences of educational
sexism. However, it has been indicated that a more
formal network of support groups should be instituted
for female students.22 Organisations promoting women
in medicine, which students can join, exist in both the
UK and the USA. However, although these organisa
tions operate on both national and local levels, students
may need a more personal approach directed at their
individual learning environment. A recent study con
firmed that female students actively participated in
teaching, had good relationships with staff and fellow
students and felt they benefited more from their
educational experiences than their male colleagues.
The authors proposed that female students today are
reaping the rewards of earlier reform atid enhanced
understanding of the educational needs of female
students. However, this study was based on the
experience of American university students, not neces
sarily studying medicine. Certainly the female students
interviewed in the present study coped well with their
experiences. Unfortunately, male students did not
generally employ the same coping strategies of social
support and reappraisal. They described losing out on
learning opportunities and subsequendy becoming
dissatisfied. It is challenging to consider what we can
MEDICAL EDUCATION 2002;36:1057-1063
offer those male students who, in some clinical situa
lions, are now operating in a women’s arena.
The way forward
The preceding discussion has illustrated that the sexism
experienced by a small number of medical students was
complex with a multifactorial causation. Taking action
as detailed below may help to ensure that all medical
students are treated with respect and have equal
learning opportunities.
Firstly, the personnel who teach students should be
encouraged to consider their own attitudes to gender
and their approaches to developing and teaching a non
sexist curriculum. 1 his is a primary consideration
because students mostly complained about the effects
of sexism on their learning opportunities and their
relationships with teaching staff, which obviously
directly affects their learning opportunities. Reflection
on one’s own teaching practice rarely happens sponta
neously and it is the responsibility of educators to
ensure that teaching staff have access to appropriate
training and are aware of these issues.
Secondly, it is essential that students, particularly
women, are provided with appropriate role models. It is
possible that female students do not see themselves as
surgeons because they have not had the opportunity to
observe women surgeons. Female students cannot
witness first hand that it is possible to deal with the
issues of ‘role-strain’ and balance family life .with an
academic career if there are not sufficient numbers of
female academic staff. Some articles clearly advocate
positive discrimination in promoting female staff until a
gender balance is created.4
However, the situation will not be remedied by
considering numbers alone, and the inclusion of strat
egies to provide mentorship for female students, who
lack the equivalent of an ‘old-boy network’, is advised.
Organisations such as Women in Medicine (UK)
provide a forum for women with similar interests.
Mentorship provides students, of both sexes, with
career advice and personal and academic support.
Some of the frustrating exclusions of male students
from clinical situations may be prevented by reviewing
how certain sensitive topics are taught. Pairing male
students with female colleagues, ensuring female
supervision and considering placing students in a more
personal, community-learning environment may help
ensure that they do not miss out on clinical teaching.
It is essential that students themselves combat
sexism, especially in overt cases. Medical schools
should operate a zero tolerance policy of sexism and
all students should be aware of the procedures to follow
- in reporting serious incidents. These procedures should
be confidential and seek to suppon the reporting
students.
Future research will be necessary to evaluate whether
any of the suggested recommendations to combat
sexism are effective. It will also be imperative that an
investigation into teachers’ perspectives on the issues
raised by the students is carried out, panicularly as one
of the main recommendations is to encourage some
teachers to change their practice.
Conclusions
Sexism still exists in medical education today. The
effects of such discrimination can be seen in unequal
learning opponunities, -students’ relationships with
teaching staff and occasionally in much student dis
tress. Further study to assess the size of the problem,
and ways of combating sexism, b.oth on individual and
institutional levels, should be undertaken.
Acknowledgements
i
The author wishes to thank Dr Lesley Pugsley,
Lecturer in Medical Education, Academic Department
of Medical and Dental Education, University of Wales
College of Medicine, for her patience and expenise in
supervising the author’s original dissertation, from
which this paper was developed. Gratitude is also due
to Dr Geoff Harding, Senior Lecturer, Department of
General Practice and Primary Care, Queen Mary,
University of London, for his suppon and encourage
ment in preparing the manuscript.
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Funding
There was no external binding for this project.
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Dissertation MSc. Medical Education, University of Wales
College of Medicine.
13 Dunn W, Hamilton D. The critical incident technique: a brief
guide. Med Teacher 1986;8:207-15.
14 Hammersley M, Atkinson P. Ethnography Principles in Practice.
London: Routledge; 1991.
15 Miles M, Hubermann A. Qualitative Data Analysis: An
Expanded Sourcebook. London: Sage Publications; 1994.
16 Ching S, Gates E, Robertson P. Factors influencing obstetric
and gynecologic patients* decisions toward medical student
involvement in the outpatient setting. Am J Obstetrics Gynaecol
2000;182:1429-32.
17 Kleinman D, Hage M, Hoole A, Kowlowitz V. Pelvic exam
ination and instruction and experience: a comparison of
laywoman-trained and physician-trained students. Acad Med
1996;71:1239-4.
© Blackwell Science Ltd
1063
18 Abraham S. The effect of sexual experience on the attitudes of
medical students to learning gynaecological examinations.
J Psychosomatic Obstetrics Gynaecol 1996;17:15-20.
19 Calkins E, Arnold L, Willoughby T. Medical students’ per
ceptions of stress: gender and ethnic considerations. Acad Med
1994;69:s22-s24.
20 Sandler B, Silverbcrg L, Hall R. The Chilly Classroom Climate:
A Guide to Improve^thc Education of Women. Washington, DC:
National Association for Women in Education; 1996.
21 Rienzi B, Allen M, Sarmiento Y, McMillin J. Alumni per
ception of the impact of gender on their university experience. ‘
J College Student Dev 1993;34:154-7.
22 Davidson V. Coping styles of women medical students. J Med
Education 1978;53:902-7.
23 Kutcher S. Coping with the stresses of medical education. Can
Med Assoc J 1984;130:373-4+381.
24 Rosenberg D, Silver H. Medical student abuse. An unneces
sary and preventable cause of stress. J Am Med Assoc
1984;251:739-42.
25 Ingleton C. Gender and learning - does emotion make a dif
ference. Higher Education 1995;30:323-335.
26 WolfT, Elston R, Kissling G. Relationships of hassles, uplifts
and life events to psychological well-being of freshman med
ical students. J Behav Med 1989;15:37-45.
27 DrewT, Work G. Gender-based differences in perception of
experiences in higher education: gaining a broader perspec
tive. J Higher Education 1998;69:542-55.
Received 28 February 2001; editorial comments to author 6 June
2001, 16 January 2002; accepted for publication 16 Afoy 2002
MEDICAL EDUCATION 2002;36:1057-1063
It goes without saying: Voices of women medical students.
It Goes Without Saying: Voices of Women Medical Students
Abstract
o
In It Goes Without Saying; The Voices of Women Medical Students, I have used the
experiences of women in medical school to illustrate the gender biases that are present in
undergraduate medical education. The collected experiences have been subdivided under
eight themes, which include gender discrimination in the written and hidden curricula, as
well as discriminatory behaviours on the part of some faculty members. I have also made
recommendations for developing a gender-sensitive educational environment, and
included further suggestions and resources from the relevant literature. This is followed
by Women as Patients and Medical Students: Common Themes, which introduces some
of the commonalities I observed between the concerns that women express as students of
medicine and as recipients of medical care. The second piece is intended to illustrate that
reducing the gender biases in our education will not only facilitate our experience as
students but will also raise the standard of care we provide for women patients.
uIt is imperative to avoid discrimination among students on the basis of the students
political or ethical ideas... (it goes without saying that discrimination on the basis of
gender, religion or ethnic or social origin is absolutely antithetical to the academic
ethic).”
Edward Shils in The Academic Ethic (1978)1
For the Gender and Medicine Project, I have collected quotations by women medical
students, both from the existing literature and through direct solicitation from students
currently attending medical school in Ontario. In the latter category, students were asked
via e-mail for their thoughts and experiences relating to gender in their education. The
respondents included the student participants in the Gender and Medicine Project. I
identified eight themes that recurred among the student concerns and organized the
quotations accordingly. Although the themes create some artificial divisions between
experiences that are related in both obvious and complex ways, I think they generally
accomplish my wish to outline core areas of concern. I have included my thoughts on
each theme, and provided suggestions for implementing meaningful changes to the
current system. However, I think the most powerful statements in this report are
contained in the student voices, and that all medical educators should take the trouble to
consider what we have expressed here.
2
0
This complaint was particularly common among the sources I consulted. Hie
observation that there are relatively few female professors and administrators in medical
schools indicates that while women may now take for granted the right to practise
medicine, they remain less likely than their male counterparts to gain power within the
medical establishment. This notion is supported by a study performed in Finland, where
women have been well represented in the medical profession for longer than in Canada.
In the Finnish system, a gendered segregation of specialization and academic
involvement persists, with women occupying fewer positions of influence than their
numbers would predict.2
u...thatfs what I thought when I was in undergrad and didn't see any women profs. I
thought, there must be something that stops women from doing this, either it's too hard
to have children, there's sexism, you're actively discouraged from doing this. That's
what the message is that I get from seeing so few women profs, that there are some
barriers somewhere that makes it more uncomfortable for women to do this. And if
there were more, I wouldn'tfeel that way and I would be more likely to consider it.”^
“Often when a woman comes to the front of the class, people make the assumption - oh,
she must be a dietician or a physiotherapist, or whatever else - or, she can’t be a
doctor, or we won’t listen. Really, women instructors have to work extremely hard to
grab the class’ attention." 3
"The lack offemale faculty is particularly distressing during discussion group times,
like patient-centered learning. Usually the advisors of this course have many stories to
share, and quitefrequently these stories have to do with things outside of medicine (i.e.
lifestyle issues). This is an integral part of our education! Yet there is no female faculty
to talk about the stresses of raising a family, maternity leave, role taking within
relationships & dealing with others with traditional views of women.’Student A <
“While we did have some professors who were women, the deans and those in charge of
the courses and departments, for the most part, were men. The assistants in the
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35
undergraduate office, the administrators of our clinical skills course, the librarians and
the employees in the cafeteria, they were all women.”Student B 4
“One of the greatest weaknesses which I and many of my classmates see is a lack of
female mentors and instructors. Having made it through two OSCEs now, I have yet to
have a female evaluator. Classes are also predominantly taught by male instructors.
More equitable exposure is found mainly in pathology, psychiatry, endocrinology and
patient-centered learning.”Student C4
“It felt really different to work with a woman surgeon - it was easier to see myself in
her position. It made thatfield seem more possible.” Student D 4
The same Finnish study cited earlier reports that women are slowly increasing their
presence in the areas of administration, teaching and research, raising the hope that
medicine may be undergoing a gradual equalization.2 Closer to home, we can look to the
appointment of Dr. Carol Herbert as Dean of Medicine at the University of Western
Ontario as a sign of progress. However, medical faculties need to be actively committed
to promoting women and other underrepresented groups in order to expedite this
process. Otherwise, experiences and numbers indicate that the current male-dominated
structure will be inclined to maintain itself.2’5’6,7’8’9 The importance of the effort to
increase leadership by women in medicine should not be underestimated: “Recruitment,
retention, and advancement of women faculty and administrators may be the most direct
means to gender equity.”10 Specific recommendations for doing so are given by
numerous authors.11*12’13
As we work for increased representation of women in the medical faculty, the situation
for current students can be improved through mentoring initiatives between women
physicians and students. The Federation of Medical Women of Canada and the Ontario
Medical Association currently have mentorship programs. However, they are not
advertised on their websites, and generally seem to maintain a low profile. Creating such
programs on a per school basis may be more effective. The University of Ottawa has a
program for the mentoring of junior women faculty, which includes an on-line Faculty
Mentoring Handbook and an open invitation to use this resource.’4
A
£6
2. Gender-biases in the written curriculum.
The written curriculum of medical schools includes the presentation slides and lecture
notes provided by professors, the contents of required and recommended textbooks, and
the case studies used in small-group learning sessions. It is also reflected in course titles
and organization. Importantly, it includes the evaluative components of all courses. Each
of these aspects of medical education conveys views on gender - usually through subtle
but pervasive patterns of emphasis and omission, and sometimes through blatantly
sexist assertions.
“I was conscious because I was pregnant last year - another text that we use currently .
referred to a pregnant uterus as something like a ‘tumorous mass’.”3
“Why has all the research we learn about in pathophysiology only involved men
subjects?”15
“Why are most drug trials, from which dosages, side effects and contraindications are
established, conducted only on men?”15
aWe did not study any breast anatomy at all. I would think this would be importantfor
future doctors?! During sexual anatomy, the female was grazed over - a great way to
reinforce the stereotype of the unknown, uninteresting, unimportant female sex drive.
On the flip side, during pathology of reproduction the lectures focused on females
(endometriosis, cervical cancer, etc) and no mention was made of male pathology. I
would hope some male problems would be addressed (i.e. prostatic cancer).” Student A*
“In anatomy, we did not study the breast but we did study the inguinal canal in
excruciatingly painful detail because ‘it’s so important clinically’. I guess breast cancer
and feeding newborns are both less important than that ever-deadiy global pandemic
of inguinal hernias” Student B4
“Our book on plastic and reconstructive surgery has an illustrated page on breast
enlargement surgery. The caption under the post-operative breasts says that ‘After
surgery, breasts appear fuller and more natural in tone and contour/ In other words.
o7
regular, healthy women whose bodies don’t conform to some current cultural ideal are
unnatural and m need of medical intervention. I think it’s shameful that this view
would be expressed and sanctioned in our curriculum. ”Student D 4
“Most of our problem-based learning cases were about men or boys. ” Student B4
“Looking at my classmates I can quickly recognise differences in age, height, weight,
ethnicity, and sex. However a large proportion of our curriculum content has been set
to a “normar set of values and states based on evidence collected through clinical trials
and basic science research. There needs to be a revolution in this practice where there
is inclusion of‘differences’ and an understanding that being different is the norm. For
o
example, in a course such as physiology, all ‘normal’ values refer to a 70-kg white man,
no mention of differences between sexes; differences between sizes; and even a lack in
differences between ethnicities. For a multicultural society such as Canada this is
unacceptable. A majority of our future patient population will not fit this ‘normal’ set
ofdata.n Student G 4
As some of these concerns indicate, one major source of gender bias in the curriculum is
the fact that medical research has long been conducted primarily on male subjects.
Therefore, information such as the typical presentations of illnesses or the side-effect
profiles of drugs, while generally presented in the curriculum as gender-neutral, have
actually only been observed in men. In addition, the men in these studies have generally
been white, so that different ethnic groups have also been systematically excluded from
our medical knowledge. Now that the evidence-based medicine approach is being
promoted as the golden standard for practise, we are at risk of further incorporating
these injustices into the medical curriculum. It is essential that we demand “adding a
‘diversity lens’ to evidence-based medicine, one that widens the view to include sex,
gender, race, religion, socio-economic status, sexual orientation and whatever other ways
individuals may vary”.*6 For more information on this subject please see the report on
evidence-based medicine in this package.
Further biases are contained within the textbooks used by each particular school.
Textbooks should be evaluated for their representations of gender; a tool for this
evaluative process has been developed.^ It would be practical for the evaluations to take
6
68
place centrally and to create a database of book critiques for all medical schools. Books
that do not provide equitable gender representations should either b£ discontinued or
modified with inserts that document the gender-biased aspects of their content. An in-
class review of such an insert may provide students with a useful lesson in the critical
evaluation of medical information. Naturally, the book publishers should be informed of
the results of the reviews, and where applicable they should be urged to change the
textbooks in order to make them acceptable for the curriculum.
A third source of bias lies in what professors choose to include and emphasize in their
lecture notes and in case studies. This area may be improved with the gender issues
workshops outlined in section 6. There are also practical guidelines for educators who
are interested in eliminating gender-biased teaching materials and behaviours from
medical school (Appendix C, Parti).18’19
3. Gender-biases in the ‘hidden’ curriculum.
In evaluating the medical curriculum, we cannot ignore the role of what has been termed
the hidden curriculum: “The messenger’s individual delivery style, subtle bias and choice
of words or emphasis (...) cannot be assessed solely by examining the written curriculum.
They are, however, central to the attitude students absorb in medical school and to the
creation of an inclusive learning environment.”18
"... a comment from a gynaecologist telling us that women with PID should
automatically be considered promiscuous... the act ofjudging is certainly not the place
ofphysicians (...) to call her promiscuous - to use that word (...) to use it in front of So
impressionable young doctors-to-be who believe everything you say - I thought, it just
felt wrong.”3
“During classes, the language and tone generally represents females and diseases
which females have as “atypicar or “abnormal” simply because they don't present in
the same way as they do in males.”Student CA
7
- -
-
“In one lecture our anatomy professor pointed to an illustration of the perineum and
called it that, then explained himself saying ‘some women don’t like it when you call this
whole area the vagina’.”Student D 4
“A lack of understanding of the implications of what is being taught on women in
society; a biochemistry professor talked at length on the benefits of eating a varied,
healthy, self-prepared diet instead of supplements/prepared meals. Who's in charge of
making most meals within families, and what kind of burden is this statement placing
on them?” Student A 4
“An ENT doctor showed us an image of a larynx covered with mucus and told our class
that ‘Otolaryngology is not for the fastidious - any more than gynaecology is’.” Student
!
i
(?
“It just felt really isolating. So much of medicine - the concepts - are male somehow.
Like you don’t really talk about the human aspects of things... you don’t talk about
illnesses in women’s language, ifyou know what I mean... And I started to notice that I don’t know if I can explain it to you - sort of, the language used in notes is very static,
very fixed - square. I don’t have the words to describe it, and when I think how I would
I describe it myself, it’s a lot moreflowing, more descriptive kind oflanguage.” 3
“A female emergency physician teaching us about heart disease explained that
‘Classically, women present atypically’. ”Student B 4
Central to the hidden curriculum question is the issue of faculty attitudes and
I
behaviours. This subject is common to several of the themes and will therefore be
discussed cumulatively in section 6.
One theme that is apparent in these experiences is that women students find the social
context of health insufficiently covered in the curriculum, both in its written and implicit
forms. The current ‘anatomicopathological’20 approach to medicine seems to alienate not
only students but also women patients. Alexandra Todd’s work in particular illustrates
that women’s health care needs are frequently missed by physicians who conduct
biomedically oriented interviews and do not raise or respond to psychosocial concerns.21
8
7o
Susan Phillips has addressed this problem in her writing and created excellent goals and
objectives for incorporating sensitivity to context, values and beliefs in their approach to
patients (Appendix C, Part ii).22
4- Gender-biased treatment of students by faculty members.
Student complaints about being discriminated against by faculty on the basis of their
gender are very common. This is one of the most powerful barriers against which women
in medical school struggle. The behaviours undermine their educational experience and
chances for advancement. At the same time they are subtle and transient enough that to
document and challenge their occurrence remains difficult. Because the faculty members
in question often do not perceive or acknowledge their own bias, they may resent
complaints about behaviours that, although destructive, carry no harmful intent. In this
problem I see the merging of two issues that are central to feminism: ingrained and
unconsciously held gender stereotypes (see section 6) and the difficulties that women
face in confronting such biases (see section 8).
... say there are 8 people working with the physician, when it comes to things like
putting the robe back on the patient, usually it’s a woman singled out to do things like
that... just kind of a different treatment. And then if you’re talking about the different
cranial nerves emerging from the brain stem, usually there’s total eye contact with the
other male people in the group, it’s very subliminal.’’3
When I raise my hand to answer a lecturer’s question or even to ask a question during
the discussion period, I’ve noticed it’s notjust me but, commonly, the women are called
on much lessfrequently and even ignored”*
“I’ve noticed that the guys seem to get asked to help with a research project more often
than the women residents. I’d really like to learn to do research; that’s part of why I
chose this residency program”*
“The male doctor I was working with made me face the wall during a genital exam of
an adolescent. Although I understand the sensitive nature of the examination, as well
as the patient’s rights, the patient was never asked if he would prefer I leave the room
Q
'll
and the doctor simply assumed that it wasn’t appropriate for me to be learning how to
perform testicular examinations and that the patient would not want me to observe his
genitalia. I found this situation extremely frustrating not only for myself but also for
the patient, since he was given the impression by the doctor that he should only be seen
and examined by male physicians.”Student CA
The discussions also tended to be between the loudest, most outspoken people in the
class because we were told to just jump right in and not raise our hands. This type of
discussion seems to me to be better suited for the men in the class than for the women,
or the quieter, politer menfor that matter.” Student B 4
o
I have heard many of my male classmates express feelings of inferiority and
inadequate preparation with respect to pelvic and obstetrical examinations and
gynaecological and obstetrical histories. Some male students expressed concern that
they were not permitted to participate in these exercises during rural week at the end of
first yeart whereas theirfemale colleagues were always involved.” Student E 4
In order to emancipate the present learning environment, education against gender
stereotyping is essential. This is discussed in section 6.
The outlined experiences also indicate that gender bias in medicine can be held against
men as well as women. This report is focused on the barriers that confront women in
medicine; I will make no apologies for taking this view, as women remain relative
newcomers within the male-dominated medical culture. However, the gender-sensitive
learning environment that this project calls for includes the awareness and dismantling
of male gender stereotypes. Rohan Maharaj and Yves Talbot have written a useful primer
on men and gender issues as they relate to family medicine.^
5. Verbal and practical discouragement from entering certain specialties.
This section provides us with an idea of what'xauses women to be concentrated in
relatively few specialties, which are generally considered to be of lower status in the
medical hierarchy.
10
72
“It (surgery) is not really conducive if you're planning on having children. You KNOW
you're going to be really stuck if you get pregnant during residency. You KNOW that
taking maternity leave means you lag behind your classmates and you will not get
good appointments. Whether it's overt or covert, you know that. It's definitely harder to
be a woman in it than a man.”3
“ ‘Well, you don't want to do that (Orthopaedic Surgery)... You want to go into Family
Medicine, that way you can have kids - stay home - don't have to work 120
hours/week.' — and this was done in a condescending manner.”3
“ ‘Well there are no female paediatric cardiologists.'... His attitude was that I couldn't
do it simply because I was a woman - simply because no women have ever done it.”^
“My training director was clearlyfrustrated when I told him I was 2 months pregnant
and would take parental leave after delivery. He said I'd better expect my resident
peers to be angry, and I should do whatever they wanted about making up my night
and weekend coverage so they wouldn't leave because of me, and leave him without
residents.”15
“My faculty advisor warned me not to apply to such a competitive program after I told
him it was my first choice. He said they usually just take one token woman and I
probably wouldn't meet their standards despite my being in the top 10 % of my class”15
“While I do realize that the incidence of chromosomal abnormalities may go up with
maternal age, and obviously the closer a woman is to menopause, the harder it will be
to get pregnant, there are ways to get that message across without making women feel
guilty about wanting to start a career.”Student B*
“One male OB-GYN told us something to the effect of ‘tell yourfemale patients to never,
ever plan on kids after 35'. An audible groan was heardfrom the females in our class.
Did he realize he was talking to 56 women who were probably going to put off
childbearing for some time? I realize the facts remain facts, yet he could have broached
the topic with more sensitivity, instead of making half of the class question their choice
of medicine as a career.” Student A 4
11
73
“Female classmates are often encouraged to enter family medicine so that they will
have time to have babies.
Other female classmates have been discouraged from
specialties, such as surgery, because they will not have enough time to have a family. I
think there is too much of an assumption that all women want to have children and
that in order to do so, they must become family physicians. This sentiment is often
echoed in cases (usually only the informal ones in class) where women are too
frequently portrayed as home-makers and in only a maternal role.”Student FA
I would like to stay in hospital surgery, but Fm a bitfamily oriented so Fm not sure... I
want to have the nice house, 2.4 children, and be happily married and all that, and Fm
not sure how that works when you’re a female surgeon.” 7
One clear theme that emerges from these experiences is the need for training and work
schedules that allow for adequate parental leave. This issue is further explored in the
Parental Leave section of the Gender and Medicine Project. The resentment of or
discrimination against students and residents with children should also be actively
challenged. Perhaps information sessions for program directors could clear up some
common misunderstandings. For instance, contrary to the prevailing myth, women do
not drop out of suigical residencies at a higher rate than men.10
The mentorship efforts suggested in section i will also be beneficial.
Another aspect of this problem is the stereotypical views of women’s abilities and
ambitions that lead some faculty members to make biased recommendations to their
students. For further discussion of this question, please see section 6.
6. Women students are held to higher standards than their male colleagues.
While this complaint was not commonly voiced directly in the consulted sources, it
struck me as important. For one thing, the same concern is implicit in section 5 on
women and their specialty choices; when women are forced to overcome ingrained
prejudice against their participation in certain specialties, they must work harder than
others simply to be deemed competent. It is also reflected in section 4 on gender-biased
12
74
treatment, in the sense that women who are ignored by faculty during class discussions
or rounds have to make additional efforts to receive the same level of instruction as their
male counterparts. The finding has also been documented in quantitative terms. Janet
Bickel writes that “an analysis of peer-reviewed scores for post-doctoral fellowship
applications revealed that women applicants had to be 2.5 times more productive than
the average man to receive the same competence score”.*0 Besides being unjust, the
pressure to exceed the already considerable demands of medical training can only be
detrimental to the health of women medical students.
u
‘...men just look incompetent for themselves, but when women fumble, they sort of give
all otherfemale students a bad name”3
The central issue that has emerged in this and the previous three sections is how to alter
the stereotypical notions of gender that are inadvertently held by virtually anyone raised
in the current culture. The question is both unworkable in scale and absolutely crucial to
meaningful change. As a start, I have some suggestions to make. First, although the
themes I have outlined focus on faculty behaviburs, both faculty and students should be
involved in gender education. It would be a mistake to exclude students from the
process, because they contribute to the current learning environment, some of them will
be faculty sooner or later, and all of them will be health care providers to gendered
people. The subject should therefore be covered in the formal curriculum for students,
and annual gender equity workshops should be provided for faculty.15 In addition, the
learning that takes place in such sessions should be reflective in nature. In other words,
students and faculty should be asked to examine their own values and thoughts, rather
than simply being provided with information. There is no doubt that medical students
who are told that the eleven features of gender equity will be on the exam will memorize
them, but such an approach will not alter beliefs, and that is the level of change that we
should be pursuing. The goals and objectives composed by Susan Phillips will again be
useful in this effort (Appendix C, Part ii).22 I am also awaiting a translation of a Swedish
paper entitled Teaching future physicians about gender differences. Gender of the
physician does matter!, which should provide further ideas.24 Perhaps the most
compelling reason to make such changes is that they will ultimately result in better
health care provision for all genders.*6
1<1
75
y. Sexual transgressions ranging from harassment to assault.
Delese Wear writes on the subject of sexual misconduct: “What do these studies tell us?
That verbal discrimination and the more flagrant forms of sexual harassment are
remarkably widespread even in the prestigious profession of medicine, a profession
dedicated to the care of human bodies and spirits, a profession dedicated to healthseeking behaviours. These studies tell us that leering, sexual innuendo and comments,
jokes about sex or women in general, unwanted touching or other physical contact, and
subtle or direct suggestions or threats for sex can thwart, diminish, or crush the spirit,
confidence, and ambition of women at any age or level of professional attainment.”8
UI said, ‘now when I'm looking for the vas deferens, which is the tube that you cut
during a vasectomy, where do I go?'And I was asking a male doctor, I mean, we were
dissecting the male genitalia... He says, ‘Well, you palpate the spermatic cord... you've
probably done that, haven't you?' like meaning on a live person. I just looked at him
‘Are you serious?' and just walked away. It wasjust so ‘nudge, nudge, wink, wink, hey
honey.'"5
“When the resident told me to go with him last Thursday night to the radiology
department to look at our patient's x-raysf all of.a sudden, as he was pointing out the
patient's pneumonia, he put his hands on my neck7to give me a massage,' he said, and
then he started grabbing at me. At first, I was so shocked I didn't know what to do.
Then Ipulled away and ran back to the ward. He later said he wasjust kidding."15
“The attending and I were on our way to see a patient at the other hospital when he
suddenly pushed me against the wall and started to kiss me. I had to really fight to get
away.
Women students should know exactly to whom they can report sexual misconduct
during their training. Dickstein suggests appointing a faculty member responsible for
gender issues on every clinical rotation.*5 This person should be identified during
orientation, and examples should be given of reportable offences.’5 In addition to an
unambiguous complaints procedure, on which I will elaborate in the following section,
the consequences for misconduct should also be clear and substantial.
id
76
The experiences I came across in this area deal with faculty and residents as
perpetrators, but it is important to be aware that “...a national survey on stress in
residency revealed that the most common source of sexual harassment experienced by
female residents (...) was patients’ families.”15 Leah Dickstein writes that “this study
indicates a clear need for public education, posted notices in hospitals and clinics, and
visitors’ passes containing clear rules of gender-fair behaviour”.’5
8. Trivialization or stigmatization of women students’ concerns.
Perhaps the greatest concern that emerged for me during this project was the awareness
that women’s complaints may not be taken seriously, and may even be punished. Delese
Wear reports on the subject of sexual harrassment that ‘A woman can spend a good deal
of emotional energy trying to figure out what she ought to do, how to handle her anger,
and in the case of more subtle behaviours, wondering whether she even has cause to be
uncomfortable.’ Wondering whether she even has cause to be uncomfortable. Such self
doubt goes to the heart of the ancient oppression of women, when even in the face of
slurs, suggestions, threats, and coercion, she asks: ‘Did I do anything to provoke this
behaviour?” 8 And this problem is not confined to incidents of sexual harrassment; it
arises in most instances of gender discrimination, as the following quotations indicate.
“That's a big issue for women right now. Because Tm in a very touchy point in my
education - if I was an intern and already graduated it's a slightly different situation,
but now, I would be more than likely to jeopardize my situation. It would be more
harmful to me than to the person I was accusing, more than likely. And I would have a
really hard time deciding it was worth it, unless it was so overwhelmingly awful...
Because even ifyou are right, arejustified, there's a stigma attached to complaining."3
“There's definitely still some sexist profs out there and the fact that nothing is done to
silence them sends the message that it's not that important. It doesn't really matter.
Even if it's offending you and making you uncomfortable, it's your problem, you should
get over it because it doesn't really bother us..."3
i<;
Z7
“Jumping up and down in a class many times in a day to point out or speak out against
this, which is what I thought my mission would be. I’ll fail medical school, but I ll make
some impact. No, you don’t make any impact, except you wear yourself out...”3
“...and if you were to change the punch line from being ‘woman’ to being ‘black’ or even
animal - ‘dog’ or ‘horse’... people would be up in arms, they would not put up with it.
But because the butt of the joke is a woman, everyone, including women laughed. And it
breaks my heart to see women laugh like that, but I guess they laugh for the reasons
they’ve laughed for years, because you’re nervous about it and you don’t want your
colleagues to think you’re a prude.”3
“What about gay women here? This would be the WORST place - how difficult - you
cant even begin to imagine... Some of the comments... just so scary to me... Radical,
lesbian, feminist’- that’s exactly the words, exactly the words used to silence women.”3
The reason that this area concerns me as much as it does is that I see student complaints
as holding great potential for changing the current gender biases inherent in medical
education. At the receiving end of any discriminatory behaviour is an individual student
or group of students. We thus constitute the most sensitive detectors of what is currently
wrong; what we perceive exceeds the capacity of any formal study or review process. And
in my experience, medical students do not complain over incidents that may be
considered trivial. We have other things to do, and generally bother to raise only the
questions that leave us significantly troubled. The idea that such efforts for change
should be met with ridicule or resistance is deplorable, both for the effect on the
individual students and for the lost potential to improve the educational process. I am
not suggesting that students are always right, but I am recommending that student
complaints always be taken seriously. Faculty members should be educated in receptive
responses to concerns specifically relating to gender and other equity issues. In addition,
an independent counsel on gender should be present in every school to receive
complaints that are either not being properly acknowledged by the faculty member in
question or over which the student would prefer to remain anonymous.
I will conclude with an illustrative experience of my own. During my first year of medical
school I approached our anatomy professor with a gender-related concern about the
16
course. We met in his office and he listened respectfully to my complaint, acknowledged
the problem and offered to make a change in the course for the coming year. It took only
that one short interaction to give me the sense that my response to my education
matters, now and in the coming years - and I can also imagine how a dismissive reaction
from this professor could have frustrated me into silence early on. We should not forget
that although.I have made several large-scale recommendations in this report, the small
things we do as students and faculty can also change the system positively or negatively,
according to what we choose.
17
79
Do Men Matter? New Horizons in Gender and Development. (2000, December). id21 Insights,
Communicating Development Research Series, Issue 35.
c ommu n i c a * jn g
i d 21 iinsights
d o v e I o ti m e n t r e s e a r c h
^ID21 Home
December 2000 Insights Issue #35
tissue #35
Back to Insights #35
Do men matter? New
horizons in gender and
development
Pillow talk: changing
men's behaviour
Targeting men for a
rtuujfls
Breadwinners and
homemakers? Children
explore gender
Why men? Why now7
Men against marital
violence: a Nicaraguan
campaign
Boys behaving badly:
challenging sexism in
Namibia
Do weak states
undermine masculinities?
§ite$ for $pre Eves:
online source? on men
and masculinities
Do men matter? New horizons in
gender and development
Why do men not feature more in gender and development policy? The
shift in emphasis from Women in Development (WID) to Gender and
Development (GAD), from enumerating and redressing women’s
disadvantages to analysing the social relationships between men and
women, has not led to a recognition within policy of the need to
understand the position of women and men. Is there a need for an
explicit focus on men in GAD?
With a few notable exceptions, men are rarely explicitly mentioned in gender
policy documents. Where men do appear, they are generally seen as obstacles
to women’s development men must surrender their positions of dominance for
women to become empowered. The superiority of women as hard working,
reliable, trustworthy, socially responsible, caring and co-operative is often
asserted; whilst men on the other hand are frequently portrayed as lazy, violent,
promiscuous and irresponsible drunkards.
Why then, focus on men? Emerging critiques of policy argue for special attention
to be paid to men and masculinities in development, as foflovys:
•
Gender is relational: it concerns the relationships between men
and women which are subject to negotiation in private and public
spheres. To focus on women only is inadequate: a better
understanding of men’s perceptions and positions and the scope
for changing these, is essential. Exploring ’masculinities’
includes focusing on socially constructed ‘ways of being a man’
rather than simply on their physical and sexual attributes.
Biological essentialism is rejected in favour of an analysis of the
social context within which gendered roles and relations are
formed.
Equality and social justice: gender concerns should not simply
be viewed as instrumental in securing a more effective delivery
of development. Instead, this critique recognises that men as
well as women may be disadvantaged by social and economic
structures and that they both have the right to live free from
poverty and repression. Empowerment processes should also v
enable women and men to be liberated from the confines of
gender stereotyped roles.
Gendered vulnerabilities: evidence from several studies
suggests that while women in general may face greater social
and economic disadvantages, men are not always the winners
and that generalising about their situation risks overlooking
gender-specific inequities and vulnerabilities, such as the
damaging health effects of certain ’masculine’ labour roles or
social practices.
•
Crisis of masculinity: it is suggested that changes in the
economy, social structures, and household composition are
resulting in ‘crises of masculinit/ in many parts of the world. The
’demasculinising’ effects of poverty and of economic and social
change may be eroding men’s traditional roles as providers and
limiting the availability of alternative, meaningful roles for men in
families and communities. Men may consequently seek
affirmation of their masculinity in other ways; through
irresponsible sexual behaviour or domestic violence for
example.
•
Strategic gendered partnerships: there is a strong argument
that if gender-equitable change is to be achieved in households,
communities and organisations, then surely men are needed as
allies and partners? This links to concerns about the need to
mainstream gender issues in development policy to ensure that
they are not sidelined or under-funded as 'women’s issues’.
In this issue of Insights authors raise a variety of key issues relating to
new ways of perceiving men in Gender and Development. The articles
all explicitly or implicitly deal with ’crises of masculinity* but differ
considerably in their analyses and suggested solutions. Common to all
however is the need to locate the individual actions and beliefs of men
and women within a wider framework of social, economic and political
change.
The chaBenge, of connecting micro with macro analysis raises questions,
reflected in Doyle’s and Bujra’s articles about the efficacy of projects h
significantly affecting gendered power relations. They both question women-only
projects, and the effectiveness of interventions which use gender as an entry
point for instrumentaBy tackling development problems without facilitating wider
empowerment or equality. As Doyle reports, women at a workshop on AIDS
awareness in Vietnam requested that men be similarly targeted. However, when
men did participate, they changed their behaviour in sexual relationships but not
the way they fundamentally thought about gendered relations of power. Bujra’s
research in Tanzania and Zambia also asks whether AIDS awareness
campaigns significantly affect gender balances power and suggests that what
needs changing is not the behaviour of individual men and women but the
relations between them.
Changing ideas about men’s roles, varying cultural conceptions of masculinity,
and the need to challenge dominant definitions of ‘what it is to be a man’, are aU
strong themes in reported experience of dealing with men and masculinities.
This is well illustrated in Thomson’s description of Save the Children’s work with
boys in the UK who struggle to cope with changing roles (with the ’crisis’ of
masculinity), the discrepancy between pubBcty-sanctioned gender roles and
what actually happens in families, and the dynamic nature of gender relations.
Indeed this dynamism echoes throughout these articles, several of which link
difficulties men may experience with responsible partnering and parenting with
changing expectations of employment and wider societal change.
Montoya focuses on a campaign in Nicaragua aimed at preventing men’s
domestic violence, emphasising the need to understand the fears and
insecurities that men experience in their relationships with women. Interestingly,
81
Montoya links the increased tensions and conflicts in families to the
environmental, economic and social devastation caused by Hurricane Mitch.
Smith's article on Oxfam projects supporting disadvantaged men in the UK
highlights the problems associated with lack of employment and the stereotyping
of alternative employment opportunities as 'women's work*. The changing shape
of men's working lives and the ways in which policy interventions conceptualise
gendered divisions of labour are key issues in studies of men and masculinities
(see European Journal of Development Research, December 2000). For
example, are different forms of work empowering or oppressing for men and
women? How do gendered labour allocations impact upon health and wellbeing?
Is it correct to assume that 'women do all the work’ in developing countries?
There is an urgent need to further investigate relations of power and dominatron
in men’s working lives.
Kandirikirira's and Down's articles explicitly link individual state action (or
inaction) with the development of damaging forms of masculinity, expressed in
violence. They differ significantly however in their suggested policy implications.
Kandirikirira attributes the sexually violent and abusive relationships between
boys and girts in Namibia (sanctioned or ignored by elders) to the policies of the
previous apartheid state which systematically distorted the image of black people
and restricted their opportunities. Participatory approaches have begun to help
overcome this legacy as individual stakeholders become aware of their own
responsibility and capacity to tackle injustice and inequitable relations. Dolan, by
contrast, in analysing the prevalence of gender- related violence in Uganda,
attributes this to the weakness of the state, to its incapacity to maintain the rule
of law and to the threat to mascdine identities that this constitutes. The
developmental challenge, Dolan argues, is to hold states rather than individuals
to account and to focus more widely on the political context in which
masculinities are formed.
Men and masculinities is a relatively new area in gender and development Ideas
concerning policy implications are in their infancy. How can research, policy, and
training contribute to the debate and complete the shift from W1D to GAD so that
the situation of women and men is better understood? Suggestions include:
•
investigating the changing roles, needs and identities of men
over lifecourses
•
researching men's roles in famflies, the reproduction of gender inequities through
work, and men's specific health vuinerabiSties
tracking and monMori ng changes in gender relationships over time, in different
cultural contexts, in association with programmes and poldes
developing positive role models for men and boys by influencing mass media
images, estabfishing activities in schools, NGOs. religious and youth groups
ensuring that legal frameworks supports gender equity, through regulating
working hours, parental leave provision, improved maintenance and inheritance
laws, for example
improving gender training wihin development organisations to focus on gender
and not women alone: for example by increasing the number male gender
trainers and improving gender analysis frameworks.
•
•
•
•
Pillow talk: changing men’s
behaviour
Can men change? Yes and no. suggests research by Care International
in Vietnam. When men are equipped with the right kind of knowledge
and skills they will improve their behaviour. However the deeper-rooted
gendered inequalities that shape sexual encounters are more difficult to
transform.
'Men In The Know; a Care International in Vietnam project, developed sexuality
training for men to promote safer sex within relationships and a trial of the
training package with 2000 men. The focus on men arose from a previous
course, ’Assertiveness Training Skills for Women for Protection from HIV/AIDS'.
during which the women expressed a desire for their partners to receive training
in women’s sexuality and safer sex in general. A participatory workshop
focussed on two broad areas: a) imparting knowledge on the physiology of sex
and b) challenging socio-cultural factors that shape sexual encounters.
A pilot component was also included, directed at men who visit sex workers,
testing a new approach (social marketing) aiming to affect behavioural change
through communication techniques commonly used in commercial marketing.
The complexity and diversity of consumers is embraced by offering different
groups of buyers similar products packaged in different ways. Similarly, CARE
International in Vietnam tries to accept diversity by communicating safer sex
messages in a variety of ways relevant to different groups of men. Key lessons
include:
Men are keen to learn how to change their behaviour, at least in
the short term, to improve their own and their partners’ sex lives.
Levels of sexual knowledge, attitude and behaviour differ from one man to the
next: multiple communication strategies are essential depending on the
individual and the desired behaviour change.
Change in sexual behaviour does not necessarily lead to change in substantive
gender inequalities that shape sexual relationships.
Men responded very positively, pleased that they can now make
responsible decisions. Partners were equally enthusiastic. Men still
decide when and where sex will happen however, although as a result of
the workshop, men are perhaps more considerate towards their
partners.
Women’s lives may have changed but this is largely because it is the men who
have chosen to change: the’basic power inequalities between men and women
remain the same. The data below suggests that although the men taking part in
the workshop have changed the way they think about sexual health, they have
not changed the way they think about gender. Many men dearly want to improve
their relationships and armed with the right knowledge and skills can become
more understanding. What can policy makers do, given the gravity of the HIV
epidemic?
•
Acknowledge that men are willing to and can change.
•
Include men in interventions, since the reality is that men have a
disproportionate influence over sexual decision making.
•
Adopt approaches such as social-marketing that address men's complexities
and design interventions tailored to their diverse needs.
•
Consider not only short-term health benefits, but longer term gendered
inequalities that often facilitate unsafe sexual practices.
Contributor(s): Frances Cleaver
Further information:
Frances Cleaver
Development and Project Planning Centre,
University of Bradford
Bradford BD7 1DP, UK
Tel: +44 (0) 1274 233 967
Fax: +44 (0) 1274 235 280
Email: f,d.cleqvert^Bradford. ac.uk
Development and Project Planning Centre
University of Bradford
UK
• )
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Views expressed in INSIGHib are not necessarily those of DFID, IDS, id21 or other
contributing institutions. Copyright remains with the original authors but (unless
stated otherwise) articles may be copied or quoted without restriction, provided id21
and originating author(s) and institution(s) are acknowledged.
. Copyright © 2003 id21. AH rights reserved.
Targeting men for a change
How can women fight against AIDS without the cooperation of men? A recent global shift
towards the recognition that men are driving the AIDS epidemic raises two key challenges: to
devise campaigns which treat men as individuals, and secondly to remember that what needs
changing is not individual men and women but the relations between them.
Women in Tanzania and Zambia are actively addressing the HIV epidemic, according to recent research
by the universities of Bradford and Leeds. Women are the main carers when people fall sick, for
example, they support orphans and provide the backbone for most voluntary efforts to raise awareness
and change behaviour.
Yet, almost everywhere women struggle with minimal support from men and inadequate resoirces. In
some cases men even sabotage their efforts. Yet there are indications of minor shifts in male behaviour
bom out of a desire for self-preservation, that are nevertheless beneficial to women. Women are
increasingly prepared, as men are beginning to realise, to challenge mate dominance. Further findings
indicate that men:
•
still make key family decisions, appropriate the product of women’s labour, expect to
marry younger women and have extra-marital relationships
•
have a high risk of contracting HIV from muMiple partnering
Some changes are evident, however. Men:
reafise that their propensty to control women is undermined by women's ncreasing economic and social independence
have begun talking about how to protect themselves from AIDS whilst still asserting male prerogatives
often counsel younger men to control their sexual urges or to use condoms
claim they are having safer sex with fewer partners - condom sales have risen dramatcaly.
rethink gender roles vrhen forced to care for the sick or orphans.
AIDS campaigns are now beginning to target men, but they are often confined to condom
promotion and personal risk awareness. Campaigns tackle particular groups such as long
distance truck drivers or army personnel rather than men in general. They appeal to men’s
self-interest rather than challenging their power over women or promoting mutuality between
the sexes.
How can men be encouraged to rethink gendered disparities? Challenges include:
•
Targeting men in AIDS campaigns whilst still recognising women’s need for support
and resources.
•
Finding ways to talk with men about sexuality and safety that ink thair sef-interest to responstuMy for their
wives, partners and children (including those as yet unborn).
Recognising that all sexualty-actrve men may be at risk, rather than the minority who appear promiscuous.
•
•
Persuading politicians and other men in the public eye to acknowledge the tssue and to promote men s
responsibility.
Why men? Why now?
Women are still the majority in the poorest groups, according to Oxfam's work on gender and
poverty in the UK and internationally. But would working with men have a positive effect on
the status of women? Would knowing more about how women and men are marginalised
contribute significantly to gender equity?
Oxfam-supported projects looking at gender equity, poverty and men in the UK highlight the fact that
links between men’s attitudes, their roles, and employment need further investigation. Would UK policy
makers do well to embrace the concept of gender taken from international development, thus avoiding a
scattergun approach which problematises women or men separately and ignores the relations between
them?
Three small-scale initiatives in England and Scotland, supported by Oxfam, work with men in community
settings: support for teenage fathers on an isolated housing estate near Hull; shop-front drop-in
community resource centre in Salford to help build the skills and confidence of long-term unemployed
men and community health project participatory appraisal for residents of Glasgow’s East End.
Men have very different attitudes towards participating in projects intended to address their problems.
Further project findings include:
•
•
•
•
•
The decline in full-time paid employment, especially for men, has left men unclear
about their roles. Where do they fit in to what seems increasingly a woman’s world?
Project workers find it difficult to contact men and therefore to invoke them in community projects.
Young men and women have different everyday problems: territorial barriers imposed by gangs, for
example, are very real for boys, but irrelevant for girls.
In relation to parenting, boys concentrate on their role as a provider whereas girls have a more hoistic and
socialised view of parental responsibilities.
Involving older unemployed men is difficult as their self-image is wedded to paid employment but younger
men are more likely to take training if on offer.
How can men best be included in community projects? Project workers reported that
•
Advertising’men's projects’ can be counter-productive, but attracting men to
recreational and technical activities, works.
•
Recruiting local, male project workers, with ’street credibility and known to men in the community also
works. Yet, recruiting such men is not easy, perhaps because ’caring’ work is low status and perceived as
‘women's work*.
Contributor(s): Sue Smith
I
)
Do weak states undermine masculinities?
The study of socially-constructed masculinities and their relationship to violence reflects a
healthy concern not to reduce the equation between men and violence to simple biological
determinism. To suggest that violence is an inevitable outcome of social constructs of
masculinity is also too static. Can flawed nurturing processes fully explain the capacity of
individuals and indeed whole societies to shift between ‘cultures of violence* and ‘cultures of
peace*? Or does the state, through its actions or inactions, shape those cultures and the
responses of individuals within them?
Masculinities can not be used as a silver bullet to explain away a wide range of violent behaviour. The
crucial question to answer is ‘when do men become violent?’, by examining the political and economic
context of men’s lives. Is violence the outcome of failed politics? If so, is stronger politics the answer”?
Such investigations would add enormously to debates about 'weak states’ and ‘complex political
emergencies’.
I
Uganda is widely regarded as a model of the ‘African Renaissance’, yet eighteen months of fieldIwork by
the Agency for Cooperation and Research in Development (ACORD) in northern Uganda suggests tha.
whilst the form of the state in the north is strong its key function of citizen protection is wealc Most
people have moved to ‘protected villages* with a military presence, but rebels raid with impunity, seizing
men, women, children, and properties at will. Men, therefore, live in conditions m whtch rtis virtually
impossible to fulfil 'masculine' roles as providers and protectors, husbands and fathers. The research
also witnessed widespread human rights abuses committed by the state, through rts armed forces and
police, including rape, killings, extra-judicial executions.
Findings indicate that:
•
•
•
State inaction in the face of human rights abuses had eroded men s self-respect,
resulting in widespread feelings of fear, intimidation, humiliation, frustration and
anger, often expressed in violence against self and the social sphere, in the forms of
alcohol abuse, suicide attempts and domestic violence.
The impossibility of seeking redress through formal channels prompts some men into passive or active
resistance to the state further prolonging war.
The threat to masculine roles and identities brought about by a weak state causes violence, rather than
*mascuKnities, per se.
Weak states are damaging, on the one hand demanding that individuals surrender their
power to the state whilst on the other failing to keep its side of the bargain - providing
protection. Men surrender the role of ’self-defence’ to the state: if it is weak and fails them, the
men suffer damaging consequences to their self-esteem and ’masculinity*.
The policy implications for NGO interventions in peace building are challenging, dearly, peace
education aimed at tackling socialisation is not the solution. Further key policy implications include.
•
NGOs need to question and understand the political and economic context which
undermines what are mostly non-violent constructs of masculinity.
•
The state's right to the monopoly of violence, political and human rights theory has it. derives from its
capacty to protect its citizens, yet persistent inaction in the face of assaults on its people disqualifies the
state from enjoying that monopoly.
Holding the state to account rather than the individual, based on analysis of political context rather than
social constructs, is a delicate but important area for ’apofiticar NGO involvement.
•
If men need help, rt is to recover their dignity, their voice, and their ’masculinity’.
Men against marital violence: a Nicaraguan
campaign
A third of women in Nicaragua has been assaulted by her male partner. What is being done to
change men's violent attitudes and behaviour within the family? After Hurricane Mitch in 1998
domestic violence worsened. In response, Puntos de Encuentro and the Asociaddn de
Hombres Contra la Violenda launched a campaign encouraging men to respect their
partners, resolve conflicts peacefully and seek help to avoid domestic violence.
How do men behave within a relationship? What are their attitudes towards their female partners? An
initial survey showed that many men in Nicaragua expect women to wait on them, to be passrve, an
dependent Men also admitted to feeling threatened by the possibility of beng dominated by women.
Do such fears and insecurities lead to conjugal violence? The study revealed, however, that men can
have non-violent, positive relationships with women, despite growing up surrounded by aggression.
The devastation caused by Hurricane Mitch pushed men to violent behaviour as family tensions and
frustrations increased in the face of disaster. Puntos de Encuentro, working closely with 250 other
organisations, developed a massive campaign in 1999 targeting men in seven worst-lit cities. The
campaign included national and local media ads over a five month period, posters, pamphlets,
86
educational materiaTs, and training for activists, mostly men: men, research had shown, could best
persuade other men to change. Central campaign messages were that
Men can avoid violent behaviour.
Violence against women hinders reconstruction of community life and the entire country.
How successful was the strategy? Did it reach men? Did men listen? Pre- and post-campaign
surveys of 2000 men each, and 660 women in the second survey revealed that:
60 percent of men surveyed knew about the campaign
men exposed to the campaign felt that men can prevent violence more than those not
exposed to it
•
men exposed to the campaign felt that violence negatively affects community
development more than those who were not exposed to it
•
men with highly dominant attitudes towards their partners were positively affected by
the campaign
• . a third of men talked to their female partners about the campaign and almost two
•
•
thirds talked to other men.
The first campaign ever aimed at men to tackle domestic violence in Central America has
contributed significantly to raising awareness and changing men’s attitudes and behaviour
•
•
•
Men are more aware of the problem of violence against women.
Men are now more willing to be part of the solution.
Campaigners are better prepared and equipped with educational tools, added
experience, and good publicity to help build new relationships between men and
women based on equity and respect
Sites for Sore Eyes:
Online sources on men and masculinities
Men and masculinities is a new area of interest but there is no shortage of websites dedicated
to putting men back onto the gender agenda.
For information on men and masculinities in development, try out the University of Bradford
Development and Project Planning Centre’s new site (from January 2001),
www.brad.ac. uk/acad/dppc/gendef.html featuring papers from the recent Seminar Series, ‘Men,
Masculinities and Gender Relations In Development from which many of the articles here were drawn.
UNDP’s ’Men and Gender Equality’ site, www.Mndp.0rq/Qender/prpQr9mmes/men/men
TjSj!]
oe.html,
UNFPA’s www. unfpa. orq/modules/intercenter/role4men/index,htm, and
wvYw pQpcQunQa,pra/ppdb/men,h(ml which has several downloadable research papers, are all excellent.
For on line resources on men and reproductive and sexual health, see UNFPA's excellent site:
www.unfpa.orfl/swp/2000/enqlish/contents.html. AVSC's 'Men As Partners’ (MAP) initiative at
www.avsc.orq/avsc/emerginq/map/index.html aims to involve men in and thus meet the needs of both
partners. Family Health International (FHI), www.fhi.orQ/en/fp/fbDubs/network/vl 8-3/index. html and
PATH, www path orfl/proflrams/p-wom/men in rh.htm, both have useful information and publication
links.
Two UNICEF reports examine men and children: The role of men in the lives of children*, at
www.unicef.orfl/reseval/pdfe/ROMfinal.pdf; and ’Men in Families* avail^le at
www unicef.orqfreseval/malesr.htm. The University of Minnesota's, www.cyfc.umn. edu/Fathemet/
examines fathers and fathering.
The Swedish Male Network, www.man-net.nu/enQelsk/styt.htm, focuses on Gender-based violence and
features links to government fact sheets, presentations and publications on gender mainstreaming.
)
Two profeminist sites are run by men: www.profeminist orq/ which challenges patriarchy and hegemonic
masculinity, and wvAv.chebucto.ns.caA>xnmunitYSupport/Men4Change/6ndex Hm or ‘Men for Change',
which promotes gender equality and an end to violence.
Two men s magazines are on the web: ’MenWeb’ which celebrates masculinity and provides support to
men at www vix.com/menma^menmaq.html, and the radical Tichilles Hee!*,
wwwach4lesbeel.freeuk.cprn/tndexhtrnl
Further links can be found at
www.roistad.no/iasonV www.vix.com/pub/men/index html
www.rrwn^St^^^.gpm/link^html
www ,qw^b, kvinnQfyrvm.^pfp^f
volv. html
Grieg, A. Kimmel, M., and Lang, J. (2000, May). Men, Masculinities and Development: Broadening ou
Work towards Gender Equality. Monograph # 10. UNDP/GIDP
MEN, MASCULINITIES AND DEVELOPMENT:
Broadening our work towards gender equality
By Alan Greig, Michael Kimmel and James Lang
UNDP/GIDP MONOGRAPH #10
MAY 2000
89
Table of Contents
Acknowledgements
Table of Contents...........................................
Introduction........................................................
The Meanings of Masculinity............................
Biological Destiny or Cultural Construction?
Discourse(s) of Power....................................
The Uses of Masculinity...................................
Power and Patriarchy.....................................
Production and Social Reproduction.............
Poverty..........................................................
Governance
.....................................
Violence and Conflict...................................
Health............................................................
Conclusions and Next Steps
....................
References.........................................................
Error! Bookmark not defined.
2
3
6
6
10
11
............................................... 11
.................................................12
.................................................15
................................................ 17
............................... '............... 18
................................................ 22
................................................ 28
32
^0
Introduction
What do men, as a distinct group, have to do with the development process? Men
play diverse roles in the economy, the community and the family. Men are husbands and
fathers, brothers and sons. Across differences of class, race, ethnicity, sexuality, age and
religion, one of the few commonalities that men share, as a 'distinct group', is their gender
privilege. Men, like women, are affected by gender power structures that are interwoven
with other hierarchical structures such as those based on race and class. Yet men,
regardless of their positioning in other hierarchical structures, generally have a strategic
common interest in defending and not challenging their gender privilege. As Connell
states:
A gender order where men dominate women cannot avoid constituting men as an interest
group concerned with defense, and women as an interest group concerned with change.
(Connell 1995)
The processes that confer privilege on one group and not another are often
invisible to those upon whom that privilege is conferred. Thus, not having to think about
race is one of the luxuries of being of a dominant race, just as not having to think about
gender is one of the patriarchal dividends that men gain from their position in the gender
order. Men tend not to think of themselves as 'gendered' beings, and this is one reason
why policy makers and development practitioners, both men and women, often
misunderstand or dismiss ‘gender’ as a women’s issue.
Gender, as a determinant of social relations that legitimizes and sustains men’s
power over women, is inherently about relations between women and men, as well as
relations among groups of women and among groups of men. Achieving gender equality
is not possible without changes in men’s lives as well as in women’s. Efforts to
incorporate a gender perspective into thinking about development requires more than a
focus on women, however vital that might be; what is also needed is a focus on men.
^1
Yet, significantly, men continue to be implicated rather than explicitly addressed in
development programmes focusing on gender inequalities and the advancement of
women. "In the gender and development literature men appear very little, often as hazy
background figures” (White 1997). There is a growing recognition, however, of the need
to define more precisely the relationship between men and 'engendered' development
policy and practice, and examine questions of men's responsibility for women's
disadvantage, as well as men's role in redressing gender inequalities.
This recognition is, in part, a consequence of the conceptual shift from the
discourse of Women in Development (WED) to that of Gender and Development (GAD):
The GAD approach signals three departures from WID. First, the focus shifts from women
to gender and the unequal power relations between women and men. Second, all social,
political, and economic structures and development are re-examined from the perspective
of gender differentials. Third, it is recognized that achieving gender equality requires
transformative change. (United Nations 1999, p. ix)
The purpose of this paper is to discuss men’s possible relationships to this process
of transformative change by exploring the meanings and uses of’masculinity’.
Discussions of masculinity provide a place in which men’s involvement in producing and
challenging inequalities and inequities in gender and other social relations can be
investigated. Masculinity renders gender visible to and for men. Understanding the
definitions and discourses surrounding masculinity can help in the analysis of how
political, economic and cultural inequalities are produced and distributed not only
between but also within the genders. Above all, an inquiry in to the ’politics of
masculinity’ offers an opportunity to rethink men’s strategic interest in challenging the
values and practices that create gender hierarchy.
Examining masculinity and the role it plays in the development process is not
simply an analytical exercise, but has widespread implications for the effectiveness of
programmes that seek to improve economic and social outcomes in virtually every
country. "If development is not engendered, it is endangered" cautioned the 1997 Human
Development Report. Gender equality is not only an end in itself, but also a necessary
means to achieving sustainable human development and the reduction of poverty.
Signatories to the 1995 Copenhagen Declaration on Social Development recognized this
when they committed themselves (in Commitment Five) to:
Promotingfull respect for human dignity and to achieving equality and equity
between women and men, and to recognizing and enhancing the participation and
leadership roles of women in political, civil, economic, social, economic and
cultural life, and in development (United Nations 1995).
The nature and effects of gender inequalities worldwide have been well
documented. In 1995, the Beijing Platform for Action listed the following critical areas
of concern: the persistent and increasing burden of poverty on women; violence against
women; inequality in economic structures and policies, in all forms of productive
activities and in access to resources; inequality between men and women in the sharing of
power and decision-making at all levels, and, gender inequalities in the management of
natural resources and in safeguarding the environment (United Nations, 1995a).
Implicit in this listing is the identification of men and male-dominated institutions
as the producers and beneficiaries of the gender order that disadvantages women in all
spheres of life. This paper addresses questions that arise when men’s contribution to
gender equality goals is considered in the context of this prevailing global gender order:
•
To what extent can men be involved in transforming the gender inequalities
that currently privilege them?
•
To what extent should gender programmes work with men, given the already
scarce resources available for their existing work with women?
•
What are the ways in which gender programmes can work with men in order
to achieve their gender equality goals?
•
How can a ‘politics of masculinity’ assist gender programmes to engage with
men as potential agents of transformative change, without compromising
current commitments to the advancement of women?
Across a range of development issues and institutions, there is an increasing
interest in men as potential agents of change and not merely objects of blame.
Commenting on the role of men in the HIV epidemic, Peter Piot, the Executive Director
of UNAIDS, has stated that ”[T]he time is ripe to start seeing men not as some kind of
problem, but as part of the solution”. The questions of "which men?" and "which
solutions?" remain to be answered.
The Meanings of Masculinity
Discussions of masculinity provide a place in which to clarify these answers. But
before turning to consider the usefulness of these discussions, it is important to look at
the different meanings ascribed to the term ’masculinity’ and the assumptions that
prefigure, as well as the implications that ensue, from these meanings. Masculinity is a
way to explain men - but there are different ideas captured with different terminology:
biological determinism or essentialism, cultural or social constructionism and masculinity
as a discourse of power.
Biological Destiny or Cultural Construction?
While both schools of thought believe that ‘masculinity’ is a useful tool to explain
men, these polarized propositions diverge in their account of what determines men’s
masculinity: nature or nurture? As biological destiny, masculinity is used to refer to the
innate qualities and properties of men that distinguish men from women. In this view,
masculinity is men’s nature, and as such helps to explain not only differences but also
inequalities between men and women. Men’s political, economic and cultural privileges
arise from their ’masculine advantage’, as variously reflected in genetic predisposition to
aggression (in contrast to the passivity of femininity), physical strength (in contrast to the
weakness of femininity) and sexual drives (in contrast to the sexual reserve of
femininity).
The problem with biological determinism is the arbitrary nature of the fixing of
men’s ’essential’ masculinity, which can range across a whole spectrum from men’s innate
physicality/animality to men’s innate rationality. Feminist scholarship and practice has
long critiqued the political convenience of explaining gender inequality and hierarchy in
terms of men’s natural superiority. But development institutions and practitioners have
been slower to take such biological determinist thinking about men and masculinity into
account. As such, many have failed to grasp how the resurgence of such thinking has
likely come in response to diverse threats to men’s power posed by geo-political,
economic and cultural changes, some of which have favored the advancement of women.
For instance, writing of events in Serbia in the 1990s, Blagojevic (1999) notes that "[tjhe
political and economic changes endangered the male identity much more than the
female”. Consequently:
New prophets appeared on the scene offering various socio-biological arguments
in support of the claim that men are inherently superior. One such was Tosevski,
who proclaims Serbian masculinity to be superior to the western variety and
advocates open promiscuityfor males.... The popularity which he enjoys, the
pervasiveness of his ideas in public discourse, and the image ofa "popular male
mythology ofSerbian masculinity" in his texts, together reveal how dramatic the
problem of an emptied male identity in Serbian culture actually is.
Resistance to the emerging global capitalist order has been similarly mobilized by
appealing to biological determinist notions of masculinity. Scholars have pointed out the
ways in which religious fundamentalism and ethnic nationalism use local cultural
symbols to express regional resistance to incorporation by a larger, dominant power (see
especially Jurgensmeyer 1995 and Barber 1995). These religious and ethnic expressions
are often manifest as gender revolts, and include a virulent resurgence of domestic
patriarchy (or militant misogyny); the problematization of global masculinities or
neighboring masculinities (as in the former Yugoslavia); and the overt symbolic efforts to
claim a distinct “manhood” along religious or ethnic lines to which others do not have
access and which will restore manhood to the formerly privileged. In effect, masculinity
becomes a rhetorical currency by which opposition to global integration, state
centralization and increasing ethnic heterogeneity can be mobilized. In such cases, we
expect to find ideas of traditional, local masculinities and their accompanying hierarchies
reaffirmed. Typically, as Connell notes (1998: 17), “hardline masculine fundamentalism
goes together with a marked anti-intemationalism”.
As
The political implications of the biological determinism that accompanies such
fundamentalism have directed much attention toward other explanations of men and their
masculinity That gender is constituted in and by society and culture, rather than nature
and biology, is of course a basic tenet of feminism, the women’s movement and,
subsequently, GAD policy and practice. But this understanding, at least in development
institutions and practice, has usually been applied to programmes concerned with the
advancement of women, and rarely to work with men. However, there is an increasing
interest in ’gendering’ men and this interest has centered on an exploration of cultural
constructions of masculinity. This exploration still seeks to explain men and their
behaviour in terms of their masculinity, but a masculinity which is defined as an
embodiment of the cultural norms and social pressures that help to determine the roles,
rights, responsibilities and relations that are available to and imposed upon men, in
contrast to women.
Accounts of the cultural constructions of masculinity often conceive and describe
it in metaphors of roles, performances and scripts. Such conceptions and metaphors give
rise to a number of insights that are of use to development practitioners seeking to work
with men toward gender equality goals. For example, separating men from their
masculine roles creates a space within which their gender, and the process of their
gendering, can become more visible to men themselves. Making men more conscious of
gender as it affects their lives as well as those of women is a first step towards
challenging gender inequalities.
The emphasis on the pressure that masculinity imposes on men to perform and
conform to specific masculine roles (emotional and psychological as well as political and
social) has highlighted the costs to men of current gender arrangements. Writing from an
anti-sexist organization in Zimbabwe, Gokova (1998) notes that:
Men have not realized how much they pay in insisting on separate gender roles...
Men deny themselves the experience of being human, particularly in sofar as
their relationship with women is concerned They miss important lessons of life
-S'
derivedfrom challenging relationships in which women play an equal role.
Living the myth of male superiority has sometimes resulted in men sufferingfrom
stress, even early death, because ofpressure to project an image that is not
naturally theirs and that is not sustainable.
This concept of the pressure of masculinity, often linked to a notion of the
fragility of masculine identity that requires constant performance, has proved fruitful in
providing explanations of stereotypically problematic male behaviours, such as violence
and sexual risk-taking. One programmatic consequence of this concept of the pressures
of masculinity has been the attention given to addressing the sources of this pressure in
processes of socialization. Working with the institutions (familial, educational, religious
and cultural) that help to socialize boys into men creates an entry point for development
practitioners concerned with increasing men’s commitment to gender equality. Such
work offers the possibility of reconstructing masculinity and creating new models and
identities for men that will enable and encourage them to work towards gender equality,
and therefore more effective models of development.
Defining masculinity in terms of its cultural construction offers ways to re-think
men’s relationship to gender in/equality. For some, this means displacing responsibility
for women’s oppression from men onto masculinity. There are dangers in this
displacement, however, related to the extent to which cultural constructions of
masculinity are regarded as determinants of men's actions in the world. Heise poses the
question: "What is it about the construction of masculinity in different cultures that
promotes aggressive sexual behaviour by men? (1997: 424)". She concludes that it is
"men's insecurity about their masculinity that promotes abusive behaviour toward women
(1997: 425)" and continues:
[TJhe more I work on violence against women, the more I become convinced that the real
way forward is to redefine what it means to be male. (1597: 426)
But the suggestion that men need a new definition of their masculinity in order to
reduce or end male violence appears to prioritize questions of identity over questions of
values. Clearly the two are related, in that the devaluing of women in most if not all
^7
cultures is constitutive of "what it means to be male". But this gender hierarchy of value
is interwoven with other hierarchies of value and structures of oppression (by sexuality,
race and class for example). In this regard, it is not helpful to abstract a discussion of
men’s behaviour in terms of their masculine identity from a broader discussion of the
values and practices that shape power relations not only between men and women, but
also among men and among women.
Discourse(s) of Power
'Masculinity', to the extent that the term can be briefly defined at all, is
simultaneously a place in gender relations, the practices through which men and
women engage that place in gender, and the effects of these practices in bodily
experience, personality and culture.
The definition offered by Connell (1995: 71), though complex, is suggestive. It
warns us that masculinity is not the property of men, and reminds us to be wary of using
the terms ’men’, ’male' and ’masculinity’ interchangeably. Discourses of masculinity are
available to, used by and imposed upon both men and women.
As a woman, I am a consumer of masculinities, but I am not more so than men
are; and, like men, I as a woman am also a producer ofmasculinities and a
performer of them. (Sedgwick 1995: 13)
Understanding masculinity as discourse broadens the focus beyond men and the
biological or cultural bases of their masculine nature or identity. The challenge
confronting development practitioners concerned with men’s relationship to gender
equality is to place this relationship in the context of relations of power not only between
but also within the genders. Addressing masculinity as discourse (by whom? for what
purposes?) helps this placement by clarifying the values and practices that create such
hierarchies of power. Misogyny, homophobia, racism and class/status-based
discrimination are all implicated in a ’politics of masculinity’ that is developed and
deployed by men to claim power over women, and by some men to claim power over
other men.
Discursive perspectives on masculinity are interested in the ways that it becomes
a site for these claims and contests of power Such perspectives pluralize masculinity
into masculinities and note the way that subordinate masculinities emerge in resistance to
the power claims of hegemonic masculinities.
Pluralizing masculinity into masculinities is more than a way to explain there are
many ways to be a man. It is useful for understanding the connections between
masculinities and the distribution and effects of power and resistance among the different
forms of masculinity. This has significant implications for development work on men
and gender equality. It suggests that such work should not be confined by a concern to
work on masculinity in order to reform the male identity and offer men better ways of
being a man, however useful such work may be to specific individuals. An
understanding of the 'politics of masculinity' indicates that the values and practices
(individual and institutional) that create gender inequality are also intimately involved in
the creation of other hierarchies of oppression. Challenging these values and practices
implies working with both women and men, at the policy and programme level, to
mobilize constituencies for change in which gender equality goals are integral to
movements and coalitions for social justice.
The Uses of Masculinity
This section turns to examine the uses of masculinity in relation to a number of
critical development issues and themes. Discussion of these usages and their
implications for men’s relationship to engendered development practice and outcomes
leads to a number of recommendations for development institutions, their policies and
programmes.
Power and Patriarchy
The naturalizing of men’s power is one of the main functions performed by
discourses of masculinity. The masculine/feminine duality rests on and supports a whole
set of dual associations that contrast the powerful male with the powerless female:
hard/soft, active/passive, product!ve/reproductive, warrior/nurturer. Such associations
ease men’s, and inhibit women’s, access to and control over political, economic and
cultural power. An effect of this ‘natural’ association between men and power is to
render their gender invisible in the acquisition of such power.
One of the significant achievements of feminist scholarship has been to name the
connections between men, gender and power and give them visible expression in the term
‘patriarchy’. In both the public and domestic spheres, patriarchy refers to the
institutionalization of men’s power over women within the economy, the polity, the
household and heterosexual relations.
Men’s relationship to such patriarchal arrangements of power must be a critical
area of concern to development programmes that seek to involve men in gender equality
work. Irrespective of men’s power vis-a-vis other men, it is clear that:
Men gain a dividendfrom patriarchy in terms of honour, prestige and the right to
command They also gain a material dividend (Connell 1995. 82)
But it is equally clear that men’s ‘patriarchal dividend’ is mediated by economic
class, social status, race, ethnicity, sexuality and age (to name some of the more salient
modifiers). Patriarchy becomes a less useful concept when applied to questions of intra
gender equity and equality. Despite the dividend, most men remain disempowered in
relation to the elites (composed of men and women) that wield political and economic
power in societies and communities throughout the world. It is this experience of
disempowerment that potentially connects some men and women across the patriarchal
divide, and offers the possibility of linking a gender politics that challenges patriarchy
with a wider politics of social transformation.
Production and Social Reproduction
But the barriers to this kind of transformative change, and especially men's
involvement in it, are considerable. Many are rooted in gender relations in the spheres of
production and social reproduction. Men continue to benefit from the fiction of the
loo
separation between the spheres of production and social reproduction. Many women, in
contrast to most men, do a double shift, working in both spheres. As Desai (1994) notes:
In the economic South, traditional gender relations inhibit men's involvement in
the family, and women assume virtually all responsibilities for child care,
regardless of their involvement in paid work.
Industrialization and urbanization in developing countries has only served to
increase the pressures on women to perform this double shift. The impact on gender
inequalities is apparent in the way this burden of the double shift continues to restrict
women’s participation and progress in labour markets and the wage economy.
Efforts toward redistributing the burden of reproductive labour toward men
within households or socializing the cost of child care or other types of caring
labour are necessaryfor both reducing women fs time poverty and helping them
participate in labour markets more fully. (Cagatay 1998: 13)
The report of the 1994 Cairo conference on population and development signaled
recognition of the need for changes in men’s lives for women’s equality. One objective
was:
To promote gender equality in all spheres of life, includingfamily and community
life, and to encourage and enable men to take responsibility for their sexual and
reproductive behaviour and their social andfamily roles. (United Nations 1994)
But the politics of masculinity inhibits the social and policy changes that are
required to "encourage and enable men" to renegotiate roles and redistribute burdens
across the productive and reproductive spheres. The effects of such a politics are evident
in the benefits that men draw from the cultural prohibitions on their involvement in social
reproduction and the grounding of masculine identities in being the provider, the
‘breadwinner’. These benefits are reinforced by macroeconomic development
frameworks and poverty reduction strategies. Their ‘male breadwinner bias’, for
example:
lol
[CJonstructs the ownership of rights to make claims on the state for social
benefits (access to services, cash transfers) around a norm offull-time, life-long
working age participation in the market based labourforce. (Elson and Cagatay
2000: 18).
There is some evidence of limited change. Some cultural traditions actively
encourage involved fatherhood, and others have proved amenable to change A study of
700 new fathers in Jamaica found that 50% of the urban fathers reported significant
involvement in family life such as cooking, cleaning and shopping. There, Fathers
Incorporated works with men to promote more positive images of fathers and encourage
community and family engagement (Brown and Chevannes 1993). Studies in Brazil have
confirmed that younger men are far more flexible in their gender role expectations than
older men (Barker 1996). There is also evidence of a backlash by men in situations
where male authority is challenged, a backlash grounded in and justified by appeals to
biological determinist notions of masculinity and their prescriptions of men’s and
women’s ’proper’ roles in the family. For example, “if men feel their authority is in
jeopardy, they may attempt to tighten control over the women and girls around them,
especially if it is perceived that female gains toward independence or equality mean a
loss in their own entitlement as men” (UNICEF 1997: 23).
Dealing with this male backlash and challenging the male bias in economic,
political and cultural practice will not be easy. As Elson (1991:15) writes:
Overcoming male bias is not simply a matter ofpersuasion, argument, and
change in viewpoint in everyday attitudes, in theoretical reasoning and in policy
process. It also requires changes in the deep structures of economic and social
life, and collective action, not simply individual, action.
The need to renegotiate an equitable division of labour (and its rewards) across both
productive and social reproductive spheres requires structural and not merely individual
change. This suggests that the emphasis given in cultural constructionist accounts of
masculinity to the need to re-socialize men to perform caring and nurturing roles and to
associate those roles with a new model of masculinity may be necessary but not sufficient
to bring about the necessary change. Indeed, framing the problem purely in terms of
102-
gender roles may distract attention from other basic issues such as economic class. Men
and women in poor and marginalized communities in many ways lack the economic
freedom to choose how they negotiate their distribution of productive and social
reproductive tasks. Collective action at community and societal level is needed in order
to create not only the cultural but also the economic conditions that can make this re
negotiation possible.
Poverty
Many governments, UNDP and a number of other development agencies have
recognized the connections between gender equality, human rights and the reduction of
poverty. As a component of a six-point action agenda for the eradication of poverty. The
Human Development Report 1997 (UNDP 1997) states:
Gender equality needs to be part of each country's strategyfor eradicating
poverty, both as an end and as a means to eradicating otherforms of human
poverty. This means: focusing clearly on ending discrimination against girls in all
aspects of health, education and upbringing starting with survival.
Empowering women by ensuring equal rights and access to land, credit andjob
opportunities. Taking more action to end violence against women, the all-toopervasive hidden side of human poverty. A creative commitment to gender
equality will strengthen every area of action to reduce poverty . because women
can bring new energy, new insights and a new basisfor organization. If
development is not engendered, it is endangered And ifpoverty reduction
strategiesfail to empower women, they willfail to empower society.
Gender inequality is responsible for, and expressed in, the different articulations
of the global ‘feminization of poverty1’. Women represent approximately 70% of the 1.3
billion poor people in the world (Beneria and Bisnath 1996: 6). Compared with men, girls
and women are most likely to be undernourished, and girls and women are most likely
receiving less health care - out of approximately 900 million illiterate adults in the world
- 2/3 are female (Cagatay 1998).
! The concept of4 feminization of poverty' can refer to a variety ideas including either one or a combination
of the following: women compared to men have a higher incidence of poverty; women’s poverty is more
severe than men’s, and/or, over time, the incidence of poverty among women is increasing compared to
men. (Cagatay 1998: 3)
103
Discourses of masculinity help to shape the power relations underpinning
gendered and inequitable division of labour and access to resources. Households,
communities, markets and states are interconnected sites of cooperation and conflict over
the control and allocation of resources, and discourses of masculinity are used to
legitimize some men's stronger bargaining position vis a vis women and other men. The
differentiation of men's work from women’s work, the differential remuneration that men
and women receive for the same work, the exclusion of women from positions of power
within the economy, and the omission of the reproductive sphere in macro-economic
planning can all be linked to discourses of masculinity that privilege the male over the
female.
In addition, although they appear to be gender-neutral, the institutional
arrangements of global society are very much gendered. The marketplace, multinational
corporations, transnational geopolitical institutions and their attendant ideological
principles (economic rationality, liberal individualism) express a gendered logic. The
“increasingly unregulated power of transnational corporations places strategic power in
the hands of particular groups of men,” while the language of globalization remains
gender neutral so that “the ‘individual’ of neo-liberal theory has in general the attributes
and interests of a male entrepreneur” (Connell 1998: 15).
Feminist economics and other approaches to engendering economic planning and
policy making at all levels can make more use of’masculinity’ as a discursive framework
within which to mark men as gendered beings and to expose the constructed and political
nature of their privilege in the economic sphere. Equally, an understanding of the politics
of masculinity can help to link broader dimensions of human poverty (such as freedom,
self-perception, and violence) to the distribution of political, economic and cultural
power between and within the genders. This suggests the need to work at the community
level, with women's and men's differing but shared experiences of poverty, to develop
collective action and advocacy for the sustainable reduction of human poverty.
|of|
Governance
Redressing gender inequities in the distribution and impacts of poverty is
connected to questions of gender inequalities in systems and structures of governance.
Development institutions, among many others, are conscious of the connections between
women's economic empowerment and political enfranchisement. Increasing attention is
being given to identifying and challenging the barriers that prevent women from
participating fully in the political process, with the aim of creating a critical mass of
women in positions of governance at all levels.
In describing the inception of the Panchayat Raj Institutions (PRI) system in
India, by which the Indian constitution was amended in order to mandate the reservation
of seats for women in local government, Devaki Jain (1996) notes:
Women's empowerment challenges traditional ideas ofmale authority and
supremacy. It is unsurprising, then, that PRI has been opposed by some men.
Ratanprabha Chive (Ratna) is the sarpanch (head) of the seven halets (hamlets)
that comprise the Ghera Purandar Panchayat. Ratna was beaten up as soon as
she assumed office by her rival who could not accept the fact that afemale had
outwitted him.
The reluctance of men to cede power to women in institutions of governance has
been evident too in the marginalizing of women within movements for national
liberation. McClintock (1997:109) has noted the ways in which the nationalism of such
movements is masculinized, and the effects this has on silencing the gender politics of
such political transformations.
Male nationalists have condemnedfeminism as divisive, bidding women hold
their tongues until after the revolution. Yetfeminism is a political response to
gender conflict, not its cause. To insist on silence about gender conflict when it
already exists is to cover, and thereby ratify, women's disempowerment . . . If
nationalism is not transformed by an analysis ofgender power, the nation-state
will remain a repository of male hopes, male aspirations, and male privilege.
Similarly, the politics of masculinity in anti-colonial struggles mimics the use
made of discourses of masculinity to claim and maintain colonial power. Thus, for
I d5
example, colonial administrations often problematized the masculinity of the colonized.
In British India, Bengali men were perceived as weak and effeminate, though Pathas and
Sikhs were perceived as hypermasculine - violent and uncontrolled (see Sinha 1995).
Similar distinctions were made in South Africa between Hottentots and Zulus, and in
North America between Navaho or Algonquin on the one hand, Sioux, Apache and
Cheyenne on the other (see Connell 1998: 14). In many colonial situations, the colonized
men were called “boys” by the colonizers (see Shire 1994).
Securing the entry of a sufficient number of women into positions of political
power and influence will help to make gender visible as a key governance issue and will
challenge the masculinizing of power that has been alluded to already. But questions of
representation remain, given the possibly divergent interests of different groups of
women in a given society. The uses of masculinity in claiming and resisting power over
local, national and global governance suggest that the entry of more women into positions
of power within these structures may be a necessary but not sufficient condition for
gender-equitable sustainable human development. More fundamentally, there is a need
to challenge the series of exclusions (by gender, race, class, sexuality, ethnicity, age and
able-bodiedness) on which such power is based and which are embodied by discourses of
masculinity and their hierarchizing of not only inter- but also intra-gender difference.
Violence and Conflict
Men's violence is a key determinant of the inequities and inequalities of gender
relations, both disempowering and impoverishing women. Violence is a fundamental
dimension of human poverty. Yet, men’s 'natural aggression' is often invoked as a
defining characteristic of an essential gender difference and as an explanation for the
gendered hierarchical arrangements in the political and economic lives of richer and
poorer countries alike.
Understanding development as freedom and as a right means recognizing that
men’s violence restricts women and children’s development by curtailing their freedoms
and restricting their rights. This understanding also means recognizing the various
toG
pressures placed upon men that may result in violent reactions and well as the need for
men to take responsibility for their actions.
It is important to give simultaneous recognition to the centrality of individual freedom
and to the force ofsocial influences on the extent and reach of individualfreedom. To
counter the problems that we face, we have to see individual freedom as a social
commitment. (Sen 1999)
Heise (1997: 414) reports on a summary of twenty studies from a wide variety of
countries that ’document that one-quarter to over half of women in many countries of the
world report having been physically abused by a present or former partner'. She
concludes that ’[t]he most endemic form of violence against women is wife abuse, or
more accurately, abuse of women by intimate male partners (Heise 1997: 414)'. In terms
of sexual health and reproductive rights, such abuse diminishes women's capacity to
express and enjoy their sexuality and to control fertility, while increasing their risks of
pregnancy complications and of acquiring sexually transmitted infections.
By moving from biological determini st to cultural constructionist accounts of
masculinity, a number of men’s anti-violence programmes have been able to work with
violent men to help them understand the ways that structural pressures, cultural messages
and/or parenting practices, have contributed to their socialization into violence.
Deconstructing their violence in this way has helped some men to change.
Violence prevention and intervention2 programmes are numerous worldwide.
United Nations entities including UNIFEM, UNICEF, UNDP and UNFPA have launched
and supported a significant number of violence prevention campaigns and projects over
the past decade, some of which involve men, and the UN General Assembly passed the
Declaration on the Elimination of Violence Against Women (resolution 48/104).
2 Prevention refers to stopping violence before it starts — initiatives that, for example, address socialization
processes, use public awareness strategies or methodologies such as peer education. Intervention refers to
work with those who commit acts of violence.
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In many countries, civil society organizations and profeminist men’s groups work
alongside women’s shelters to confront men’s violence. Over 100 men’s groups in the
United States - including Men Overcoming Violence (MOVE) in San Francisco, St.
Louis’s Rape and Violence End Now (RAVEN), the Massachusetts-based Men’s
Resource Center, upstate New York’s Volunteer Counseling Service, and Boston’s
EMERGE - actively work to end men’s violence against women. Other U S.-based
groups, such as MVP Strategies, have developed training materials for men and women
in high school and universities, corporations, law enforcement agencies and military
services. Similar programmes exist throughout the world. The Men Against Abuse and
Violence, based in Mumbai, India is a volunteer organization whose focus is to end
domestic violence. In Mexico, CORIAC holds workshops to reduce men’s violence
against women while in Nicaragua, CANTERA develops training and resource materials
for working with men on issues of domestic violence, using popular education
methodologies. The International White Ribbon Campaigns (WRC) invite men to wear
white ribbons for one week - usually commencing November 25, the International Day
for the Eradication of Violence Against Women - symbolizing their opposition to men’s
violence against women, to overcome complacency, to develop local responses to support
battered women and to challenge men’s violence. Wearing a white ribbon is a means to
break that silence and encourage self- reflection. Today, WRC has been successfully
launched in more than a dozen countries in Africa, Asia, Latin America, and in the
United States and Australia.
Beyond the public awareness and therapeutic value of such interventions, it is also
important to explore the political opportunities of deconstructing the connections between
men, masculinity and violence. In describing a project that works on male violence in
Nicaragua, Montoya (1999) stresses the importance of contextualizing such violence in
history and culture:
Violence in couple relationships is a problem ofpower and control. .
is
maintained by the social structures of oppression in which we live - based, among
others, on gender, class, age, and race inequalities. A national history of wars
and a culture of settling conflict throughforce also maintain it. Colonialism and
imperialism have had a role in intensifying this violence.
log
Implicit in this quote too is a connecting of different types of violence; the
interpersonal violence in couple relationships is placed in the context of the structural
violence of inequalities based on gender, class, age and race. It is also located in a
culture that 'naturalizes' violence, rendering it ’normal’ (in itself, an act of violence against
those who have come to accept violence) and a history of wars, colonialism and
imperialism.
Placing men's violence in a historical and cultural context helps overcome the
naturalizing of men's violence, or what might be called the 'masculinizing of violence'.
Indeed, it points out the role that discourses of masculinity play in exploiting what is
claimed to be men's ‘natural’ aggression and militarism for specific political purposes.
Enloe (1990) notes the way that public power continues to be used to construct gender in
such a way as to militarize a society and mobilize its 'fighting' men. Blagojevic (1999)
comments on the mythology of a dominant Serbian masculinity that became popular in
Serbia in the 1990s in order to compensate for men's reactions to the war:
The behaviour ofmany men during this last war was neither "manly" nor
"macho", and, contrary to the popular media image of the Serbs as warriors, they
did not generally support the war. They toofound themselves to be, in many
ways, victims ofpatriarchal megalomania and the madness of civil war.
Men's and women’s relationship to violence is usually more complex than
gendered accounts of perpetrators (male) and victims (female) suggests. This is not to
deny the material reality of women's suffering at the hands of men and that women are at
far greater risk of being the victims of acts of violence committed by men than vice versa.
But questions of responsibility become more complicated when such gender-based
interpersonal violence is contextualized within structures, cultures and histories of
violence that both men and women have produced and reproduced. To address these, it
may be useful to look not merely at the violence of men but at the violence that lies at the
heart of masculinity’s hierarchizing of difference and the misogyny, homophobia and
racism that are embedded in discourses of masculinity. In this sense, a development
response to the connections between men, masculinity and violence should not only
health promotion work with men, especially in the area of sexual health. For example, a
recent report from UNAIDS (2000):
[CJhallenges harmful concepts of masculinity and contends that changing many
commonly held attitudes and behaviours, including the way adult men look on
risk and sexuality and how boys are socialized to become men, must be part of the
effort to curb the AIDS epidemic. Broadly speaking, men are expected to be
physically strong, emotionally robust, daring and virile, the report says. Some of
these expectations translate into attitudes and behaviours that endanger the
health and well-being of men and their sexual partners with the advent ofAIDS.
HIV prevention work, with both straight and gay men and looking at both
homosexual and heterosexual transmission, has addressed HIV-risk taking behaviour as a
facet or demonstration of masculine identity. Deconstructing the need for this
demonstration and highlighting the pressures on men to ’perform’ their masculinity
through risk-taking have created a space for men to be more conscious of the reasons for
and consequences of their own sexual behaviour.
Focusing on risk as the mediating term between masculinity and poor public
health, however, threatens to decontextualize gender from issues of sexuality and power
relations more generally. Pleasure and desire are less often identified as mediating terms,
and yet the power and privilege of men in their relations with women often translates into
a sense of entitlement to express their desire and seek pleasure in their heterosexual
relations with women. Arguably, it is men's assertion of their entitlement to pleasure, and
the demonstration of power that underpins this assertion, that help to explain the effects
of masculinity on sexual health.
Pleasure and power are also important concepts for understanding the nature and
health outcomes of sex between men. Parker’s work in Brazil on the desires, practices
and identities of men who have sex with men offers many valuable insights (Parker
1998). Clearly, the notion of risk-taking sexual behaviour as proof of masculinity is
inadequate in contexts where men’s choice of active and passive positions in anal sex
both reflects and recasts the gendering of sexual and social roles that see men as
110
dominant and women as submissive. Parker also notes the way that men play with
masculine-feminine 'boundaries’ and also, in their transition in to gay identities,
demarcate a gay masculinity that both confronts and reinforces more orthodox
arrangements of power in terms of gender and sexuality.
The connections between health and gender inequality are most urgently
expressed by the HIV epidemic. “The HIV epidemic is driven by men,” commented
Calle Almedal, a senior official with UNAIDS (cited in Foreman 1999: viii). Of the
estimated 30 million people infected with HIV, about 17 million are men (Foreman 1999:
172). Ana Luisa Liguori, head of the MacArthur Foundations programs in Mexico points
out that if there is a positive side to the AIDS crisis it is that “it provides proof that the
very unequal relationship between men and women in poor countries is a danger for the
human race” (cited in Foreman 1999: 62).
Given that male sexuality, and the cultural, economic and political contexts that
shape its expression, is the main HIV risk factor for many women, efforts to integrate
men into HTV prevention programmes are urgently required.
‘Involving men more fully in HIVprevention work is essential if rates ofHIV
transmission are to be reduced. While such a move may not be universally
popular, it seems necessary if we are to ensure that men take on greater
responsibilityfor their own sexual and reproductive health, and that of their
partners andfamilies" (Rivers and Aggieton: 1999: 18).
Successful HIV risk reduction programs have targeted men’s behaviour in such diverse
countries as Thailand, Great Britain, Australia and Senegal. In the Caribbean, the Gender
Socialization and Life Skills Education project works with younger men to control HTV
and reduce teen pregnancy and violence. In the Dominican Republic, a collection of
NGOs have promoted the Avancemos (ccLet’s Move Ahead”) programme to promote
condom use among clients of sex workers. In Zimbabwe, teaching of life skills and
Ill
responsibility issues has been incorporated into primary school curriculum by using HIV
as an entry point.
Perhaps the most successful HIV risk-reduction programme has been in Uganda,
where the rate of new infections of HIV has moved from being one of the highest in
Africa to one of the lowest. Life Skills Education programs are run in every school, and
Straight Talk, a magazine on sexual issues targeted to a young audience, is distributed
free as a monthly insert in the country’s state-owned daily newspaper. Significantly,
these socialization approaches have been combined with efforts to mobilize community
action on some of the social and cultural determinants of HIV vulnerability. Training
programmes, such as Stepping Stones, have been used to initiate a dialogue between
women and men at the community level on issues of gender and sexuality.
Development institutions can build on these examples if they recognize that
involving men in work on gender equality and health must look beyond programmes
targeted at men’s behaviour. There is a need to initiate dialogues between women and
men about the structures of inequality that determine the distribution of morbidity and
I
mortality, and the role that the politics of masculinity plays in maintaining such
structures.
The Workplace and Organizations
Changes in mainstream policies and resource allocations must reflect the
interests and views of women as well as men. This mainstreaming strategy
emphasizes systematic attention to gender equality issues and the experience of
women in organizational practices, policies and programmes. (UNDP 1998: ii)
Gender biases at the institutional level are deeply embedded in organizational
cultures and practices, management systems and bureaucratic structures. ‘Gender
mainstreaming’ is one method of overcoming institutional biases and involves not only a
recognition of the gender implications of development programming and resource
allocation, but also challenges an organization to reflect on the gendered processes that
exist in its own operational structures.
112-
UNDP, with an oveniding mandate of poverty reduction, recognizes that
sustainable poverty reduction requires gender equality. Consequently, through gender
mainstreaming programmes and its men’s initiatives, UNDP is taking steps in a self-
reflective process meant to identify barriers to a more gender equitable working
environment. In general, these types of self-reflective exercises may also identify other
forms of inequitable power relations that are not based solely upon gender, such as those
based upon class and race.
During a gender mainstreaming workshop in February 1999, a group of male
UNDP staff was encouraged to discuss the role of men as advocates for gender equality
and the advancement of women. This group soon evolved into the UN Men’s Group for
Gender Equality, which has identified a number of barriers to a more gender equitable
organization:
•)
•
The organizational culture. There are barriers embedded in the organization such as
sexism, male/female staff ratios, hierarchical structures in decision-making, and
prevailing attitudes that hold gender to be a ‘women’s issue’.
*
lack of ample opportunity and/or spaces for men to discuss gender equality with
eSher men and women.
Z'
•
The limited number of men participating in mainstreaming efforts. For example, the
mainstreaming workshop had a six-to-one female-to-male participation ratio.
The UN Men’s Group for Gender Equality subsequently disseminated a statement
called “Gender Mainstreaming: A Men’s Perspective” that outlined what it believes to be
issues behind these barriers:
>■
(1) Fear: Men are oftenfearful whenfirst presented with a gender
mainstreaming agenda. The advancement of women may be perceived as a threat
to men fs personal andprofessional status. This may be buttressed by anxiety
)
I
Hi
about ridicule or compromised masculinity if one is widely perceived as an
advocate of women fs equality.
(2) Lack of experience: Men recruited by UNDP, and a majority of those already
workingfor the organization, do not have experience - whether academic or
professional - on related gender issues. Concurrently, it isfrequently women
who are recruited or appointed to handle gender concerns, regardless of their
expertise. Therefore, any meaningful dialogue on gender equality and the role of
men and women in gender mainstreaming could be viewed as disunitedfrom a
common agenda.
(3) Organizational culture : UNDP "s organizational culture is a product of
accumulated legacies, which can maintain a partition between men and women.
There is an absence of incentive structures for staff to view gender equality as
integral.
In its current capacity, the UN Men’s Group for Gender Equality sponsors panels
and seminars, and also facilitates a web site and electronic discussion list. By creating
spaces for dialogue about gender issues, the institutional barriers to gender equality and
possible solutions, the group seeks model how men can become involved in gender
mainstreaming.
•/
Practically, gender mainstreaming requires that gender be brought into the center
of discussions about development, and not marginalized as a ‘women’s issue’
Organizations need not only to take a ‘gendered lens’ to its mission and practice; gender
mainstreaming also requires internal organizational self-examination, and investigating
the assumptions and criteria for administrative decision-making and human resource
policies.
Men must be integrated fully in discussions regarding gender mainstreaming, lest
their attitudes provide the chief obstacle to women’s equality, organizationally and
politically. Senior staff and managers can encourage and provide incentives for the
promotion of gender equality. When the organizations charged with facilitating
development adopt an effective inward/outward looking gender mainstreaming policy.
11^
they can begin to fulfill their commitments to gender equality, poverty alleviation and
human rights.
Conclusions and Next Steps
Thinking about masculinities and men’s roles in working towards gender equality
is relatively new in the development field. This paper has presented a review of the
meanings and uses of masculinity to catalyze thinking around these issues - to inspire
new conversations and debate - and to offer a conceptual backdrop for practitioners
engaged in work with men. To carry this work forward, continued efforts should be
made to publicize and advocate for the importance of men’s responsibilities and roles in
work towards gender equality in international fora, local and national policy debates, and
development programming. Making masculinities visible and men more conscious of
gender as it affects their lives and those of women is a first step towards challenging
gender inequalities.
Beyond the broadening and deepening of conversations concerning men,
masculinity and gender equality, a second step in this undertaking is the facilitation of
programming efforts. UN agencies and the UN Men’s Group for Gender Equality can
help practitioners talk to each other about conceptual starting points, assumptions and
practical methodologies to be used on the ground. The clearinghouse of resources and
methodological tools on the Men’s Group web site
(http://www.undp.org/gender/DroKrainmes/men/men ge.html) can be expanded and linked with
other such efforts. Through data collection efforts, context-specific information can be
compiled and shared concerning gender norms and attitudes, community assets,
socialization processes, and good practices that are replicable across geographical and
ideological settings.
The conclusion of the 1995 Human Development Report articulated a vision of
transformation:
115
Owe of the defining moments of the 20th century has been the relentless
struggle for gender equality. . . IVhen this struggle finally succeeds - as it
must - it will mark a great milestone in human progress. And along the
way it will change most of today's premises for social, economic and
political life. Let us hope that the success of that struggle will be one of
the defining moments of the 21st century, because gender equality will
enable both women and men to live lives ofgreaterfreedom and integrity.
To achieve this vision, numerous actors (men and women, communities, civil
society organizations, development agencies and governments) should carry out
transformative work at multiple points of entry in the development process. Some of this
work is ongoing, but can be optimized with greater connections to actors at different
levels, and a clearer understanding of the discourses of masculinity.
What follows are some suggested areas to help practitioners think about these
issues more broadly and to identify spaces for intervention.
•
Gender mainstreaming and institutional cultures. To start, gender mainstreaming
means taking gender out of its enclave of “women’s work” and embedding it in a
sustainable human development and human rights agenda supported by both men and
women. Many organizations have some gender-specific policies in place, ranging
from resource allocation and policies against sexual harassment, to hiring practices
and maternal and paternal leave. However less apparent structures that perpetuate
discrimination such as the ‘blocks’ of institutional cultures can be targeted for .
change. Initiatives such gender mainstreaming capacity building programmes and
men’s discussions groups can create spaces for consciousness raising and self
reflection that ultimately lead to stronger, more effective and equitable organizations.
•
Policymaking. Beyond institutional policies, discussions around gender equality and
discourses of masculinity can be brought to the table in local, regional and national
116
policy debates. Such perspectives can deepen the understanding of the social content
and outcomes of policies and highlight the need to coordinate the different levels of
policy. For example, surveys measuring the social and economic costs of domestic
violence can influence the design of more integrated policy frameworks at the local
level (among communities, schools, law enforcement agencies and health care
providers) as well as national level social, economic and labour policies.
•
Focusing on socialization and youth. The family, educational systems and religious
institutions play key roles in gender socialization, and can also act as agents of
transformation. In the family, increased involvement by fathers can have powerful
effects on both boys’ and girls’ socialization. In schools, attention to empowering
girls and efforts to pay attention to the ways in which male socialization steers boys
away from intellectual pursuits are vital steps. In religious institutions, spiritual
leaders can act as role models who value compassion and community building over
more constraining gender roles.
•
Addressing issues of class and other modifiers of inequality. Understanding different
forms of inequality may help build bridges between men and women who recognize
and are affected by similar patterns of disempowerment. Although gender can be a
fundamental vehicle for determining power relations, gender works in conjunction
with other power structures, such as those based upon differences in ethnicity, class
and race. When we ask "What’s in it for men?" it becomes clear that gender equality
is part of a broader social justice agenda that will benefit most men materially and all
men psychologically/spiritually. Reflections on class and race, for example, also can
be helpful in the context of the advancement of women by raising question such as
‘Svhich women are we talking about”?
•
Sexuality. It is difficult to think about gender inequality without also talking about
sexuality, and the sex-gender system that mandates gender relations be grounded in a
specified sexual relation (i.e., heterosexual relations). Being able to recognize diverse
expressions of sexuality disrupts traditional views of the sex-gender system, and may
(17
policy debates. Such perspectives can deepen the understanding of the social content
and outcomes of policies and highlight the need to coordinate the different levels of
policy. For example, surveys measuring the social and economic costs of domestic
violence can influence the design of more integrated policy frameworks at the local
level (among communities, schools, law enforcement agencies and health care
providers) as well as national level social, economic and labour policies.
•
Focusing on socialization and youth. The family, educational systems and religious
institutions play key roles in gender socialization, and can also act as agents of
transformation. In the family, increased involvement by fathers can have powerful
effects on both boys’ and girls’ socialization. In schools, attention to empowering
girls and efforts to pay attention to the ways in which male socialization steers boys
away from intellectual pursuits are vital steps. In religious institutions, spiritual
leaders can act as role models who value compassion and community building over
more constraining gender roles.
•
Addressing issues of class and other modifiers of inequality. Understanding different
forms of inequality may help build bridges between men and women who recognize
and are affected by similar patterns of disempowerment. Although gender can be a
fundamental vehicle for determining power relations, gender works in conjunction
with other power structures, such as those based upon differences in ethnicity, class
and race. When we ask "What's in it for men?" it becomes clear that gender equality
is part of a broader social justice agenda that will benefit most men materially and all
men psychologically/spiritually. Reflections on class and race, for example, also can
be helpful in the context of the advancement of women by raising question such as
‘"which women are we talking about”?
•
Sexuality. It is difficult to think about gender inequality without also talking about
sexuality, and the sex-gender system that mandates gender relations be grounded in a
specified sexual relation (i.e., heterosexual relations). Being able to recognize diverse
expressions of sexuality disrupts traditional views of the sex-gender system, and may
be a good analytical tool for practitioners to think about the options and potentialities
of gender relations.
A
II6]
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Feminist Studies: MASCULINITY,DOMESTIC WORKERS IN CALCUTTA IN THE LATE TWENTIETH CENTURY Page I of 17
Ray, R. (2000). Masculinity, Femininity and Servitude: Domestic Workers in Calcutta in the Late
Twentieth Century. Feminist Studies, Fall 2000.
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Feminist Studies
Fall, 2000
MASCULINITY, FEMININITY AND SERVITUDE: DOMESTIC WORKERS IN
CALCUTTA IN THE LATE TWENTIETH CENTURY.
Author/s: Raka Ray
In a memorable scene in Aparajito, the second film of Satyajit Ray’s Apu Trilogy, the destitute
Brahmin widow Sarbajaya watches her son learn to serve. She has recently obtained work as a
cook in the household of a rich Brahmin, where her employers are considerate and
inconsiderate in the manner of feudal lords. In this scene, she observes from the top of the
stairs as the master of the house sends for her son Apu to light his pipe and tells him to pluck
gray hairs from his head, rewarding him with a tip. In the next scene we see Sarbajaya and her
son on a train, having left the job behind.
Sarbajaya’s reaction is entirely different from that recorded by V. Tellis-Nayak in his study of
Indian domestic servants, who reports primarily resignation and a surprising lack of stigma
attached to the job. [1] Sarbajaya’s face as she looks upon the scene makes it dear that nothing
could be worse than watching one’s son become a servant I say ’’son" here deliberately because
it is not clear that Sarbajaya’s reaction would be quite as strong in the case of a daughter.
Indeed, in the first film of the trilogy'. Father Panchali, the daughter Durga (who dies at the end
of the film) is shown at the service of her little brother, looking after him, feeding him, and
ultimately being responsible for his well-being. Durga was bom to serve, in one way or another,
but not Apu, the Brahmin son. The scene described above is as much a powerfill comment on
mother love and gender expectations as it is about the extreme and peculiarly gendered stigma
attached to the identity ’’domestic servant" in India.
How do we understand the humanity' of a group of people who get paid to do tasks that no one
wants to do? This is a question that lies at the heart of scholarship on domestic servants. Some
argue that the humanity of servants develops in a distorted way because of both the nature and
the conditions of this work. Servants are reduced to a state of "perpetual infantilism" which
leads to extreme hopelessness, and to a corresponding lack of resistance. [2] Others have
written movingly about the everyday ways in which domestic workers resist degradation. Both
sets of authors, however, see domestic workers primarily through the lens of the power and
authority' that inhere in relations between the employer and employee. [3]
In recent studies of the working class in India, several scholars have argued that ideologies and
practices of gender, caste, and religion both shape the contours of the workplace and the
trajectory of class identities. [4 J As Gillian Hart and Karin Kapadia have argued elsewhere, an
analysis of the meanings and relations of gender is necessary' to better understand class
consciousness. [5] In this article, I explore not the social identities underlying worker identities
but how work and the way work is constructed feed into gender identities. In other words, I
argue that relations between worker and employer are refracted through the lens of gender and
are used by the workers to build and reflect upon their gendered selves. My argument stems
from the realization that the fulfillment of gendered expectations framed every conversation I
had with domestic servants in Calcutta. This article then, is about how domestic servants in
India negotiate their identities as w'omen and men and about how they evaluate their
embodiment of those identities. It explores the way female and male servants imagine and
articulate their lives as gendered beings, given that they perform, on a daily basis, the most
undesirable tasks of society.
-AMASCULINIT Y, FEM1N1NHY AND SERVH UDE DOMESTIC WORKERS IN CALCU T1A LN THE LAIE T WEN TIETH (12/15/01
I
Feminist Studies: MASCULINITY,DOMESTIC WORKERS IN CALCUTTA IN THE LATE TWENTIETH CENTURY Page 2 of 17
I turn first to the structure of paid domestic w'ork in India and then discuss notions of class,
masculinity, and femininity in the city of Calcutta (where the research was conducted),
situating these ideas within the distinctive caste and gendered class culture of Calcutta’s
middle, or bhadralok, classes. Thus I explore the gendered ideology of those who employ
servants in Calcutta. For this distinctive class, the bhadralok, hegemonic masculinity is defined
by the absence of menial labor and the presence of education and cultural capital. There is in
addition an idealized notion of independence, though few bhadralok achieve it. [6] Idealized
femininity, on the other hand, involves being protected and staying at home, it is virtually
impossible for those who do paid domestic work to achieve respected masculinity or femininity
when their very' definitions seemed designed to exclude them.
The final sections of the article explore how, under these conditions, domestic servants try to
define their masculinity and femininity against their employers and how they accept, reject,
embrace, and modify the way others see them as women and as men. I argue that female and
male domestic workers seek, on the one hand, to appropriate bhadralok ideals and to deny their
employers the monopoly of being bhadralok. On the other hand, they redefine what it means to
be a good man or a good woman, bringing these definitions closer to the lives they lead. The
study of both sides of the domestic work relationship allows me to explore the dialectic of
employer and employee gender ideologies, to examine how employers build ideas of bhadralok
femininity and masculinity precisely by excluding servants, as well as to show how servants
fight that exclusion with varying degrees of success.
The data for this paper are drawn from a larger study of sixty' interviews (thirty employers and
thirty workers) conducted in 1998 and 1999. Fifteen of the workers lived in the homes of their
employers. Because Eve-in work heightens the question of workers’ femininity or masculinity, I
focus my inquiry on them. [7]
PAID DOMESTIC WORK IN INDIA
Because paid domestic workers in the West, Latin America, and East Asia are primarily
female, domestic service has appeared to be synonymous with women’s work in most research.
[8] Yet precisely because the "domestic" is seen as a distinctively female realm, the presence of
men questions the taken-for-grantedness of the gendered separation of spheres. [9] Domestic
servants in India have historically been both female and male, but women and children have
begun to dominate the ranks of this occupation in India, which reflects both the secular trend
toward more female labor force employment and the worsening of economic inequality. [10]
The 1971 census showed that there were 675,878 domestic servants in India, of whom only
251,479 were women. A decade later, the picture was quite different, with the 1981 Census of
India reporting that there were at least 807,410 people who worked as domestic workers in
India, evenly divided between 402,387 men and 405,023 women. [11]
This article focuses on Calcutta rather than on India as a whole. A focus on one region enables
a more grounded reading of the practices of domestic servitude. Calcutta is an ideal site for the
investigation of femininity and masculinity in domestic servants for several reasons. First, the
region of West Bengal, in which Calcutta is situated, has a rich and elaborate feudal tradition.
Second, the 1981 Census shows that the sheer numbers of domestic servants, at 149,100, are
far greater in W’est Bengal than in other more populous states. Finally, the transition from
primarily male to primarily female domestic workers has happened relatively recently in
Calcutta, rendering the issue more salient in Calcutta than in other cities where male servants
are increasingly invisible. [12]
According to economists, the increasing numbers of female servants in Calcutta are due to their
expulsion from agriculture and organized sectors of industry (such as jute) and the partition of
Bengal, which made refugees out of women who had not previously had to w ork outside the
home. As employment alternatives closed for women, they expanded for men, so that the
numbers of w'omen domestic workers slowly increased, while the numbers of men decreased.
[13] At the same time, the trend tow'ard smaller apartments and families caused employers to
think of women as safer servants around their daughters than men. [14] As in other dual-sex
occupations, men have the higher status within the ranks of servants and command higher
wages. These changes mean that female domestic servants are becoming the norm, with the
more expensive male workers being out of reach for most middle-class families today. Yet
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employers still think male servants are better, even though they no longer can afford nor
perhaps would hire a male ser vant today. At the same time, as it becomes clear that many men
have other options than domestic servitude, those who remain in this profession must explain it
to themselves and to others.
BHADRALOK SOCIETY
The femininity and masculinity of servants is judged both by employers and the servants
themselves against a complex backdrop of class deprivation, normative ideas of what it means
to be female and male, and the actual practice of doing domestic work. Femininity and
masculinity are not simply cultural ideal-types, but they are also created through practice; and it
is through practice that they are weighed, judged, and transformed. Although there are many
w’ays of being masculine, there is at ever}7 moment a masculinity of the powerful, which Robert
W. Connell terms "hegemonic masculinity7." Hegemonic masculinity is historically, culturally,
and materially specific, as are the masculinities of those excluded from the masterful
configuration. [15] Although Connell focuses on men of the metropole, how do we best
understand hegemonic masculinity in Calcutta, especially the masculinity of men who have few
cultural or economic resources? I examine first the particular construction of hegemonic
masculinity and hegemoni c gender ideology in Calcutta, before turning to the way employers
and employees understand subaltern masculinities and femininities.
Bengali society today is dominated by the values of the bhadralok (which literally means
respectable man or gentleman), most of whom belong to the three upper castes. As civil
servants, teachers, doctors, lawyers, and descendants of absentee landlords, the bhadralok, who
came into being in the late nineteenth century, were the first products of English education and
the first to intellectually challenge British authority over Indians. [ 16] Bhadralok stand in
opposition to both those who own the means of production (landlords and industrialists) and
workers. They place a high value on men of letters, high culture, and the intellect Bhadralok
are opposed to either chhotolok or gariblok, who are poor or not "civilized." They do not do
manual labor, although they are associated with skilled and clerical work. [17] Their values
have exercised considerable influence on gender and class relations in contemporary Bengal,
and they have done so, as Sumanta Banerjee has shown in his study of elite and popular culture
in nineteenth- century Calcutta, at the expense of lower-caste popular values. [18]
The bhadralok are also defined by a distinctive masculinity. [19] These men were not warriors
and yet were instrumental in the creation of a nationalist project about the place of women and
men in the world. [20] Their gender ideology was primarily one of respectability. For the
bhadralok—the gentle-man-this means not doing menial labor, being educated, having
independence of means, and maintaining a genteel and cultured life. Hegemonic masculinity in
Bengal has little to do with strength and virility.
For the bhadramahila—the gentle-woman—respectability is also defined by the absence of
menial labor. In addition, a bhadramahila is protected, culturally refined, and responsible for
the inner life of the family. [21] The bhadramahila's respectability comes not from
independence but the luxury of its opposite. Bhadramahila have lajja—shame and modesty—
attributes closely connected with virtue and respectability. As Himani Banerjee articulates it,
"to be civilized is to have a sense of shame." [22] It is the uncivilized woman (the poor woman
or the low-caste woman) who does not have shame, is not protected, is sexually powerful and
immoral, and is therefore a threat to the moral fabric of society.
Today’s bhadramahila have to work outside the home (although women’s labor force
participation in Calcutta is exceedingly low, at 7.04 percent), but they are supposed to work in
genteel professions such as teaching? [23] Even when women do work, the assumption that the
home is her real world is inviolable, as is the ideology of female dependence upon male kin
[24]
The employers of domestic workers with whom 1 spoke were all clearly bhadralok, while the
employees, by definition, were not. Indeed, from the 1880s onwards, the ability to hire servants
became a mark of bhadralok status. [25] Given this society, how do we understand the
relationship between hegemonic and subaltern femininities and masculinities?
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EMPLOYERS ON THE MANHOOD AND WOMANHOOD OF DOMESTICS
If you look at the skill content required in cooking—it is much higher than in say, washing the
dishes. Any old person can wash the dishes. The male psyche calls for a more skilled job.
(Male employer, age thirty )
I prefer male servants. But it's difficult to get them nowadays because they can get jobs
elsewhere. You see, men, if they work for eight hours in a factory, they are free after that. If
they work for me, they’ are not free. They are, after all, always at my beck and call. (Female
employer, age seventy')
In Calcutta, both women and men work as domestic servants, but they are not interchangeable.
Men are the preferred workers but are increasingly hard to come by. In the imagination of
employers, men are by nature less willing to do work that requires them to be at one's beck arid
call and are now discovering they don't have to be. Although this is considered an occupation
with few skills, men are thought to possess more of the skills that the occupation requires. They
are also thought to need skilled work more than women do. Their nature dictates that they be
independent or swadhin, and social structure provides them more opportunities to be so. [26]
Women, by contrast, are thought to be more accustomed to having to obey. They have access to
fewer alternative opportunities, and although they are less desired, they are increasingly found
in service jobs where they are on call for their employers and cannot return home at the end of
the day.
The middle- and upper-middle-class employers we interviewed in Calcutta consistently
revealed a preference for male servants, even though they were not quite as clear about their
reasons for this preference. [27] Yet not all male servants were the same, and employers
frequently contrasted the male servants of today with the male servants of yesterday. One spoke
of the old family retainer who was fiercely protective of them. "He brought us up. He was our
ayah and our nanny. He would not steal a penny. We knew he had a wife somewhere and some
children, but he only visited them once a year and never wanted to extend his visit He was
intensely loyal, and his life was with us. My brothers took the place ofhis children." Visible
here is a crucial attribute of the male servants of the past—unswerving loyalty and a willingness
to put their employers' families above their own. Today's employees think only of their own
families. A certain subservient loyalty, then, is the mark of "good" subaltern masculinity.
Yet how do people reconcile male servant preference with a highly sex-segregated society like
India’s? Male servants walk in and out of bedrooms, handle women's clothes, and are present at
intimate moments when other men could not be. We asked one elderly conservative woman,
who preferred male servants, how she felt about men servants touching her clothes. Her
response was immediate. "Doesn't bother me; Pm perfectly happy. A servant isn't really a man;
a servant is a servant." We asked her whether it struck her as odd that her male servant did
work that her husband would never do or think it possible for men to do. She answered that
"the male servant is doing this for money. My husband doesn't think he has to do the work. He
earns money and gives it to me—his wife. As far as he is concerned, either I will do the work or
hire someone to do it. It's up to me."
Although the male servant appears to embody a less valued masculinity by virtue of performing
such menial and heavy labor, he is not always emasculated. Nobody wants a male servant in the
house when there is a young daughter at home. In days past male servants could serve
employers vith young daughters because women in the extended or joint families acted as
guardians and buffers. In today’s nuclear families, however, the threat of the male servant is
larger, precisely from the belief that he is not bhadralok. The fear of being alone in the house
with a male servant, articulated by one widow, stems from her understanding of men of a lower
class as having a brute strength, which employers otherwise want for heavy' work. [28] Thus the
male servant is sometimes more than a man and often less. Ultimately, the masculinity' of male
servants coexists uneasily with the bhadra femininity and masculinity' of his employers.
With smaller families and apartment living has grown an increased acceptance of and even
preference for women servants. Male servants may be status enhancing, but women are cheaper
and more trustworthy. Employers have complex emotions about hiring women and girls. The
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fear of women’s sexuality is such that there is an increasing drive to recruit young prepubescent
girls from the village and to send them back when they reach puberty. Uppermost in all
employers’ minds when they hire a young woman is the risk of her potential sexuality, because
unprotected women are perceived as sexually dangerous and therefore not respectable.
Issues of respectability and protection loom large in the hiring of women servants. In many
families, the husbands rarely speak to the female servants, and the female servants seldom
speak directly to them. The idea that women should be respected and respectable does not fit
well wqth the hiring of female domestics. One man, who refuses to hire women servants, recalls
a moment of extreme embarrassment in his youth when he was riding the bus. Calcutta buses
have several seats reserved for "ladies." When there aren’t enough women in the bus, those
seats are occupied by men, who vacate the seat when a woman comes aboard. On one such
occasion, this young man was sitting in the "ladies" seat and vacated the seat when a woman
come on board, without glancing up at her face. After she sat down, they both realized to their
mutual embarrassment that he had given up his seat for the servant of the house. Confusingly,
the notice on the bus, "reserved for ladies," both does and does not apply to her.
No matter their present, often tentative, class location, the bhadralok have been weaned on
feudal tales and have nostalgic fantasies of servants of the past [29] They consistently contrast
today's male servants with male servants as they used to be-selfless and loyal, like fathers to
them. Today’s male serv’ants are failures precisely because they have alternate aspirations and
identities. They do women's work because they need the money, yet they are still men who do
heavy work and are potential sexual predators. If male servants possessed bhadralok
masculinity, they could not be good servants. It is precisely because they will serve and do
menial work that the bhadralok can afford their masculinity.
Women servants are certainly women, but they are dangerous and endangered precisely because
they are not protected, as a bhadramahila should be. Women servants complicate life for the
bhadralok, for how is he to treat them? And yet, if female servants were not considered
different, to whom would the bhadralok contrast his women? A female servant conscious of
bhadramahila propriety would be of little use to her employers. Because she cannot afford
propriety and protection, the bhadramahila can.
SUBALTERN CONSCIOUSNESS
The women and men who work as domestic servants are constantly faced with expectations
based on hegemonic bhadralok readings of their femininity or masculinity. My interviews with
them consistently reveal that their work is the experiential world around which they construct
gender. How does hegemony work
in this context? Does it effectively reproduce social inequalities? Or does it fail to penetrate the
daily culture of the dominated classes? [30] Karin Kapadia argues that "untouchable" women
do not accept upper-caste interpretations of their identity, while Kalpana Ram shows how
Mukkuvar fishermen are able to use their relationship to the sea to carve out alternative
identities for themselves. [31] Paul Willis, on the other hand, claims that social inequality
reproduces itself despite and through resistance. [32] I argue that female and male servants
idealize and seek to attain some part of bhadralok gender ideology but not the whole of it. They
modify it such that they can consider themselves to have achiev ed a desired femininity and
masculinity, but they do not resist bhadralok gender ideology wholesale. Bhadralok
constructions of domesticity and gender act as a powerful master discourse for these domestic
servants.
Based on my interviews with serv’ants, I isolate several core themes that servants articulate in
evaluating their own gender identities. For male servants, the lack of swadhinata, or autonomy,
underpins their sense of failure as men. Yet others counteract this sense of failure with their
ability' to sacrifice themselves in order to fulfill their responsibilities toward their famihes. For
women, their inability to be protected marks their failure to be bhadramahila. Yet some assert
their humanity and right to be loved and acknowledged in the face of this lack of protection.
Although employers judge the masculinity of male servants in terms of their lack of swadhinata
(which causes their servility) and their female servants because they are not protected, the
servants instead foreground the concepts of male responsibility and female relationality as
alternative ideologies which legitimate their masculinity or femininity.
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In what follows, I present thematic stories from my respondents, highlighting one life story for
each theme m order to enable readers to understand each worker’s choices and constraints in
full context. This use of life histories provides depth and context to the interaction of individual,
agency and social structure which other methodologies do not illuminate as well. [33]
SUBALTERN FEMININITIES
As studies of w'orking-class women in Bengal have shown, a woman who does not work in a
genteel occupation is potentially either a victim or a loose woman. [34] Given these choices,
women domestic servants long for protection, actively seek it, or explain their misfortunes as
due to its lack. Yet, protection is not the only thing they seek, the only standard by which they
live. Despite, or perhaps because of, a life in which they have been less loved and nurtured than
their brothers, and mamed off young, some women assert the right to live a more loved life, to
be recognized and appreciated, even at the cost of protection. [35] This desire for satisfying
relationships, often construed as sexual licentiousness on the part of their bhadralok employers,
may lead them to step outside the protection they otherwise hold so dear.
In search of protection. Although many young women in India migrate to the city in search of
autonomy from their families, the search for protection seemed stronger than the search for
autonomy in the women I interviewed. [36] These women struggled to survive in a world that
they saw as particularly hostile to unprotected women. Respectability was a powerful source of
protection, and yet respectability was itself premised on already having protection. Thus, some
women's pursuit of protection was relentless.
I
a
J
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■■
i
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Mitali was bom m Naihati and came to Calcutta to seek work after her father died of snakebite
when she was eight years old. Her mother died when she was an infant. As an eight-year-old
girl, she survived by living on the railroad tracks gathering and selling the coal that fell off the
trains that thundered by. An extremely attractive woman today, she realized early that because
her parents were not there to protect her, she had to find a husband who would. Thus as a child,
ste says, she had two desires. The first was to see many films, and the second was to make sure
she found a husband. The narrative of her life follows a search for protection.
She accepted her first job as a domestic servant simply because it offered her a roof even
though they paid her pennies a day As Mitali learned some skills, she left that household, for a
senes ofjobs. As she went from house to house, husbands and young boys frequently tried to
molest her—"they kept getting under my mosquito net," she says euphemistically FinaDy she
convinced a woman employer to let her sleep on her kitchen floor, while continuing to work for
ottff Julies. She recalls with appreciation her employer’s anxiety when she returned late
frcm a film one mght The relief that somebody was looking out for her more than compensated
for her employees wrath.
One particular story poignantly reveals what it means to be an unprotected poor woman in
urban India. Mitali worked part-time m several houses, sweeping and mopping in one house,
cooking m another. Her daily journey from one employer to the next took her past a street
comer where a goonda (thug) hung out This man, she says, wanted her for himself and
threatened to kidnap her if she did not go to him willingly. She worried about it incessantly.
What should she do? T thought I should maybe give up working in that house so I didn’t have to
pass him, but I needed the money, so I couldn't stop." Then however, she began wearing sindur
on her head (the vermilion mark that is the most overt Hindu sign that a woman is married), in
order to protect herself, and the plan worked. The man stopped harassing her immediately,
because she was now under some other man's protection. The very success of this plan,
however, worried her. "I thought, ifpeople see me with sindur, they will think I am already
mamed and then how will I really get married? I had no parents to many me off, so I was
already worried about that, and I was really anxious now." It was this anxiety that prompted her
imally to give up the job m the house to which she could not travel without encountering the
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Subsequently, Mitali worked for an older woman who became very fond of her. She called this
old lady "Ma" or "mother" and confesses that she frequently bed to her and went to the movies,
much as a daughter would. "I earned 200 rupees, and I thought 'good! 100 for the movies and
100 to be saved for my marriage.’" But when she finally fell in love with a local night
watchman, she turned to Ma for help. "I told Ma I have liked this boy, but how- do I know he
won't take advantage of me and then abandon me?" The employer sent for the man and ensured
that he agreed to many' her. She then accompanied them to the court to make sure the marriage
was legalized. Mitali had effectively called upon precapitalist modes of loyalty and employer
responsibility in order to enforce a contract that would guarantee her protection. Now that she
has a son, she still works for Ma. She wishes she didn't have to keep working and her husband
weren't so poor, but she considers that she has achieved what she had to, given her circumstan
ces. "No one after all wants to make a living working in people's houses. But that is fate. I was
so worried that no one would many me because my parents were dead, but that worked out."
What strikes one about Mitali's story is the single-mindedness with which she sought
protection. If protection is ideally associated with passivity, a being-done-to rather than a doing,
it takes on a whole new meaning here. The protection that Mitali sought was symbolic and
institutional. She understood that being unprotected implied sexual availability and that this
had little to do with her desires. She also understood that the only way for a woman to be
considered respectable was to appear to be protected and that although a woman's body is never
really safe, it must, at least be symbolically guarded.
Marriage is a formal system of protection, and parents are often eager to marry their daughters
off when they feel incapable of protecting them further. When a young girl has no parents, her
relatives are especially anxious to get her married. Thus Sonali (forty-five), whose parents died
when she was one year old, was married when she was eleven, becoming her husband's third
wife. She left her husband's home as soon as she could and has been working for the same
employer for the past twenty years. There are no alternative protections available for Sonali.
Thus she stays with her employers despite their exploitation of her, their refusal to give her
new clothes, and the sharp tongue of her mistress.
The failure of patriarchal protection is not limited to parents. Many women work as live-ins
despite being married because they wish to escape the violence of their husbands. Rama, who is
fifty-six, works to support her five grandchildren, left in her care by her daughter’s death.
Although her daughter was clearly burned to death by her husband, Rama spoke of it as suicide.
When I challenged her, she told me that she couldn't afford to point a finger at her son-in-law,
for who would look after the children if he were in prison? If there was ever a reminder that the
ideal of husbandly protection is often not a reality', this surely is it
Husbands and famifies can’t always protect them, so women workers have learned to protect
themselves. They Uy to remain indoors as much as possible, and they strictly pofice their own
behavior and the behavior of their daughters. Women domestic workers five in a cultural world
where the respected and respectable, protected and protectable bhadramahila is the ideal. Yet,
their world is filled with rea1 and mythic predators—from their employers to their own
husbands. Often orphaned young, unable to find a husband or married off to strangers, the
workers I spoke with desperately hold on to respectability' under circumstances and occupations
that are calculated to rob them of it Protection for these women is not only a cultural ideal but
a very real need as well. In search of recognition. Lakshmi (age forty') was bom in Calcutta and
is relatively new to domestic work, having done it for only the past seven years. She is married
and thus technically has protection, but in her eyes, her marriage violates what sh e considers to
be an essential principle of humanity-the right to be loved. Although Lakshmi knew that 1 w'as
interested in her life as a domestic worker, she did not wait for me to ask the first question. As
soon as we sat down she initiated the conversation by talking to me about her marriage. "I
married by choice" were her first words. "I married by choice despite resistance from my
family. My uncles and aunts asked me repeatedly, Lakshmi, are you sure, are you absolutely
sure,’ but I said I was." Her parents had died when she was young, and she was raised by
affectionate and well-meaning relatives. However, her life was not easy after marriage. Her
husband sold goods out of a roadside stall, and they could not make ends meet. Once she
became pregnant, she started to cook for a family but could not sustain it because of her
pregnancy. She tried her hand at several other jobs-piece-rate sewing, making and selling dung
patties, and so on. That was still not enough to sustain her sansar (family, or world). As babies
were bom, she continued to try various ways to make ends meet. She initiated a move which
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helped her husband's store, by buying cooking oil at wholesale prices and selling it retail. She
recalls with pride how she was so scared to get on a bus that she would clutch her husband's
shirt as they got on and off the bus. Now, however, she has figured out which the best places
are and can manage to bring back 100 liters of oil on her own.
But even as she talks with pride about her new confidence and abilities, she returns continually
to her relationship with her husband and to her realization that he never loved her as she
thought he did. She repeats the questions her relatives asked her twenty years ago-"Are you
sure, Lakshmi? Are you absolutely sure?"-to emphasize to me just how wrong she had been.
For the love he had, she has now' concluded, was for the dowry he thought she would bring. She
suspects that he felt cheated when she came to him empty-handed. What else can explain her
inability to win his love or his refusal to give her the adhikar (right) to make demands on him.
He always wants her subordinated (parajito, or defeated) to him. "So for these few years now, I
have been doing this ayah work," she says, it is as if this work she does is a result of his not
loving her.
Lakshmi returns repeatedly to the subject of her husband's failure to love and appreciate her,
his jealousy and possessiveness, and his will to dominate. The issue that brings tears to her
eyes is that he has never given her a sari, not even for the religious festivals.
A lady gave me a watch the other day. She said her husband had given it to her and that he had
given her another watch before that Do you know, he also buys all her saris for her! When she
told me that, I went home and cried that night and thought: "How fortunate she is, to have the
love of her husband, a husband who loves enough to buy her these things." Had my husband
bought me so much as a blouse-piece, I would be the happiest woman.
"What do you want from your future?" I ask. She is silent for a moment, and then says, "Just
some love. There is much I did not understand when I was younger. One can't live without love.
Just like a plant or a tree, one withers and dies. There is a man who loves me now and does a
lot for me, but he is not my husband." She looks away and then turns to me again "But tell me
this, am I wrong to accept love from someone else when my husband has refused it to me for so
long? If a thief steals, are you going to beat him up or find out what the circumstances were that
led him to commit this act?"
What she means by "love" is many things. Love represents, on the one hand, a fulfillment of all
that is missing, and on the other, it represents responsibility, recognition, and appreciation. It is
her husband's failure to give her recognition that leaves her feeling unfulfilled. It is the absence
of his "confirming response" as Jessica Benjamin would say, and the absence of his
acknowledgment that she is important to him or affects him, that Lakshmi finds unbearable.
[37] Because he has never shown her that she matters to him, he has lost the right to keep her.
The minute her duties toward her daughters are fulfilled (i.e., they are married), she says, she
will leave her husband. She will move into the home of her employer’s daughter and work as a
live-in. If her husband gives her no love, at least her employer and her family do. She does not
expect the same sort of love from her husband as from an employer. However, her employers
love her as employers can, while her husband does not love her as husbands co uld or should.
[38] Lakshmi will, in other words, give up a culturally accepted form of protection, under these
conditions.
Economic logic would not predict a move from live-out to live-in work Most servants want
nothing more than to be able to move out of their employers' homes and out from their power
twenty-four hours a day; however, Lakshmi’s search for a satisfying relationship propels her in a
different direction. Her employer appreciates her and her abilities, but her husband does not.
When she asked me whether I thought she was wrong to accept love from a man who was not
her husband, she was asking me to understand the conditions under which she had come to this
decision. She had come to a moral position based on her husband's failure to give her the
affection and recognition which should have been her right. It was unportant to Lakshmi that I
think of her decision in that light and not think of her as a woman committing adultery'. She
seeks to give her decision respectability by assuring me that the man who loves her has "no
dirty-ness in him"-he does not simply want sex from her, and he has given her two blouses for
her saris. She recognizes and has every intention of fulfilling her responsibility' toward her
children, but she no longer recognizes her obligation toward her husband. She is willing to defy
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his patriarchal authority, but she will do so by opting for a benevolent paternalistic or
matemalistic relationship with her employer. Here domestic service provides Lakshmi with the
op portunity to trade protections-a failed one for one that just might work. It could be argued
that Lakshmi’s actions were in fact an assertion of an alternative, non-bhadramahila morality,
but I suggest that her deliberate desexualization of her relationship with her lover indicates that
she is in fact steeped in that morality
Lakshmi is not alone in emphasizing her employer’s affection for her. The search for a decent,
caring relationship is often uppermost in women servants’ minds, and when they don’t find it
with their husbands, some turn to their employers, often pulling their female employers into
their lives. Pushpa recalled her first employers with great fondness: "I was fortunate when I
worked for them. I was so young and irresponsible, but they were a good and loving family.”
Many of these women have been denied parental love and often the love of a husband. They
long therefore not just for a romantic love but also for the parentlike figure that they never had.
And yet, the failure to win one’s husband’s love is a bitter pill to swallow. "What does it matter
what work I do when my own husband does not love me," says one woman. And another says:
"I don’t like this work. What will it take for me to be free from this life? If my husband were
better, then life would be tolerable. I don’t get love from anybody-not parents and not my
husband. And now my children resent me because I am not there for them." In many of these
women’s stories, the hostile encounters they describe with their employers have much less
emotion in them than the encounters with those who are supposed to love them. In their already
deprived lives, they are unwilling to give up the right to be loved.
Manisha Ray has documented the way that upper-middle-class Bengali women are almost
schooled in romantic fantasy and expectation, taught to daydream about the men they will one
day many (often a stranger they barely know). [39] These fantasies are not restricted to women
of the upper classes. Indeed, through novels, folktales, folk songs, television, and flints, Indian
women of all classes are steeped in a culture of longing. [40] These desires do not belong
simply to the realm of unattainable fantasy' for poor women. Takshmi, for one, has transformed
the desire to be loved into a source of strength. She has made it her right, transformed it into a
requirement for humanity, and can therefore use the violation of this right as a justification for
her subsequent actions. She uses her employment as a lever to enable her to leave her marriage,
just as Mitali used her employment to enter it. If Mi tali pursued protection because she had
never had it, Lakshmi can walk away from it because the protection of marriag e costs too much
for her.
SUBALTERN MASCULINITIES
If the essence of domestic service is subservience, if it is less about the completion of tasks than
about being at the beck and call of the employer, then it is also a job that runs counter to
hegemonic ideas of masculinity, both bhadralok and other. [41] There is a clear awareness on
the part of male domestics that this is a bad job. Given the recent transition to a majority female
occupation, there is also regret among some m the older generation of male servants that the job
is being progressively de-skilled and is therefore even less desirable for men than it previously
w'as. [42] Further, those men who work as domestics today have failed to find a better job when
popular opinion maintains that men can easily find less demeaning jobs. Given the increasing
association of women with this already low-prestige occupation, how do male domestics
manage their gender identity? How do they negotiate their daily presence in a space that is
demarcated for women?
When the ideal is bhadralok society, male domestic workers—men who work as cooks.
factotums, and sweepers-have failed to be men on several counts. Bhadralok are men of culture
and education, and they do white-collar jobs. If they are successful, they are professionals and if
unsuccessful, clerks, but bhadralok never work with their hands. Because of the caste system,
many forms of menial labor are steadfastly associated with servitude. In addition, bhadralok
have jobs which allow them to be patriarchs of their homes at the end of the w'ork day. For livein male domestics, this is not a possibility. So it is that in the domestic workers’ eyes, what
prevents them from being men of the bhadralok classes is both that they' do menial work and
that they do dependent (paradhin), not independent (swadhin), w'ork. Finally, bhadralok earn
enough to support an establishment, so their wives can remain protected and not have to work.
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These are standards few w'orking-class men can live up to. Factory work, which meets two out
of the three criteria, is the prized working-class job, but it is not easy to find. There are many
informal-sector jobs that allow men to be more swadhin, but they do not provide security. There
is no other job that fails to meet the first two criteria as profoundly as domestic service, and
thus the men engaged in this work are often bitter and frustrated with themselves.
Most men who work as domestic servants cannot afford to have wives who do not work.
However, some men redefine masculinity such that even if a man is not the sole support of his
family, he is a good man if he is financially responsible. It is a masculinity of duty, both filial
and paternal, a masculinity that resists the image of the failed and ineffective man. By being
financially responsible for the family, by being, in other words, a "good family man," these men
defy the images that the bhadralok have of the chhololok class. Unlike the good subaltern of the
past, these men do not put their employers’ families first; they swear undying loyalty not to the
families of their employers, but to their own.
Swadhin versus Paradhin work.
We are not free, and therefore we are not men.
Arun
Arun is the oldest domestic servant in his apartment building. Although he has worked with the
same family for over twenty years as their cook, they pay him little, and he has little affection
for his employers. When, fresh from interviewing w omen domestic workers, I ask him if his
employers are fond of him, he shrugs. "Sure, but not enough to give me more money or new'
clothes, or even money for medicines when I am sick?"
Arun was the youngest son of eight children, bom in the district of Medinipur to poor fanners
who had a little land themselves but had to farm other people’s land to make ends meet
Because he was the youngest, he was at least able to study until the fourth grade. Just as
Lakshini was more interested in talking to me about her marriage than her work, Arun wanted
to tell me about his childhood and adolescence, when his life was really worth living Arun told
me about life in the village (which he left when he was fourteen) and about the time he was a
soldier in the underground struggle for Indian independence. His tired eyes and lined face
brightened as he described his participation in the resistance against the British, the
cooperation of the neighboring villagers together, and the conch-shell alarm blowing when
British soldiers came looking for them. After several years of guerilla warfare, his father,
increasingly afraid for his son's safety, helped him escape to Calcutta where he joined his older
brothe r. Arun's summary of the next fifty years of his life is an account of his failure to keep a
succession ofjobs through lack of skill, illness, or sheer bad luck Finally, he began work as a
cook. Today, twenty-six years later, he still works for the same family.
I suppose I am OK here. I say sometimes that I will leave. They [the employers] say, where will
you go, you have no other skills? Do what you can here. Arid they are right. As I grow older,
they will forgive me if I do less than acceptable work. But who else will forgive me?
Sometimes, if I forget to put salt in the food, they still eat it. Others wont let me get aw ay with
it.
He believes, as his employers have repeatedly told him, that he does not have the ability- to find
a less demeaning job. His lack of skill keeps him dependent, and his dependence on this
particular family has grown m the years he has been with them. He knows that his mind and
body have slow ed down. Thus, today, he dare not leave. Arun's narration of his participation in
the struggle for Indian independence contrasts particularly' with his assessment of the lack of
freedom in his later life. He realizes that his sons are not going to support him when he can no
longer work.
My sons are useless. They will give me nothing. So I have decided what will happen to me
when I am old I will kill myself. I have lived my life with my head bow'ed, but I will not bow
my head at the end of my life. I have lived paradhin, but I will take some sleeping pills and that
will be the end of it.
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Arun can hope only to die like a man—freely and independently.
Hegemonic masculinity is unkind to those who fail to pass muster. Almost without exception
the men with whom I spoke blamed themselves for not attaining the status of an independent
man. The wxnd paradhin is usually applied to subjected peoples (as India was paradhin under
the British). There was no male domestic servant who did not use this word, which confirms
the degree of subservience and lack of control this work implies. There seems, at least on this
ground, to be agreement between employer and male servant about the nature of this work and
its effect on men. This is not a job for adult and independent men, because they have to ask
permission to go out for an hour and are often closely monitored and ultimately because they
are dependent on the employer’s charity and whims. One man told me how he had served his
former employer w'ell and was stunned when he was left with nothing when his employer
moved to another city, his expectations of feudal relations of servitude betrayed.
Raghu, a young servant in his thirties who originally came to Calcutta as an adventure, has
been working as a domestic for several years now; Although he didn’t think doing domestic
work was a problem when he was single, he believes this work should not be done after one is
married. Yet this presents a no-win situation. On the one hand, a man doesn't want to look
paradhin to his wife. On the other hand, he needs security more once he has a family. His job is
paradhin, but it seems secure; he struggles to maintain his self-respect while doing it. For
example, he refuses to accept old clothes from his employer and so maintains some semblance
of being swadhin.
Because the key to the swadhin bhadralok world is education, the men voice regret at not
achieving enough education to have a clerical job. Achin, whose father frequently abandoned
his family for months at a time, speaks bitterly about begging his father to allow him and his
brother to go to school, and about his refusal to do so. Shibu, who has two daughters, constantly
worries about their future, and considers himself weak because his wife has to work
There is shame involved in not being independent as well as not being able to support one’s
family. Some male servants regret that their wives have to work, and some lie to their in-laws
about their employment Achin’s in-laws, for example, do not know that their daughter works
outside the home and they think he is a chaufieur-a job that has more dignity and more
independence. Chauffeurs (or drivers, as they are called in India) occupy an intermediary space
between paradhin and swadhin work. They are skilled, and they work outside the home. He
know-s that his daughter tells her friends that he is a chauffeur as well. He is embarrassed, but
he understands his daughters need to tell her friends her father does more bhadra (civilized)
work than he does.
On responsibility and sacrifice. Not all male servants accept that they are less than men
because they do paradhin work and because their wives work Rather than accepting failure by
the standards of upper-caste Bengali bhadralok masculinity, Kamal, and others like him,
actively counter the disparagement of their w’ork and life by redefining the notion of a good
man.
About forty’ years of age, Kamal has been working for the same family for over twenty years.
When his male employer died, the widow became increasingly dependent on him Today, he
says, he does everything from washing dishes to bank-related errands. His wife works part-time
for the same family. He earns well compared with the other male domestics I spoke with, and
his employer helps his daughter with her homework in her apartment. He appeared both
confident and resigned and spoke calmly about the decisions he had made about his life. "What
does it matter what work I do as long as I can cany out my responsibilities to my family? There
is no good work or bad work, just well-paid work and badly paid work" Here he effectively
bypasses the caste system and the bhadralok disparagement of menial labor. What matters is
not the substance of the work but whether it enables one to put food on the table. Kamal thus
sees himself as the w-orker of capitalism, the contractual worker.
When I asked him what troubled him most about his life, he quickly responded that he didn’t
feel troubled. Many think "there is no dignit} in this work.” I don’t have that attitude at all. If I
can do it well and earn enough to support my family, then I am willing to do anything.... I don’t
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agree that there is a difference between this work and others. Some feel revulsion (ghenna) that
a man should do "domestic work" but not me. People think sweeping, mopping, and washing
dishes are women’s work. But why shouldn’t all people do everything? I find that 99 out of 100
people feel ghenna, but I am not like this.
Well aware that the image of men doing women’s work stirs feelings of revulsion in many
people, he steadfastly refuses to participate in a culture of shame. Instead, he has made the idea
of supporting his family central to his sense of self.
Kamal knows full well that his is not swadhin work and that he is dependent on his employer.
However, he has schooled himself to react not as a man who is being made to serve but as a
man who has a responsibility toward his family who depend on him, and who therefore controls
traditionally male reflexes. Many male servants spoke wistfully about their desire to be drivers,
and regretted their continued domestic work, but Kamal was firm about his choices. As a
father, he feels that his daughter is safer in the apartment building where he works than she
would be in the slum in which they' would otherwise live. Without delusion and with some
resignation, Kamal has thought carefully about his life circumstances. He is socially ambitious
but knows that the most likely candidate to escape this life is not himself or his wife, but their
daughter. He urges her to be serious about her studies and scrapes together money for her dance
lessons. He compares himself with other fathers in the building and knows that he is a better
father than most, despite his financial constraints. Employers in the apartment building talk
about his daughter with some admiration, and he sees in their eyes an expectation that she will
make it. That is Kamal's source of pride. He is a good man because he has succeeded in being a
good father. Indeed, by a sleight of hand, he manages to conflate fatherhood with manhood.
For several male domestics, the feeling of pride comes from having done their duty. By doing
paradhin work, they have ensured that nobody else in their family ever will again. Dipu says: "I
have been working since I was twelve not as swadhin, but in othefs houses. Naturally I have
had to take the employers' wrath. I told my sons that as long as I am alive, they can study and
then could get [white-collar jobs). They want it and I want it for them. I do not want that my son
should work in your house." His sons are in college, his brothers work in the local government
offices, and his daughter is married. He was able to pay for funeral ceremonies after his father
died, and he sends money home to his mother.
Thus the admirable man sacrifices his masculinity in order to ensure the survival of his charges.
Although the warrior who sacrifices his life so his people may five is considered a man and a
hero, one who fives to ensure that his people survive is commonly not. But Kamal, Dipu, and
others like them consider what they have done heroic. They have swallowed their pride and the
shame of their paradhin work so that their families will not tread that path. Unlike the male
servants of the past, they sacrifice their lives not for their employers' families but for their own.
CONCLUSION
The women and men whose life stories appear here often work twelve- to sixteen-hour days,
cooking and cleaning, sweeping and mopping, dusting twice a day to remove the layers of dust
that cover every item of furniture in the tropics, running errands, polishing silver, grinding
spices, washing clothes by hand, wringing them out to dry, and taking care of other people's
children while praying that their own will be spared this life. They are the workers that the
lives of the middle classes are built on, yet the)' are the workers that no one w'ants to be.
I have argued in this article that domestic workers judge themselves by the extent to which they
have achieved or failed to achieve hegemonic gender norms. Domestic work in Calcutta, and
indeed, in India, is individualized, unorganized, and made familial. Unions are either not
interested in organizing these workers or give up after initial attempts, because the dispersed
workplaces make collective action difficult. This is particularly true of those who do live-in
work. Given this, and the extreme stigmatization of this occupation, it is not surprising that
these domestic workers minimize their identities as workers and instead think of themselves as
women and men, mothers and fathers, wives and husbands, daughters and sons. These are not,
however, the only alternate identities that domestic servants can choose. In other parts of India,
where there are powerful political parties and organizations representing lower castes (such as
in the state of Bihar), domestic workers could make their caste identities primary. In Calcutta,
however, domestic workers, by and large, lack caste or class representation.
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I have also argued that although the workers do focus on gendered identities, it would be a
mistake to romanticize these constructions as resistance, for they do not invent the content of
these identities as they please. Their identities are constituted through their class location, the
work they do, and their particular relationship to a domestic space, which is also their place of
work. Unlike the Mukkuvar fishermen and women, or factory workers, live-in domestic
workers have Utile autonomous space outside bhadralok culture. (43] Unlike part-time workers,
they have no homes to which to return at the end of the day. They are therefore materially and
discursively constrained within a universe that is not of their own making
Yet, if there is a common thread between Mitali's, Lakshmi's and Kamal’s narratives, it lies in
the way in which they represent themselves. None has had the chance to tell "their story" before
this, and they are not interested in a story of victimhood, although it is against that backdrop
that they want others to understand their tales. They want their agency, their ability to exercise
choice in the midst of lives usually bereft of choice, to be appreciated. As I return to my
question then, I choose neither structure nor agency but, rather, end with partial failures,
defeats, and victories.
Bhadralok society can idealize particular notions of femininity and masculinity precisely
because the subaltern classes cannot attain them; however, Uve-in domestic workers struggle
with these ideals and try to fit their fives within them. Regardless of whether the}7 ultimately
accept or reject the bhadralok evaluation of themselves, they judge their lives by the very ideals
which were designed to be out of their reach. Yet they also reach out to ideas culled from
popular discourse and classic myth-ideas of love and responsibility. They hold on to ideas
about womanhood and manhood that allow them hope and pride, which bhadralok ideology
does not do. And in this process, female and male domestic workers are simultaneously
defeated by and partially victorious over hegemonic gender ideologies.
Raka Ray is associate professor of sociology and South and Southeast Asian Studies at the
University of California at Berkeley. She is the author of Fields of Protest Women's
Movements in India (University of Minnesota Press, 1999; Kali for Women, 2000).
NOTES
Research for this study was partially funded by the Chancellor’s Research Grant, University of
California-Berkeley', fd like to thank Seemin Qayum, with whom the larger project is conceived
and conducted, for the many conversations and insights which helped shape this article; Barrie
Thome and Michael Burawoy for reading earlier drafts; Nirmala Banerjee and Gautam Bhadra
for their time and ideas; Bharati Ray and Ashok Bardhan for adding clarity, and my research
assistant Roya Razaghian. fm also grateful to the Feminist Studies reviewers for their
thoughtful comments.
(1.) V. Tellis-Nayak, "Power and Solidarity: Clientage in Domestic Service," Current
Anthropology 24 (February' 1983): 67-74.
(2.) Anna Rubbo and Michael Taussig, "Up Off Their Knees: Servanthood in South-West
Columbia," Latin American Perspectives 39 (fall 1983): 2-23.
(3.) See, for example, Julia Wrigley; Other People's Children (New York: Basic Books, 1995);
Bonnie Thornton DilL Across the Boundaries of Race and Class: An Exploration of Work and
Family among Black Female Domestic Servants (New York: Garland, 1994); Carole Turbin,
"Domestic Service Revisited: Private Household Workers and Employers in a Shifting
Economic Environment," International Labor and Working Class History 47 (spring 1995): 91100, Mary' Romero, Maid in the U.S.A (New York. Routledge, 1992), Judith Rollins, Between
Women: Domestics and Their Employers (Philadelphia: Temple University Press, 1985);
Pierette Hondagneu-Sotelo and Cristina Riegos, "Sin Organizacion, No Hay Solucion: Latina
Domestic Workers and Non-Traditional Labor Organizing," Latino Studies Journal 8 (fall
1997): 54-83. Evelyn Nakano Glenn's Issei, Nissei War Bride: Three Generations of Japanese
American Women in Domestic Service (Philadelphia. Temple University Press, 1986) is a
powerful exception. More recently, Pierette HondagneuSo telo and Ernestine Avila address the
ways in which migrant domestic workers try' to mother their children from afar. See "Tm Here,
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but fm There': The Meanings of Latina Transnational Motherhood," Gender and Society 11
(October 1997): 548-71.
(4.) See, for example, Dipesh Chakrabarty, Rethinking Working-Class History’: Bengal, 18901940 (Princeton: Princeton University Press, 1989); Leela Fernandes, Producing Workers: The
Politics of Gender, Class, and Culture in the Calcutta Jute Mills (Philadelphia: University of
Pennsylvania Press, 1997); and Samita Sen, Women and Labour in Late Colonial India: The
Bengal Jute Industry (Cambridge: Cambridge University Press, 1999).
(5.) Gillian Hart, "Engendering Everyday Resistance. Gender, Patronage, and Production
Politics in Rural Java," Journal of Peasant Studies 19 (October 1991). 93-121; and Karin
Kapadia, Siva and Her Sisters: Gender, Caste, and Class in Rural South India (Boulder:
Westview Press, 1995).
(6.) In the late nineteenth century in Colonial Bengal, the Bengali elite lost their power over
their land and had to turn increasingly to professional, administrative, and clerical employment.
See Mrinalim Smha, Colonial Masculinity’: The Manly Englishman' and the ’Effeminate
Bengali' in the Late Nineteenth Century' (Manchester and New York: Manchester University
Press, 1995); and Sumit Sarkar, Writing Social History (Delhi: Oxford University Press, 1997).
(7.) Of the fifteen servants, eight are women and seven are men. They are all first-generation
domestic workers, who came to Calcutta from the rural areas of Bengal either because their
land could not sustain them or, in the case of the women, because they were married. Most are
lower castes, two are Brahmin (a married couple), and one man is Christian. Three women are
separated from their husbands, one is widowed, and the others are married. All the men are
mamed, although two do not live with their wives. They range in age from thirty to sixty-six
and have been working between seven and thirty years.
The employers are primarily upper middle class, upper caste, and Bengali. They live in old
bungalows and apartment buildings and work in the corporate world and the professions. The
youngest employer was thirty and the oldest, eighty. All of them grew’ up with servants, and
none has been without servants for a long stretch of time. All interview's were open-ended
conversations. The interview's with employers were conducted jointly by Seemin Qayum (from
the University of London) and myself and lasted from one to four hours, with the average being
two and a half hours.
I interviewed live-in workers at the sites they chose, usually their "quarters" in the apartment
buildings of their employers. It was more difficult to interview' the workers than employers for
several reasons. Because they are live-in workers, they are constantly at the beck and call of
their employers and have little time to spare. Most workers have between one and three hours
off in the afternoon. This is the time they use to shower, eat their lunch, sleep, or do their own
errands. They were rarely free at night before 10 p.m. Thus, I often started conversations in the
afternoon and completed them at night. Worker interviews were conducted in Bengali.
Why would domestic serv’ants agree to speak with me, since I am clearly of the emplover class?
There is no simple answer to this question. I entered the ''field" with the help of a domestic
servant I have known and talked with for many years. He introduced me to my first three
interview ees who, in turn, led me to others. Because I was recommended to them by people
they trusted, were they initially more open to me? Or w'as it the substance of the questions that
convinced them that I was safe? Perhaps it is the intensity’ of their desire to speak and the lack
of opportunity to do so that made the barriers fall. Although most interview's with employees
started out slow ly, soon I could barely keep up with note taking, as the workers, especially the
women, spilled out their life stories. One woman said that my intentions were good, but the
people who really needed to read my book (such as her employer) would not. "You see," she
said, "They probably' think 'Why w-ould anyone write a book about those people? Such people
have no conscience. Can you really reach them?"
(8.) See, for example, Lesley Gill, Precarious Dependencies: Gender, Class, and Domestic
Service in Bolivia (New York: Columbia University Press, 1994); Elsa Chaney and Mary
Garcia Castro, Muchachas No More: Household Workers in Latin America and the Caribbean
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(Philadelphia: Temple University Press, 1989), Christine B.N. Chin, "Walls of Silence and
Late-Twentieth Century' Representations of the Foreign Female Domestic Worker The Case of
Filipina and Indonesian Female Servants in Malaysia," International Migration Review 31
(summer 1997): 353-85. Indeed, despite the fact that their own data show that there are many
thousands of male domestic servants in India, a study sponsored by the Catholic Bishops’
Conference of India (CBCI) declares: "In Indian tradition, females are most often involved in
domestic chores" and claims that in most cases employers prefer female servants because of the
idea that women are more "submissive, polite, and loyal" (CECI, 1980, 31).
(9.) Domestic servants have historically been male in Africa. See Karen Hansen, African
Encounters with Domesticity' (New Brunswick, N.J.: Rutgers University Press, 1992).
(10.) As Ruth Milkman and her colleagues have persuasively argued, "a crucial determinant of
the extent of employment in paid domestic labor in a given location is the degree of economic
inequality there." See Ruth Milkman, Ellen Reese, and Benita Roth, "The Macrosociology' of
Paid Domestic Labor," forthcoming in Work and Occupations 25 (November 1998): 453-510.
(11.) See the Census of India, 1971 and 1981, Series 1, India, Part HI-B (iii) General Economic
Tables, 1981. However, this is a vastly undercounted number because the census includes only
maids and other house cleaners (category7 531) but not cooks, ayahs (nannies), or any other
category of domestic worker. In addition to women and men, this class comprises thousands of
children, both girls and boys, who work as domestic servants, whom the Census leaves out.
According to a study commissioned by the CBCL, 16.65 percent of the domestic servants
interviewed were under the age of fifteen. See Catholic Bishops' Conference of India, A
National Socio-Economic Survey of Domestic Workers (Madias: Catholic Bishops' Conference
of India Commission for Labour, 1980), 36.
(12.) Census of India, 1981, Tamil Nadu Series 20, part in A&B (ii); Census of India, 1981,
Maharashtra, Series 12, part DI A&B (iii); Census of India, 1981, Uttar Pradesh, Series 22, part
HI A&B (v); Census of India, 1981, West Bengal, Series 23, part DI A&B (ii).
(13.) Nirmala Baneijee, Women Workers in the Unorganized Sector The Calcutta Experience
(Hyderabad, India: Sangam Books, 1985); and Bela Bandopadhyay, interview with author,
Calcutta, 22 Jan 1998.
(14.) Gautam Bhadra, interview with author, 7 Jan. 1998.
(15.) Robert W. Connell, Masculinities (Berkeley and Los Angeles: University of California
Press, 1995).
(16.)Sarkar, 170.
(17.) For other writings on the bhadralok, see Sumanta Banerjee, The Parlour and the Streets:
Elite and Popular Culture in Nineteenth-Century Calcutta (Calcutta: Seagull Books, 1989); and
Rabindra Ray, The Naxalites and Their Ideology (Delhi. Oxford University Press, 1988).
(18.) Baneijee, Parlour and the Streets.
(19.) Perhaps because they resisted the British through the intellect rather than the sword, the
bhadralok were defined by the British as effete, the opposite of both the British gentleman and
the loyal Pathan warriors. This charge of effeminacy applied specifically to the Bengali elite
and not to Bengali workers or peasants. See Sinha, 16. The British wondered at these "softbodied little people" who could nonetheless compete successfully against the British in the civil
service exams and become the salaried workers, professionals, and civil servants that form the
core of the Bengali postcolonial elite. See John Rosselli, "The Self-Image of Effeteness:
Physical Education and Nationalism in Nineteenth-Century Bengal," Past and Present 86
(February7 1980): 121-48.
(20.) Partha Chatterjee, "Nationalist Resolution of the Woman Question," in Recasting Women:
Essays in Indian Colonial History, ed. Kumkum Sangari and Sudesh Vaid (Delhi: Kali for
..AMASCUL1N1TY, FEMININIT Y AND SERVIT UDE DOMESTIC WORKERS IN CALCUTT A IN THE LATE T WENT1ETH 12/15/01
lib
Feminist Studies: MASCULINITY,DOMESTIC WORKERS IN CALCUTTA IN THE LATE TWENTIETH CENTURYPage 16 of 17
Women, 1989), 233-53.
(21.) Chatteijee.
(22.) Hrmani Banerjee, "Attired in Virtue: The Discourse on Shame (lajja) and Clothing of the
Bhadramahila in Colonial Bengal," in From the Seams of History, ed. Bharati Ray (Delhi:
Oxford University Press, 1995), 81.
(23 .) Census of India, 1991, Series L, Provisional Population Tables.
(24.) Hilary Standing, Dependence and Autonomy: Women’s Employment and the Family in
India (London and Princeton: Princeton University' Press, 1984).
(25.) Ibid. , and Meredith Borthwick, The Changing Role of Women in Bengal, 1849-1905
(New York: Routledge, 1991). For a fascinating study of the advice given to middle-class
women hiring servants at the turn of the century, see Swapna Banerjee, "Exploring the World
of Domestic Manuals: Bengali Middle-Class Women and Servants in Colonial Calcutta," in
Sagar South Asia Graduate Research Journal 3, no. 1 (1996).
(26.) Swadhinata here refers to a specific relationship to work. It is not so much the fact that
one works for someone else that prevents one from being swadhin. People who work in offices
do work for someone else. But, rather, it is the fact of having to be on call all day and be unable
to go home at the end of the day, which makes one paradhin (unfree). While both employers
and servants use this word, the servants use it repeatedly, as we shall see.
(27.) Hansen reports a similar dynamic in Zambia. In Janet Bujra's study of Tanzania, only two
out of the sixty employers interviewed thought women were better servants. See Janet Bujra,
"Men at Work in the Tanzanian Home: How Did They Ever Learn?" in African Encounters with
Domesticity, 242-65.
(28.) Bengali landlords, for example, frequently used lower-caste men to fight off rivals and
frighten tenants. See Roselli.
(29.) I am grateful to the anonymous reviewer who reminded me of this point.
(30.) James Scott, Weapons of the Weak (New Haven: Yale University Press, 1995).
(31.) Kapadia; Kalpana Ram, Mukkuvar Women: Gender, Hegemony, and Capitalist
Transformation in a South Indian Fishing Community (Delhi: Kali for Women, 1992).
(32.) Paul Willis, Learning to Labour (1977, Aidershot, England. Gower, 1981).
(33.) See, for example, Luisa Passerini, Autobiographies of a Generation: Italy, 2968 (Hanover,
N.H.: Wesleyan University Press, 1996); and Barbara Laslett and Barrie Thome, eds.. Feminist
Sociology: Life Histories of a Movement (New Brunswick, N.J.: Rutgers University Press
1997).
(34.) Fernandes; and Standing.
(35.) Psychologist Sudhir Kakar concludes, following his interviews with two working-class
women in Delhi, that despite their many hardships, there is nothing to dim the luminosity of
their romantic longings." See Sudhir Kakar, The Indian Psyche (Delhi: Viking India/Penguin,
1996), 71.1 would argue that it is not just romantic love to which they cling but rather to the
idea of being acknowledged, recognized, and appreciated.
(36.) The literature on domestic workers in Latin America emphasizes young women's desire
for autonomy as well. See Elisabeth Jelin, "Migration and Labor Force Participation of Latin
American Women: The Domestic Servants in the Cities," Signs 3 (spring 1977): 129-41.
AMASCULINH Y, FEMlNINI'l Y AND SERVITUDE DOMESTIC WORKERS IN CALCUT1A IN THE LAIE 1WEN11ETH 12/15/01
Feminist Studies: MASCULINITY,DOMESTIC WORKERS IN CALCUTTA IN THE L^TE TWENTIETH CENTURY Page 17 of 17
(37.) Jessica Benjamin, Like Subjects, Love Objects: Essays on Recognition and Sexual
Difference (New Haven: Yale University Press, 1995), 33.
(38.) Lakshmi uses the same Bengali word bhalobasha to refer to the affections of her employer
and husband.
(39.) Manisha Roy, Bengali Women (Chicago and London: University of Chicago Press, 1972).
(40.) See, for example. Hum Aapke Hai Kaun? (Who am I to you?) and Dilwale Dulhaniya Le
Jayenge (The gallant one uill win the bride), two of the most popular Hindi films in recent
years.
(41.) Rubbo and Taussig.
(42.) See also Hansen.
(43.) Ram.
COPYRIGHT 2000 Feminist Studies, Inc.
in association uith The Gale Group and LookSmart. COPYRIGHT 2001 Gale Group
..AMASCULINH Y, FEMININITY AND SERVITUDE DOMES TIC WORKERS IN CALCUTTA IN THE LATE 1WEN TILTH 12/15/01
Fausto-StcHing, A. (1997). How to Build a Man. In R. N. Lancaster and M. di Leonardo (Eds.), The
Oender/Sexuality Reader. New York: Routledge, pp. 244-248
16
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Anne Fausto-Sterling
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How to Build a Man
[245]
structures. In the 1950s, Money extended these embryological understandings into the realm of
psychological development. As he saw it, all humans start on the same road, but the path rapidly
begins to fork. Potential males take a series of turns in one direction, potential females in another.
In real time, the road begins at fertilization and ends during late adolescence. If all goes as it
should, then there are two, and only two, possible destinations—male and female.
But, of course, all does not always go as it should. Money identified the various forks in the
road by studying individuals who took one or more wrong turns. From them, he derived a map
of the normal. This is, in fact, one of the very interesting things about biological investigators.
They use the infrequent to illuminate the common. The former they call abnormal, the latter
normal. Often, as is the case for Money and others in the medical world, the abnormal requires
management. In the examples I will discuss, management means conversion to the normal. Thus,
we have a profound irony. Biologists and physicians use natural biological variation to define nor
mality. Armed with this description, they set out to eliminate the natural variation that gave them
their definitions in the first place.1
How does all this apply to the construction of masculinity? Money lists ten road signs direct
ing a person along the path to male or female. In most cases these indicators are clear, but, as in
any large city these days, graffiti sometimes makes them hard to read and the traveler ends up
taking a wrong turn. The first sign is chromosomal sex, the presence of an X or a Y chromosome.
The second is gonadal sex: when there is no graffiti, the Y or the X instructs the fetal gonad to
develop into a testis or an ovary. Fetal hormonal sex marks the third fork: the embryonic testis
must make hormones that influence events to come—particularly the fourth (internal morphologic
sex), fifth (external morphologic sex), and sixth (brain sex) branches in the road. All of these, but espe
cially the external morphologic sex at birth, illuminate the road sign for step number seven, sex
of assignment and rearing. Finally, to become either a true male or a true female in John Money s
world, one must produce the right hormones at puberty (pubertal hormonal sex), acquire and
express a consistent gender identity and role, and, to complete the picture, be able to reproduce in
the appropriate fashion (procreative sex).2
Many medical texts reproduce this neat little scheme, and suggest that it is a literal account of
the scientific truth, but they neglect to point out how, at each step, scientists have woven into the
fabric their own deeply social understandings of what it means to be male or female. Let me
illustrate this for several of the branches in the road. Why is it that usually XX babies grow up to
be female while XYs become male? Geneticists say that it is because of a specific Y chromosome
gene, often abbreviated SDY (for “Sex-Determining Gene” on the Y). Biologists also refer to the
SDY as the Master Sex-Determining Gene and say that in its presence a male is formed. Females,
on the other hand, are said to be the default sex. In the absence of the master gene, they just nat
urally happen. The story of the SDY begins an account of maleness that continues throughout
development. A male embryo must activate this master gene and seize its developmental pathway
from the underlying female ground plan.
When the SDY gene starts working, it turns the indifferent gonad into a functional testis. One
of the first things the testis does is to induce hormone synthesis. It is these molecules that take
control of subsequent developmental steps. The first hormone to hit the decks (MIS, or Muller
ian Inhibiting Substance) suppresses the development of the internal female organs, which lie in
wait ready to unveil their feminine presence. The next, fetal testosterone, manfully pushes other
embryonic primordia to develop both the internal and external trappings of physical masculinity.
Again, medical texts offer the presence/absence hypothesis. Maleness requires the presence of
special hormones; in their absence, femaleness just happens.3
this point, two themes emerge. First, masculinity is an active presence that forces itself
onto a feminine foundation. Money sometimes calls this “The Adam Principle—adding some
thing to make a male. Second, the male is in constant danger. At any point male development
can be derailed; a failure to activate SDY, and the gonad becomes an ovary; a failure to make MIS,
lU?
[246]
Anne Fausto-Sterling
and the fetus can end up with fallopian tubes and a uterus superimposed on an otherwise male
body; a failure to make fetal testosterone, and, despite the presence of a testis, the embryo devel
ops the external trappings of a baby girl. One fascinating contradiction in the scientific literature
illustrates my point. Most texts write that femaleness results from the absence of male hormones,
yet at the same time scientists worry about how male fetuses protect themselves from being femininized by the sea of maternal (female) hormones in which they grow.4 This fear suggests, of
course, that female hormones play an active role, after all; but most scientists do not pick up on
that bit of logic. Instead, they hunt for special proteins the male embryo makes in order to pro
tect itself from maternally induced feminization. (It seems that mother is to blame even before
birth.)
Consider now the birth of a boy-child. He is perfect: Y chromosomes, testes descended into
their sweet little scrotal sacs, a beautifully formed penis. He is perfect—except that the penis is
very tiny. What happens next? Some medical texts refer to a situation such a this as a social emer
gency, others see it as a surgical one. The parents want to tell everyone about the birth of their
baby boy; the physicians fear he cannot continue developing along the road to masculinity. They
decide that creating a female is best. Females are imperfect by nature, and if this child cannot be
a perfect or near-perfect male, then being an imperfect female is the best choice. What do the cri
teria physicians use to make such choices tell us about the construction of masculinity?
Medical managers use the following rule of thumb:
Genetic females should always be raised as females, preserving reproductive potential, regardless of
how severely the patients are virilized. In the genetic male, however, the gender of assignment is
based on the infant s anatomy, predominantly the size of the phallus.^
Only a few reports on penile size at birth exist in the scientific literature, and it seems that
birth size in and of itself is not a particularly good indicator of size and function at puberty. The
average phallus at birth measures 3.5 cm (1 to 1.5 inches) long. A baby boy born with a penis
measuring only 0.9 inches raises some eyebrows, but medical practitioners do not permit one
born with a penis less than 0.6 inches long to remain as a male.6 Despite the fact that the intact
organ promises to provide orgasmic pleasure to the future adult, it is surgically removed (along
with the testes) and replaced by a much smaller clitoris which may or may not retain orgasmic
function. When surgeons turn “Sammy” into “Samantha,” they also build her a vagina. Her pri
mary sexual activity is to be the recipient of a penis during heterosexual intercourse. As one sur
geon recently commented, “Its easier to poke a hole than build a pole.*’
All this surgical activity goes on to ensure a congruous and certain sex of assignment and sex
of rearing. During childhood, the medical literature insists, boys must have a phallus large enough
to permit them to pee standing up, thus allowing them to “feel normal” when they play in little
boys peeing contests. In adulthood, the penis must become large enough for vaginal penetration
during sexual intercourse. By and large, physicians use the standard of reproductive potential for
making females and phallus sizes for making males, although Suzanne J. Kessler reports one case
of a physician choosing to reassign as male a potentially reproductive genetic female infant rather
than remove a well-formed penis.7
At birth, then, masculinity becomes a social phenomenon. For proper masculine socialization
to occur, the little boy must have a sufficiently large penis. There must be no doubt in the boys
mind, in the minds of his parents and other adult relatives, or in the minds of his male peers
about the legitimacy of his male identification. In childhood, all that is required is that he be able
to pee in a standing position. In adulthood, he must engage in vaginal heterosexual intercourse.
The discourse of sexual pleasure, even for males, is totally absent from this medical literature. In
fact, male infants who receive extensive penile surgery often end up with badly scarred and thus
physically insensitive members. While no surgeon finds this outcome desirable, in assigning sex to
143
How to Build a Man
[247]
an intersexual infant, sexual pleasure clearly takes a backseat to ensuring heterosexual conven
tions. Penetration in the absence of pleasure takes precedence over pleasure in the absence of
penetration.
In the world ofJohn Money and other managers of intersexuality, men are made, not born.
Proper socialization becomes more important than genetics. Hence, Money and his followers
have a simple solution to accidents as terrible as penile amputation following infant circumcision:
raise the boy as a girl. If both the parents and the child remain confident of his newfound female
identity, all will be well. But what counts as good mental health for boys and girls? Here, Money
and his coworkers focus primarily on female development, which becomes the mirror from
which we can reflect the truth about males. Money has published extensively on XX infants born
with masculinized genitalia. Usually such children are raised as girls, receiving surgery and hor
monal treatments to feminize their genitalia and to ensure feminine puberty. He notes that fre
quently such children have a harder time than usual achieving clarity about their femininity. Some
signs of trouble are these: in the toddler years, engaging in rough-and-tumble play, and hitting
more than other little girls do; in the adolescent years, thinking more about having a career and
fantasizing less about marriage than other little girls do; and, as an adolescent and young adult,
having lesbian relationships.
The homologue to these developmental variations can be found in Richard Greens descrip
tion of the “Sissy Boy Syndrome.” Green studied little boys who developed “feminine” inter
ests—playing with dolls, wanting to dress in girls’ clothing, not engaging in rough-and-tumble
play. These boys, he argued, are at high risk for becoming homosexuals. Moneys and Greens
ideas work together to present a picture of normality. And, surprise, surprise, there is no room in
the scheme for a normal homosexual. Money makes a remarkable claim. Genetics and even hor
mones count less in making a man or a woman than does socialization. In sustaining that claim,
his strongest evidence, his trump card, is that the child born a male but raised a female becomes
a heterosexual female. In their accounts of the power of socialization. Money and his coworkers
defined heterosexual in terms of the sex of rearing. Thus, a child raised as a female (even if bio
logically male) who prefers male lovers is psychologically heterosexual, although genetically she
is not.
Again, we can parse out the construction of masculinity. To begin with, normally developing
little boys must be active and willing to push one another around; maleness and aggression go
together. Eventually, little boys become socialized into appropriate adult behavior, which includes
heterosexual fantasy and activity. Adolescent boys do ’not dream of marriage, but of careers and a
professional future. A healthy adolescent girl, in contrast, must fantasize about falling in love,
marrying, and raising children. Only a masculinized girl dreams of a professional future. Of
course, we know already that for men the true mark of heterosexuality involves vaginal penetra
tion with the penis. Other activities, even if they are with a woman, do not really count.
This might be the end of the story, except for one thing. Accounts of normal development
drawn from the study of intersexuals contain internal inconsistencies. How does Money explain
the higher percentage than normal of lesbianism, or the more frequent aggressive behavior among
masculinized children raised as girls? One could imagine elaborating on the socialization theme:
parents aware of the uncertain sex of their children subconsciously socialize them in some inter
mediary fashion. Shockingly for a psychologist, however. Money denies the possibility of sub
consciously driven behavior. Instead, he and the many others who interpret the development of
intersexual children resort to hormonal explanations. If an XX girl, born with a penis, surgically
corrected” shortly after birth, and raised as a girl, subsequendy becomes a lesbian. Money and
others do not look to faulty socialization. Instead, they explain this failure to become heterosex
ual by appealing to hormones present in the fetal environment. Excess fetal testosterone caused
the masculinization of the genitalia; similarly, fetal testosterone must have altered the developing
brain, readying it to view females as appropriate sexual objects. Here, then, we have the last bit of
144
[248]
Anne Fausto-Sterling
the picture painted by biologists. By implication, normal males become sexually attracted to
females because testosterone affects their brain during embryonic development. Socialization
reinforces this inclination.
Biologists, then, write texts about human development. These documents, which take the
form of research papers, textbooks, review articles, and popular books, grow from interpretations
of scientific data. Often written in neutral, abstract language, the texts have the ring of authority.
Because they represent scientific findings, one might imagine that they contain no preconcep
tions, no culturally instigated belief systems. But this turns out not to be the case. Although based
in evidence, scientific writing can be seen as a particular kind of cultural interpretation—the
enculturated scientist interprets nature. In the process, he or she also uses that interpretation to
reinforce old or build new sets of social beliefs. Thus, scientific work contributes to the con
struction of masculinity, and masculine constructs are among the building blocks for particular
kinds of scientific knowledge. One of the jobs of the science critic is to illuminate this interac
tion. Once this is done, it becomes possible to discuss change.
Notes
1.- In the 1950s Dr. John Money argued that gender was merely a matter of body image and upbring
ing. One of his most dramatic cases, offered over and over again in defense of his viewpoints, was a
pair of twin boys. One suffered a circumcision accident at the age of eight months and lost his
penis. Money decided to raise this child as a girl, advised that “she” be castrated, given reconstruc
tive genital surgery, and at puberty be given female hormones. Money claimed that this child easily
assumed a female identity and grew into a woman who accepted her gender identity. Recendy,
however. Dr. Milton Diamond and Keith Sigmundson (Archives of Pediatric and Adolescent Medicine,
March 1997) found and interviewed Money’s patient, now in his thirties. In fact he never accepted
his female identity, and as a teenager demanded to learn his whole medical history and decided to
continue life as a male, even though he did not have a functional penis. This case report made the
front pages of the New York Tinies and a debate now rages about how to interpret this new informa
tion.
2. For a popular account of this picture, see John Money and Patricia Tucker, Sexual Signatures: On
Being a Man or a Woman (Boston: Litde, Brown, 175).
3. The data do not actually match the presence/absence model, but this does not seem to bother most
people. For a discussion of this point, see Anne Fausto-Sterling, “Life in the XY Corral,” Women’s
Studies International Forum 12 (1989): 319—31; Anne Fausto-Sterling, “Society Writes Biology/Biology Constructs Gender,” Daedalus 116 (1987): 61-76; and Anne Fausto-Sterling, Myths of Gender:
Biological Theories about Women and Men (New York: Basic Books, 1992).
4. I use the phrase “male hormone” and “female hormone” as shorthand. There are, in fact, no such
categories. Males and females have the same hormones, albeit in different quantities and sometimes
with different tissue distributions.
5. Patricia Donahoe, David M. Powell, and Mary M. Lee, “Clinical Management of Intersex Abnor
malities,” Current Problems in Surgery 8 (1991): 527.
6. Robert H. Danish, Peter A. Lee, Thomas Mazur, James A. Amrhein, and Claude J. Migeon, “Mi
cropenis II: Hypogonadotropic Hypogonadism,” Johns Hopkins Medical Journal 146 (1980): 177—84.
7. Suzanne J. Kessler, “The Medical Construction of Gender: Case Management of Intersexed
Infants,” Signs 16 (1990).
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The other dimensions of thought which have gone into the Indian family
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women have relevance even when under-privileged; are strong, not weak; and
that they continue to be the acknowledged repository of unknown, unseen yet
tangible elements of human power.
Tara Ali Baig, India's Woman Power}
The specific interests which distinguish the Indian women’s movement from
those of the Western countries arise from India’s distinct cultural traditions and
social structure. Having established that the influence of British colonialism
was not unambiguously progressive in terms of women’s liberation, it is
nevertheless tempting to think that women’s resistance to male domination in
India was initiated by the British women who started the women’s organisations
and helped to define their aims. But just as the impact of colonial domination on
women was complex and contradictory, so too the influence of the British
women’s movement was not a simple importation of the Western organisation,
but represented a single intervention within the totality of Indian history.
Women’s resistance to oppression in India neither began nor ended with the
British women’s intervention, but had its roots in the Indian social structure and
cultural heritage.
This heritage both preceded and followed on from the British women’s
initiatives, which meant that the two movements had very different starting
points and developed in distinctive directions. The common strand was that in
both countries the institutions of male supremacy supported male privilege, but
the forms of male supremacy were different in each case, with different
1 implications for the formation of gender relations and the development of
women’s resistance. The specific form of male supremacy in India affected
men’s views and treatment of women, as well as how women saw themselves
and constructed their demands.
We have made the comparison between India and the West, not to examine
the historical roots of Western women’s subordination,2 but to draw attention to
the distinct character of the movement for women’s liberation in India, so that
we can understand the women who are the subject of this study, and so that
today’s women’s movements in the West might learn from and be inspired by
bi\tor,f and bx>rit?°e of women in Tndia.
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Daughters of Independence
7. Patriarchy and the
Matriarchal Heritage
In Part II we will examine the roots of women’s inequality and of their
resistance in India, by looking at what we see as the major influences on the
formation of gender relations, that is, the development of the patriarchal form of
family organisation, the formation of the caste hierarchy, and the impact of
foreign domination. We will argue that:
One, the patriarchal form of family organisation and its associated ideology did
not emerge as a universally accepted or natural way of living, but was the scene
of a struggle, in which the patriarchal form gained dominance without a final
victory. This struggle reveals the historical l oots of women’s resistance to male
domination, and provides the basis for a distinct view of women as strong and
powerful;
Two, the subordination of women was crucial to the development of caste
hierarchy, the women being subject to increasing constraints the higher the
caste in the hierarchy. Caste, too, was the subject of struggle, and the anti-caste
movements were always associated with the removal of constraints on women.
The upper castes maintained their supremacy by incorporating some of the
opposing cultural traditions into their own, while increasing the social
distinction between themselves and the lower castes. These efforts illuminate,
the historical connection between women’s subordination and social hierarchy,
and provide the basis for strong physical controls over powerful women in a
patriarchal society;
Three, the impact of foreign domination on the formation of the social classes
had a contradictory effect on the position of women in the middle class. The
class structure appeared to build on the existing gender divisions within the
caste system, reinforcing women’s subordination though changing its form. But
it also allowed a small number of women from the urban, educated middle class
to survive independently of the patriarchal caste system in the higher levels of
waged work.
I
I
The Brahmins would have liked to annihilate the Shakti [female power principle]
cults altogether and replace the female with the male as the dominant and
superior principle. The roots of these cults ... are so powerful that they have
persisted even to this day ... We need to ... understand Shakti... as an energy
within ourselves which generates the power tov act.
Chandralekha, The Book Review3
As a result of these influences, we suggest that women’s desire for
emancipation in India did not stem primarily from the initiative of the British
women who started the movement, but from the way this intervention combined
with Indian women’s unique cultural heritage which provides a tradition of
women as strong and powerful beings, and with their position in the social
structure which offered them the possibility of an independent existence.
.r
50
■
i
I.
Women in India have a unique cultural heritage. It is not always easy, however,
to trace its history, since the best preserved stories are normally those of the
groups who achieved dominance. India’s earliest written history is recorded in
the Vedas, the religious books written by the priestly groups of the Aryan
speaking race, known as the brahmins. It was the males of these groups who
eventually achieved social and religious supremacy, although not without
opposition.
If we only look at the dominant groups’ history, we see only one side of the
story. To find the other stories we have to look at alternative sources such as
later written history, oral history, archaeological evidence, and surviving
religious practices and social organisation. This is particularly necessary in the
case of women’s history, since most written history is recorded by men and
represents predominantly male concerns. Piecing the picture together from
other sources indicates that male supremacy was not a natural or an inevitable
development in the history of gender relations, but was the result of a struggle
between the female power principle and the idea of the male as the dominant
source of power.
What is distinctive about this heritage compared with that of women in the
West is that although the male principle attained supremacy in both areas of the
world, in India the idea of women as powerful was accommodated into the
patriarchal culture and retained its visibility. It also remained strong amongst
certain sections of the population who opposed the patriarchal ideas of the
brahmins. The visibility of women’s power was maintained in Muslim cultures
too, as indicated by Fatima Memissi4 and Azizah Al-Hibri.5 We want to
examine the struggle over the male and female principles by identifying two
areas where it can be seen to have taken place. One of these is. in the different
forms of family structure, the other is in the different forms of religious
culture.
51
i
Daughters of Independence
We use the term patriarchy to refer to the particular system of family
organisation which includes patrilineal inheritance, the sons and daughters-inlaw staying in the father’s house, and the authority of the father over the women
and the younger men, supported by a cultural tradition which emphasises the
supremacy of the male power principle.6 We do not use it to refer to male
dominance, since we wish to distinguish betwen patriarchy as a specific family
system, and male dominance as a general system of sexual hierarchy.
The definition of matriarchy is as much in dispute as is the definition of
patriarchy.7 When we refer to the matriarchal heritage, we do not mean the
obverse of patriarchy, that is, a system of family organisation where mothers
have authority over men and the younger women. There is no evidence for a
matriarchy having existed anywhere in the world, in the sense of women’s rule
over men being embodied in the family or social structure.8 What we do mean
by the matriarchal heritage is a history of struggle where the idea of female
power was constantly reasserted through the religion and where family forms
giving women greater freedom existed despite the opposition of the dominant
patriarchal groups. The evidence for the struggle is found in the conflicts and
accommodations between different modes of religious thought, and between the
matrilineal and patrilineal family systems.
Matrilineal Family Organisation
The matrilineal systems of descent, although by no means constituting a
matriarchy, did provide the basis for a greater degree of freedom for women
compared with the patrilineal system. This freedom differed in its form and
extent in different matrilineal communities; we have already seen one example
amongst the Nayars of Kerala.9 The important factor is that matrilineal groups
depend on retaining a similar degree of control over both male and female
members, whereas control over women is much more severe than control over
men in patrilineal descent10 Kerala today has the highest female literacy rate,11
the highest ratio of females to males,12 and the second highest age of marriage
for women in India.13 These indices of women’s relatively better position in the
state of Kerala are normally attributed to the continued existence of the
matrilineal family and the associated cultural worth attached to women.14
When the Aryans migrated to India around 1500 B.C., they brought with
them the patrilineal form of family organisation, where the line of descent is
from father to son, and the women leave their father’s house on marriage to live
with the husband and father-in-law. The Aryans are believed to have destroyed
the superior civilisation which they encountered in the Indus Valley, in the north
west of the subcontinent, and gradually to have established dominance over the
Dravidians who were the indigenous inhabitants of the main peninsula.13
Many historians believe that the Aryans encountered matrilineal family
organisation amongst the indigenous people.16 This they deduce from
communities in outlying areas of India where matriliny has persisted. In the
South of the country, Kerala and Tamil Nadu certainly seem to have been
Gender and Hierarchy
I
I
1
matrilineal.17 We have already discussed the Nayars of Malabar, whose
matriliny survived to British times, but similar family forms continued amongst
almost all the communities in this region of Kerala, assisted no doubt by the
isolation created by the sea to the West and the mountains to the East.18 The
hills and forests of Travancore and Cochin and other parts of South India have a
number of tribes, of which many are matrilineal, some are patrilineal and others
use both systems, passing half the property to the sons and half to the sister’s
sons.19
In the Himalayas, the Khasis to the north and the Garos to the east are both
matrilineal.20 and there are matrilineal traces in the Brahui who live in
Baluchistan in the west of the subcontinent.21 The brahmin scriptures refer to the
Arattas in the Punjab, whose heirs are their sisters’ children, not their own, and
to a matrilineal system in Mahishmati in central India, where women could
choose a plurality of husbands.22 This was, of course, anathema to the
brahmins, where only men could have several spouses at once.
The struggle between the two family systems can best be seen in the division
of castes into two factions, the Right Hand and the Left Hand. Hutton
concludes that the division reflects the two descent systems, since the division
occurs throughout Dravidian South India except for Malabar, where the
patrilineal system barely penetrated. He suggests that the division signifies the
refusal of some matrilineal groups to accept the new patrilineal system:
I
The inference that the factions of the Right and Left Hand arose as a result of the
introduction of the [patrilineal) principle, which some castes were unwilling to
accept, is inescapable. The fact that the women of one or two castes belong to one
faction while the men belong to another does nothing to weaken this inference,
since there is nothing more likely than that the women of a caste might be
opposed to it while the men were wishful to adopt it.23
Hutton’s ‘inescapable’ inference illustrates not only the struggle between the
two family forms, but also the political divisions and the conflict of interest
between men and women associated with the two systems of descent. The
struggle in the structure of the family is paralleled by the struggle in the religious
culture between the male and the female deities as the dominant power
principle.
Matriarchal Religious Tradition
Many countries, including India, have matriarchal myths. Several writers have
warned that the myths, on examination, may confirm male superiority rather
than provide a history of female power, since they tell of how the women were
vanquished because they ruled irresponsibly.24 Consequently, it is important to
distinguish myth from reality,23 and to make clear the level at which myths are
significant Although the myths read like a story, they are not to be taken as a
history of what happened, but as a conceptual framework within which
people viewed the world. The religious myths and beliefs represent a cultural
!
Gender and Hierarchy
Daughters of Independence
’I
history, embodying a struggle over ideas, meanings and interpretations. The
persistence of the female power principle symbolises the continued visibility of
the power of women as part of the cultural heritage.
Before the arrival of the Aryans, the population of India is believed to have
consisted of agricultural communities who lived according to die seasons. God
was female, representing life in the form of the Earth Mother. The religion of
the Indus Valley was based on fertility, and the people worshipped the mother
goddess together with other fertility symbols, all of which are found m
Hinduism today.27 Terracotta figurines of the mother goddess, like those
excavated at Mohenjo-Daro in the Indus Valley, were also found at Buxar m
Bihar which suggests the extension of the Indus V alley culture, with its goddess
religion, into the Ganges valley in the North-east.28 Kali the destructive goddess
was also known in the Indus Valley, and the Shakti cult (female power) may be
traced back to this time.29 There may also be an early form of the god Shiva.
Kali and Shiva are pre-Ary an deities which became more important than Indra,
the major god of the early Aryan scriptures,31 indicating that the cultural
struggle for supremacy was by no means always resolved in favour of the
immigrants.
,
,
Apart from numerous goddesses, a snake cult associated with the mother
goddess is found in many regions of the South, and in the Himalayas to the
North. Devi, the goddess in the hills, is explicitly known as Devi Mata, the
mother goddess.32 Devi is important in local ceremonies all over India, but she is
also involved in the national Hindu festivals of Holi and Dasserah. The Holi
spring festival is associated with fertility rites and sexuality, and some of its
features are thought to go back to a prehistoric ‘matriarchal stage. At a local
level, one study showed that half of the 90 deities worshipped in the village
belonged to the ‘non-brahmin tradition’, and most of these were mother
goddesses.35 The ‘brahmin tradition’ consists of the specialist scriptures written
by the brahmins and requiring a guru for interpretation,36 although the rigid
division of the religion into two parts is not really tenable, since both ‘traditions
are a result of conflicts and compromises between the orthodox brahmins and
the common people.
*
Nevertheless, significant differences occur in the brahmin and the nonbrahmin’ traditions, which symbolise the opposition between the male and
female principles. The concept of marriage, involving male control of female
sexuality, is important for understanding how the mother goddess was
incorporated into the patriarchal brahmin religion.37 In the villages, the old
matriarchal religion was brahminised by providing orthodox male deities as
husbands for the mother goddesses. In Madura, the goddess is married every
year to the god, but the goddess is still recognised by the people as the real deity,
not the brahmin god.38 In Bengal, the scriptures report that Adya, the mother of
the gods, was married to Shiva.39 Durga, also known as Parvati, was married to
Shiva and Lakshmi was married to Vishnu.40 Krishna married several thousand
mother goddesses, and one in particular at an annual ceremony, indicating that
prior to Krishna, the human representative of the goddess’s consort was
sacrificed every year.41
The features of the goddess in the ‘non-brahmin’ religion symbolise popular
resistance to the control of women’s power in the ‘brahmin’ religious tradition.
An excellent illustration of this is found in a study of goddess worship in the
region of Chattisgarh by Lawrence Babb.42 He shows that in the ‘brahminical’
version, the goddess has a dual, changing nature. As Kali, she is a malevolent
destroyer, the manifestation of a terrible sinister force, black anger, implacable
and bloodthirsty. The story of Kali — India’s matriarchal myth — is that she
was created to save the gods from their more powerful enemies, but having done
so, she continued on a rampage of uncontrollable killing, which could only be
stopped by her husband Shiva lying down in front of her. In her malevolent
aspect she receives blood sacrifice. As Lakshmi she is benevolent, bestower of
wealth, progeny and happiness, and passively devoted to her husband. In this
aspect she never receives blood sacrifice. The goddess is Lakshmi when she is
under the control of the male god. In this aspect she is seen standing meekly
beside her husband Vishnu. When she is in her terrible aspect, she stands alone,
and if Shiva is there he is not her husband but her servant, also in terrible form
but subordinate to the goddess. As Susan Wadley suggests, it is marriage and
the dominance of the male that transforms the goddess’s dangerous power into
benevolence.43
Significantly, in the ‘brahminical’ form, the goddess has both aspects, but is
more commonly subordinate. In the ‘non-brahminical’ form, however, the
goddess is never represented as married, and is always dominant. In this form,
the local goddess is known by many different names, one of which is Shitala, the
smallpox goddess. A case of smallpox is treated as possession by the goddess,
and certain things are likely to enrage her, particularly the sight of a pregnant
woman, who must never approach the patient, and a married couple, who may
only approach the patient singly. Remembering that the ‘non-brahminical’
religion belongs to the people, requires no specialists and is passed on and
contributed to by the people themselves, it appears that Shitala’s hatred of
marriage and pregnancy symbolises the local people’s rejection of the
patriarchal brahmin attempts to control women’s sexuality. The religious
myths of the brahmins may tell the story of women’s destructive power and how
it was constrained by men through control of the women’s sexuality, but the
religion of the common people tells the story of women’s continuing power and
their resistance to male control.
Women’s Heritage
The worship of the mother goddess does not constitute a matriarchy, but it does
constitute a matriarchal culture, in the sense that it preserves the value of
women as life-givers and sources of activating energy, and it represents the
acknowledgement of women’s power by women and men in the culture. Nor
does the matrilineal family cpnstitute a matriarchy: there is no guarantee that
women will be as free as men in such societies, but the evidence from Kerala
suggests that matrilineal organisation has had beneficial effects on women’s
current position compared with women in patrilineal communities.
Daughters of Independence
Both of these aspects form part of the heritage of women in India. Froin this
heritage arises a view of women as powerful and strong. Women in India have
managed to maintain the visibility of their power, despite its incorporation into
the patriarchal culture, and unlike in the West, the concept of women s power is
built into the common cultural assumptions. Consequently, the dominant image
of woman is different in India from that of the West, and has different
implications for women’s liberation in India.
The implications for women are that they see themselves as powerful ana
strong, an image upon which they can act. The heritage also demonstrates that
the roots of women’s struggle and resistance go back a very long way,.and
provide the Indian women’s movement with a history of its own, m which the
intervention of the BriUsh feminists represented only one strand amongst many.
The heritage informs both the desire for emancipation amongst women, and the
nature of their demands.
,
The heritage has implications for men too, in terms of how they see women,
and the systems they devise for controlling women. In male-dominated
societies, women’s power must be contained: there are different methods ot
doing this. Western women are defined as weak and in need of protecUon. In
India, amongst both Hindu and Muslim cultures, women are seen by men as
dangerously powerful. Men have to constrain women since women are
incapable of controlling themselves; not because they are too weak to do so, but
because their power is too great. Such a view legitimates a system of strong
physical controls to restrain women’s power, which makes no sense within the
Western concept of women as the weaker sex. The male-dominated cultures of
both India and the West control women’s power but in different ways,
depending on the specific historical development of gender relations in the two
regions. In the following chapter, we discuss the nature of the controls over
women in India in the context of the historical development of the caste system.
8. Women and Caste
I
The most radical of the nineteenth century reformers had seen the subjugation of
women as an instrument for perpetuating brahminical domination in society.
Vina Mazumdar, Symbols of Power44
The connection between gender and caste has been recognised for some time,
and it is this we want to explore. The women’s question in the 19th and 20th
Centuries revolved around issues such as sati, child marriage, purdah, divorce
and widow remarriage. It is significant that these issues concerned the control of
women’s sexuality, and that most of them affected only the two highest castes.
We will argue that control over women’s sexuality was essential to the
development of the patriarchal caste hierarchy, both for the maintenance of the
caste and for the legitimation and control of inheritance, and we will show how
the constraints on women developed historically with the formation of the caste
system.
In relating gender to social hierarchy, we are suggesting that women’s
subordination needs to be understood not in terms of their powerful sexuality
alone, but also in terms of the material and ideological dangers that it posed for the
caste structure. Our argument is that the development of the gender division,
based on the control of female sexuality, was integral to the formation of the
social structure, based on the control of economic resources, revealing the
crucial link between women’s sexuality and the economic position of the
community.
If women are viewed as ‘too powerful’, it is relevant to ask what exactly was
their power going to destroy? Was the threat a purely abstract notion, or was
there something concrete and material that their power endangered? The key to
this question lies in the system of caste. There are two systems for
understanding caste: ‘vama’, the national system, and ‘jati’, the local system.
We will concentrate on the national system, since although it is too crude to
clarify the detailed operation of caste at local level, it does have sufficient
generality to be useful for discussing caste nationally.45
o
5"
!
1
I
Daughters oj Inaepenaence
Features of the Caste System
Caste divides the population into four major groups: the brahmin (priestly
caste) at the top, followed by the kshatriya (waipior caste), then the vaishya
(commoners, usually known as trading and artisan castes), and at the bottom
the sudra (agricultural labourers) some of whom are beyond the pale of caste
and are known as untouchables. The sudra is not allowed to take the caste
initiation ceremony, at which mal§ members of the other three castes receive
the sacred thread and are ‘reborn’ into the caste (and therefore known as ‘twiceborn’ castes). Within the four m^jor groups there are thousands of sub-castes,
which vary regionally.
Caste is both a structural system and a cultural one. The structure consists of
a hierarchy of in-marrying groups, organised into herediUry occupations.46 ‘In
marrying’ means that they will in general not marry outside their own caste or
sub-caste. There are exceptions, noUbly of women marrying ‘up’ to men of a
higher caste. The hereditary division of labour is also not rigid: a person from a
weaving caste does not have to be a weaver, but a weaver could not be a
brahmin priest, nor is a brahmin agricultural labourer likely.
The cultural system comprises belief in karma (that the circumstances of
birth depend on previous actions), commitment to caste occupation and
lifestyle, belief in the hereditary transmission of psychological traits associated
with occupation, tolerance of distinct lifestyles for other castes, and belief in a
hierarchy of values along a scale of purity and pollution.47 In the scale of purity
and pollution, brahmins are generally, but not always, the purest and sudras the
most polluted. Brahmins are not ‘ naturally’ pure; they can become polluted and
in extreme cases lose caste, if they behave in impure ways or fail to perform
important rituals. This ritual purity is in the nature of a religious status, but it
usually coincides with economic wealth and social esteem. Three of the major
signs of purity are vegetarianism, teetotalism and tight constraints on women,
indicating that a significant degree of ritual purity comes through domestic
activities.
The caste system has survived for 2,000 years, though not without
modification.50 As we shall see, the caste system was subject to many
challenges over the years both to the position of the dominant castes and to the
structure itself, but although the challengers established oppositional move
ments and changes in relative ranks, they did not succeed in eradicating the
hierarchy as a whole. The system’s resistance to revolt is thought to lie
traditionally in the unity of manufacture and agriculture. The craft workers in
the village manufactured all the tools needed by the peasants in exchange for a
share in the peasants’ produce, so that the community was entirely self_sufficient, but the individual never became independent of the community.5
The cultural autonomy of the system meant that the upper castes never tried to
—• impose their strict rules of conduct on the lower castes; in fact they forbade the
lower castes from following the upper caste lifestyle, and used the differences to
distinguish the lower orders from themselves.52 This cultural autonomy was
important because it enabled alternative cultures to flourish, including, as we
Gender and Hierarchy
saw earlier, a distinctive matriarchal culture in the face of a predominantly
patriarchal structure.
The Impact of Caste on Women
Increased control over women is one of the factors that a caste must observe
along with vegetarianism and teetotalismxbefore it can claim to be ritually
pure. Specifically, this control involves two major aspects. One is women’s
disinheritance from immovable property in the form of land, and their
exclusion from the productive economy, involving removal from public life
to the domestic sphere of the home in the form of seclusion or purdah. The
second is the far greater control exercised by men over women’s sexuality,
through arranged marriage, child marriage, the prohibition of divorce, and
strict monogamy for women, leading to sati and a ban on widow remarriage,
including infant or child widows. These strictures were enforced most
severely by the higher castes, particularly the brahmins, but some of the
lower castes also adopted them. A lower caste that had improved its
economic position could attempt to move up the hierarchy over a number of
generations, but economic power alone was not sufficient. The caste had
also to adopt the cultural attributes of ritual purity, which meant
constraining women’s freedom.53 This pattern of social mobility accompanied
by increased control over women is not restricted to Hindus. Amongst
Muslims, the Ashrafs are the former ruling groups, whilst the non-Ashrafs are
the lower-caste converts from Hinduism. The control over Ashraf women is
severe, and similar controls are imposed by non-Ashraf men when they improve
their economic position.54
We want to show that the increased constraints on women are an essential
part of a rise in caste hierarchy, by looking at the ideological and material basis
for it. Several writers on caste have observed the relationship, but being
normally more concerned with caste than with the position of women, they have
failed to note the significance of the relationship for an analysis of women’s
subordination. For example, Hutton states:
There are also drawbacks to the caste system in India which arise not so much
because of the nature of the system as incidentally to its development. One of
these is the hardship entailed to generations of women in all those castes that aim
at raising their position in the social scale. Any caste or sub-caste that wishes to
rise ... finds inessential to conform to ... the marriage of girls before they reach
the age of puberty, and [to] the forbidding their remarriage even if widowed in
infancy.55
The two words ‘incidental’ and ‘essential’ reveal a remarkable inconsistency in
this passage. Hutton suggests that the hardship to women entailed in raising the
caste’s position is nothing to do with the nature of the system. And yet he is
forced to admit that the hardship is essential to higher status. How can it be
‘essential’, and at the same time not ‘in the nature’ of the caste hierarchy? What
!i
■
Gender and Hierarchy
Daughters of Independence
because sexual contact with lower caste men would not only pollute the purity
of the caste, but also allow the lower castes access to it, undermining its social
exclusiveness as well as its biological purity. This is important, but we need to
go further, to see whether this cultural explanation has any material basis. The
notion of the gateways to the higher castes being guarded against the dangers
posed by female sexuality is much the same as the idea we encountered earlier
about women’s sexual power being potentially destructive to men. We need to
know what it is that could be destroyed by lower-caste access if female
sexuality were insufficiently guarded. We want to look at this by tracing the
impact of the early patriarchal immigrants, as expressed in brahmin writings,
on the existing culture of the common people, as depicted in Chapter 7,
and examining how this process of struggle and accommodation affected
women.
-l
Hutton glosses over is the essential gender division which allows the men to
benefit from higher caste status at the expense of the women, for the hardship is
not experienced by all the members of the caste. The women alone are subject
to it, whilst the men gain privileges both in relation to the men of the lower
castes and the women of their own caste.
Amongst writers who have noted the relationship between caste and gender
division is Srinivas, but he treats it descriptively rather than analytically. Whilst
documenting the increasing constraints imposed on women as castes attempt
to raise their position, he discusses it only as an index of ‘Sanskritization’, a
term describing cultural social mobility. For instance:
the institutions of the ‘low’ castes are more liberal in the spheres of marriage and
sex than those of the Brahmins. Post-puberty marriages do occur among them,
widows do not have to shave their heads, and divorce and widow marriage are
both permitted and practised ... But as a caste rises in the hierarchy and its ways
become more sanskritized, it adopts the sex and marriage code of the Brahmins.
Sanskritization results in harshness towards women.
Srinivas does not use this relationship to reach an understanding of women’s
subordination, nor does he provide any analytical framework which could help
to explain why caste and gender might be related in this way. It appears in his
accounts to be a cultural accident.
More significantly, Nur Yalman has drawn attention to the essential nature
of the relationship between gender and caste, although his discussion is
specifically concerned with rituals to ensure women’s purity rather than the
actual constraints which limit their freedom. He links the sexual purity of
women with the purity of the caste, suggesting that female sexuality presents a
threat because of the danger of her introducing impure or low caste blood into
the lineage.
It is through women (and not men) that the ‘purity* of the caste-community is
ensured and preserved... [The] danger of low quality blood entering their
caste ... only exists with women. The male seed they receive^should be the best
available ... The ‘dangers’ here are... the low-caste men.57
The Aryan Impact on Women
Our knowledge of this period comes from the Vedas, the Aryan religious books
which constitute the earliest written history of the region. They were written
mostly by brahmin males, so it is not clear how far their ideal view of women
was actually practised, and there are contradictions even within the theory.
Nevertheless, this was regarded by some of the 19th Century reformers and the
revivalists of the 20th Century women s movement as the ‘Golden Age’, to
which they looked back with nostalgia as a time of liberality for women. Yet
compared with the value accorded to women in the matriarchal culture, it was
far from ideal.
The Aryans held a radically different view of women from that prevailing
within the indigenous culture. They brought with them a pantheon of
predominantly male gods, the patriarchal joint family, and a three-class social
structure, divided into kshatriyas (warriors and aristocracy), brahmins (priests)
and vaishyas (commoners).60 At first there was no caste consciousness, no
hereditary occupations and no rules about marriage within the class. The
development of this form of social organisation into a caste structure was a slow
process which only began when the Aryans, having established dominance over
the native population around 1500 B.C., began to class the indigenous people
and those of mixed descent as outsiders, relegating them to a fourth category of
sudras (servants) and excluding them from the Vedic religion.61
At this time the king was the supreme political force and the kshatriyas held
the highest rank, but the brahmins began to stake their claim as the primary
caste by claiming that only they could bestow divinity on the king. Slowly the
brahmins established an alliance with the kings to maintain the position of both
groups at the top of the hierarchy. Caste became hereditary, rules of in-marriage
were established, and it became impossible for individuals to rise in the
hierarchy except as members of entire sub-castes. These new strictures were
laid down by the brahmin law-givers, and although they were portrayed as rigid
rules, there was in fact a great deal of flexibility within the system.62
■
But his analysis does not help us to understand (nor was it his intention) why
some women’s lives were so much more restricted than others, regardless of the
religious rituals around their sexuality, for amongst the matrilineal Nayars the
rituals were purely symbolic,58 limiting their sexuality relatively little in
practice.
Veena Das takes Yalman’s analysis a stage further, adding to the notion of
purity the question of access:
P
Women were literally seen as points of entrance, as ‘gateways’ to the caste
system. If men of ritually low status were to get sexual access to women of higher
status, then not only the purity of the women but that of the entire group would be
endangered. Since the main threat to the purity of the group came from female
sexuality, it becomes vital to guard it.59
Her suggestion is that women are so strenuously guarded by the higher castes
t
i
61
nc.
-Wk
Within the patriarchal joint family, women were considered as part of the
males’ property in the same way as a field belonged to the men of the family.
The analogy of the field and the seed was used to describe the right of the men to
the use of women and to the women’s issue.63 Only sons inherited immovable
property, the daughters taking with them a dowry in the form of goods to their
marital family. These economic facts of patrilineal inheritance ensured that
sons were valued and daughters were not, amongst propertied families in
particular. Women could not sacrifice to the gods, because their presence was
considered polluting, so a man had to have male children to perform the
sacrifices which would allow his soul to rest after death.64 However, women in
propertied families had access to learning and could become scholars, poets and
teachers. Women in commercial circles took an active part in business
transactions, and in the lower strata they worked in agriculture, military
manufacturing, weaving, dyeing, embroidery and basket-making, amongst
other occupations.65 Women also took part in the administration of the country,
for the marriage hymn expresses the hope that the bride will be able to speak
with composure and success in the democratic assemblies until her old age.66
Marriage was not compulsory for women, and young men and women could
mix together socially.67 Later, when caste rules on marriage became more
important for the higher castes, the woman could choose her husband from a
group of suitable men.68 Widows could remarry and monogamy seems to have
been the norm, but polygyny and polyandry were not unknown.69 However,
women were also classed with dwarfs, humpbacks, lean, lame and blind men,
idiots and eunuchs, as unfit to attend the king’s court.70 That women’s position
was better than in later periods was true, but compared with the value given to
women by the matriarchal culture, it represented a sharp decline, from woman
as life-giver and equal sharer in property and produce, to woman as impure and
herself the property of men.
I’
Challenge and Response
Caste supremacy, however, with its emphasis on a social elite and the
superiority of the male, did not go unchallenged either by women or the lower
castes. The resistance arose at various times over the centuries, usually
corresponding with some change in the economic order. The Muslim invasions
later posed a further challenge to the caste hierarchy from outside the society.
The high-caste response was to tighten up on caste divisions by distinguishing
themselves more clearly from other castes, and to compromise by incorporating
some aspects of the opponents’ culture into their own.
The first major change occurred around the last few centuries B.C., when
trade with other countries began to expand, currency was introduced, and large
urban centres developed. The expansion in trade opened up opportunities to all
the castes, and some members of the lower castes were able to raise their
03 economic position. A large number of atheistical sects developed at this time,
including Buddhism and Jainism, which appealed to the lower-caste members
62
c
a
h
a
y
of this rising class, and Ghurye has suggested that the two religions represented
the assertion of kshatriya superiority over the religious authority of the
brahmins.71 For vaishyas, whose economic position did not now accord with
their religious position, and for sudras, whose ritual status did not permit them
caste initiation or religious knowledge, the new atheistic religions represented a
humanitarian, anti-caste, anti-brahmin protest. Another radical difference was
. that women were allowed to join, to participate in learning and devotions, and to
become nuns.72
The response of the brahmins to kshatriya supremacy, to vaishya and sudra
protest, and to the atheistic challenge to the Vedic religion, was to defend their
position by tightening up the rules on social relationships. This affected both
women and the lower castes. The relationships between the four castes and
their legitimate social activities were rigidly defined and strict controls over the
lives of women were laid down. The brahmins at this time began to emphasise
their superiority over every other group in society.73
The increasingly strict sex and caste orthodoxy for brahmins was imparted
through the new law books known as the Smritis. These advocated for the first
time a strict monogamy for women, reflected in brahmin opposition to
polyandry and widow remarriage. They also advocated marriage before
puberty for girls, and backed it up with the social sanction that a brahmin man
who married a girl over 10 years old would be treated as the husband of a sudra
woman, and not allowed to eat with other brahmins.74 Significantly, these
strictures were not adopted by the kshatriyas, the lower castes or the matrilineal
groups.75 At this time too, brahmin men increased the exclusiveness of
education, by limiting it mainly to themselves. Kshatriya and vaishya men were
allowed only restricted access, and sudras and women virtually none.76 Women
were no longer allowed to attend the democratic assemblies, and high-caste
women were withdrawn from their previous occupations in education and the
arts.77
The new orthodoxy finds many expressions in the Smritis. Although from
the earliest Aryan times a woman’s purpose had been defined only as producing
sons for her husband, the Smritis introduced an additional element of total
dependence, as in the famous statement from the Code of Manu: ‘A woman
should never be independent. Her father has authority over her in childhood,
her husband in youth, and her son in old age.’78 The reason for this was her evil
nature: ‘Manu (the creator) allotted to women a love of bed, seat and ornament,
impure desires, wrath, dishonesty, malice and bad conduct.’79 More specifically:
‘Women remain chaste only as long as they are not in a deserted place and do
not get the chance to be acquainted with any man. That is why it is necessary
that respectable women should always be guarded by friends.’80 And: ‘Women,
even when they are of good family, beautiful and married, do not hesitate to
transgress morals ... At the first opportunity they leave wealthy and goodlookiHg husbands to share an adulterous bed with other men.’81
/ When caste distinction became mpre^pronounced, women’s unbridled lust
torjnen had to be firmly controlled: According to Manu, a man could only
achieve merit by protecting the purityUfms wife and, through her, of his sons.82
63
i’
•ii
Uenaer ana merurcny
Daughters of Independence
i ■
Since she could not be expected to control herself, he had to do it for her. The
importance of sexual control over women to the maintenance of caste
distinction can be seen in the low status classifications given to the children of
various mixed caste unions, of which the Chandala was the lowest, bom of a
sudra man and a brahmin woman.83
)
( The brahminical ideal of the pativrata woman (husband worshipper) was
emphasised at this time: a brahmin woman’s first duty was to worship her
husband as god, no matter how cruel, unfaithful or immoral he might by The
most famous example of the ideal is Sita of the Ramayana Epic, who is
abducted by a demon king but, even though she has resisted seduction, has to
prove her innocence through ordeal by..fire after her rescue and subsequent
rejection by her husband Rama.(in the Mahabharata EpicQGandhan
blindfolded herself for life when she discovered at her wedding that her husband
was blind.84^
.
t
. .
,
The next major decline in women’s position came in the classical age
around 500 A.D. The word ‘classical’ in fact refers to the prosperity of upper
caste men in the Northern regions only. Amongst the upper castes, women 5
position deteriorated during this period. Child marriage was compulsory and
widows were regarded as contemptible, and forbidden to remarry. The earliest
evidence of widow-burning was in 510 A.D., and was demanded more yid
more by upper-caste men, especially kshatriyas, during the next few centunes.
It was claimed that the act brought the woman the highest religious merit, hence
the meaning of the word sati, ‘a virtuous woman’. The only way a high-caste
woman could be sure of avoiding such a fate was by becoming a Buddhist nun, a
theatrical entertainer or a prostitute.85
The decline in women’s position was directly connected with the brahmins
finally establishing economic and social supremacy in Northern society, for it
was in this period that they consolidated their land holdings. The brahmins
eventually won the contest for primacy over the kshatriyas and vaishyas of the
mercantile communities by becoming landowners, thus providing the material
basis for their caste supremacy and their power over women. The maintenance
of land and other property within the joint family was the material basis of the
patriarchal family structure and the in-marrying nature of the caste system,
which was regulated by the religious laws.87 The family structure was
patrilineal, property passing down the male line, and patrilocal, the sons staying
with the father. The daughters went to live with the husband’s family on
marriage. The property laws forbade the daughters from inheriting immovable
property, since such property would have passed to their husbands family at
marriage. Instead, women were given a portion of movable property to take with
them, known as dowry.
The transmission of property to the daughters through dowry had important
implications for women, as is suggested by Jack Goody88 more generally, and
Prabhati Mukherjee more specifically in relation to India.8 It meant that within
the patriarchal family, significant portions of the property were removed from
the patrilineal line of inheritance, and distributed to the daughters’ marital
families. This provided a substantial material reason for anxiety over the birth
•ff
e
1
I
1
of daughters. And if the daughters were allowed to marry freely, the
accumulated property could not be retained within the group, but could soon be
redistributed amorigst families without property. To retain differentials in
economic position required daughters to marry as closely as possible within the
group, and this entailed both strict general rules of in-mamage for the upper
castes, and control over the particular man that the woman married. The
consequence was tight constraints on female sexuality and on any movements
or activities which might interfere with such constraints. The more property a
woman had, the more important it was to control her sexuality, since the
distribution of her property coincided with her sexual attachment. So the ru
in-marriage and the control of female sexuality not only maintained the purity
of caste, but also ensured that the property remained within the caste.
That women were regarded as men’s property amongst the upper castes, and
that control over women was important for the retention of property is suggested
by the numerous references in the religious texts at this time to women and
property together. For instance, it was said that ‘A virtuous '"an^never
interferes with the wives or properties of others, the source of all trouble. The
x institutions of private property and the patriarchal family were regarded as the
main reason for the origin of state authority. Tn a kingless state, private
property cannot be retained and a wife is not under control.
In this time too, women and sudras were regarded as equally contemptible.
The Code of Manu. distinguished between the twice-born castes on the one
hand, and women and sudras on the other.92 Women and sudras were regarde
as life-long slaves from birth to death, with slavery inborn in them; the same
value was attached to the life of a woman and a sudra, for anyone who killed an
artisan, a mechanic, a sudra or a woman had to perform two penances and give
11 bulls to atone for it.’4
,
Here we can see two links between gender and caste. Women s position
.deteriorated with the economic supremacy of the caste. And this deterioration
had a material basis in the maintenance of property within the caste.
The next major challenge to brahmin supremacy came with the Muslim
invasions, of which the most significant were the arrival of the Arabs and
the Turks in the 11th and 12th Centuries, and the Mughals in the 16th
The Muslims did not destroy the caste structure, but used it to establish
an administrative system designed to collect revenue and maintain law and
order.” The invasions led to another tightening up by the brahmins on
women’s position. Around 1000 A.D. the rule of no remarriage for w.dows
amongst the top castes was extended even to child widows of whom there were
large numbers because of the low age of marriage. The incidence of sati
increased, particularly amongst the warring regions of the North, the women
often being forced onto the pyre by their husband’s relatives and sometimes by
their own sons.97 And the seclusion of women, purdah, became more common
amongst the higher castes.98 Baig suggests that conquest made the people
defensive, inducing particularly the upper castes to retreat into more rigid
orthodoxy and providing a solid reason for protecting women from the foreign
invader."
65
Je.
isaugnters of independence
The coming of the Mughals in the 16th Century consolidated Islamic power
in India. They established an empire which lasted until the arrival of the
Europeans in the 18th Century. During this time women’s lowly position
amongst the upper castes of both Muslim and Hindu communities was
reinforced. Purdah, child marriage, widow discrimination and the pativrata
(husband worshipping) ideal were the norm amongst high-caste Hindu women,
and were regarded as symbols of prestige. Purdah ii^ particular spread under
Mughal rule, especially in areas where Muslim-Hindu conflict was strongest,
based on the fear of abduction and rape from the opposing side.100
Muslim women, however, had a better legal status than Hindu women, even
though their rights often did not work to their advantage. For example, Muslim
women were allowed to study the religious books, divorce and remarriage were
possible (although divorce was at the discretion of the husband) and they had
rights of inheritance. Polygyny was allowed in both religions, but Islam
restricted the number of wives to four, whereas Hindu law specified no limits.101
Clearly these could be considered improvements only within a patriarchal
context, but the original egalitarianism of Islam did bring a small measure of
protection to Muslim women. For example, the Sharia defines suicide as illegal,
and becoming sati comprised suicide, but even though the matter was
discussed, no restraint on its practice by Hindus was attempted.102 The Islamic
law against suicide did, however, prevent sati being adopted by Muslims.
Resistance and Integration
So far we have looked only at the way the upper castes tightened the caste and
gender divisions in response to challenges to their supremacy from below and
outside. But the upper castes also responded to the challenge by loosening some
of the cultural divisions and accepting certain ‘non-brahmin’ traditions into the
orthodox religion, including aspects of the matriarchal culture. This was not as
contradictory as it appears, because the notion of woman as powerful was
incorporated to legitimise strong controls. The particular constraints imposed
on upper-caste women had rarely applied to women of the lower castes,
although they experienced their own hardships. But lower-caste women were
not secluded, since their labour was needed in the fields for survival. There was
no sati and widows could remarry. Many lower-caste communities allowed
divorce, and polygyny, though permitted, could not be practised by those who
could not afford to support a large family.103 Amongst these communities,
women’s involvement in wider areas than those specified by the brahmins was a
fact of life, and the demand for women’s inclusion in religious and social
activities became a feature of all the socio-religious reform movements in
India.104
At the same time as brahminism was tightening its hold on its own women
and the lower castes, two new movements began which embodied matriarchal
and populist resistance to patriarchal brahmin elitism. One was a resurgence of
mother goddess cults and fertility worship, of which the most famous was Tantra
66
I
I'
t>1
<
jr
d
ei
in the 5th Century A.D. and which had its centre in the non-Aryan regions of
the North-east Tantra was open to all castes and to women. It was explicitly
against both the orthodox ritual of the Hindu religion and the patriarchal caste
structure of the brahmins. It worshipped the mother goddess, since life was
created in the womb, and had its roots in the pre-Ary an culture. The cult
influenced Buddhism to form a new school, adding female saviours, Taras, to
tjje-^xisting male ones. The worship of Taras still exists in Nepal and Tibet.
And ^-influenced Hinduism, which developed the Shakti cult, representing the
female power principle. Shakti believes that the female is the source of all
energy and action, and only she can activate the male god.10- Shakti is the
active, practicalT~v,iolent goddess, compared with the passive, contemplative,
non-violent god.106)rhe cults also influenced artistic expression in the form of
erotic poetry, "Sticli as the story of Krishna and Radha,107 and in the form of
erotic temple sculpture such as that found at Khajuraho.108
The other movement was the Bhakti cult in the 6th and 7th Centuries A.D.,
which was strongest in the non-Aryan South, but later spread all over India.
Bhakti means devotion, and was based on the belief that a direct personal
relationship with god was possible, without the mediation of a brahmin expert
or the performance of esoteric ritual.109 This cult too opened religion to ordinary
people, and was anti-caste and anti-establishment, representing a resistance to
brahmin culture with its emphasis on caste and gender superiority. Their saints
and followers included women and men, and were predominantly of the lower
castes.110 But significantly their number included women from the higher castes,
particularly widows, otherwise condemned to a life of penance.
So despite brahmin supremacy, the matriarchal and populist cultures
continued to make their opposition felt. They found a common interest in their
exclusion from the brahmin religion and the ownership of land and in the
restrictions on their activities, which formed the basis for an alliance of women
ouu the
U1C ivwv*
______
-_____
_ __________
and
lower vaovvo
castes against patriarchal
caste
elitism.
Here___________________
we can see another
link between gender and caste, for the partnership against caste supremacy and
male dominance was to be repeated many times over the centuries.
We have already seen that the brahmin religion, under the pressure of
economic change and the threat of opposition movements, maintained
supremacy by becoming more orthodox, tightening the divisions between castes
/ and increasing the sexual controls over women of their own caste. But they also
adopted a more liberal approach to other cultural groups and incorporated their
different interests into the brahmin religion. They became at the same time
more orthodox themselves and more tolerant of others. This was possible for
two reasons. First, the high degree of integration between the religious ideology
and the rural economy prevented the revolts from destroying the economic
basis of the caste system in the villages.112 And second, the tradition of cultural
autonomy not only allowed other cultures to flourish, but also enabled the
brahmins to use the cultural differences to accentuate caste divisions.
The brahmin priests made two important concessions. They conceded that
- women and the lower castes could have a direct relationship with god based on
personal devotion, without the intervention of a priest, even though women,
67
I
Daughters of Independence
Gender and Hierarchy
vaishyas and sudras were still classed together as lower forms of life. This can
be seen in the Bhagavad-Gita:
The ideas about women’s ritual impurity which arose, along with the physical
constraints on their activities, stressed that women’s menstrual, reproductive
and sexual functions made them inherently impure. These ideas justified her
low ritual status within the caste and her inability to control her own sexuality in
the interests of the caste. Her sexual insatiability was at the root of all problems,
and the lower castes’ failure to control their women’s sexuality was partly what
made them impure. This idea reinforced the caste divisions, for if the lower
castes behaved like the brahmins, the distinctions would dissolve. So the gender
division reinforced the caste division, and the gender ideology legitimated not
only the structure of patriarchy but also the organisation of caste.
For whosoever makes me his haven,
Base-born though he may be,
Yes, women too, and artisans, even serfs,
Theirs it is to tread the highest Way.113
In making this concession the brahmins maintained control by modifying some
of the popular secular writings to give them religious authority, propounding the
doctrines of karma (that the circumstances of birth were determined by previous
actions) and dharma (the sacred law which regulated the morality of the
actions). And second, they dropped some of their own gods, incorporating the
matriarchal fertility cults into the worship of Shiva and providing ‘brahminical’
husbands for the ‘non-brahminical’ mother goddesses.114 Since the mother
goddess could not be suppressed, she was finally incorporated into brahmin
ritual,115 but this integration could not occur without contradiction. It is
intriguing to consider the brahmin priests, holding Manu’s opinion of women,
yet allowing the introduction of matriarchal goddesses into the pantheon. The
mother goddess was associated with magic, sexual orgies and blood sacrifice,
representing the miracle of birth, the creation of life through sexuality, and
menstruation as a symbol of fertility. To the brahmin, childbirth, sexuality and
menstruation were all sources of pollution, yet this polluting matriarchal
culture was absorbed into the pure patriarchal religious ritual in the form of
mother worship.116 The success of such an integration was a tribute both to the
persistence of the matriarchal culture and to the adaptability of the brahmin
patriarchy.
Having acknowledged women’s power, the contradiction was resolved
culturally, as we have seen, by defining it as dangerous unless controlled by
men. But the underlying material basis of this ideological resolution, as we have
also seen, was the preservation of wealth within the caste, for which purpose the
women had to be sexually controlled by men.
We can now answer the question of what precisely women’s power
endangered. Lakshmi is benevolent because her controlled sexuality bestows
legitimate heirs for the maintenance of caste wealth and retains family property
within the caste. Kali is malevolent because her uncontrolled passion is liable to
introduce impure blood into the caste and to dissipate caste wealth, making a
mockery of patrilineal inheritance and the accumulation of property, and
thereby destroying the caste system itself. Unconstrained, mortal women are as
much to be feared as potential destroyers and robbers of the patriarchal heritage
— cultural and material — as are members of the lower orders. As the
scriptures say:
------
i
f
J:
I
I
4
Women constantly suck the blood of men like leeches ... That very woman
/whom man considers his beloved robs him of his manhood through sexual
‘indulgence, and of his mind, his wealth and all his possessions. Hence is there
any greater robber than woman?117 "'j
;o
a.
k ra
J
risine merchant class. They commercialised Indian agriculture so that i
nroduced less food for immediate consumption and more raw materials fo
British industry. And they changed the nature of property from collective to
9. The New Middle Class
‘"^As'we'saw'inPait I, the changes forced large numbers of people back to the
land which was unable to support them. Many of the peasants found ‘hemselves
in debt became the British had also changed the tax into a rent so ha the siz^ of
the oavment no longer varied with the harvest, but was a fixed sum whic
increased periodically. But the methods of agriculture did not improve since
oroductionwas still precapitalist and without the benefit of machinery, so the
oeasants had to pay more and more rent on the basis of the same amount o
production. This development created a class of money-lenders from amongst
die zamindars (landlords) and the better-off peasants. The change in and
ownership meant that the zamindars were able to turn the peasants off he land
for non-payment of rent, creating a class of landless labourers. In EnglandI he
landless labourers provided the wage labour for the new urban-based capitalist
industries, but in India the British inhibition of indigenous caPlta'1®'^re^ic
large Lrplus of pauperised ‘free’ labour. This was the origin of Ind.a s chronic
The attempt on the part of some women to cast off their shy temperament and
adopt certain useful professions like nursing, teaching and other public services,
ushered in an era of socio-economic freedom for the womenfolk... The
changing pattern of socio-economic life ultimately led to a remarkable
awakening in women in general.
Pratima Asthana, Women’s Movement in India{11
poverty, which persists and increases to this day.
Caste is defined primarily by social honour, attained through personal lifestyle,
in which the domestic arena is crucial. The ownership of property is usually a
precondition for social honour, in that a certain economic minimum is needed to
maintain the lifestyle.118 For example, the caste has to be able to afford to
maintain the women if they are withdrawn from labouring in the fields. Social
mobility in the caste structure is closed for individuals both in principle and
practice, but in practice whole communities can change in rank over a long
period of time.119
Class, however, is defined primarily by the ownership of property (land
under feudalism, capital under capitalism), although social honour is usually
associated with property ownership. Class within a capitalist structure is
defined by the wage relation, that is, whether a person earns wages or pays
them, for which the occupational arena is crucial. Social mobility in the class
structure is open to individuals in principle but limited in practice.120
Traditionally, social, economic and political power largely coincided in the
caste structure, but the development of the class system introduced certain
changes. The formation of social classes in India was largely the effect of the
new capitalist economic structure, resulting from the British conquest and the
integration of India into the British and world economy.121 The British entered
India at a time when the power of the state was weakened because of the decline
of the Mughal empire. Some Indian merchants had accumulated capital from
trade and begun to invest it in urban industrial enterprises, but the strength of the
caste system in the villages made it difficult for the merchants to develop into a
social class which could successfully challenge the power of the state, as had
happened in England.122
The British stepped into the vacuum, and took over the administrative
system designed by the Mughals for the control of the population and the
collection of revenue. They destroyed Indian industry and undermined the
Creation of the Middle Class
The middle class arose from the British need for English-educated Indians to
Minister the country under British superiors. The British set up education n
India for this purpose, and explicitly encouraged the men of the upper castes; to
avail themselves of the new opportunities The British cr®a‘ed?ie
f th
class out of the existing public officials from the Mughal time^
money-lenders, and out of the literary class of educated brahmins. The
literal groups were almost exclusively brahmins, the money-tenders we e
nredominantly brahmins and kshatriyas, and the industrialists were mai y
vaishyas, since they were traders by caste occupation, although some also came
British came predominantly from those groups who had been P°werf"' 'r’ *e
rural areas. The administration also needed lawyers, teachers and accountan s
and soon these groups wanted their own profess.onal .serv^eSn7^;SeddOuXd
So the middle class in India came to consist primarily of the
professional groups, with the merchants and the industrialists in the ml"orl‘y'
The position of the professionals in the class structure is ambiguous because,
although they are wage-earners not employers, the discrepancy between their
income and7 that of the manual labourers is sufficient to place them
economically and socially closer to the larger-scale employers. The professional
groups therefore constitute part of the middle class, and in I"dla^‘r P°^t10
’tXS-?—iXn.L.’X...
i
71
Gender and Hierarchy
Daughters of Independence
by the middle class (which led but did not initiate the mass movement against
British imperialism)128 grew from the discrepancy between the supply of and
demand for government jobs, and from the barriers to further progress placed by
the British on the professionals and the industrialists. More people had acquired
an English education than the British needed, and the pressure on agriculture
and the obstruction of industry left this newly-educated middle class with few
opportunities apart from the British administrative posts, over which there was
increasing competition, and increasing dissatisfaction for those who were
unsuccessful. Public servants could not rise to the top because the British held
all the senior posts, professionals who had arisen around the administration
were similarly blocked at the top levels,129 and industrialists were inhibited in
their accumulation of capital by British domination of the market and control
over private investment and public finance.130
It was the new middle class who rose to power and took over the political and
administrative machinery of the state after Independence. The circumstances
of its development meant that although there was some breakdown of the caste
structure, the new power elite still consisted of the higher castes.131 A sample
survey conducted in one of the states 20 years after Independence found that the
professions were still dominated by the upper castes. Amongst Hindus in the
Indian Administrative Service, 65 per cent were brahmins, 30 per cent were
kshatriyas, and 4 per cent were vaishyas. There were no sudras.132 There is
evidence from Jamshedpur that caste is no barrier to factory employment,133 but
this is qualified by evidence from five factories in Poona which showed that
although sudras are not excluded, they are given low-level jobs whilst brahmins
are given high-level ones.134 These findings on the relationship between caste
and class in industrial and professional occupations suggest that the capitalist
class structure is building upon the existing divisions in society, and is breaking
them down to only a limited extent.
that the class structure, rather than destroying the gender divisons within the
Ca ThXTr’ effecWa^S^new ecXmicXpo^es8 beTLne available
...» or 4.
class. The Kish hsd
enter the new administrative occupa
’
other professions serving the Indian^ommun
care amongst female relatives oi
*«sd
»
especially in medicine and
^ucation and health
..elusion demanded that these
sk
swkl -i
S’™*beraTfamihes rf * cl„. » »»
*.M.*si n.r^
ISa. “*”S1 hierarchy.
I
ch,„.n8rf ..
»«—
“fromWethemM
* •«*
<f
to
X'S
influence of British
™^
fl2nce•£
of thX^
The Impact on Women
The rise of the middle class had a contradictory effect on the position of women.
Similar strictures on women’s activities to those prevailing amongst the rural'
upper castes are also imposed on women of the urban middle class, and similar
discrepancies between the strictures imposed on upper- and lower-caste women
in the villages seem to occur between middle- and working-class women in the
towns. For example, Kamla Bhasin argues that in the middle class: ‘There has
been some improvement because of various social and economic factors, but
even today the majority of women live in perpetual subservience, self-denial
and self-sacrifice.’135
In the city of Chandigarh, despite the fact that the number of women taking
outside employment increases towards the top of the occupational and
educational hierarchy, the vast majority of educated middle-class women are
still confined to domestic activities. By far the largest proportion of employed
women occurs in the lowest occupational class.136 Studies such as these suggest
from the powerful influence of the ^ome
which provided economic
—
and social hierarchy.
73
e.
10. The Problems Remain,
So Does the Struggle
u
ie
c
recruitment, which is itself illegal. For example, the ,Nationa’.C°"?™SnS'°"us
Labour concluded that the ban on night work,
often
Ore number of women workers to below 50, to avoid the obllgati°r1 to.provide
equal pay, maternity leave or a creche.149 Dowry, far from being erad'cated has
a^own to greater proportions - a doctor can now demand 3 lakh rupees or
£20 000 in dowry - and dowry death^ have replaced sail as the married
•i
Do we really believe that when all the movements subsided, all the feminists who
were involved with them vanished?... Maybe the difficulty lies with our
definition of what constitutes participation ,.. The example of India raises a lot
of questions about... our categories and definitions.
Elizabeth Sarah, Towards a Reassessment of Feminist History™
At Independence in 1947 the women’s movement succeeded in bringing
women’s legal position to a level in advance of many of the rich countries of the
West.139 The Constitution conferred equal rights and status on all citizens,
forbidding any discrimination on grounds of caste, creed, religion or sex. The
state was required to secure to all citizens — men and women — equality, the
right to education and to adequate means of livelihood.140 Women acquired full
political rights including the right to vote, to contest elections and to enter the
administrative services.141 Labour legislation to protect the interests of women
workers was included in the Factories Act, the Plantation Labour Act and the
Mines Act, passed between 1948 and 195 2, which regulate working conditions
where 50 or more women are employed, providing for equal pay for equal work,
maternity benefits, creches and nursing time, and specifying a maximum load
and maximum hours for women. It is illegal to employ women on night work and
on underground and dangerous operations, to restrict the recruitment of
women, and to terminate employment on the grounds of pregnancy.142 Under
the Hindu Code, many of the disabilities suffered by Hindu women were
removed by the five Acts on personal law. Monogamy was established as a rule
for both men and women, divorce became permissible under certain conditions,
the minimum age of marriage was fixed at 18 for women and 21 for men, and
women were given the right to inherit and adopt.143 Later laws included the
Prohibition of Dowry, the Suppression of Immoral Traffic,144 and a liberal
abortion law providing social reasons as grounds for abortion.145
Sushila Mehta describes these laws as ‘paper tigers’. They are enforced
neither by the machinery of the state nor by women themselves, and equality
remains a distant dream for most women even after 30 years of Independence.146
For example, in spite of the law on equal pay, women in lower paid jobs
generally receive between 10 per cent and 60 per cent of men’s wages,
depending on the industry.147 The protective legislation has been used to restrict
fcZZ ~ The implemeniation of fh.
continues to be hindered by patriarchal family structures and by barners ot
caste and class. The position is made worse by the West’s continued dram on
the Indian economy, which is now preventing all but the mos eJ1?
XS society has paid lip service to the new laws, most men have not
accepted their practical implications. The laws also require honest implementation by the male-dominated administrative machinery. And a majority of
XenLbothilliterateandpoor.unawareoftheifle
the fact that women’s subordination remains embodied in
pe’-sonal relations
mXXt mw of the laws which are not directed at changing the socia
structure itself are attacking the symptoms rather than the causes of women
inequality.
I.
The Movement Disappears, the Ideas Remain
The struggle for women’s equality goes on. In 1977, when we did our study
the women’s movement had no clear organisational focus such. as. the
Independence movement had provided. But there were w°men wtose ide as had
their history in that movement. The women who speak in the following pages
are from that privileged group of the educated middle class who work in
professional occupations. They are from two of the ^drtional Profess‘o^sJor
women, education and medicine, and from two of the more recent areas
government service and public and private sector industry. They havei similar
social origins to the activists in the earlier women s movement, and they are
the bearers and beneficiaries of the movement’s heritage. °ar
just before the rise of the ‘second wave’ movement in Delhi, and 30 years afte
the demise of the ‘first wave’. Throughout that time women. had re ainec both
the ideas of the movement and its struggles on an individual or collective
basis.
75
74
I
Daughters of Independence
Some writers have begun to question the assumption that when a movement
is no longer active, the ideas on which it was built fall into disuse, and the people
who acted collectively disappear.153 In India the ideas of sexual equality and the
challenge to male domination which were raised by the women’s movement
continued to inspire women activists. For example, Renuka Ray of the All India
Women s Conference and Romola Sinha, both in their seventies, are still at
work organising women into consumer action groups, and providing refuge for
battered wives, prostitutes, women refugees and runaways.154 Nor did the ideas
evaporate as the women actively involved in the movement grew older, for they
passed on their inspiration to the next generation. Reeta Rao, one of the women
we talked to, was 19 at Independence. Her orthodox father had kept her at
home, but she took comfort and inspiration from her aunt:
My mother’s eider sister was a great influence. I thought of her as my real
mother... She stood by me through all my problems. My aunt had studied in
purdah, married out of caste, worked with Gandhi, gone to jail, lived in an
ashram. I wanted education desperately. My aunt had fought to learn herself. I
took on my aunt’s values, I knew I had to have education.
Promilia Khanna was only three in 1947, but the experience of Independence
and Partition (when India and Pakistan were separated) changed her parents’
lives, and their outlook. This they passed on to their children by bringing them
up to continue the struggle against sexual inequality.
My mother and father believed in equality but the social institutions gave pre
eminence to male children. My parents were trying to bring us up equally and I
resented unequal treatment. I was always taught to question the social
institutions, and I always rebelled against male-dominated institutions.
A significant number of women who spoke to us in 1977 expressed, without
prompting, ideas which derived directly from the women’s movement.155 These
women were evenly divided across age groups, and included women from all
four areas of work (education, medicine, government service and industry).
They were no more dormant or passive in recognising male domination and
fighting for their rights in 1977, than they were in 1947. They know they are not
treated as individual people but as sexual stereotypes. They experience their
subordination at work and in the home. They are angry about it, and this anger is
expressed in different ways. But none of these women accepts the inequality,
and many of them are determined to change it.
In Part III we will examine how the gender division relates to the divisions of
social hierarchy in terms of caste and class, by focusing on the change that
occurs when women struggle to emerge from domestic seclusion to professional
employment. In looking at the change, we will analyse the social processes by
which the women’s personal experiences can be seen to be not purely
---- individual, but crucially related to the social structure.
76
Gender and Hierarchy
Notes
1. Tara Ali Bldg (1916) India’s Woman Power. New Delhi: S. Chand, p.xiv.
2. See for example Merlin Stone (1976) The Paradise Papers. London:
Virago.
3. Manjulika Dubey (1983), ‘Interview with Chandralekha’, The Book
Review VII, 6, May-June, p.272. Chandralekha is a woman activitist, Bharata
Natyam dancer, graphic artist and writer, who works in villages teaching low-cost
communication and media techniques.
4. Fatima Memissi (1975) Beyond the Veil. New York: Wiley.
5. Azizah Al-Hibri (1981) ‘Capitalism is an Advanced Stage of Patriarchy:
but Marxism is not Feminism’, in Lydia Sargent (ed), Women and Revolution: the
Unhappy Marriage of Marxism and Feminism. London: Pluto.
6. The definition of patriarchy is problematic. See Veronica Beechey
(1979) ‘On Patriarchy’, Feminist Review, 3.
7. See Michelle Zimbalist Rosaldo and Louise Lamphere (1974) Woman,
Culture and Society. Stanford, Calif.: Stanford University Press, Introduction.
8. Paula Webster (1975) ‘Matriarchy: A Vision of Power’, in Rayna Reiter
(ed), Towards an Anthropology of Women. London: Monthly Review Press. We
use ‘matriarchal’ as a cultural concept, and confine its use to an adjective describing
a culture rather than a noun implying a structure.
9. See Part I, Chapter 3.
10. David Schneider (1962) ‘The Distinctive Features of Matrilineal
Descent Groups’, in D. Schneider and K. Gough (eds), Matrilineal Kinship.
Berkeley: University of California Press, pp.5-6.
11. Female literacy is 54.3 per cent in Kerala compared with 18.7 per cent in
the whole of India. Tamil Nadu is the next highest state with female literacy of 26.9
percent. Source: Ashish Bose (1975) ‘A Demographic Profile of Indian Women’,
in Devaki Jain (ed), Indian Women. New Delhi: Government of India, p.163.
12. The sex ratio in Kerala is 1,016 females per 1,000 males, compared with
930 females per 1,000 males in all India. In all other states and union territories
except Dadra and Nagar Haveli, males outnumber females, although females
normally outnumber males in other countries. Source: Department of Social
Welfare (1978) Women in India: a Statistical Profile. New Delhi: Government of
India, p.6. For a discussion of the implications of the declining sex ratio, see:
Kumudini Dandekar (1975) ‘Why has the Proportion of Women in India’s Popula
tion been Declining?*, Economic and Political Weekly 18 Oct, pp. 1663-7, and
Asok Mitra (1979) Implications of Declining Sex Ratio in India’s Population.
Indian Council for Social Sciences Research: Programme of Women’s Studies I.
For sex ratio in selected countries, see Bose, ‘Demographic Profile’, p.145.
13. Mean age at marriage of women in Kerala is 20.88 years, compared with
17.23 in all India. Source: Department of Social Welfare, Women in India,
p.59.
14. Department of Social Welfare (1974) Towards Equality. Report of the
Committee on the Status of Women in India. New Delhi: Government of India,
pp.54-6.
15. Stanley Wolpert (1977) A New History of India. New York: Oxford
University Press, pp.14, 24, 27.
16. For example ibid., p.77, and Romila Thapar (1966) A History ofIndia,
vol.l. Harmondsworth: Penguin, p.103.
a
Gender and Hierarchy
Daughters of Independence
17. Wolpert, New History of India, p.77.
18. Kathleen Gough (1962) ‘Nayar’; ‘Tiyyar’; ‘Mapilla’, in Schneider and
Gough, Matrilineal Kinship, chs.6-9. For ecology of Kerala, see pp.299-302.
19. J.H Hutton (1963) Caste in India. Bombay: Oxford University Press, p.9.
20. Ibid., p.29.
21. Ibid., p.151.
22. Ibid., p.154.
23. Ibid., p.167.
24. Joan Bamberger (1974) ‘The Myth of Matriarchy: Why Men Rule in
Primitive Society’, in Rosaldo and Lamphere, Woman, Culture and Society.
Mandy Merck (1978), ‘The City’s Achievements: the Patriotic Amazonomachy
and Ancient Athens’, in Susan Lipshitz (ed), Tearing the Veil. London: Routledge &
Kegan Paul.
25. Margaret Stacey and Marion Price (1980), ‘Women and Power’,
Feminist Review 5, pp.35-6.
26. Baig, India’s Woman Power, pp.4-5.
27. Thapar, History of India, p.43.
28. Hutton, Caste in India, p. 152.
29. B.G. Gokhale
59} Ancient India. Bombay: Asia Publishing House,
p.18.
30. Ibid., p.18 and Hutton, Caste in India, p.224.
31. Ibid., p.225.
32. Ibid., p.152.
33. Maria Mies (1980) Indian Women and Patriarchy. New Delhi:
Concept, p.40.
34. D.D. Kosambi (1965) The Culture and Civilization ofAncient India in
Historical Outline. London: Routledge & Kegan Paul, p.47. Kosambi uses the
word ‘matriarchal’ without indicating whether he means a structural or a cultural
concept.
35. McKim Marriott (1955) ‘Little Communities in an Indigenous Civiliza
tion’, in McKim Marriott ‘Village India: Studies in the Little Community’, The
American Anthropologist 57, pp.171-2. Quoted in Mies, Indian Women and
Patriarchy, p.40. The ‘Little Community’ is equivalent to the ‘non-brahmin
tradition’.
36. Mies, Indian Women and Patriarchy, pp.39-41.
37. Lawrence Babb (1970) ‘Marriage and Malevolence: the Uses of Sexual
Opposition in a Hindu Pantheon’, Ethnology IX, pp.137-49.
38. Hutton, Caste in India, pp. 153-4.
39. B.K. Sarkar
Folk Element in Hindu Culture, quoted in Hutton,
ibid., p.154.
40. Kosambi, Culture and Civilization, p.TlO.
^41. Ibid., p.116.
42. Babb, ‘Marriage and Malevolence’.
®
43. Susan Wadley (1977) ‘Women and the Hindu Tradition’, in Doranne
Jacobson and Susan Wadley, Women in India: Two Perspectives. New Delhi:
Manohar.
44. Vina Mazumdar (1979) (ed) Symbols of Power. New Delhi: Allied
Publishers, p.xvii.
45. See M.N. Srinivas (1962) Caste in Modern India. London: Asia
Publishing House, ch.3.
46. Surajit Sinha (1967) ‘Caste in India’, in Anthony de Reuck and Julie
Knight (eds), Caste and Race. London: Ciba Foundation, p.94.
47. Ibid., p.95.
48. Ibid., p.97.
49. Srinivas, Caste in Modem India, ch.2.
50. Thapar, History of India, p.48. See also Max Weber (1958) The
Religion of India, flew York: The Free Press.
51. Anupam Sen (1982) The State, Industrialization and Class Formations
in India. London: Routledge & Kegan Paul, p.18.
52. N.K. Bose (1951) ‘Caste in India’, Man in India 31, pp. 107-23. Quoted
in Sinha, ‘Caste in India’, pp.96-7.
53. M.N. Srinivas (1977) ‘The Changing Position of Indian Women , Man
12, pP^21z^’na Bhatty (1976) ‘Status of Muslim Women and Social Change’, in
B.R. Nanda (ed), Indian Women from Purdah to Modernity. New Delhi: Vikas,
pjlO.
55. Hutton, Caste in India, p.129. Emphasis added.
56. Srinivas, Caste in Modern India, p.46.
57. Nur Yalman (1968) ‘On the Purity of Women in the Castes of Ceylon
and Malabar’, Journal of the Royal Anthropological Institute 93,1, pp.43-4.
58. Ibid., pp.45-6.
.
59. Veena Das (1976) ‘Indian Women: Work, Power and Status, in B.K.
Nanda, Indian Women, p. 135.
60. Wolpert, New History of India, pp.26, 32.
61. Thapar, History of India, pp.37-8.
62. Ibid., pp.38-40, 54.
63. Mies, Indian Women, pp.55-7.
64. Wolpert, New History of India, p.28.
,
65. A.S. Altekar (1962) The Position of Women in Hindu Civilization.
Delhi: Motilal Banarsidas, pp. 179-81. Padmini Sengupta (1960) Women Workers
of India. Bombay: Asia Publishing House, pp.1-4.
66. Rigveda X, 85, 86. Quoted in Altekar, Position of Women, p.lVU.
67. G.G. Mirchandani (1970) ‘Status of Women in India’, India Today.
Delhi: United News of India Research Bureau, p.249.
68 Romila Thapar (1963) ‘The History of Female Emancipation in
Southern Asia’, in Barbara Ward (ed), Women in the New Asia. Paris: UNESCO,
p.476.
69. Mies, Indian Women, ppAl-8.
70. Mahabharata (Shanti Parva). Quoted in Ashok Rudra (1975) ‘Cultural
and Religious Influences’, in Jain, Indian Women, p.43.
71. G.S. Ghurye (1932) Caste and Race in India. London: Routledge &
Kegan Paul, p.69.
72. Thapar, History of India, pp.64-9.
73. Ibid., pp.109, 121-4.
74. Mies, Indian Women, pp.47-51.
75. Altekar, Position of Women, p.58.
76. Thapar, History of India, p.123.
77. Maitrayaniya Samhita IV, 7, 4. Quoted in Altekar, Position of Women,
p.190.
78. Manusmriti, Dharmashastra IX, 3.
c.
79
Gender and Hierarchy
Daughters of Independence
79. Ibid. V, 147.
80. Arundhati, Diva Purana. Quoted in Rudra, ‘Cultural and Religious
Influences’, p.47.
81. Mahabbarata, Anusasana Parva. Quoted in ibid., p.47.
82. Manusmriti, Dharmashastra IX, 14.
83. Ibid., Ill, 13.
84. Mies, Indian Women, p.45.
85. Thapar, History of India, pp. 13 6, 151 -2.
86. Ibid., p. 166.
87. Thapar, ‘History of Female Emancipation’, pp.252, 476-7.
88. Jack Goody (1976) Production and Reproduction. Cambridge:
Cambridge University Press.
89. Prabhati Mukheijee (1978) Hindu Women: Normative Models. New
Delhi: Orient Longman.
90. Krsnajanma Kanda 35, 77-86. Quoted in Ram Sharan Sharma (1966)
Light on Early Indian Society and Economy. Bombay: Manaktalas p.24.
91. Ayodhya Kanda 67, 11. Quoted in ibid., pp.23 and 27-8.
92. Manu V, 139. Quoted in ibid., p.30.
93. Ibid., p.33.
94. Parasara VI, 16. Quoted in ibid., p.29.
95. Sen, State, Industrialization and Class Formations, p.132.
96. Mies, Indian Women, p.48.
97. Thapar, History of India, p.247.
98. Mies, Indian Women, p.60.
99. Baig, India’s Woman Power, pp.12, 258.
100. Mies, Indian Women, pp.51-2, 65-8.
101. Thapar, ‘History of Female Emancipation’, p.478.
102. Thapar, History of India, p.292.
103. Mies, Indian Women, pp.65-8.
104. Thapar, History of India, p.67.
105. Ibid., pp.160, 261.
106. Mies, Indian Women, pp.40-1.
107. Nigel Frith (1975) The Legend of Krishna. London: Abacus.
108. Thapar, History of India, pp.258-61.
109. Ibid., pp.133-4.
110. Ibid., pp. 184-8.
111. Department of Social Welfare, Towards Equality, p.43.
112. Sen, State, Industrialization and Class Formations, p.18.
113. Bhagavad-Gita IX, 32. In R.C. Zaehner (1966) Hindu Scriptures.
London: J.M. Dent, p.289.
114. Thapar, History of India, pp.l 31 -4.
115. Ibid., p.161.
116. Mies, Indian Women, pp.46-7.
117. Devi Bhagavat. Quoted in Rudra, ‘Cultural and Religious Influences’,
p.47.
117. Pratima Asthana (1974) Women’s Movement in India. Delhi: Vikas,
pp.57-8.
118. Andre Beteille (1971) Casle, Class and Power. Berkeley: University of
California Press, Ch.VI.
119. See Chapter 8.
Ri,
4
1I
120. Beteille, Caste, Class and Power, Ch.VI.
121. A.R. Desai (1959) The Social Background of Indian Nationalism.
Bombay: Popular Book Depot.
122. Sen, State, Industrialization and Class Formations, pp.37-45.
123. Ibid., pp. 132,48,53, 64.
124. Jbid., pp.65-9.
125. Ibid., pp.80-6.
126. B.B. Misra (1961) The Indian Middle Classes. London: Oxford
University Press, pp.307, 12-13.
127. Ibid., p.12.
128. Bipan Chandra (1974) ‘The Indian Capitalist Class and British
Imperialism’, in R.S. Sharma (ed), Indian Society: Historical Probings. New
Delhi: People’s Publishing House, pp.390-1.
129. Jawaharlal Nehru (1939) Glimpses of World History. London:
Lindsay Drummond, pp.434-9.
130. Chandra, ‘Indian Capitalist Class’, pp.394-7.
131. Misra, Indian Middle Classes, p.307.
132. Richard Taub (1969) Bureaucrats under Stress. Berkeley: University
of California Press, pp.63-5.
133. M.D. Morris (1960) ‘The Labour Market in India’, in W.E. Moore and
A.S. Feldman (eds), Labour Commitment and Social Change in Developing
Areas. New York: SSRC, pp.173-200. Quoted in Sinha ‘Caste in India’,
pp. 102-3.
134. R.D. Lambert(1963) Workers, Factories and Social Change in India.
Princeton: Princeton University Press, pp.34-6. Quoted in M.N. Srinivas (1966)
Social Change in Modem India. Berkeley: University of California Press,
P 174135. Kamla Bhasin (1972) ‘The Predicament of Middle Class Indian
Women — an Inside View’, in Kamla Bhasin (ed), The Position of Women in
India. Srinigan Arvind Deshpande, p.40.
136. Victor S. D’Souza (1980) ‘Family Status and Female Work Participa
tion’, in Alfred de Souza (ed), Women in Contemporary India and South Asia.
New Delhi: Manohar, p.129.
137. Pratima Asthana, Womens Movement in India, p.23. See also E.C.
Gedge and M. Choksi (eds), (1929) Women in Modem India. Bombay: D.B.
Taraporewala, Ch.3, 4.
138. Elizabeth Sarah (1982) ‘Towards a Reassessment of Feminist
History’, Women's Studies International Forum 5, 6, pp.520-1.
139. See comparisons, notes 140-3, and 145 below.
140. Sushila Mehta (1982) Revolution and the Status of Women in India.
New Delhi: Metropolitan, p.104. In the USA, the most ‘advanced’ capiUlist
country of the world, the Equal Rights Amendment, adding a guarantee of sexual
equality to the Constitution, failed to reach the statute book during the 1980s
because the required number of states did not ratify it
141. Ibid., p.104. Women in Switzerland, one of the richest countries of
Europe, did not receive the vote until the 1970s. In at least one canton, women still
do not have the vote on canton affairs.
142. The Factories Act was passed in 1948, the Plantation Labour Act in
1951, and the Mines Act in 1952. See Kamala Mankekar (1975) Women in India.
New Delhi: Central Institute of Research and Training in Public Cooperation, p. 19.
Gender and Hierarchy
Daughters of Independence
CT*
(1983) There's Always Been a Woman's Movement this Century. London:
■ Routledge & Kegan Paul.
. , .
154. Geraldine Forbes (1982) ‘Caged Tigers: “First Wave Feminists in
India’, Women's Studies International Forum 5, 6, p.535.
155. 20 out of the 120 women explicitly identified themselves as feminists,
without being asked.
The Equal Pay Act and the Sex Discrimination Act came into force in Britain in
1975. There is no legal provision for creches or nursing time.
143. Five Acts were passed between 1954 and 1956:
1. Special Marriage Act (1954) provided for civil marriage for all Indians and
divorce by mutual consent. Minimum age of marriage, 21 for men, 18 for
women. If married under this Act a Hindu man would be automatically
regarded as independent of the joint family, and inheritance would be governed
by the Indian Succession Act.
»
2. Hindu Marriage Act (1955) stipulates monogamy and provides for divorce and
inter-caste marriage.
3. Hindu Succession Act (1955) provides equal shares of property for widow,
daughter, mother and son, in the case of non-testamentary death. Women have
absolute right of ownership and disposal over property with the condition that
male successors have a presumptive right to acquire any property of which the
female successors wish to dispose.
4. Hindu Minority and Guardianship Act (1956) gives custody of a child under 3
years of age to the mother, and the natural guardian thereafter is first the father
and second the mother.
5. Hindu Adoptions and Maintenance Act (1956) provides for the adoption of
daughters, and allows women to adopt children as well as men. See Jana
Matson Everett (1981) Women and Social Change in India. New Delhi:
Heritage, pp. 187-8, and Sushila Mehta, Revolution, Ch.7.
Eire does not allow divorce even today.
144. Suppression of Prostitution and Immoral Traffic Act 1958, Prohibition
of Dowry Act 1961. See Sushila Mehta, Revolution, pp.115, 121.
145. Department of Social Welfare, Towards Equality, pp.327-9. In Spain
abortion is not legal under any circumstances.
146. Mehta, Revolution, pp. 125-6.
147. Mankekar, Women in India, pp.30, 31.
148. Rama Joshi (1978) ‘The Status of Female Labour and the Law’,
Bulletin of Comparative Labour Relations 9, pp.225-6.
149. Mankekar, Women in India, p.34.
150. Mehta, Revolution, pp.207-8, 243-4. Most issues of Manushi carry
reports of dowry deaths. See Note 3a Ch.l.
151. For a discussion of the Indian economy in 1977 in the context of world
capitalism, see Andre Gunder Frank (1977) ‘Emergence of Permanent Emergency
in India’, Economic and Political Weekly XII, 11, March 12. Recognition of the
West’s role in pauperising the Third World is expressed (more ambiguously than
by Frank) by Willy Brandt (1980) North-South: a Programme for Survival. The
Report of the Independent Commission on International Development Issues.
London: Pan. ‘A long and assiduous learning process was necessary until it was
generally accepted that higher wages for workers increased purchasing power
sufficiently to move the economy as a whole. Industrialized countries now need to
be interested in the expansion of markets in the developing world.’ Ibid., pp.20-1.
The analogy means that if the Third World is made so poor that it cannot buy
Western capitalism’s goods, then the West would also suffer through the collapse of
its markets. So the poverty of the Third World is seen to threaten the very structure
of Western capitalism’s political, industrial and financial institutions. Ibid., p.239.
152. Mehta, Revolution, pp. 125-6.
153. Elizabeth Sarah, ‘Towards a Reassessment’, p.520. Dale Spender
R7
A
83
Reeves, H. and Baden, S. (2000, February). Gender and Development: Concepts and Definitions. BRIDGE
(development - gender), Report No 55. Brighton, UK: Institute of Development Studies, pp. 1-37.
development - gender
Report No 55
Gender and Development:
Concepts and Definitions
Prepared for the Department for International Development (DFID)
for its gender mainstreaming intranet resource
by Hazel Reeves and Sally Baden
February 2000
BRIDGE (development - gender)
Institute of Development Studies
University of Sussex
Brighton BN1 9RE, UK
Tel: +44 (0) 1273 606261
Fax: +44 (0) 1273 621202
Email: bridqe@ids.ac.uk
Website: http://www.ids.ac.uk/bridqe/
© Institute of Development Studies
ISBN 1 85864 381 3
164
a
Contents
-
1. Introduction
1
2. Quick Definitions
2_
3. Detailed Explanations and Further Reading...
Culture..................................................................
Gender Analysis...................................................... .
Gender Discrimination.............................................
Gender Division of Labour............... .......................
Gender Equality and Equity.....................................
Gender Mainstreaming....
Gender Needs...........................................................
Gender Planning.......................................................
Gender Relations...,
Gender Training.........................................................
Gender Violence....................................................... .
Intra-household Resource Distribution...................
National Machineries for Women.............. .............
Patriarchy...................................................................
Sex and Gender........................................................
Social Justice.............................................................
WID/GAD....................................................................
Women's Empowerment...........................................
Women's Human Rights....
4
6
7
8
10
............................. 12
14
16
............................ 18
20
22
24
26
o
28
30
.....31
33
35
........................... 37
J
<65
1. Introduction
Selected concepts central to Gender and Development thinking are expiamed here
These are intended to help you explore some of the key ideas_and 's&u^ ,n
and Development and their implications for policy and prachce. The
The succinct
succinc.
definitive.
Readers
are
advised
to
explanations here are neither comprehensive nor c.... .
detailed discussions.
discussions.
consult the recommended readings for more detailed
i
I6fc
2. Quick Definitions
Culture
I The distinctive patterns of ideas, beliefs, and norms
i which characterise the way of life and relations of a
I society or group within a society
]_______ _____ ____ _ _________ ___
..Gender Analysis
I The systematic gathering and examination of
! information on gender differences and social relations in
| order to identify, understand and redress inequities
• based on gender
j____ :________ _ _________ '
---
Gender Discrimination
The systematic, unfavourable treatment of individuals
on the basis of their gender, which denies them rights,
opportunities or resources
Gender Division of Labour
The socially determined ideas and practices
which define what roles and activities are deemed
appropriate for women and men
Gender Equality and Equity
Gender equality denotes women having the same
opportunities in life as men, including the ability to
participate in the public sphere
Gender equity denotes the equivalence in life outcomes
for women and men, recognising their different needs
and interests, and requiring a redistribution of power
and resources
Gender Mainstreaming
An organisational strategy to bring a gender perspective
to all aspects of an institution’s policy and activities,
through building gender capacity and accountability
Gender Needs
Shared and prioritised needs identified by women that
arise from their common experiences as a gender
Gender Planning
The technical and political processes and procedures
necessary to implement gender-sensitive policy
.)
Gender Relations
Hierarchical relations of power between women and
men that tend to disadvantage women
Gender Training
I A facilitated process of developing awareness and
I capacity on gender issues, to bring about personal or
| organisational change for gender equality
Gender Violence
| Any act or threat by men or male-dominated institutions,
i that inflicts physical, sexual, or psychological harm on a
! woman or girt because of their gender
I_______________ _______________
2
Intra-household Resource
Distribution
Tlhe dynamics of how different resources that are
generated within or which come into the household, are
accessed and controlled by its members
National Machineries for
Women
J Agencies with a mandate for the advancement of
: women established within and by governments for
i integrating gender concerns in development policy and
I planning
i
Patriarchy
i
__________ __ __________
I Systemic societal structures that institutionalise male
physical, social and economic power over women
Sex and Gender
I Sex refers to the biological characteristics that
I categorise someone as either female or male; whereas
gender refers to the socially determined ideas and
practices of what it is to be female or male
Social Justice
Fairness and equity as a right for all in the outcomes of
development, through processes of social
transformation
WID/GAD
The WID (or Women in Development) approach calls for
greater attention to women in development policy and
practice, and emphasises the need to integrate them
into the development process
In contrast, the GAD (or Gender and Development)
approach focuses on the socially constructed basis of
differences between men and women and emphasises
the need to challenge existing gender roles and
relations
Women’s Empowerment
A *bottom-up’ process of transforming gender power
relations, through individuals or groups developing
awareness of women’s subordination and building their
capacity to challenge it
Women’s Human Rights
The recognition that women’s rights are human rights
and that women experience injustices solely because of
their gender
168
3. Dptailed Explanations and Further Reading
CULTURE
“We talk about poverty
across societies, and
no-one raises any
problems. We talk about
gender subordination
across societies, and
people cry cultural
imperialism!”
(White, 1993:9)
See also: FAQ ‘What
right have we to interfere
in other people’s
cultures?’
The distinctive patterns of ideas, beliefs, and norms which
characterise the way of life and relations of a society or group
within a society
Culturally determined gender ideologies define rights and
responsibilities and what is ‘appropriate* behaviour for women and
men. They also influence access to and control over resources,
and participation in decision-making. These gender ideologies
often reinforce male power and the idea of women s inferiority.
Culture is sometimes interpreted narrowly as ‘custom’ or
‘tradition’, and assumed to be natural and unchangeable. Despite
these assumptions, culture is fluid and enduring.
Dominant cultures reinforce the position of those with economic,
political and social power, and therefore tend to reinforce male
power. Globalisation also has implications for the diffusion of
culture, particularly of western culture.
The defence of ‘culture’ and ‘tradition’ is often used by men to
justify practices that constrain women’s life chances and
outcomes. Interventions to challenge power imbalances proposed
by local women’s organisations or NGOs are often denied
legitimacy, or where an international agency is involved,
denounced as ‘western’ interference or ‘cultural imperialism’.
Many within the international development community also remain
resistant to goals of gender equity because they perceive these
as interfering with the most intimate domain in society.
Some
women have themselves defended ideas of ‘culture and tradition
in order to hold on to what little power they have, or as a form of
resistance. For example, before the revolution in Iran, women
took up the veil to show resistance to the processes of
westernisation that the country was experiencing.
Nevertheless, there are real issues of concern for local women’s
groups when externally initiated interventions are tainted by
colonial attitudes. In the past, women were often seen as ‘victims’
that needed protection. Male colonisers, however well intentioned,
perpetuated this paternalistic idea to justify their colonial
domination. More recently, certain western feminists have also
colluded in this notion, giving overwhelming priority to such issues
as veiling, arranged marriages, and female genital mutilation, at
the expense of other perhaps more immediate concerns.
Southern feminists challenge this idea of women as victims.
They
want to set their own agendas - which may imply
redistributive action or tackling poverty - and gain support for
these from western feminists.
Further reading
Development Assistance Committee (DAC), 1998. ‘Gender,
Equality and Culture’, in DAC Source Book on Concepts and
Approaches linked to Gender Equality, OECD, Paris
4
169
j
Mohanty, C. (1991) 'Under Western Eyes. Feminist Scholarship
and Colonial Discourse’; in Mohanty, C., Russo, A. and L. Torres
(eds.), 1991, Third World Women and the Politics of Feminism,
Bloomington, Indiana University Press
Moore, H. 1994, A Passion for Difference, Cambridge, Polity
Oxfam, 1995, ‘Women and Culture,’ Gender and Development,
Oxfam Journal, Vol.3, No.1, February, Oxfam, Oxford
Nussbaum, M., and Glover, J., 1995. Women, Culture and
Development: A Study of Human Capabilities, Clarendon Press,
Oxford
5
I7o
gender
ANALYSIS
Gender snafysis, once
confined to the margins
of development theory,
has over the last ten
years penetrated both
the thinking and the
operations of
international
development institutions’
(Miller and Razavi, 199Q-
anaiysis. induding the Gender ko!eS or Ha^
Social Relations Analysis.
'O
arvard framework, and
men's roles an^ ^hd^e^tiw^cce^lo^^ ’d9 W°men’S and
ana*ysis and tends to
category.
°f
Ci
SSUme that women are a homogeneous
o
aspects of social differentiation such
women, divided by other
The aim is to understand thp
• C ass’ race anc* ethnicity,
different institutional contexts and^i^h 0\gender relat»ons in
bargaining position an^ formulatp J
tO ,dentifV women’s
has proved chalfenging fo adopt thTs
,O
this 11
work.
9 9 ° adOp' ,hls aPProach in operational
See also:
Gender training.
Gender planning
WID/GAD
Other gender analysis frameworks includethe Moser/DPU
Framework;
the Longwe Method/Women's
Framework; and Levy s Web of Institutionalisation. Empowerment
analysis7 to the andysfe^of rnZdcefs * of
tO aPP‘y 9ender
sectoral policies, and of public expendium anc
Further reading
expenditure: six tools','mk^eo'cENECON u'^r5
of Sciences, University of Man’cheste^
UNDP, New York
'nt0
PUb,'C
Graduate Scho°f
ueve,opment Monograph Series. No.6.
•Se^A^alysTFimewo^k-^n' M’ and Aus,in' J- 1991Analysis in Development Plane
Press. Connecticut
VerPo1’
al- 1991. Gender
A Case Book- Kumarian
6
-r I
GENDER
DISCRIMINATION
“Not all women are poor,
and not all poor people
are women, but all
women suffer from
discrimination”
(Kabeer, 1996:20)
The systematic, unfavourable treatment of individuals on the
basis of their gender, which denies them rights, opportunities or
resources
Across the world, women are treated unequally and less value is
placed on their lives because of their gender.
Women's
differential access to power and control of resources is central to
this discrimination in all institutional spheres, i.e. the household,
community, market, and state.
Within the household, women and girls can face discrimination in
the sharing out of household resources including food,
sometimes leading to higher malnutrition and mortality indicators
Gender discrimination:
for women. (See Intra-household Resource Distribution). At its
• women work 67% of most extreme, gender discrimination can lead to son preference,
the world’s working expressed in sex selective abortion or female feticide. In the
hours
labour market, unequal pay, occupational exclusion or
• 2 out of 3 of the
segregation into low skill and low paid work limit women’s
world’s illiterate
earnings in comparison to those of men of similar education
people are women
levels. Women’s lack of representation and voice in decision
• women’s earnings
making bodies in the community and the state perpetuates
range from 50-85% of discrimination, in terms of access to public services, such as
men’s earnings
schooling and health care, or discriminatory laws.
• globally women make
up just over 10% of
The law is assumed to be gender-neutral when in fact it may
representatives in
perpetuate gender discrimination, being a product of a culture
national government
with oppressive gender ideologies. Even where constitutional or
(adapted from Oxfam,
national legal provisions uphold gender equality principles,
1995:181, and ’Facts and religious or other customary laws that privilege men may take
Figures’ section)
precedence in practice. However, the law, when reformed with
women’s input, can be a potent tool for challenging
discrimination, if combined with other strategies, including
capacity-building to overcome barriers to claiming rights.
See also:
Women’s human rights,
Social justice,
Intra-household resource
allocation
Further reading
The Convention on the Elimination of all forms of Discrimination
against Women (CEDAW) in 1979 brought into international
focus the rights of women as human rights, including the right to
be free from discrimination. Women activists regard this
convention as a key tool to support their struggle against
discrimination in all spheres, pushing governments towards
attaining these internationally recognised minimum standards.
Birdsall, N., and Sabot, R., (eds.), 1991, Unfair Advantage:
Labour Market Discrimination in Developing Countries,
IBRD/Worid Bank, Washington
Seager, J.» 1997, The State of Women in the World Atlas:
Women's status around the Globe: Work, Health, Education and
Personal Freedom, Penguin, London
7
H2-
GENDER DIVISION
OF LABOUR
The socially determined ideas and practices
which define what roles and activities are deemed appropriate for
women and men
Whilst the gender division of labour tends to be seen as natural
and immutable, in fact, these ideas and practices are socially
constructed. This results in context-specific patterns of who
does what by gender and how this is valued. Gender divisions of
labour are not necessarily rigidly defined in terms of men's and
women’s roles, as is sometimes assumed.
They are
characterised by co-operation in joint activities, as well as by
separation.
Often, the accepted norm regarding gender
divisions varies from the actual practice.
‘Women’s labour is not
infinitely elastic. It cannot
stretch to cover all the
deficiencies left by
reduced public
expenditure. It cannot
absorb all the shocks of
adjustment. ’
(Elson, 1995:15)
However, roles typically designated as female are almost
invariably less valued than those designated as male. Women
are generally expected to fulfil the reproductive role of bearing
and raising children, caring for other family members, and
household management tasks, as well as home based
production. Men tend to be more associated with productive
roles, particularly paid work, and market production. In the labour
market, although women’s overall participation rates are rising,
they tend to be confined to a relatively narrow range of
occupations or concentrated in lower grades than men, usually
earning less.
Historically, women’s productive roles have been ignored or
under-valued, particularly in the informal sector and subsistence
agriculture. This has led to misconceived development projects;
for example the services of extension agents and agricultural
inputs being targeted at men. Because women’s labour is
undervalued, it is often assumed by mainstream development
policies to be infinitely elastic. For example, policy makers expect
that women can take on roles previously fulfilled by public
services, such as care for the sick and elderly, when cutbacks
are made.
See also:
Gender needs,
Gender analysis.
Women’s empowerment
The formal documentation and recognition of women’s roles and
the related time burden is crucial for gender-sensitive
development interventions. Recently, international organisations
have begun to measure all forms of economic activity by gender.
International definitions of economic activity have also been
broadened to include subsistence farming, food processing and
homeworking ‘in anticipation of profit’. Time budget surveys are
also being implemented in some places to measure women’s
input into reproductive work.
- Gender and development policies and programmes can
challenge and change women’s socially prescribed roles, in
pursuit of gender equity. For example, women have been
successfully trained and employed as water technicians or
builders in communities where these were jobs previously a male
8
H2>
i"
domain. However, programmes aiming to increase women’s
participation in spheres beyond the household must ensure that
they are properly remunerated.
They should also be
accompanied by consideration of how men, or public provision,
can reduce women's responsibilities in the home.
Further reading
Adepoju, A., and Oppong, C., (eds.), 1994, Gender, work &
population in Sub-Saharan Africa, ILO, James Currey, London
Anker, R_, 1997, Gender and Jobs:
Occupations in the World, ILO, Geneva
Sex Segregation
of
Beneria, L, 1992, ‘Accounting for women’s work: progress of two
decades,’ World Development, Vol.20, No.11
Boserup, E., 1970, Women's Role in Economic Development,
Gower, Aidershot
Stichter, S. and J. Parpart, (eds.), 1990, Women, Employment
and the Family in the International Division of Labour,
Basingstoke; Macmillan
9
17^
GENDER
EQUALITY &
EQUITY
The term ‘gender equity’ is often used interchangeably with
’gender equality’. Here, a distinction is drawn between these two
concepts, reflecting divergent understandings of gender
differences and of the appropriate strategies to address these.
Gender equality denotes women having the same opportunities in
. life as men, including the ability to participate in the public sphere
This expresses a liberal feminist idea that removing discrimination
in opportunities for women allows them to achieve equal status 1o
men. In effect, progress in women's status is measured against a
male norm. Equal opportunities policies and legislation tackle the
problem through measures to increase women’s partidpation in
public life. For example, in Chile, the National Service for Women
(SERNAM) developed an Equal Opportunities Plan for Chilean
Women 1994-1999. This focused on equitable participation in
education, the labour market, health services, and politics.
Judidal reform is another key tool in the fight for equality, but lack
of implementation and enforcement might limit its impact.
However, this focus on what is sometimes called formal equality,
does not necessarily demand or ensure equality of outcomes. It
assumes that once the barriers to participation are removed, there
is a level playing field. It also does not recognise that women’s
reality and experience may be different from men’s.
Gender equity denotes the equivalence in life outcomes for
women and men, recognising their different needs and interests,
and requiring a redistribution of power and resources.
The goal of gender equity, sometimes called substantive equality,
moves beyond equality of opportunity by requiring transformative
change. It recognises that women and men have different needs,
preferences, and interests and that equality of outcomes may
necessitate different treatment of men and women.
See also:
WID/GAD,
Gender analysis,
Gender relations
An equity approach implies that all development policies and
interventions need to be scrutinised for their impact on gender
relations. It necessitates a rethinking of policies and programmes
to take account of men's and women's different realities and
interests. So, for example, it implies rethinking existing legislation
on employment, as well as development programmes, to take
account of women’s reproductive work and their concentration in
unprotected, casual work in informal and home based enterprises.
It is worth examining the content of policies, not just the language,
before deciding whether an equity or an equality approach is
being followed. Gender equity goals are seen as being more
political than gender equality goals, and are hence are generally
less accepted in mainstream development agencies.
Further Reading
Development Assistance Committee (DAC), 1998, 'Evolution of
the Thinking and Approaches on Equality Issues’ in DAC, 1998,
DAC Sourcebook on Concepts and Approaches linked to Gender
10
.)
i.
GENDER
MAINSTREAMING
Beijing
Platform for Action:
‘...governments and
other actors should
promote an active and
visible policy of
mainstreaming a gender
perspective in all policies
and programmes’
(cited in DAC, 1998:28)
An organisational strategy to bring a gender perspective to all
aspects of an institution’s policy and activities, through building
gender capacity and accountability
The 1970s strategies of integrating women into development by
establishing separate women’s units or programmes within state
and development institutions had made slow progress by the mid1980s. (See National Machineries for Women). In light of this, the
need was identified for broader institutional change if pervasive
male advantage was to be challenged. Adding women- specific
activities at the margin was no longer seen as sufficient. Most
major development organisations and many governments have
now embraced ‘gender mainstreaming’ as a strategy for moving
towards gender equality.
_ strategy, gender concerns are seen as
With a ___________
mainstreaming
impOrtant to all aspects of development; for all sectors and1 areas
fundamental
of activity, and a L...J
--------r.r. part of the planning process.
Responsibility for the implementation of gender policy is diffused
across the organisational structure, rather than concentrated in a
small central unit.
Such a process of mainstreaming has been seen to take one of
two forms. The agenda-setting approach to mainstreaming seeks
to transform the development agenda itself whilst prioritising
gender concerns. The more politically acceptable integrationist
approach brings women’s and gender concerns into all of the
existing policies and programmes, focusing on adapting
institutional procedures to achieve this. In both cases, political as
well as technical skills are essential to a mainstreaming strategy.
See also:
National Machineries for
Women,
Gender planning
Further reading
Any approach to mainstreaming requires sufficient resources, as
well as high-level commitment and authority. A combined strategy
can be particularly powerful. This involves the synergy of a
catalytic central gender unit with a cross-sectoral policy oversight
and monitoring role, combined with a web of gender specialists
across the institution. The building of alliances both within the
institution and with outside constituencies, such as women s
organisations, is crucial for success. Mainstreaming tools include
gender training, introducing incentive structures which reward
efforts on gender, and the development of gender-speafic
operational tools such as checklists and guidelines.
BRIDGE, 1997, ‘Institutionalising gender’, Development and
gender in brief, Issue 6, BRIDGE, IDS, Brighton
DFID (Social Development Division), 1998, ‘Putting gender
mainsteaming into practice’, mimeo, paper presented to the DFID
Management Board, 8 May
Goetz, A., (ed), 1997, Getting Institutions Right for Women in
Development, Zed Books, London
12
176
Moser, C., Tomqvist, A., and van Bronkhorst, B., 1998,
Mainstreaming Gender and Development in the World Bank:
Progress and Recommendations, The International Bank for
Reconstruction and Development/The World Bank, Washington,
D.C.
Razavi, S., and Miller, C., 1995, 'Gender mainstreaming: a study
of efforts by the UNDP, the World Bank and the ILO to
institutionalize gender issues’, Occasional Papers, No.4,
UNRISD, Geneva
Schalkwyk, J., Thomas, H., and Woroniuk, B., 1996.
Mainstreaming: a Strategy for Achieving Equality between
Women and Men’. SIDA, Stockholm
i
5
13
177 "
GENDER NEEDS
Shared and prioritised needs identified by women that arise?from
their common experiences as a gender
Certain women’s interests, of a political or practical nature, related
to their experience as a gendered person. Such prioritised
concerns have been translated into the concept of gender needs
(Moser, 1989). This identifies the way in which women’s gender
interests, defined by women themselves, can be satisfied in the
planning process. Although needs and interests are conceptually
different (Molyneux, 1998), in practice, they are closely related in
the planning process. Needs, as well as interests, result from a
political process of contestation and interpretation and thus
should not be externally defined or seen as fixed.
Practical Gender Needs (PGNs) according to Moser (1989) are
the immediate needs identified by women to assist their survival
in their socially accepted roles, within existing power structures.
Polides to meet PGNs tend to focus on ensuring that women and
their families have adequate living conditions, such as health care
and food provision, access to safe water and sanitation, but also
seek to ensure access to income-earning opportunities. PGNs do
not directly challenge gender inequalities, even though these
needs may be a direct result of women’s subordinate position in
sodety.
See also:
Gender analysis
Gender planning
Women’s empowerment
Strategic gender needs (SGNs), are those needs identified by
women that require strategies for challenging male dominance
and privilege. These needs may relate to inequalities in the
gender division of labour, in ownership and control of resources,
in participation in decision-making, or to experiences of domestic
and other sexual violence. These needs are often seen as
feminist in nature as they seek to change women’s status and
position in society in relation to men. As such, they are more
likely to be resisted than PGNs.
in reality, it is difficult to distinguish so clearly between strategic
and practical needs. Any policy or programme may meet both
sets of needs. Through collective organising around practical
gender needs, women may achieve more strategic and
transformatory goals. This politidsation of practical gender needs
is a favoured entry point for NGOs and women’s organisations.
However, women may not always recognise or prioritise their
strategic gender needs, particularly if it could threaten their
immediate practical needs. At any time, gender interests may not
be prioritised over women’s other interests which cut across
these, such as those of class and race, so assumptions cannot be
made of women’s solidarity.
Further reading
Molyneux, M., 1985, ‘Mobilisation without emancipation?
Women’s interests, the state and revolution in Nicaragua’,
Feminist Studies, Vol.11, No.2
14
17g
i
J
Molyneux, M., 1998. ‘Analysing women's movements', in Jackson,
C., and Pearson, R., 1998, Feminist Visions of Development:
Gender Analysis and Policy, Routledge, London
Moser, C,. 1989, ‘ Gender planning in the third world: meeting
practical and strategic needs’. World Development, Vol. 17 No 1 T
pp1799-1825
15
179
GENDER
PLANNING
The technical and political processes and procedures necessary
to implement gender-sensitive policy and practice
The purpose of gender planning is to ensure gender-sensitive
policy outcomes through a systematic and inclusive process. If
gender policy has transformatory goals, then gender planning as
a process will necessarily be a political one, involving consultation
with and participation of different stakeholders.
'Project planning and
implementation from a
gender-based
perspective can have
only one ultimate
goal...contribute to
changing the balance of
the sexual division of
power and resources so
as to make it more
equitable’
(Macdonald, 1994:45)
There is a variety of gender planning frameworks based on
differing approaches to gender analysis, each with its own
planning principles and tools. For example, Caroline Moser (1993)
developed a gender planning framework consisting of gender
planning tools, gender planning procedures, and the components
of gender planning practice. The gender planning tools indude
gender roles identification, gender needs assessment, and the
collection of disaggregated data at the household level. The
gender planning procedures involve the diagnosis of the gender
problem, formulation of gender objectives, procedures for
monitoring and evaluation, gender-based consultation and
participation, and identification of an entry strategy. The final
aspect, practice, identifies the need to institutionalise gender
planning, and to operationalise this through recognised
procedures. Building capacity amongst planners is necessary to
ensure policy is transformed into practice with the minimum of
dilution.
The social relations approach differs in its focus on power in
gender relations (See Gender Analysis). This approach uses an
institutional framework for the analysis of gender inequalities as a
tool for gender-aware planning. It recognises that the means
through which needs are met is as important as the planned ends
of any intervention. The planning process is conceived as
participatory and constituted by an analysis and evaluation of
causes, effects, means and ends. A seven-point ‘Gender audit for
development interventions’ supports this framework. (Kabeer and
Subrahmanian, 1996).
See also:
Gender mainstreaming.
Gender training.
Gender analysis,
WID/GAD
Whilst gender transformatory polides are increasingly being
generated, concerns are focusing on the ‘misbehaviour’ of such
policies, i.e. a tendency to slip in implementation from
transformatory objectives to outcomes that fail to challenge
existing gender relations. It has been recognised that GAD
approaches are constrained by resistance and subversion, from
within
both
implementing
organisations
and
targeted
communities. Gender planning needs therefore to be part of an
on-going process of gender mainstreaming, backed up by
sufficient resources, commitment and authority. Gender planning
procedures need to involve the participation of stakeholders and
dear lines of accountability.
At the project level, a variety of planning tools are used to
operationalise gender policy, including general and sector-specific
checklists and guidelines. Logical Framework Analysis is an
16
Ito
i
example of a planning tool'which, if used in a gender-sensitive
manner, can help to ensure accountability, participation of various
stakeholders, and that relevant monitoring and evaluation
procedures are implemented
Further reading
Kabeer, N., and Subrahmanian, R., 1996. 'Insititutions, relations
and outcomes: framework and tools for gender-aware planning’,
IDS Discussion Paper, No.357, IDS, Brighton
Macdonald, M., (ed.), 1994, Gender Planning in Development
Agencies: Meeting the Challenge, Oxfam, Oxford
Moser, C., 1993, Gender Planning and Development: Theory,
Practice and Training, Routledge, London
17
12,1
GENDER
RELATIONS
If gender is about
relations between men
and women, then the
male side of the eqution
must also be figured in.
If women’s gender
identities are to be
changed, then men's
must change also.'
(White in Macdonald,
1993:20)
Hierarchical relations of power between women and men that
tend to disadvantage women
These gender hierarchies are often accepted as ‘natural’ but are
socially determined relations, culturally based, and are subject to
change over time. They can be seen in a range of gendered
practices, such as the division of labour and resources, and
gendered ideologies, such as ideas of acceptable behaviour for
women and men.
Analyses which focus on gender relations differ in emphasis from
those which take ‘gender roles’ as a starting point. They give
more prominence to the connectedness of men’s and women’s
lives, and to the imbalances of power embedded in male-female
relations. They also emphasise the interaction of gender relations
with other hierarchical social relations such as class, caste,
ethnicity and race. But whether gender relations act to alleviate,
or to exacerbate other social inequalities, depends on the context.
Gender relations constitute and are constituted by a range of
institutions, such as the family, legal systems or the market. They
are a resource which is drawn on daily to reinforce or redefine the
rules, norms and practices which govern social institutions. Since
historically women have been excluded from many institutional
spheres, or their participation circumscribed, they often have less
bargaining power to affect change who institutions operate.
See also:
Gender equity,
Gender analysis,
Sex and gender,
WID/GAD
So, for example, where they are perceived to transgress their
accepted roles, women can be physically or sexually abused by
male partners with relative impunity. In many cultures, beatings
or rape in marriage are considered acceptable in the existing legal
framework. Even where, following lobbying of women’s groups,
rape or violence within marriage is outlawed, women may be
reluctant to seek redress because the male dominated judicial
system is unsympathetic, or because they fear ostracism. Where
women retaliate, they become criminalised themselves. However,
change is possible: in a few recent cases, following sustained
campaigns, women have been acquitted of ‘crimes’ against
violent partners and new laws have been passed to respond to
such attenuating circumstances.
Hierarchical gender relations constrain development efforts. For
example, rigidities in the gender division of labour limit the
effective mobilisation of women’s labour to support export
production. Poverty reduction efforts are hampered where men
use their authority to usurp control over resources targeted at
women. Development strategies need to be informed by an
analysis of gender relations and to support women’s own
attempts to change the rules and practices which reinforce these
gender hierarchies.
18
I&2-
*
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*
Further reading
Pearson, R., Whitehead, A., and Young, K., 1984, ‘Introduction:
the continuing subordination of women in the development
process,’ in Young, K., Wolkovitz, C„ and McCullagh, R_, 1984,
Of Marriage and the Market, Routledge and Kegan Paul, London
Razavi, S„ and Miller, C., 1995, ‘From WID to GAD: Conceptual
Shifts in the Women and Development Discourse', Occasional :
Paper, UNRISD, Geneva
Pearson, R_, and C., Jackson, 1998, ‘Introduction: interrogating
development. Feminism, gender and policy’, in Jackson, C., and
Pearson, R., (eds.), 1998, Feminist Visions of Development’
Gender Analysis and Policy, Routledge. London
19
185
S’
GENDER
TRAINING
‘Gender training...is a
tool, a strategy, a space
for reflection, a site of
debate and possibly for
struggle. Training is a
transformative process'
(Macdonald, 1994:31)
See also:
Gender analysis,
Gender mainstreaming,
Gender planning
A facilitated process of developing awareness and capacity on
gender issues to bring about personal or organisational change
for gender equality
Gender training is one of a range of institutional strategies used to
integrate gender into the work of development co-operation
agencies. Its objectives can include raising general awareness of
the relevance of gender to an organisation’s work and skills
transfer in gender analysis, gender-aware planning, programme
design and implementation. Gender training typically involves:
group discussion and reflection on gender roles and relations;
case studies of the impact of development policies and
programmes on gender relations; as well es role plays and
simulation games which highlight gender dynamics.
The trainer’s, as well as the organisation’s, approach to gender
and development influence the training approach, and hence the
framework used (See Gender Analysis). These vary in the degree
to which they see the need for personal attitudinal and
behavioural change, or focus primarily on changing organisational
procedures and practices. Personal transformation tends to be a
training objective for Southern NGOs/women’s organisations
rather than development co-operation agencies, and the ‘further
reading’ below.
r
As awareness grows within an organisation, so the emphasis of
gender training shifts to more tailored courses to meet specific
needs and demands, and to more skills-based training. Gendei
training was initially mainly focused at the project level, but more
recently emphasis has shifted to sectoral and macro-economic
policy-making.
Attention has recently focused on the need to evaluate the impact
of gender training. Experience suggests that training is most
effective when it is part of a broader strategy of organisational
change.
Further reading
Kabeer, N., 1994, ‘Triple Roles, Gender Roles, Social Relations.
The political subtext of gender training frameworks’, in Reversed
Realities: Gender Hierarchies in Development Thought, Verso,
London
Miller, C., and Razavi, S., 1998 ‘Gender analysis: alternative
paradigms’ Gender in Development monograph Series No 6,
UNDP, New York
Moser, C., 1993, ‘Training strategies for gender planning: from
sensitising to skills and techniques’, in Moser, C., 1993, Gender
Planning and Development: Theory, Practice and Training,
Routledge, London
Royal Tropical Institute (KIT), 1998, Gender Training: The Source
Book, KIT Press/Oxfam Publishing, Oxford
20
1^
■J
■r.
Wach, H., and Reeves, H., 1999, ‘Southern gender training
materials: an overview and resource guide’, BRIDGE Report.
Institute of Development Studies, Brighton
Williams, S., with Seed, J., and Mwan, A., 1994, The Oxfam
Gender Training Manual, Oxfam, Oxford
21
1^5
GENDER
VIOLENCE
Any act or threat by men or male-dominated institutions, that
inflicts physical, sexual, or psychological harm on a woman or girl
because of their gender
“Women should wear
purdah [head-to-toe
covering] to ensure that
innocent men ... are not
unconsciously forced
into becoming rapists ’
Parliamentarian of the
ruling Barisan National in
Malaysia
(cited in Heise et a!
1994:iii)
Percentage of women
surveyed reporting
physical assaults by
intimate partner:
Japan:59%
Zambia: 40%
Colombia: 20%
Tanzania: 60%
(UN, 1995:160)
See also:
Gender discrimination,
Social justice.
Women "s human rights
Gender violence occurs in both the public' and private' spheres.
It happens in virtually all societies, across all social classes, with
women particularly at risk from men they know. Official figures
are scarce, and under reporting is rife, especially when the
violence involves another family member.
Violence against
women, and particularly systematic rape, has frequently been
used as a weapon of war against particular ethnic groups or entire
populations.
There is, however, no single definition of gender violence
accepted internationally and there is much debate over the
breadth of inclusion. Commonly, the acts or threats of such
included in the definition are rape, sexual harassment, wife
battering, sexual abuse of girts, dowry-related violence, and nonspousal violence within the home. Other definitions extend to
marital rape, acts such as female genital mutilation, female
infanticide, and sex-selective abortion. In addition, certain
definitions include ‘sexual exploitation’ such as enforced
prostitution, trafficking of women and girls, and pornography.
It is now recognised in international law that violence against
women is a human rights issue with major health and economic
implications. The rape of women in wartime has been recognised
and explicitly prohibited since 1949 in article 47 of the Fourth
Geneva Convention Relative to the Treatment of Civilian Persons
in Times of War. The United Nations (UN) recently appointed a
Special Rapporteur on violence against women. However,
legislation alone is insufficient to address this problem.
The prevention and elimination of violence against women is
hampered by pervasive attitudes that devalue women’s lives and
by institutional resistance, including from the judicial system and
the police, to recognising the extent of the problem. There is
hostility to interfering with ‘private’ domestic disputes. Even where
countries have issued appropriate legislation, its implementation
and enforcement may well be weak. Additional support activities
are required. Legislative reform, training of the police and lawyers,
provision of shelters, and the building of capacity for women to
combat violence and pursue their rights, are all necessary.
Development policy must understand both the obstacles gender
violence places in the way of effective development, and the
debilitating impact it has; on women’s lives. Policy concerns
should not only focus on programmes specifically targeted at
violence against women, but on violence as an aspect of other
programmes, such as microenterprise schemes. Development
interventions themselves could make women more vulnerable to
violence if men feel threatened by attempts to enhance women’s
status.
22
l&6
)
Further reading
■The British Council, 1999, ‘Violence against Women: A briefing
document on international issues and responses’. The British
Council, London
Bunch, C., and Carrillo, R., Gender Violence: A Development and
Human Rights Issue, Center for Women’s Global Leadership
Davies, M.t (ed), 1994, Women and Violence: Realities and
Responses Worldwide, Zed Books, London
Heise, L., with Pitanguy, J., and Germain, A., 1994, ‘Violence
Against Women: The hidden health burden,’ World Bank
Discussion Paper, No.255, International Bank for Reconstruction
and Development, The World Bank, Washington D.C.
Oxfam, 1998, ‘Violence against women’. Gender and
Development Journal, Volume 6, no.3, November, Oxfam, Oxford
23
187
INTRA
HOUSEHOLD
resource
distribution
,ha' 3,6 generate<l
wilhin.^o, whicb°come fnto
accessed by its different members
COn,rohed and
female members orhousehoids^fhe'""ir' 106 °f biaS a9ainst
such as income, food nutrition health
allocatlon of resources
Patterns-are not unwersa hoiT
h
These
however,’ a
and
other-factors such as Iqe andZh
a'S° mediated bX
a9e, andhiaL
birth
little evidence of nutrittonal
h order. For examPfe. there is
against girt children'in S*‘
Saftaran Ato.
Wely noled. I, has also been sho»n ihJ this pattern has been
resources controlled by
women, for example in f
female-headed households, are
distnbuted differently to resources
some evidence that women spend controlled by men. There is
a higher percentage of their
generally smaller incomes on
family consumption and children’s
welfare.
The consensus appears
to be shifting to the view
that intrahousehotd
relations are indeed
characterised by power"
within the ho^eMd^s^n^emn 318■
(Kabeer, 1998:103)
activities Performed
Conventional micro-economists Ivni^i?10
henCe lrrelevan(
consumption unit and^rea? t X a
Vk 63 the hous^old as a
neutrality. It was the New HousehoM
' assumin9 SenderGary Becker in the 1960s) ^hTrh..^01^. <Pione^ed by
microeconomic approach and hinhr m a d the
h convent>onal
production within the household In^hk^6^
lrnPor,ance of
Pooled and distributed in an altnXt,>
’ 3,1 resources are
male household head to maximise thT3""!/ by 3 benevo,ent
members. However, gender an=>h
welfare of household
anthropologists and economists have
part'?Lllarl>' feminist
characterisation of the household k
.demonstrated that this
Power imbalances and cX*XVeZsX?
always poo^andTt'ressed the
resources are not
fact that
within the household in determinino ar of
°f ^ar9ainln9 Processes
relations within the householTare
t0 resources- Gender
both conflict and co-operaton whJT 8660 3S characferised by
Y W°men tend t0 have 'ess
bargaining power in the
example. S%. The SsS r hO"Seho,d resou^a (for
household are seen also to innuJn^
See also:
Gender relations.
Gender discrimination,
Women’s human rights
a0^ dYnam'cs with'n the
for women outside the home in emni opportunit,es and outcomes
theorists suggest that women’s barT^
exarnp,e- Cerfa'n
household is enhanced when
posrtion within the
mechanisms for enhancing womenTbarohOnie' °tfler
property rights, and
assessments of well-beino
Cr Y
h
9ender-differentiated
24
that benefits will ‘trickle-down’ to the rest of the household. Where
women are targeted with income-generating opportunities, it
cannot either be assumed that women will retain control of those
resources they bring into the household. This suggests the need
for improved data collection and analysis procedures that collect
more data at individual level, incorporate consideration of
intrahousehold dynamics and recognise the heterogeneity of
household arrangements.
Further reading
Bruce, J., 1989, 'Homes Divided’, World Development, Vol. 17,
No.7, pp979-991, Pergamon Press
Evans, A., 1991, ‘Gender issues in rural household economics’,
IDS Bulletin. Vol.22, No.1, Institute of Development Studies,
Brighton
Kabeer, N., 1998, ‘Jumping to conclusions: struggles over
meaning and method in the study of household economics', in
Jackson, C., and Pearson, R, 1998, Feminist Visions of
Development: Gender Analysis and Policy, Routledge, London
Sen, A., 1990, ‘Gender and co-operative conflicts’ in Tinker, I.,
(ed.), 1990, Persistent Inequalities, Oxford University Press, New
York
Haddad, L., and Hoddonott, J„ 1997, Intrahousehold Resource
Allocation in Developing Countries: Models, Methods and Policy,
International Food Policy Research Institute, John Hopkins
University Press, London
25
I8cf ’
national
machineries
Agencies with r
a mandate for the advancement of women
established within and by governments for integrating gender
concerns in development policy and planning
9 Sender
FOR WOMEN
National Mach,nenes for Women (NMWs) - whether offices
desks, or ministries - were central tn tho
♦whether offices,
onices,
the 1970s (see WID/clnx th
'"tegration strategies of
1980s and 1990^ n
k •
exPanded in numbers in the
NMWs h
2
being a fea(ure °f most governments
NMWs have made many positive achievements most im^danHv
^S’?gJ?e P‘ace of gender issues in developme^XS
(Goetz, 1998).
‘Linking NGOs and
women's organisations
with policy-makers in
government is a key role
for NMWs in the context
of mainstreaming'
(Oxaal, 1997:2)
However, NMWs have often p------en weak, under-resourced,
vulnerable to changing politicalipr°v
fortunes'
departments.’ Tte fac"
within social and iwelfare
”
national machineries i------ - *
lS.t?_bll!hed during periods of fiscal
restraint and government restructuring has''made
claims on
resources difficult to advance.
sgssa-ss-s
and ius^'Jpos'i IlPj)llt'Cal comnirtment to greater soaal equality
strategies for NMWs of
See a/so:
Gender mainstreaming,
Gender planning
NGOs and olto women’s'XSonf
”,b
Further reading
«NaSarx’x" xx-xrR-
XZS 'Xs aXX"XXXnX
26
Ho
Development Assistance Committee (DAC), 1998, ‘National
Machinery for Women’s Affairs’ in DAC Source Book on Concepts
and Approaches Linked to Gender Equality, OECD, Paris
Goetz, AM., 1998, ‘Mainstreaming gender equity to, nations'
development planning', in Miller, C., and Razavi, S., (eds.), 1998,
Missionaries and Mandarins, IT Publications, London
Oxaal, Z., 1997, ‘Bringing gender out of the ghetto: national
machineries for women’, Development and Gender In Brief, Issue
5, Institute of Development, Brighton
Rowan-Campbell, D., 1995, ‘National Machineries for women: a
balancing act', in Heyzer, N., A Commitment to the World’s
Women: Perspectives on Development for Beijing and Beyond,
UNIFEM, New York
J
27
HI
PATRIARCHY
Systemic societal structures that institutionalise male physical,
social and economic power over women.
Some feminists use the concept of patriarchy to explain the
systematic subordination of women by both overarching and
localised structures. These structures work to the benefit of men
by constraining women’s life choices and chances.
‘In attacking both
patriarchy and capitalism
we will have to find ways
to change both society
wide institutions and our
most deeply ingrained
habits. It will be a long,
hard struggle’
(Hartmann 1976:169)
There are many differing interpretations of patriarchy. However,
the roots of patriarchy are often located in women’s reproductive
role and sexual violence, interwoven with processes of capitalist
exploitation. The main ‘sites’ of patriarchal oppression have been
identified as housework, paid work, the state, culture, sexuality,
and violence. Behaviours that discriminate against women
because of their gender are seen as patriarchal ‘practices’; for
example occupational segregation, exclusion, and unequal pay.
The concept of patriarchy has been drawn into gender and
development theorising; in order to challenge not only unequal
gender relations but also unequal capitalist relations, sometimes
seen as underpinning patriarchy (Mies, 1986; DAWN, 1995).
Feminists who explain gender inequality in terms of patriarchy
often reject male-biased societal structures and practices and
propose greater female autonomy or even separatism as a
strategy. In some views, women are seen as having room for
manoeuvre within a constraining patriarchal system by negotiating
a ‘patriarchal bargain’ with men. This entails a trade-off between
women’s autonomy, and men’s responsibility for their wives and
children.
See also:
WID/GAD,
Gender discrimination,
Gender violence,
Culture
An overarching theory of male power may help to conceptualise
the extent of gender inequality but fails to deal with its complexity.
It tends to assume that gender oppression is uniform across time
and space. More recent thinking has therefore rejected such a
universal concept, identifying the need for detailed historical and
cultural analysis to understand gender-based oppression. Neither
are women a homogeneous group constrained in identical ways.
Gender inequalities are crosscut by other social inequalities such
as class, caste, ethnicity and race, which could be prioritised over
gender concerns in certain contexts. A rigid and universal concept
of patriarchy denies women space for resistance and strategies
for change. A more nuanced analysis is needed that takes into
account difference and complexity, and the agency of women.
Further reading
Development Alternatives with Women for a New Era (DAWN),
1995, ‘Rethinking social development: DAWN’s vision
(Development Alternatives with Women for a New Era)’, World
Development,ol.23, No.11, pp2001-04
Kandiyoti, D., 1998, ‘Gender, power and contestation: rethinking
bargaining with patriarchy’, in Jackson. C., and Pearson, R..
(eds.), 1998, Feminist Visions of Development: Gender Analysis
and Policy, Routledge, London.
28
H2-
< T■
I
Mies, M., 1986, Patriarchy and Accumulation on a World ScaleWomen in the International Division of Labour Zed Books
London
Walby, S„ 1990, Theorizing Patriarchy. Blackwell. Oxford
29
IA5
'"'I'
SEX & GENDER
‘Sex’ refers to the biological characteristics that categorise
someone as either female or male: whereas ‘gender’ refers to the
socially determined ideas and practices of what it is to be female
or male
Whilst often used interchangeably, ‘sex' and 'gender' are in fact
distinct terms.
See also:
Gender analysis.
Gender relations,
WID/GAD
‘Sex’: a person’s sex is biologically determined as female or male
according to certain identifiable physical features which are fixed.
Women's marginalisation has often been seen as ‘natural’ and a
fact of their biology. However these biological differences cannot
explain why women have less access to power and lower status
than men. To understand and challenge the cultural value placed
on someone’s biological sex, and unequal power hierarchies, we
need the relational concept of ‘gender’.
‘Gender’: how a person’s biology is culturally valued and
interpreted into locally accepted ideas of what it is to be a woman
or man. ’Gender’ and the hierarchical power relations between
women and men based on this are socially constructed, and not
derived directly from biology. Gender identities and associated
expectations of roles and responsibilities are therefore
changeable between and within cultures. Gendered power
relations permeate social institutions so that gender is never
absent.
The value of the distinction between the terms ‘sex’ and ‘gender’
has been challenged more recently as ‘sex’ has also been seen to
be socially constructed (Baden and Goetz, 1998).
Use of the term gender, rather than sex, signals an awareness of
the cultural and geographic specificity of gender identities, roles
and relations.
It also recognises gender inequality as the
outcome of social processes, which can be challenged, rather
than as a biological given. For this reason, its use can generate
considerable opposition, particularly from conservative religious
and cultural groups but also in mainstream development
institutions.
Further reading
Baden. S.» and Goetz, A., 1998, ‘Who needs [sex] when you can
have [gender]: Conflicting discourses on Gender at Beijing’, in
Jackson, C.. and Pearson, R., (eds.) 1998, Feminist Visions of
Development: Gender Analysis and Policy, Routledge, London
Ostergaard, L., 1992, ‘Gender’, in Ostergaard, L, (ed),l992.
Gender and Development: A Practical Guide, Routledge, London
White, S., 1993, ‘Gender and development: a review of key
issues’, mimeo, paper for JFS Workshop, Edinburgh, July 5-7
30
19
’’
SOCIAL JUSTICE
Fairness and equity as a right for all in the outcomes of
development, through processes of social transformation
The idea of 'social justice' as the outcome of struggles against
social inequalities implies change towards a more 'fair' society.
This requires strategies to redress past injustices, violation of
rights or persistent economic and social inequalities. Social
movements such as the women's, worker's, and human rights
movements, have fought against perceived social injustices from
a variety of entry points. Such movements have also challenged
the ideologies and prejudices that legitimate social inequalities, in
order to mobilise people for change.
There are varying conceptions of justice'. Common to them all is
a formal idea of justice - the idea that inequalities of distribution
must be justified by an impartial and rational assessment of
'relevant’ differences between the people involved. One key
theory of justice, based on Rawls’ ideas, translates this into the
idea of 'justice as fairness’ with its equity overtones and need for
redistributive strategies. Other thinking, derived from welfare
economics, focuses on more ’efficiency' ideas of maximising
overall utility or welfare, such that no-one can be made better off
without someone else being worse off. In development thinking a
‘capability’ perspective of justice is common, based on the work of
Amartya Sen, i.e. the idea that people should have the
capabilities to survive and function and the freedom to pursue
well-being. This requires both aggregative and redistributive
considerations.
Mainstream poverty debates have tended to focus on meeting the
basic needs of poor people and maximising their opportunities,
rather than seeing poverty as an issue of social inequality or
injustice. More radical perspectives, often adopted by NGOs, do
see poverty as an issue of injustice and focus on organising and
building capacity for the assertion of rights by the marginalised.
The idea of poverty as an issue of rights is growing in influence in
the development discourse, however, as for example in the DFID
White Paper.
See also:
Gender discrimination,
Women's human rights
Strategies towards social justice have often overlooked the
specific gender injustice or discrimination, as well as wider social
injustices, faced by women. The women’s movement has been
working to ensure that efforts to address injustice, through human
rights measures, or economic and social policies, are informed by
an understanding of gender inequalities.
Further reading
Facio, A., 1995, 'From basic needs to basic rights’, Gender and
Development, Vol.3, No.2, Oxfam. Oxford
Harcourt, W., 1997, 'The search for social justice’, development,
Vol.40, pp5-11, The Society for International Development, SAGE
Publications, London
3!
I. A 5
Gasper, D., 1997, ‘The capabilities approach to well-being, justice
and human development’. Journal of International Development
Vol.9, No.2
Sen, A.. Gender inequality and theories of justice’, in Nussbaum,
M., and Glover, J., 1995, Women, Culture and Development: A
Study of Human Capabilities, Clarendon Press. Oxford
Sen, G., 1997. ‘Globalization, justice and equity: a gender
perspective’. Development, Vol.40, No.2. pp21-26. The Society
for International Development, SAGE Publications London
'J
J
32
WID/GAD
‘Gender relations do not
operate in a social
vacuum but are products
of the ways in which
institutions are organized
and reconstituted'
(Kabeer, 1996:17)
See also:
Gender analysis,
Gender planning,
Sex and gender
The WID (or Women in Development) approach calls for greater
attention to women in development policy and practice, and
emphasises the need to integrate them into the development
process
The WID perspective evolved in the early 1970s from a liberal
feminist framework and was particularly influential in North
America. It was a reaction to women being seen as passive
beneficiaries of development. It marked an important corrective,
highlighting the fact that women need to be integrated into
development processes as active agents if efficient and effective
development is to be achieved. Women’s significant productive
contribution was made visible, although their reproductive role
was downplayed. Women’s subordination was seen in terms of
their exclusion from the market sphere, and limited access to and
control over resources. Programmes informed by a WID approach
addressed women’s practical needs by, for example, creating
employment and income-generating opportunities, improving
access to credit and to education. Women’s ‘problem’ was
therefore diagnosed as insufficient participation in a benign
development process, through an oversight on behalf of policy
makers.
In contrast, the GAD (or Gender and Development) approach to
development policy and practice focuses on the socially
constructed basis of differences between men and women and
emphasises the need to challenge existing gender roles and
relations
GAD emerged from a frustration with the lack of progress of WID
policy, in changing women’s lives and in influencing the broader
development agenda. GAD challenged the WID focus on women
in isolation, seeing women’s ‘real’ problem as the imbalance of
power between women and men. There are different
interpretations of GAD, some of which focus primarily on the
gender division of labour and gender roles focus on gender as a
relation of power embedded in institutions (see Gender Analysis).
GAD approaches generally aim to meet both women’s practical
gender needs and more strategic gender needs (see Gender
Needs), by challenging existing divisions of labour or power
relations (see Gender Division of Labour; Gender Relations).
Although WID and GAD perspectives are theoretically distinct, in
practice it is less clear, with a programme possibly involving
elements of both. Whilst many development agencies are now
committed to a gender approach, in practice, the primary
institutional perspective remains as WID and associated anti
poverty’ and ‘efficiency’ policies. There is often a slippage
between GAD policy rhetoric and a WID reality where ‘gender’ is
mistakenly interpreted as ‘women’.
33
IA7
Further reading
Kabeer, N., and Subrahmanian, R.. 1996, ‘Institutions, relations
and outcomes: framework and tools for gender-aware planning',
IDS Discussion Paper. No.357. Institute of Development Studies.
Brighton
Miller. C., and Razavi, S., 1995. 'From WID to GAD: conceptual
shifts in the Women and Development discourse’, Occasional
Paper. UNRISD, Geneva
Moser. C., 1993, Gender Planning and Development: Theory,
Practice and Training, Routledge, London
Young, K., 1993, ‘Framework for analysis', in Young, K., 1993,
Planning and Development with Women, Macmillan Press
London
i
a
34
WOMEN’S
EMPOWERMENT
Beijing Declaration:
‘Women’s empowerment
and their full participation
on the basis of equality
in all sphere of society,
including participation in
the decision-making
process and access to
power, are fundamental
for the achievement of
equality, development
and peace (paragraph
13).’
(cited in DAC, 1998: 10)
See also:
Gender analysis,
Gender needs,
Gender training,
WID/GAD
See also: FAQ
‘How can we measure
empowerment?’
A ‘bottom-up’ process of transforming gender power relations,
through individuals or groups developing awareness of women's
subordination and building their capacity to challenge it. The term
‘empowerment’ is now widely used in development agency policy
and programme documents, in general, but also specifically in
relation to women. However, the concept is highly political, and
its meaning contested. Thus, there are dangers in the uncritical
overuse of the term in agency rhetoric, particularly where it
becomes associated with specific activities, or used in simplistic
ways.
Central to the concept of women’s empowerment is an
understanding of power itself. Women’s empowerment does not
imply women taking over control previously held by men, but
rather the need to transform the nature of power relations. Power
may be understood as ‘power within,’ or self confidence, ‘power
with’, or the capacity to organise with others towards a common
purpose, and the ‘power to’ effect change and take decisions,
rather than ‘power over’ others.
Empowerment is sometimes described as being about the ability
to make choices, but it must also involve being able to shape
what choices are on offer. What is seen as empowering in one
context may not be in another.
Empowerment is essentially a bottom-up process rather than
something that can be formulated as a top-down strategy. This
means that development agencies cannot claim to 'empower
women’, nor can empowerment be defined in terms of specific
activities or end results. This is because it involves a process
whereby wornen, individually and collectively, freely analyse,
develop and voice their needs and interests, without them being
pre-defined, or imposed from above. Planners working towards an
empowerment approach must therefore develop ways of enabling
women themselves to critically assess their own situation and
shape a transformation in society. The ultimate goal of women’s
empowerment is for women themselves to be the active agents of
change in transforming gender relations.
Whilst empowerment cannot be ‘done to’ women, appropriate
external support can be important to foster and support the
process of empowerment. A facilitative rather than directive role is
needed, such as funding women’s organisations that work locally
to address the causes of gender subordination and promoting
dialogue between such organisations and those in positions of
power.
Recently, interest has grown among development professionals in
approaches to measuring women’s empowerment, particularly in
relation to microcredit programmes. A number of ‘indicators of
empowerment’ have been developed in different contexts. Again,
caution must be exercised in assuming that empowerment can be
externally defined and objectively assessed, or that such
indicators can be easily transferred.
35
1^
Further reading
Development Assistance Committee (DAC), 1998,
‘Empowerment’ in DAC Source Book on Concepts and
Approaches Linked to Gender Equality, OECD, Paris
Rowlands, J., 1996, ‘Empowerment examined’, in Anderson, M.,
(ed). Development and Social Diversity, Oxfam. Oxford
Oxaal, Z., 1997, Gender and empowerment: definitions,
approaches and implications for policy’, BRIDGE Report, No. 40,
Institute of Development Studies, Brighton
Johnson, H., 1992, ‘Women’s empowerment and public action:
experiences from Latin America’ in Wuyts, M., Mackintosh, M.,
and Hewitt, T., (eds.), 1992, Open University Press, Milton
Keynes
Wieringa, S., 1994, ‘Women’s interests and empowerment:
gender planning reconsidered’, Development and Change
Vol.25, No.4
36
^00
. -J
Further reading
Brems, E., 1997, Enemies or allies? Feminism and cultural
relativssm as dissident voices in human rights discourses’, Human
Rights Quarterly, Vol.19 pp136-164
International Women’s Tribune Centre (IWTC), 1998, Rights of
Women: A Guide to the Most Important United Nations Treaties
on Women’s Human Rights, International Women’s Tribune
Centre, New York
Oxaal, Z., and Baden, S., 1996, ’Human Rights and poverty a
gender analysis’ BRIDGE Report, IDS, Brighton
j
?
38
2oL
WOMEN’S
HUMAN RIGHTS
Percentage of countries
that have ratified the
Women’s Convention
(CEDAW) worldwide:
• 60 percent without
reservations
• 29 percent with
reservations
•
11 percent not
ratified
(IWTC, 1998:126)
‘Despite these
meticulously worded
international treaties,
discrimination against
women persists on every
level in every corner of
the world'
(IWTC, 1998:20)
See also:
Culture,
Gender discrimination,
Gender violence,
Social justice,
See also: FAQ
‘As gender is a human
rights issue, isn’t
legislation the answer?'
and
‘What right have we to
interfere with other
people’s cultures?'
The recognition that womens rights are human rights and that
women experience injustices solely because of their gender. The
UN Universal Declaration of Human Rights (1948) laid out the
idea of the universality of rights, but failed to take into account
women's needs and interests as women. Its focus was on formal
political and civil rights, hence conceiving rights to be relevant to
the ‘public’ rather than the private’ sphere. As such, violations of
women’s bodily integrity, which occurred in the private sphere
were not part of the human rights discourse.
The Convention on the Elimination of all forms of Discrimination
against Women (CEDAW) established in 1979 marked an
important step towards explicit prohibition of discrimination
against women. During preparations for the World Conference on
Human Rights in Vienna (1993), women’s groups mobilised
around the slogan of “Women’s rights are human rights!” which
signifies the indivisibility of women’s rights from universal human
rights. Participants in the UN Beijing Women’s Conference (1995)
continued with this call, attempting to broaden the conception of
rights to include social, economic, and cultural rights, as well as
reproductive and sexual rights put on the agenda at the 1994
Cairo population conference.
Gender-based violence has been a high profile issue in advocacy
efforts on women’s human rights. Groups have campaigned for
the recognition as human rights of, for example, the right of
women to freedom from rape, from sexual assault as refugees
and displaced women, from abuse in custody, and particularly
domestic violence. The 1993 Vienna Conference on Human
Rights was a watershed as it marked the first international
recognition of violence against women as a human rights
violation. There is now a UN Special Rapporteur on Violence
Against Women with the specific remit to gather facts and report
to the UN.
Whilst there has been progress in the recognition of women’s
human rights in international human rights instruments this has
not been matched by progress in the implementation and
enforcement of these rights by state bodies. Many countries have
failed to ratify CEDAW, and some that have ratified it have failed
to uphold it. Even when international and national laws recognise
women’s human rights, they may be undermined by patriarchal
customary laws or social practices. Furthermore, human rights
advocates, including those promoting women’s rights, face
challenges from those who regard human rights discourse as a
western, imperialist imposition on other cultures.
Mobilisation of women to claim their rights is essential in order to
press for reforms, and for the implementation and enforcement of
human rights and national legal instruments.
This requires
Strategies
of
capacity-building
in
terms
of
literacy,
legal
knowledge, and political participation. Gender-awareness training
for the judiciary and the police, in addition to strengthening
women’s participation in these fields, is also crucial.
37
^02
■3
/'
'!
I I:
i s
CH I
I
I
•J
1
i:
p
v
u
ni
11
i
a
1
ir
needs, it cannot meet strategic gender net ds since it does not alleviate
women’s burden of domestic labour and chik care. In addition, in many large
cities the fear of male harassment prevents bw-income women from using
public transport, particularly late at night. Where women-only transportation
is introduced, this meets the more strategic gender need of countering male
violence.
In rural communities the timing of meetings can radically affect women’s
attendance, and consequently their capacity to gain access to important
information relevant to them in both their productive and reproductive roles.
Complaints by rural extension workers that women fail to attend their
meetings are widespread. In a project in Botswana, for instance, meetings
were held in the morning in order to ensure that male farmers, gathering in
their productive and community politics role, were sober and attentive.9
However, this timing automatically excluded women who were busy at this
point of the day with essential reproductive responsibilities. Since informa
tion about family planning as well as credit schemes was intended primarily
for women, rural extension workers were obliged to reschedule the meeting
to an hour later in the day when women had ‘free’ time.
The examples cited above show the limitations of individual sectoral
interventions for low-income women. Because of the necessity to balance
their triple role, women require integrative strategies which cut across
sectoral lines. They also reveal that the majority of planning interventions
intended for women meet practical gender needs, and do not seek to change
existing divisions of labour. Therefore they are not ‘feminist’ in content. In
reality, practical gender needs remain the only specific policy target for most
of those concerned with planning for women. Nevertheless, examples such
as these do show that practical gender needs can be met once planners
differentiate target groups not only on the basis of income, now commonly
accepted, but also on the basis of gender.
The way the state has changed its policy towards women in developing
countries, and the extent to which shifts in policy have occurred during the
past thirty years, can best be understood through the examination of different
policy approaches to women.
4
Third World policy approaches to
women in development
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Throughout the Third World, particularly in the past fifteen years, there has T5
been a proliferation of policies, programmes and projects designed to assist
3
low-income women. Until recently, however, there has been little systematic p
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classification or categorization of these various policy initiatives, other than g* Su
the informative work of Buvinic (1983, 1986). This concern for low-income ”
__________
o
women’___________________
s needs has coincided historically
with ____________
a recognition of their important role in development. Since the 1950s many different interventions hive
i
been formulated. These reflect changes in macro-level economic and social
policy approaches to Third World development, as well as in state policy
towards women. Thus the shift in policy approaches towards women, from
‘welfare’, to ‘equity’ to ‘anti-poverty’, as categorized by Buvinic (1983), to
two other approaches which I categorize as ‘efficiency’ and ‘empowerment’
has mirrored general trends in Third World development policies, from
modernization policies of accelerated growth, through basic needs strategies
associated with redistribution, to the more recent compensatory measures
associated with structural adjustment policies.
Wide-scale confusion still exists concerning both the definition and use
of different policy approaches. Many institutions at both national govern
ment and international agency level are unclear about their policy approach
to women. Often the ubiquitous, so-called ‘women in development’ approach
' has mystified rather than clarified conceptual categories. This has served to
legitimize a range of approaches to women, which incorporate different
underlying assumptions in relation to their practical and strategic gender
needs. It is precisely because of confusions such as these that it is important
to develop simple, but sufficiently rigorous, tools to enable policy-makers
and planners to understand with greater clarity the implications of their
interventions in terms of both their potential and limitations in assisting Third
World women.
To identify the extent to which policy interventions have been appropriate
to the gender needs of women, it is necessary to examine their underlying
53 J’
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Table 4.1 Different policy approaches to Third World women
Tabel4.1 (Continued)
Isssues
Welfare
Anti-poverty
Efficiency
Empowerment
Origins
Earliest approach:
- residual model of
social welfare under
colonial administration
- modernization/
accelerated growth
economic development
model
Original WID approaclj:
- failure of modernization
development policy
- influence of Boserup
and First World Feminists
on Percy Amendment of
UN Decade for Women
Second WID approach:
- toned down equity
because of criticism
- linked to
redistribution with
growth and basic needs
Third and now
predominant WID
approach:
- deterioration in the
world economy
- policies of economic
stabilization and
adjustment rely on
women’s economic
contribution to
development
Most recent approach:
- arose out of failure of
equity approach
- Third World women’s
feminist writing and
grassroots organization
Period most popular
1950—70; but still
widely used
1975-85: attempts to
adopt it during the
Women’s Decade
1970s onward: still
limited popularity
Post-1980s: now most
popular approach
1975 onward: accelerated
during 1980s, still limited
popularity
Purpose
To bring women into
development as better
mothers: this is seen as
their most important
role in development
To gain equity for women
in the development
process: women seen as
active participants in
development
To ensure poor women
increase their
productivity: women’s
poverty seen as a
problem of
underdevelopment, not
of subordination
To ensure development
is more efficient and
more effective:
women’s economic
participation seen as
associated with equity
To empower women
through greater selfreliance: women’s
subordination seen not
only as problem of men
but also of colonial and
neo-colonial oppression
Needs of women met
and roles recognized
To meet PGN in
reproductive role,
relating particularly to
food aid, malnutrition
and family planning
To meet SGN in terms of
triple role - directly
through state top-down
intervention, giving
j political and economic
autonomy by reducing
inequality with men
To meet PGN in
productive role, to earn
an income, particularly
in small-scale
income-generating
projects
5
To meet PGN in context
of declining social
services by relying on
all three roles of women
and elasticity of
women’s time
Comment
Women seen as passive
beneficiaries of
development with focus
on their reproductive
role; non-challenging,
therefore widely
popular especially with
government and
traditional NGOs
In identifying subordinate
position of women in
terms of relationship to
men, challenging,
criticized as Western
feminism, considered
threatening and not
popular with government
Poor women isolated as
separate category with
f tendency only to
recognize productive
role; reluctance of
government to give
limited aid to women
means popularity still at
small-scale NGO level
Equity
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PGN = Practical gender need
SGN = Strategic gender need
Women seen entirely in
terms of delivery
capacity and ability to
extend Working day;
most popular approach
both with governments
and multilateral agencies
To reach SGN in terms of
triple role - indirectly
through bottom-up
mobilization around PGN
as a means to confront
oppression
Potentially challenging
with emphasis on Third
World and women’s
self-reliance; largely
unsupported by
governments and
agencies; avoidance of
Western feminism
criticism means slow,
significant growth
of under-financed
voluntary organizations
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51 kcion^ej^r gaidt. plu^nin^ in ine Hara ,/oini
rationale from a gender planning perspective. In this chapter different policy
approaches to women in development are examined in terms of roles recog
nized, practical or strategic gender needs met, and the extent to which
participatory planning procedures are included. (Such analysis, summarized
in Table 4.1, provides the basis for the development of further principles of
gender planning.)
While the policy interventions are described chronologically, from wel
fare through to empowerment it is recognized that the linear process that this
implies is an over-simplification of reality. In practice, many of the policies
have appeared more or less simultaneously. Implementing agencies have not
necessarily followed any ordered logic in changing their approach, most
frequently jumping from welfare to efficiency without consideration of other
approaches. Similarly, different policies have particular appeal to different
types of institutions. Policy-makers often favour combined policy
approaches in order simultaneously to meet the needs of different constituen
cies. Finally, shifts in policy approach often occur not only during the
formulation stage, but also during the implementation process (Buvinic
1986). Given these caveats, the following policy types described should be
viewed as ‘ideal types’. The purpose here is to measure how far different
policies meet practical or strategic needs (see Table 4.1).
■
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THE WELFARE APPROACH
Introduced in the 1950s and 1960s, we Ifar ? is the earliest policy approach
concerned with women in developing co mtries. Its purpose is to bring
women
development as better mothers. Women are seen as passive
beneficiaries ofdevelopment. The reprodut five role of women is recognized
and policy seeks to meet practical gene er needs through that role by
top-down handouts offood aid, measures against malnutrition and family
planning. It is non-challenging and therefc re still widely popular.
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The welfare approach is the oldest and still the most popular social develop
ment policy for the Third World in genera , and for women in particular. It
can be identified as pre-WID. Its under ying rationale towards women
reflects its origins, which are linked to the 'esidual model of social welfare,
first introduced by colonial authorities in n iany Third World countries prior
to independence. Their concern with law e nd order and the maintenance of
stable conditions for trade and agricultural; ind mineral expansion meant that
social welfare was a low priority. Echoing the nineteenth-century European
Poor Laws with their inherent belief that social needs should be satisfied
through individual effort in the market place, administrations dealt largely
with crime, delinquency, prostitution and other forms of ‘deviant’ behaviour.
aTi.. a V,
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Voluntary charity organizations in turn carried a large share of the burden of
social welfare (Hardiman and Midgley 1982). Because of welfare policy’s
compatibility with the prevailing development paradigms of modernization,
it was continued by many post-independence governments (MacPherson and
Midgley 1987). On the basis that ‘social welfare institutions should come
into play only when the normal structure of supply, the family and the market,
break down’ (Wilensky and Lebeaux 1965: 138), the ministries of social
welfare, created for the implementation of such residual measures for ‘vul
nerable’ groups, were invariably weak and under-financed.
In fact it was First World welfare programmes, widely initiated in Europe
after the end of World War n, specifically targeted at ‘vulnerable groups’,
which were among the first to identify women as the main beneficiaries. As
Buvinic (1986) has noted, these were the emergency relief programmes
accompanying the economic assistance measures intended to ensure recon
struction. Relief aid was provided directly to low-income women, who, in
their gendered roles as wives and mothers, were seen as those primarily
concerned with their family ’ s welfare. This relief distribution was undertaken
by international private relief agencies, and relied on the unpaid work of
middle-class women volunteers for effective and cheap implementation.
The creation of two parallel approaches to development assistance - on
the one hand, financial aid for economic growth; on the other hand, relief aid
for socially deprived groups - was then replicated in development policy
towards Third World countries. This strategy had critical implications for
Third World women. It meant that international economic aid prioritized
government support for capital-intensive, industrial and agricultural produc
tion in the formal sector, for the acceleration of growth focused on increasing
the productive capacity of the male labour force. Welfare provision for the
family was targeted at women, who, along with the disabled and the sick,
were identified as ‘vulnerable* groups, and remained the responsibility of the
marginalized ministries of social welfare.
In most countries these ministries and the profession of social planning,
frequently seen as their mandate, were from the outset dominated by women,
particularly at the lower levels. Consequently, welfare policy was, and still
is, frequently identified as ‘women’s work’, serving to reinforce social
planning as soft-edged, and of lesser importance than the hard-edged areas
of economic and physical planning. Further assistance was then also provided
by NGOs, such as the mother’s clubs created in many Third World countries,
and, to a lesser extent, by bilateral aid agencies with specific mandates for
women and children, such as the United Nations Children’s Fund (UNICEF).
The welfare approach is based on three assumptions. First, that women
are passive recipients of development, rather than participants in the
development process. Secondly, that motherhood is the most important role
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for women in society. Thirdly, that child-re iring is the most effective role
for women in all aspects of economic develop ment. While this approach sees
itself as ‘family-centred’ in orientation, it foci ises on women entirely in terms
of their reproductive role, it assumes men’; role to be productive, and it
identifies me mother-child dyad as the unit c f concern. The main method of
implementation is through ‘top-down’ hand( uts of free goods and services,
and therefore it does not include women or ge nder-aware local organizations
in participatory planning processes. When tr. lining is included it is for those
skills deemed appropriate for ‘non-working ’ housewives and mothers. In
their mothering roles low-income women ha been the primary targets for
improving family welfare, particularly of c lildren, through an increasing
diversity of programmes, reflecting a broade fling of the mandate of welfare
over the past three decades.
With its origins in relief work, the first and still the most important,
concern of welfare programmes is family physical survival, through the
direct provision of food aid. Generally this is provided in the short term after
such natural disasters as earthquakes or famines. However, food aid has
increasingly become a longer-term need for refugees seeking protection.
Although die majority of refugees in camps are women, left as heads of
households to care and often provide for the children and elderly, they usually
do not have refugee status in their own right but only as wives within the
family (Bonncrjea 1985). Projects implemented by the United Nations High
Commission for Refugees (UNHCR) and NGOs most often focus on these
women in their reproductive role, with special attention given to those
pregnant or lactating. These are identified as a ‘vulnerable* group in the same
category as the elderly, orphans and the handicapped (Weeda 1987).1
In the extensive international effort to combat Third World malnutrition,
another emphasis of welfare programmes is nutritional education. This
targets children under five years, as well as pregnant and nursing mothers.
Since the 1960s, Mother-Child Health Programmes (MCH) have distributed,
cooked or rationed food along with giving nutrition education at feeding
centres and health clinics. In linking together additional food for children and
nutrition education for mothers, MCH focuses on the mother-child dyad, and
the reproductive role of women, on the assumption that extra provisions will
make them better mothers. Although by the early 1980s considerable criti
cism had been expressed about the use of food aid to guarantee nutritional
improvement of children, the focus on women in their role as mothers was
not seen as problematic.2
Most recently, especially since the 1970s, welfare policy towards women
has been extended to include population control through family planning
programmes. Thus development agencies responding to the world’s popula
tion ‘problem’ identified women, in their reproductive role, as primarily
I
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responsible for limiting the size of families. Early programmes assumed that
poverty could be reduced by simply limiting fertility, to be achieved through
the widespread dissemination of contraceptive knowledge and technology to
women. Only the obvious failure of this approach led population planners to
realize that variables relating to women’s status, such as education and
labour-force participation, could affect fertility differentials and consequent
ly needed to be taken into consideration. By 1984 the World Bank’s World
Development Report, for instance, identified reducing infant and child
mortality, educating parents (especially women) and raising rural incomes,
women’s employment and legal and social status, as key incentives to fertility
decline (World Bank 1984). However, recognition of the links between
women’s autonomy over their own lives and fertility control is not wide
spread and women continue to be treated in an instrumental manner in
population programmes. The lack of satisfactory birth-control methods, and
the introduction of more invasive techniques (such as IUDs and hormonal
implants) is making birth control even more ‘women-centred’. As DAWN
(1985) has argued, this lets men off the hook in terms of their responsibility
for birth control, while increasingly placing the burden on women. Their
ambivalence towards contraceptive technology will only be removed when
the technology is better adapted to the social and health environments in
which they are used.
Although welfare programmes for women have widened their scope
considerably over the past decades, the underlying assumption is still that
motherhood is the most important role for women in Third World develop
ment. This means that their major concern has been with meeting practical
gender needs relating to women’s reproductive role. Intrinsically, welfare
programmes identify ‘women’ rather than lack of resources, as the problem,
and place the solution to family welfare in their hands, without questioning
their ‘natural’ role. Although the top-down handout nature of so many
welfare programmes tends to create dependency rather than assisting women
to become more independent, they remain popular precisely because they are
politically safe, not questioning or changing the traditionally accepted role
of women within the gender division of labour. Such assumptions tend to
result in the exclusion of women from development programmes operated
by the mainstream development agencies which provide a significant pro
portion of development funds (Germaine 1977). The fact that the welfare
approach is not concerned to meet such strategic gender needs as the right
for women to have control over their own reproduction was highlighted by
a Third World women’s group when they wrote:
Women know that childbearing is a social not a purely personal phenome
non: nor do we deny that world population trends are likely to exert
x airu Wui id policy approa^aes io women 63
considerable pressure on resources and institutions by the end of the
century. But our bodies have become a pawn in the struggles among states,
religions, male heads of households, and private corporations. Pro
grammes that do not take the interests of women into account are unlikely
to succeed.
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has been criticized as Western feminism, is considered threatening and is
unpopular with governments.
(DAWN 1985:42)
Although by the 1970s dissatisfaction with the welfare approach was wide
spread, criticism differed as to its limitations. This depended on which of the
three constituencies it came from; first, in the United States, a group of mainly
female professionals and researchers who were concerned with the increas
ing evidence that Third World development projects were negatively
affecting women; second, development economists and planners who were
concerned with the failure of modernization theory in the Third World; and
third, the United Nations (UN), that combined both of these concerns. The
voicing of these concerns led to the United Nations 1975 International
Women s Year Conference. This formally ‘put women on the agenda’ and
provided legitimacy for the proliferation of a wide diversity of Third World
women’s organizations, in turn leading to the UN designating 1976-85 as
the Women’s Decade.
During this decade die critique of the welfare approach resulted in the
development of a number of alternative approaches to women: namely,
equity, anti-poverty, efficiency and empowerment. The fact that these
approaches share many common origins, were formulated during the same
decade and are not entirely mutually exclusive, means that there has been a
tendency not only to confuse them, but indeed to categorize them together
as the ‘women in development’ (WID) approach. With hindsight, it is clear
that there are significant differences between these approaches which it is
important to clarify.
The lack of definition of WID has been widespread in the proliferating
number of national-level WID ministries and bureaux, which implement a
large number of policies under the umbrella of the WID approach (Gordan
1984). This has also been the case with bilateral and multilateral donors?
I
THE EQUITY APPROACH
Equity is the original 'WID' approach, introduced with'n
1976-85 UN
Women's Decade. Its purpose is to gain equityfor women in the development
process. Women are seen as active participants in development. It recognizes
women’s triple role and seeks to meet strategic gender needs through direct
state intervention, giving political and economic autonomy to women and
reducing inequality with men. It challenges women’s subordinate position,
o
By the 1970s studies showed that although women were often the predomi
nant contributors to the basic productivity of their communities, particularly
in agriculture, their economic contribution was referred to neither in national
statistics nor in the planning and implementation of development projects
(Boserup 1970). At the same time new modernization projects, with innova
tive agricultural methods and sophisticated technologies, were negatively
affecting women. These were displacing them from their traditional produc
tive functions, and diminishing the income, status and power they had in
traditional relations. Findings indicated that neo-colonialism, as much as
colonialism, was contributing to the decline in women’s status in developing
countries.
Tinker, in her documentation of development projects that had widened
the gap between men and women, argued that development planners were
‘unable to deal with the fact that women must perform two roles in society
whereas men perform only one’ (1976:22). She attributed the adverse impact
of development on women to three types of planning error: first, errors of
omission or failure to acknowledge and utilize women’s productive role;
second, errors that reinforced values which restrict women to the household
engaged in childbearing and childrearing activities; and third, errors of
inappropriate application of Western values regarding women’s work
(1976). On the basis of evidence such as this, the WID group in the United
States challenged the prevailing assumption that modernization was equated
with increasing gender equality, asserting that capitalist development models
imposed on much of the Third World had exacerbated inequalities between
men and women. Recognition of the damaging effects of ignoring women in
USAID projects during the First Development Decade (1960—70) made the
WID group work to influence USAID policy. Lobbying of Congressional
hearings resulted in the 1973 Percy Amendment to the US Foreign Assistance
Act, which mandated that US assistance help ‘move women into their
national economies’ in order to improve women’s status and assist the
development process (Tinker 1982; Maguire 1984).
The original WID approach was in fact the equity approach.4 This ap
proach recognizes that women are active participants in the development
process, who through both their productive and reproductive roles provide a
critical, if often unacknowledged, contribution to economic growth. The
approach starts with the basic assumption that economic strategies have
frequently had a negative impact on women. It acknowledges that they must
be ‘brought into’ the development process through access to employment
and the market place. It therefore accepts women’s practical gender need to
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64 Rationale for gender planning in the Third World
earn a livelihood. However, the equity approach is also concerned with
fundamental issues of equality which transcend the development field. As
Buvinic (1986) has described, its primary concern is with inequality between
men and women, in both public and private spheres of life and across
socio-economic groups. It identifies the origins of women’s subordination
not only in the context of the family, but also in relations between men and
women in the market place. Hence it places considerable emphasis on
economic independence as synonymous with equity.
In focusing particularly on reducing inequality between men and women
in the gender division of labour, the equity approach meets an important
strategic gender need. Equity programmes are identified as uniting notions
of development and equality. The underlying logic is that women have lost
ground to men in the development process. Therefore, hi a process of
redistribution, men have to share in a manner ./hich entails women from all
socio-economic classes gaining and men from all socio-economic classes
losing (or gaining less), through positive discrimination policies if necessary.
The rational consequence of this is seen to be greater equality with an
accompanying increase in economic growth (Buvinic 1983). Although the
approach emphasized ‘top-down’ legislative and other measures as the
means to ensure equity, gendered consultative and participatory planning
procedures were implicitly assumed. This was particularly the case since the
introduction of the equity approach itself had been the consequence of
the bottom-up confrontation of existing procedures by feminist women’s
organizations.
In fact, the theme selection for the 1975 International Women’s Year
(IWY) Conference showed that the equity approach, despite its identification
as ‘developmental’, in many respects was more concerned to reflect First
World feminist preoccupations with equality. Third World delegations, while
acknowledging women’s problems, identified development as their main
concern, maintaining that this would increase women’s status. Second World
delegates were more concerned with peace, claiming that the capitalist
system and its associated militarism was responsible for women’s problems
- hence the theme of Equality, Developmen : and Peace (Stephenson 1982).
Hie World Plan of Action for the Implem mtation of the Objectives of the
IWY firmly reflected the equity approach. It called for equality between men
and women, required that women should le given their fair share of the
benefits of development, and recognized th i need for changes in the tradi
tional role of men as well as women (UN 1976a). The Plan set the agenda
for futur ' on for the Women’s Decade, w th the common goal of integrat
ing women into the development process. In reality, the interpretation of the
agenda varied. This was reflected in the lan ?uage used, which ranged from
(he definitely expressed aim to ‘integrate’, ‘increase’, ‘improve’ or ‘upgrade’
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Third World policy approaches to women
65
women’s participation in development to the more tentatively worded desire
to ‘help create a more favorable climate for improving women’s options in
development’ (World Bank 1980: 14).
Despite such rhetoric, equity programmes encountered problems from the
outset. Methodologically, the lack of a single unified indicator of social status
or progress of women and of baseline information about women’s economic,
social and political status meant that there were no standards against which
‘success’ could be measured (USAID 1978). Politically, the majority of
development agencies were hostile to equity programmes precisely because
of their intention to meet not only practical gender needs but also strategic
gender needs, whose very success depended on an implicit redistribution of
power. As Buvinic has commented:
Productivity programmes for women usually require some restructuring
of the cultural fabric of society, and development agencies do not like to
tamper with unknown and unfamiliar social variables. As a rule of thumb
they tend to believe in upholding social traditions and thus are reluctant
to implement these programmes.
(1983: 26)
From the perspective of the aid agency, equity programmes necessitated
unacceptable interference with the country’s traditions. At the same time
recognition of equity as a policy principle did not guarantee its implementa
tion in practice. In Europe the Organization for Economic Cooperation and
Development Assistance Committee’s (OECD/DAC) Guiding Principles to
Aid Agencies for Supporting the Role of Women in Development identif icd
‘integration’ as critical for a policy on WID issues. However, in a review of
European Development Assistance, Andersen and Baud (1987) argued that
although policy statements of most donor countries were in general accord
with the idea of equality, nevertheless at the level of policy, integration had
been mainly interpreted to mean an increasing number of women in existing
policies and programmes. Thus, they concluded that ‘implicit in such an
approach was the idea that current development models were in principle
favourable to women, and that they therefore did not need to take account of
women’s vision or priorities’ (1987: 22).
Despite their endorsement of the Plan of Action, similar antipathy was felt
by many Third World governments, legitimized by their belief in the irrelev
ance of Western-exported feminism to Third World women. In fact, one of
the outcomes of the 1975 Conference was the labelling of feminism as
ethnocentric and divisive to WID. Many Third World activists felt that to
take ‘feminism to a woman who has no water, no food and no home is to talk
nonsense’ (Bunch 1980: 27), and labelled Third World socialists and femin
ists as bourgeois imperialist sympathizers. At the same time the fact that there
06 Rafon^f^^e^annin^n the Third ^World
«
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Third World policy approaches to women
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was only one reference to women in the various documents of the 1970 UN
New International Economic Order Conference revealed that the importance
of women was still identified in terms of their biological role by those
formulating policies for the Third World.
In a climate of widespread antagonism to many of its underlying principles
from development agencies and Third World governments alike, the equity
approach has been effectively dropped by the majority of implementing
agencies. However, its official endorsement in 1975 ensured that it continues
to provide an important framework for those working within government to
improve the status of women through offici il legislation, on issues such as
those described in Chapter 3. Tinker and Jaquette (1987), in reviewing the
1976-85 Women’s Decade conference documents, noted that the goal of
legal equality of women had been accepted a: a minimum basis of consensus
from which to begin the discussion of rrore controversial issues. This
included the rights of divorce, of custody of c hildren, property, credit, voting
and othe*- "♦^en rights.
Significant though the ratification of sue! legislation is, it is necessary to
recognize that it meets potential strategic g mder needs, rather than actual
needs. As illustrated in Chapter 3, property rij hts, arranged marriages, dowry
and child custody rights provide much cited < xamples of the highly sensitive
strategic gender needs which are often still c urtailed by custom, even when
amended by law. Even the incorporation of ?ractical gender needs into the
mainstream of development plans does not | ;uarantee their implementation
in practice. Mazumdar (1979) noted that i he incorporation of women’s
concerns into the framework of India’s Si i Year Plan indicated India’s
constitutional commitment to equality of oj portunity. Such constitutional
inclusions, however, in no way ensured pnetieal changes. In her opinion
these are largely a function of the strength of the political power base of
organized women’s groups. Ultimately, the equity approach has been con
structed to meet strategic gender needs through top-down legislative
measures. The bottom-up mobilization of women into political pressure
groups to ensure that policy becomes action is the mandate of the empower
ment approach, developed by Third World women, and described later.
THE ANTI-POVERTY APPROACH
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Anti-Poverty is the second WID approach, the 'toned down ’ version ofequity,
introducedfrom the 1970s onwards. Its purpose is to ensure that poor women
increase the:r productive. Women's poverty is seen as the problem of
underdevelopment, not Oj tbordino.tion. It recognizes the productive role of
women, .
. -eks to meet pracn al gender needs' to eam an income,
67
particularly through small-scale income-generating projects. It is most
popular with NGOs.
The anti-poverty approach to women can be identified as the second WID
approach, in which economic inequality between women and men is linked
not to subordination but to poverty. The emphasis thus shifts from reducing
inequality between men and women, to reducing income inequality.
Women’s issues are separated from equity issues and linked instead to the
particular concern for the majority of Third World women, as the ‘poorest
of the poor’. Buvinic (1983) has argued that this is a toned-down version of
die equity approach, arising out of the reluctance of development agencies
to interfere with the manner in which relations between men and women are
constructed in a given society. However, this shift also coincided with the
end of the unsuccessful First Development Decade, and the formulation of
alternative models of Third World economic and social development.
By the early 1970s it was widely recognized that modernization theory,
with its accelerated growth strategies based on maximizing GNP, had failed,
either to redistribute income or to solve the problems of Third World poverty
and unemployment. Contrary to predictions about the positive welfare effects
of rapid economic growth, financial benefits had not ‘trickled down’ to the
poor. An early initiative was the International Labour Organization’s (1LO)
World Employment Programme in which employment became a major
policy objective in its own right. The ‘working poor’ were identified as the
target group requiring particular attention, and the informal sector with its
assumed autonomous capacity to generate employment was seen as the
solution (Moser 1978,1984). In 1972 the World Bank officially shifted from
a preoccupation with economic growth to a broader concern with the eradi
cation of absolute poverty and the promotion of ‘redistribution with growth’.
Integral to this was the ‘basic needs strategy’, with its primary purpose to
meet ‘basic needs’ such as food, clothing, shelter and fuel, as well as social
needs such as education, human rights and ‘participation’ in social life
through employment and political involvement (Ghai 1978; Streeton el al.
1981). Low-income women were identified as one particular ‘target group’
to be assisted in escaping absolute deprivation: first, because the failure of
‘trickle-down’ was partially attributed to the fact that women had been
ignored in previous development plans; and secondly, because of the tradi
tional importance of women in meeting many of the basic needs of the family
(Buvinic 1982).
The ar.-poverty policy approach to women focuses mainly on their
productive role, on the basis that poverty alleviation and the promotion of
balanced economic growth requires the increased productivity of women in
low-income households. Underlying this approach is the assumption that the
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68 Rationale for gender planning in th • Third World
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origins of women’s poverty and inequali y with men are attributable to their
lack of access to private ownership o ' land and capital, and to sexual
discrimination in the labour market. Co isequently, it aims to increase the
employment and income-generating opti ms of low-income women through
better access to productive resources, ’’he preoccupation of basic needs
strategies with population control also resulted in increasing recognition that
education and employment programmes could simultaneously increase
women’s economic contribution and reduce fertility.5
One of the principal criticisms of employment programmes for women is
that since they have the potential to modify the gender division of labour
within the household, they may also imply changes in the balance of power
between men and women within the family. In anti-poverty programmes this
redistribution of power is said to be reduced, because the focus is specifically
on low-income women, and because of the tendency to encourage projects
in sex-specific occupations in which women are concentrated, or to target
only women who head households. The fear, however, that programmes for
low-income women may reduce the already insufficient amount of aid
allocated to low-income groups in general means that Third World govern
ments have remained reluctant to allocate resources from national budgets
to women. Frequently, the preference is to allocate resources at the family or
household level, despite the fact that they generally remain in the hands of
the male head of household.
While income-generating projects for low-income women have prolif
erated since the 1970s, they have tended to remain small in scale, to be
developed by NGOs (most frequently all-women in composition), and to be
assisted by grants, rather than loans, from international and bilateral agencies.
Most frequently they aim to increase productivity in activities traditionally
undertaken by women, rather than to introduce women to new areas of work,
with a preference for supporting rural-based production projects as opposed
to those in the service and distri bution sectors, which are far more widespread
in the urban areas of many developing countries.6
Considerable variation has been experienced in the capacity of such
projects to assist low-income women to generate income. Buvinic (1986) has
highlighted the problems experienced by anti-poverty projects in the
implementation process, due to the preference to shift towards welfareorientated projects. However, such projects also experience considerable
constraints in the formulation stage. In theory, ‘basic needs’ assumed a
panic
\ .To?.- yet in practice anti-poverty projects for women rarely
inch
partiospateplanning procedures; mechanisms to ensure that
wom^- e-' creder-nations be included remaked undeveloped.
In the
; 'n of pn/ncts, fundamental conditions to ensure v^hdity are often
to r’Asily available raw
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Third World policy approaches to women 69
markets and small-scale production capacity (Schmitz 1979; Moser 1984).
Despite widespread recognition of the limitations of the informal sector to
generate employment and growth in an independent or evolutionary manner,
income-generating projects for women continue to be designed as though
small-scale enterprises have the capacity for autonomous growth (Schmitz
1982; Moser 1984).
In addition, the particular constraints that women experience in their
gendered roles are also frequently ignored. These may include problems of
perception in separating reproductive from productive work, as well as those
associated with balancing’ productive work alongside domestic and child
care responsibilities. In many contexts there are cultural constraints that
restrict women s ability to move freely outside the domestic arena and
therefore to compete equally with men running similar enterprises (Moser
1981). Where men control household financial resources, women are unable
to save unless special safe facilities are provided (Sebsted 1982). Equally,
where women cannot obtain equal access to credit, such as through lack of
collateral, they are often unable to expand their enterprises unless nontraditional forms of credit are available to them (Bruce 1980; IWTC 1985).
Finally, the tendency to distinguish between micro-enterprise projects for
men, and income-generating projects for women, is indicative of the prevail
ing attitude, even among many NGOs, that women’s productive work is of
less importance than men’s, and is undertaken as a secondary earner or ‘for
pocket money’.
Anti-poverty income-generating projects may provide employment for
women, and thereby meet practical gender needs, by augmenting their
income, but unless employment leads to greater autonomy it does not meet
strategic gender needs. This is the essential difference between the equity
and anti-poverty approaches. In addition, the predominant focus on the
productive role of women in the anti-poverty approach means that their
reproductive role is often ignored. Income-generating projects which assume
that women have ‘free time’ often only succeed by extending their working
day and increasing their triple burden. Unless an income-generating project
also alleviates the burden of women’s domestic labour and child care - for
instance, through the provision of adequate socialized child caring - it may
fail even to meet practical gender need to earn an income.
THE EFFICIENCY APPROACH
Efficiency is the third, and now predominant WID approach, particularly
since the 1980s debt crisis. Its purpose is to ensure that development is more
efficient and effective through women's economic contribution. Women's
participation is equated with equity for women. It seeks to meet practical
Third World policy approaches to women 71
70 Rationale for gender planning in the Third World
gender needs while relying on all of women’s three roles and an elastic
concept of women’s time. Women are seen primarily in terms of their
capacity to compensate for declining social services by extending their
working day. It is very popular as an approach.
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Although the shift from equity to anti-poverty has been well documented,
the identification of WID as efficiency has passed almost unnoticed. Yet, I
would argue the efficiency approach is now the predominant approach for
those working within a WID framework - indeed, for many it may always
have been. In it the emphasis has shifted away from women and towards
development, on the assumption that increased economic participation for
Third World women is automatically linked with increased equity. This has
allowed organizations such as USAID, the World Bank and OECD to
propose that an increase in women’s economic participation in development
links efficiency and equity together. Amongst others, Maguire (1984) has
argued that the shift from equity to efficiency reflected a specific economic
recognition of the fact that 50 percent of the human resources available for
development were being wasted or under-utilized. Although the so-called
development industry realized that women were essential to the success of
the total development effort, it did not necessarily follow that development
improved conditions for women.7 The assumption that economic participa
tion increases women’s status and is associated with equity has been
widely criticized. Problems such as lack of education and under-producUve
technologies have also been identified as the predominant constraints
affecting women’s participation.
The shift towards efficiency coincided with a marked deterioration in the
world economy, occurring from the mid-1970s onwards, particularly in Latin
America and Africa, where the problems of recession were compounded by
falling export prices, protectionism and the mounting burden of debt. To
alleviate the situation, economic stabilization and adjustment policies de
signed by the International Monetary Fund (IMF) and the World Bank have
been implemented by an increasing number of national governments. These
policies, through both demand management and supply expansion, lead to
the reallocation of resources to enable the restoration of a balance of pay
ments equilibrium, an increase in exports and a rejuvenation in growtfi rates.
With increased efficiency and productivity as two of the main objectives
of Structural Adjustment Policies (SAPs), it is no coincidence that efficiency
is the policy approach towards women which is currently gaining popularity
amongst international aid agencies and national governments alike. Again
top-down in approach, without gendered participatory planning procedures,
in reality SAPs often simply mean a shifting of costs from the paid to the
unpaid economy, particularly through the use of women’s unpaid time. While
I
the emphasis is on women’s increased economic participation, this has
implications for women not only as reproducers, but also increasingly as
community managers. In the housing sector, for instance, one such example
is provided by ‘site and service’ and upgrading projects with self-help
components which now regularly include women in the implementation
phase. This is a consequence of the need for greater efficiency, not only are
women as mothers more reliable than men in repaying building loans, but
also as workers they are equally capable of self-building alongside men,
while as community managers they have shown far greater commitment than
men in ensuring that se.’ ices are maintained (Fernando 1987; NimpunoParente 1987).
Disinvestments in human resources, made in the name of greater
efficiency in IMF and World Bank ‘conditionality’ policies, have resulted in
declines in income levels, severe cuts in government social expenditure
programmes, particularly health and ed ucation, and reductions in food sub
sidies. These cuts in many of the practical gender needs of women are seen
to be cushioned by the elasticity of women’s labour in increasing self
production of food, and changes in purchasing habits and consumption
patterns. In fact, underlying many SAPs, as Elson has identified, are three
‘kinds of male bias’ (Elson 1991: 6; Moser 1992a). The first male bias, as
described above, focuses on the unpaid domestic work necessary for repro
ducing and maintaining human resources. It concerns the extent to which
SAPs implicitly assume that processes carried out by women in such unpaid
activities as caring for children, gathering fuel, processing food, preparing
meals and nursing the sick will continue regardless of the way in which
resources are reallocated. For SAPs define economies only in terms of
marketed goods and services and subsistence cash production and exclude
women’s reproductive work. This raises the question as to how far SAPs are
only successful at the cost of longer and harder working days for women,
who are forced to increase their labour both within the market and the
household. Preoccupation has been expressed regarding the extent to which
women’s labour is infinitely elastic, or whether a breaking point may be
reached when their capacity to reproduce and maintain human resources may
collapse (Jolly 1987).
Moreover, the issue not only concerns the elasticity of time, but also the
balancing of time. Evidence from a longitudinal study of a low-income
community in Guayaquil, Ecuador, showed that the real problem was not the
length of time women worked, but the way, under conditions of recession
and adjustment, they were forced to change the balance of their time between
activities undertaken in each of their triple roles. Over the past decade these
low-income women have always worked between twelve and eighteen hours
per day, depending on such factors as the composition of the household, the
t,
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72 Rationale for gender planning in the Third World
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time of year and their skills. Therefore, the hours worked have not changed
fundamentally. What has changed is the time allocated to different activities.
The need to gain access to resources has forced women to allocate increasing
time to productive and community managing activities, at the expense of
reproductive activities, which in many cases have become a secondary
priority delegated wherever possible to daughters or other female household
members. The fact that paid work and unpaid work are competing for
women’s time has important impacts on children, on women themselves and
on the disintegration of the household (Moser 1992a).
The problem of balancing time is also of importance in relation to a second
‘male bias’ in SAPs. This involves ignoring barriers to labour re-allocation
in policies designed to switch from non-tradables to tradables, by offering
incentives to encourage labour-intensive manufacturing, and, particularly in
sub-Saharan Africa, crops for export. In the urban sector, gender barriers to
the re-allocation of labour have often meant greater unemployment for men
displaced from non-tradables, while for any women drawn into exportorientated manufacturing, they have meant extra work, as, factory
employment is added to the unpaid domestic work which unemployed men
remain reluctant to undertake. In rural areas the introduction of exportorientated crops has often meant increased agricultural work for women with
less time for the production of subsistenc e family crops, resulting in both
increased intra-household conflict and in vorrying consequences for child
ren’s nutrition levels (Evans and Young 1 ?88; Feldman 1989) (see Chapter
2, section beginning on page 18).
The third ‘male bias’ concerns the household as the social institution
which is the source of the supply of laboui. This concerns the assumption of
an equal intra-household distribution of re sources, which in turn means that
chang''*' ’n resource allocations in income, food prices and public expendi
ture, accompanying stabilization and S \Ps, affect all members of the
household in the same way (Elson 199 ). Here policy assumes that the
household has a ‘joint utility’ or ‘unifiee family welfare’ function with a
concern to maximize the welfare of all it . members, even if it assumes the
altruism of benevolent dictatorship. Cons squently, planners have treated it
as ‘an individual with a single set of objc stives’ (Evans 1989; Elson 1992)
(see also Chapter 2, section beginning on page 18).
Until recently, structural adjustment ha 5 been seen purely as an economic
issue, and evaluated in economic terms (Jolly 1987). Although documenta. tion regarding its social costs is still uns; stematic, it does reveal a serious
deterioration in living conditions of low-i icome populations resulting from
a decline in income levels. A gendei-differentiated impact on intra
household resource distribution, with particularly detrimental effects on the
lives of children and women, is also apparent (Cornia et al. 1987, 1988;
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Third World policy approaches to women
Afshar and Dennis 1992). Within the household a decline in consumption
often affects women more than men. The introduction of charges for educa
tion and health care can reduce access more severely for girls than for boys.
The capacity of the household to shoulder the burden of adjustment can have
detrimental effects in terms of human relationships, expressed in increased
domestic violence, mental health disorders and increasing numbers of
women-headed households resulting from the breakdown in nuclear family
structures (UNICEF n.d.).
UNICEF’s widely publicized plea to devise adjustment policies ‘with a
human face’ now challenges the efficiency basis of IMF and World Bank
policy. It argues that women’s concerns, both in the household and in the
workplace, need consciously to be made part of the formulation of adjustment
policies. This in turn will require the direct involvement of women in both
the definition of development and the adjustments in its management (Jolly
1987). On paper, UNICEF’s current recommendations to assist low-income
women would appear highly laudable. Yet optimism that an international
agency has the capacity to effect policy measures designed to increase the
independence of women must be treated with caution.
This point can be illustrated through the appraisal of some of the recent
compensatory policies endorsed by UNICEF. These are designed to protect
basic health and nutrition of the low-income population during adjustment,
before growth resumption enables them to meet their basic needs inde
pendently. In a number of nutrition interventions, such as targeted food
subsidies and direct feeding for the most vulnerable, it is assumed that women
in their community managing role will take responsibility for the efficient
delivery of such services. For example, in Lima, Peru, the Vaso de Leche
(Glass of Milk) direct feeding programme, which provides a free glass of
milk to young children in the low-income areas of the city, is managed by
women in their unpaid time. Similarly, the much-acclaimed communal
kitchen organizations which receive targeted food subsidies depend on the
organizational and cooking ability of women to ensure that the cooked food
reaches families in the community (Sara-Lafosse 1984). While both pro
grammes are aimed at improving the nutritional status of the population,
especially the low-income groups, this is achieved through reliance on
women’s unpaid time (Cornia et al. 1988).
These examples illustrate the fact that the efficiency approach relies
heavily on the elasticity of women’s labour in both their reproductive and
community managing roles. It only meets practical gender needs at the cost
of longer working hours and increased unpaid work. In most cases this
approach fails to reach any strategic gender needs. Because of the reductions
in resource allocations, it also results in a serious reduction in the practical
gender needs met.
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74 Rationale for gender planning in the 1 hird World
right to determine choices in life and to influence the direction of change,
through the ability to gain control over crucial material and non-material
resources. It places far less emphasis than the equity approach on increasing
women’s ‘status’ relative to men. It thus seeks to empower women through
the redistribution of power within, as well as between, societies. It also
questions two underlying assumptions in the equity approach: first, that
development necessarily helps all men; and secondly, that women want to
be ‘integrated* into the mainstream of Western designed development, in
which they have no choice in defining the kind of society they want
(UNAPCWD 1979).
The best-known articulation of the empowerment approach has been
made by the Development Alternatives with Women for a New Era
(DAWN). This is a loose formation of individual women and women’s
groups set up prior to the 1985 World Conference of Women in Nairobi?
Their purpose has been not only to analyze the conditions of the world’s
women, but also to formulate a vision of an alternative future society, which
they identify as follows:
THE EMPOWERMENT APPROACH
Empowerment is the most recent approa 'h, articulated by Third World
women. Its purpose is to empower women through greater self-reliance.
Women ’ - '-•'^ordination is seen not only a: the problem of men but also of
colonial and neo-colonial oppression. It rec ognizes women's triple role, and
seeks to meet strategic gender needs indirei tly through bottom-up mobiliza
tion around practical gender needs. It is po entially challenging, although it
avoids the criticism of being Western-inspired feminism. It is unpopular
except with Third World women's NGOs ai id their supporters.
f
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The fifth policy approach to women is that c f empowerment. It is still neither
widely recognized as an ‘approach’ nor d >cumented as such, although its
origins arc by no means recent. Superficial!:' it may appear synonymous with
the equity approach, with references ofte n made to a combined equity/
empowerment approach. In many respects empowerment developed out of
dissatisfaction with the original WID as equity approach, because of its
perceived co-option into the anti-poverty and efficiency approaches. How
ever, the empowerment approach differs from the equity approach. This
relates not only in its origins, but also in the causes, dynamics and structures
of women’s oppression which it identifies,, and in terms of the strategies it
proposes to change the position of Third World women.
The origins of the empowerment approach are derived less from the
research of First World women, and more from the emergent feminist
writings and grassroots organizational experience of Third World women; it
accedes that feminism is not simply a recent Western urban middle-class
import. As Jayawardena (1986) has written, the women’s movement was not
imposed on women by the United Nations or Western feminists, but has an
independent history. The empowerment approach acknowledges inequalities
between men and women, and the origins of women’s subordination in the
family. But it also emphasizes the fact that women experience oppression
differently according to their race, class, colonial history and current position
in the international economic order. It therefore maintains that women have
to challenge oppressive structures and situations simultaneously at different
levels.
The empowerment approach questions some of the fundamental assump
tions concerning the interrelationship between power and development that
underlie previous approaches. It acknowledges the importance for women to
increase their power. However, it seeks to identify power less in terms of
domination over others (with its implicit assumption that a gain for women
implies a loss for men), and more in terms of the capacity of women to
increase their own self-reliance and internal strength. This is identified as the
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Third World policy approaches to wo\nen 75
We want a world where inequality based on class, gender and race is
absent from every country and from the relationships among countries.
We want a world where basic needs become basic rights and where
poverty and all forms of violence are eliminated. Each person will have
the opportunity to develop her or his full potential and creativity, and
women’s values of nurturance and solidarity will characterize human
relationships. In such a world women’s reproductive role will be re
defined: childcare will be shared by men, women and society as a whole
... only by sharpening the links between equality, development and peace,
can we show that the ‘basic rights’ of the poor and the transformations of
the institutions that subordinate women are inextricably linked. They can
be achieved together through the self-empowerment of women.
(1985:73-5?
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Using time as a basic parameter for change, DAWN distinguishes between
' long-term and short-term strategies. Long-term strategies are needed to break
down the structures of inequality between genders, classes and nations.
Fundamental requisites for this process include national liberation from
colonial and neo-colonial domination, shifts from export-led strategies in
agriculture and greater control over the activities of multinationals. Short
term strategies are identified as necessary to provide ways of responding to
current crises. Measures to assist women include food production through
the promotion of a diversified agricultural base, as well as in formal and
informal sector employment.
Although short-term strategies conespond to practical gender needs,
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long-term strategies contain a far wider agenda than do strategic gender
needs, with national liberation identified as a fundamental requisite for
addressing them. DAWN in their description of this approach, however, do
not identify the means to ensure that once national liberation has been
achieved, women’s liberation will follow. As discussed in Chapter 3, recent
liberation and socialist struggles in countries such as Cuba, Nicaragua and
Zimbabwe have shown this not necessarily to have been the case (Murray
1979a, 1979b; Molyneux 1981, 1985b). One of the reasons why the categori
zation of practical and strategic gender needs does not consider time as a
determinant of change lies in the implicit, underlying assumptions that
short-term change leads to long-term transformation. In the same way it
cannot be assumed that meeting practical strategic gender needs will auto
matically result in the satisfaction of strategic gender needs.
The new era envisaged by DAWN also requires the transformation of the
structures of subordination that have been so inimical to women. Changes in
law, civil codes, systems of property rights, control over women’s bodies,
labour codes and the social and legal institutions that underwrite male control
and privilege are essential if women are to attain justice in society. These
strategic gender needs are similar to those identified by the equity approach.
It is in the means of achieving such needs that the empowerment approach
differs most fundamentally from previous approaches. Recognition of the
limitations of top-down government legislation actually, rather than poten
tially, to meet strategic gender needs has led adherents of the empowerment
approach to acknowledge that their strategies will not be implemented
without the sustained and systematic efforts of women’s organizations and
like-minded groups. Hence it explicitly includes gendered consultative and
participatory planning procedures. Important entry points for leverage identi
fied by such organizations are therefore not only legal changes but also
political mobilization, consciousness raising and popular education. All of
these are mechanisms to ensure that women and gender-aware organizations
are included in the planning process.
In its emphasis on women’s organizations, the empowerment approach
might appear similar to the welfare approach, which also stressed the import
ance of women’s organizations. This has led some policy-makers to conflate
the two approaches. However, the welfare approach recognizes only the
reproductive role of women and utilizes women’s organizations as a topdown means of delivering services. In contrast, the empowerment approach
recognizes the triple role of women and seexs through bottom-up women’s
organizations to raise women’s consciousness to challenge their subordina
tion. In fact, Third World women’s organizations form a continuum. This
ranges from direct political action, through exchanging research and infor
mation, to the traditional service-orientated organizations with their class
Third World policy approaches to women
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biases and limited scope for participatory action. While acknowledging the
valuable function of different types of organizations, the empowerment
approach seeks to assist the more traditional organizations to move towards
a greater awareness of feminist issues. Thus Sen (1990) acknowledges that
the perceptions of the individual interests of women tend to be merged with
the notion of family well-being. The ‘political agency’ of women may be
sharpened by their greater involvement with the outside world.
Another important distinction between the empowerment and equity
approaches is the manner in which the former seeks to reach strategic gender
needs indirectly through practical gender needs. The very limited success of
the equity approach to confront directly the nature of women’s subordination
through legislative changes has led the empowerment approach to avoid
direct confrontation. It utilizes practical gender needs as the basis on which
to build a secure support base, and a means through which strategic needs
may be reached. The following examples of Third World women’s organiz
ations are much quoted ‘classics’ of their kind, which have provided
important examples for other groups of the ways in which practical gender
needs can be utilized as a means of reaching strategic gender needs.
In the Philippines, GABRIELA (an alliance of local and national women ’ s
organizations) ran a project which combined women’s traditional task of
sewing tapestry with a non-traditional activity, the discussion of women’s
legal rights and the coi^dtution. A nation-wide educational ‘tapestry-maki ng
drive’ enabled the discussion of rights in communities, factories and schools,
with the end product a ‘Tapestry of Women’s Rights’ seen to be a liberating
instrument (Gomez 1986).
A feminist group in Bombay, India, the ‘Forum against Oppression of
Women’ first started campaigning in 1979 on such issues as rape and
bride-burning. However, with 55 percent of the low-income population
living in squatter settlements, the Forum soon realized that housing was a
much greater priority for local women, and, consequently, soon shifted its
focus to this issue. In a context where women by tradition had no access to
housing in their own right, homelessness, through breakdown of marriage or
'domestic violence, was an acute problem, and the provision of women’s
hostels a critical practical gender need. Moreover, mobilization around
homelessness also raised consciousness of the patriarchal bias in inheritance
legislation as well as in the interpretation of housing rights. In seeking to
broaden the problem from a ‘women’s concern’ and to raise men’s aware
ness, the Forum has become part of a nation-wide alliance of NGOs, lobbying
national government for a National Housing Charter. Through this alliance
the Forum has ensured that women’s strategic gender needs relating to
housing rights have been placed on the mainstream political agenda, and have
not remained simply the concern of women.
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Conflicts often occur when empowered women’s organizations succeed
in challenging their subordination. One widely cited example is the SelfEmployed Women’s Organization (SEWA) started in Ahmedabad, India, in
1972 by a group of self-employed women labourers. It initially struggled
for higher wages and for the defence of members against police harassment
and exploitation by middlemen. At first, with the assistance of the maledominated Textile Labour Association (TI A), SEWA established a bank, as
well as providing support for low-income women such as skill training pro
grammes, social security systems, produc ion and marketing co-operatives
(Sebsted 1982). It has been said that th< TLA expelled SEWA from its
organi^vlvu, not only because the TLA le iders felt increasingly threatened
by the women’s advance towards self-ind ipendence, but also because their
methods of struggle, in opposition to TL i policy of compromise and col
laboration, provided a dangerous model for male workers (Karl 1983).
SEWA has survived considerable setbacks in its development largely due to
its widespread membership support. The fact that it has developed into a
movement has made it increasingly diffi :ult to eliminate. In addition, at
various times the grant support SEWA has received from international
agencies has assisted in giving the orgai ization a level of independence
within the local political context.
As highlighted by DAWN, ‘empowerin; ourselves through organization*
has been a slow global process, accelerating during and since the Women’s
Decade. A diverse range of women’s org:mizations, movements, networks
and alliances have developed. These cover a multitude of issues and pur
poses. Common interests range from disarmament at the international level
to mobilization around specific laws and codes at the national level. All share
a similar commitment to empower women, and a concern to reject rigid
bureaucratic structures in favour of non-hierarchical open structures, al
though they are not necessarily the most efficient organizational form.
Experience to date has shown that the most effective organizations have been
those that started around concrete practical gender needs relating to health,
employment and basic service provision, but which have been able to utilize
concerns such as these as a means to reach specific strategic gender needs.
In Chapter 9 this issue is further examined with the categorization of the
range of women’s organizations.
The potentially challenging nature of the empowerment approach has
meant that it remains largely unsupported either by national governments or
bilateral aid agencies. Despite the widespread growth of Third World groups
and organizations, whose approach to women is essentially one of empower
ment, they remain under-funded, reliant on the use of voluntary and unpaid
women's time, and dependent on the resources of those few international
Third World policy approaches to women 79
I
!
!•
i
NGOs and First World governments prepared to support this approach to
women and development.10
It is clear that the ‘room for manoeuvre’ still remains limited, with welfare,
and more recently efficiency, the predominant policy approaches endorsed
by most governments and international agencies. With increasing political
and ideological control in many contexts, severe difficulties continue to be
encountered in shifting policy towards the anti-poverty, equity or empower
ment approach. However, there are also individuals and groups involved in
changing policy approaches; government and aid agency personnel who
argue that a ‘gendered’ efficiency approach can also be the means, with a
hidden agenda, to empower women; the proliferating number of under
financed, small-scale Third World women’s organizations in which women
are increasingly struggling not only to meet practical gender needs but also
to raise consciousness to struggle for strategic gender needs.
Part One of this book has provided the conceptual rationale for gender
planning. This is based on the identification of the triple role of women, the
fundamental analytical distinction between practical and strategic gender
needs, and the identification of five different policy approaches to WID,
which differ in terms of roles recognized and gender needs met. In Chapter
5, the methodological tools deriving from these principles are further elabor
ated in a description of gender planning. This is a new planning tradition,
which in incorporating gender into planning, challenges current planning
stereotypes.
I!
i 7
Batliwala, S. (1994). The Meaning of Women’s Empowerment: New Concepts from Action An G Sen, A.
Germain, and L. Chen (Eds.), Population Policies reconsidered - Health, Empowerment and Rig s.
Harvard Series on Population and International Health. Cambridge, Massachusetts.
9
The Meaning of
Women’s Empowerment:
New Concepts from Action1
SrHatha Batliwala
Since the mid-1980s, the term empowerment has
become popular in the field of development,
especially in reference to women. In grassroots
programs and policy debates alike, empowerment
has virtually replaced terms such as welfare,
upliftment, community participation, and poverty
alleviation co describe the goal of development
and intervention. In spite of the prevalence of the
term, however, many people are confused as to
what the empowerment of women implies in
social, economic, and political terms. How em
powerment strategies differ from or relate to such
earlier strategies as integrated rural development,
omen’s development, community participation,
conscientization, and awareness building is even
less clear.
Nonetheless, many large-scale programs are
being launched with the explicit objective of
“empowering” the poor and “empowering”
women. Empowerment is held to be a panacea for
social ills: high population growth rates, environ
mental degradation, and the low status ofwomen,
among others.2
The attention given here to women s empow
erment is based on the premise that it is an
enabling condition for reproductive rights (Correa
and Petchesky, this volume). This chapter at
tempts an operational definition of women s
empowerment, and delineates the components
and stages of empowerment strategies, on the
basis of insights gained through a study of
grassroots programs in South Asia. Undoubtedly,
the nature and priorities of the women s em
powerment process in South Asian countries are
shaped by the historical, political, social, and
economic conditions specific to that region. Still,
there are sufficient commonalities with other
regions — such as an extende^period of colonial
rule; highly stratified, male-dominated social struc
tures; widespread poverty and vulnerable econo
mies; and fairly- rigid gender- and class-based
divisions of labor —— to render the definition and
analytic framework for empowerment presented
in this essay more widely relevant.
The Concept of Empowerment
The concept of women s empowerment ap
pears to be the outcome of several important
critiques and debates generated by the women s
movement throughout the world, and particu
larly by Third World feminists. Its source can be
2.1^
1
ic concept of‘"popular education developed in
itin Americn in the 1 9/Os (V?alters 1791)- l*ie
■'(ter had its roots in Frcirc’s theory of concientization,” which totally ignored gender, but
.. as also i nfluenccd by Gramscian thought, which
reused the need fcr participatory mechanisms in
istitutions and society in order to create a more
quitable and nonexploitative system (Forgacs
1988; Freirc 1973).
Gender subordination and the social conruction of gender were a priori in feminist
aalysis and popular education. Feminist popular
'ducators therefore evolved their own distinct
approach, pushing beyond merely building aware
ness and toward organizing the poor to struggle
ctively for change. They defined their goals in
le following terms:
.. .To unambiguously take the standpoint
ofwomen; [and].. .demonstratetowomen
and men how gender is constructed
socially,...and...can be changed...[to
show] through the lived experience of the
participants, how women and men are
gendered through class, race, religion, cul
ture, etc.;...to investigate collectively...
how class, [caste], race and gender
intersect...in order to deepen collective
understanding about these relationships...
...To build collective and alternative vi
sions for gender relations...and...deepen
collective analvsis of the context and the
position of women...locally, nationally,
‘
cratic community and worker organiza
tions and a strong civil society which can
pressurize for change (Walters 1991).
Meanwhile, in the 1980s feminist critiques
emerged of those development strategies and
grassroots interventions that had failed to make
significant progress toward improving the status
of women. They attributed the failure mainly to
the use of welfare, poverty alleviation, and mana
gerial approaches, for example, that did not ad
poor women live — low wages, poor nutrition,
and lack of access to health care, education, and
training. Position is the social and economic sta
tus of women as compared with that of men.
Young argues that focusing on improving the
daily conditions of women’s existence curtailed
the less visible but powerful underlying structures
of subordination and inequality.
Molyneux (1985) made a similar distinction
between women’s “practical and strategic in
terests. While women’s practical needs — food,
health, water, fuel, child care, education, im
proved technology, and so forth — must be met,
they cannot be an end in themselves. Organizing
and mobilizing women to fulfill their long-term
strategic interests is essential. I his requires
more satisfactory set of arrangements to
those which exist.. .such as tire abolition of
women and men nationally, [and inter
nationally]... [and] to help build demo-
’23
Populnr- •: Pc'.:c:rf Reconsidered
c
C“
women’s awareness of, and readiness to act against,
certain development strategies for the pro
...To help women develo'p the skills to
assert themselves...and to challenge op
pressive behavior...to build a network of
:r
the “position” of women (Young 1988). Young
defined coTiziitiOTi as the material state in which
...analysis of women’s subordination
and...the formulation of an alternative,
tional lives...
71
dress the underlying structural factors that per
petuate the oppression and exploitation of poor
women (Moser 1989). These approaches had
made no distinction between the “condition” and
regionally and globally,.. .To develop ana
lytical tools...to evaluate the effects of
motion of women’s strategic interests...
[and develop strategic] to bring about
change in their personal and organiza
71
C 8
c !
c
c
_1
c r
c
c 6
C
I■
I
the sexual division of labor, the alleviation
of die burden of domestic labor and child
c E
c
rare, the removal of institutionalized forms
of discrimination, the establishment -of
C
political equality, freedom of choice over
childbearing a nd... measures against male
violence and. control over women
(Molyneux 1985)-
“
c-(-
u
c
c I
broadly defined as control over mat-rial assets,
intellectual resources, and ideology. The mater .al
assets over which control can be exercised may be
physical, human, or financial, such as land, water,
, ■ from these roots rhar the not.on of empo
U ‘ Xrew, and it came co be most clearly
cr
4 in 1985 by DAWN3 as rhe empowan-culated
Em.
erment approa
lor'esrs. people’s bodies and labor, money, and
access to money. Intellectual resources mcludc
rt.qaircd transformation
of subordination through ndiol
knowledge, information, and ideas. Comro over
changes in law, property rights, and ot icr msut
Lns that reinforce and perpetuate male domma-
ideology signifies rhe ability to generate, propa„te sustain, and institutionalize specific sets of
beliefs, values, attitudes, and behavior --virtu
ally determining how people perceive and func
U° By the beginning of the 1990s, women’s em
powerment had come to replace most earlier
tion within given socioeconomic and political
terms in development jargon. Unfortunate y, as i
has become a buzzword, the sharpness of the
perspective that gave rise to it has be-n diluted
environments. 4
Power thus accrues to those wno control or are
able to influence the distribution of material re
Consequendy, its implications for macro- an
micro-level strategies need clarification. 1 he key
question is: How do different approaches to
women’s “condition,” or practical needs, affect
the possibility or nature of changes m women s
“position,” or strategic interests?
This question is most pertinent to the whole
issue ofwomen’s reproductive rights. Many ofthe
existingapproaches to contraception and womens
reproductive health, for example, focus entire y
on improved technologies and delivery systems
for birth control, safe delivery, prenatal and post
natal care, and termination of fertility. But none
of these addresses the more fundamental ques
tions of discrimination against girls and women
in access to food and health care; male dominance
in sexual relations; women’s lack of control over
their sexuality; the gender division of labor that
renders women little more than beasts of burden
they can shape prevailing ideologies, whether so
cial, religious, or political. This control, in turn,
confers the power of decisionmaking
In South Asia, women in general, and poor
women in particular, are relatively powerley with
little or no control over resources and little
decisionmaking power. Often, even the hmited
resources at their disposal - such as a.hrde land
a nearby forest, and their own bodies, abor an
skills _ are not within their control, and the
decisions made by othefc affect their lives every day.
This does not mean that women are, or have
always been, totally powerless; for centimes they
have tried to exercise their power ^thin the
family (Nelson 1974; Stacey and Price 1981).
women’s “position,” and are not necessar y a.fected by reduced birthrates or improvements in
women’s physical health. This is one of the di
seized control of resources when they cord
seek to address.
>
extent of power held by particular individuals or
groups corresponds to the number of kinds of
resources they can control, and the extent to which
in many cultures; or the denial by many societies
of women’s right to determine tire numM o
children they want. These issues are all linked to
chotomies drat an empowerment process must
)
sources, knowledge, and the ideology mat governs
social relations in both public and private hfe. Tne
What is Empowerment?
The most conspicuous feature of the term
empowennent is that it contains the vord^^p
They also have taken control of the resources to
which society has allowed them access, and even
die Chipko movement in nonJiern In
a an
Green Belt movement in Kenya, tor example
(Misra 1978; Rodda 1791)- They have always
attempted, from theirtraditional position as work“ Jofcrs,
"ivc, no. only .o .nJluonce
their immediate environment, but also to expand
thHr space. However, rhe prevailing patriarchal
ideoloey, which promotes dm values of submis-
which, to sidestep philosophical debate, may be
—
V.
AcEo.
129
2_lb
sacrifice, obedience, and silent suffering,
,ficn undermines even these attempts by women
o assert themselves or demand some share of
resources (Hnwkcsworth 1990; Schuler and
Cadirgamar-Rajasingham 1992).
' The process of challenging existing power
Since the causes of women’s inferior status
and unequal gender relations are deeply
rooted in history, religion, culture, in the
psycholog}' of the self, in laws and legal
systems, and in political institutions and
social attitudes, if the status and material
relations, and of gaining greater control over the
conditions ofwomen’s lives is to change at
all, the solutions must penetrate just as
sources of power, may be termed empowerment.
This broad definition is refined by feminist schol
deeply
ars and activists within the context of their own
regions. For instance:
The term empowerment refers to a range
of activities from individual self-assertion
to collective resistance, protest and mobi
lization that challenge basic power rela
tions. For individuals and groups where
class, caste, ethnicity and gender deter
mine their access to resources and power,
their empowerment begins when they not
only recognize the systemic forces that
oppress them, but act to change existing
power relationships. Empowerment, there
fore, is a process aimed at changing the
nature and direction of systemic forces
which marginalize women and other dis
and
Kadirgamar-
Rajasingham 1992).
Theories that identify any one system or struc
ture as the source of power — for instance, the
assertion that economic structures are the basis or
powerlessness and inequality — imply that im
provement in one dimension would result in a
redistribution of power. However, activists work
ing in situations where women are economically
strong know that equal status does not necessarily
resulc If anything, ample evidence exists that
strengthening women’s economic status, though
positive in many ways, does not always reduce
their other burdens or eradicate other forms of
oppression; in fact, it has often led to intensifying
pressures (Brydon and Chant 1989; Gupte and
Borkar 1987; Sen and Grown 1985). Similarly, it
advantaged sections in a given context
is evident that improvements in physical status
(Sharma 1991-1992).
and access to basic resources, like water, hie ,
Empowerment is thus both a process and the
-suit of that process. Empowerment is mamjsted as a redistribution of power, whether be-
-ween. nations, classes, castes, races, genders, or
fodder, hedlth.care, and education, do not auto
matically lead to fundamental changes in women s
position. If that were so, middle-class women,
with higher education, well-paid jobs, and ad
equate nourishment and health care, would not
■dividuals.The goals ofwomen’s empowerment
:e to challenge patriarchal ideology (male domi
continue to be victims of wife beating or bride
nation and women’s subordination); to transorm me structures and institutions that reimcrce
:nd perpetuate gender discrimination and cocial
burning.
There is widespread confusion and some de
inequality (die family, caste, class, religion, edu
cational processes and institutions, die media,
aealdi practices and systems, laws and civil codes,
political processes, development models, and gov
eminent institutions); and to enable poor women
to gain access to, and control of, both material
end informational -^sources. The process of em
powerment must thus address all relevant struc
tures and sources of power:
130
719
(Schuler
Policies Reconsidered
gree of anxiety about whether women s empow
erment leads to the disempowerment of men. It is
obvious that poor men are almost as powerless as
poor women in terms of access to and control over
resources. This is exactly why most poor men
tend to support women’s empowerment pro
cesses that enable women to bring much-needed
resources into their families and communities, or
that challenge power structures that have op
pressed and exploited the poor of both genders.
existing social order is unjust and unnatunil. They
seek to change othci women’s consciousness:
altering dieir self-image and their beliefs about
their rights and capabilities; creating awareness of
how gender disciimination, like other socioeco
nomic and political factors, is one of the forces
aedng on diem; challenging the sense of inferior
ity that has been imprinted on diem since birth;
and recognizing the true value of their labor and
contributions to the family, society, and economy.
Women must be convinced of their innate right
ited from touching books, and women and men
of certain castes are forbidden tc touch religious
books.
Through empowerment, women gain access
to new worlds of knowledge and can begin to
make new, informed choices in both their per
sonal and their public lives. However, such radi
cal changes are not sustainable if limited to a few
individual women, because traditional power
empowerment may take many forms. The anti
arrack5 agitation of 1992—1993 in Nellore Dis
trict of Andhra Pradesh State in southern India,
for instance, in which thousands of women par
structures will seek to isolate and ostracize them.
Society is forced to change only when large num
bers of women are mobilized to press for change.
The empowerment process must organize women
into collectives, breaking out from inTrndual
isolation and creating a united forum through
which women can challenge their subordination.
With the support of the collective and the activist
ticipated, was triggered by a lesson in an adult
literacy primer depicting the plight of a landless
agent, women can re-examine their lives criti
cally, recognize the structures and sources of
woman whose husband drank away his meager
power and subordination, discover their strengths,
and initiate action.
The process of empowerment is thus a spiral,
changing consciousness, identifying areas to tar
get for change, planning strategies, acting for
change, and analyzingaction and outcomes, which
leads in turn to higher levels of consciousness and
more finely honed and better executed strategies.
1 he empowerment spiral affects everyone in
volved: the individual^ the activist agent, the
collective, and the community. Thus, empower
to equality, dignity, and jusdee.
The external agents of change necessarj^ for
wages at the local liquor shop. The agitation has
created a major political and economic crisis for
the state government, which earns huge revenues
through licensing of liquor outlets and excise
dudes on liquor (see Box 1; also, Anveshi 1993;
Joseph 1993).
A key role of the external activist lies in giving
women access to a new body ofideas and informa
tion that not only changes their consciousness
and self-image, but also encourages action. This
means a dynamic educational process. Histori
cally, the poor in much of South Asia, and espe
cially poor women, were beyond the pale of
formal education, and so developed learnins7 sys
tems of their own. '/aluable oral and practical
traditions evolved to transfer empirical knowl
edge and livelihood skills from generation to
generation: about agriculture, plant and animal
life^ forest lore, weaving, dying, building craft,
fishing, handicrafts, folk medicine, and a myriad
of other subjects. This body of traditional knowl
edge and skills was, however, developed within
specific ideological and social frameworks. Such
knowledge and practices are often suffused with
<abcos, superstitions, and biases against women.
For example, menstruating women arc prohib-
132
Population Policies Reconsidered
ment cannot be a top-down or one-way process.
Armed with a new consciousness and growing
collective strength, women begin to assert their
right to control resources (including their own
bodies) and to participate equally in decisions
within the family, community, and village. Their
priorities may often be surprising, even baffling,
to the outsider. In die aftermath of die 1991
Bangladesh cyclone, one of the first demands
made by women in a badly affected area was the
rebuilding of the schoolhouse and the providing
of schoolbooks to their children; this was in stark
contrast to the demands of the-local men, who
talked only about houses, seeds, poultry, and
loans (Akhtar 1992). In another-project in south
ern India, one of the first issues taken up by the
(
<
(
(
(
Resistance, however, occurs when women com
pete with, men for power in the public sphere, or
when they question die power, rights, and privi
leges of men within die family — in other words,
when women challenge patriarchal family rela
tions (Batliwala 1994). This is, in fact, a test of
how far the empowerment process has reached
into women s lives; as one activist put it, “the
family is the last frontier of change in gender
relations ... You know [empowerment] has oc
curred when it crosses the threshold of the home”
(Kar.nabiran 1993).
1 he process of women’s empowerment must
challenge patriarchal relations, and thus inevita
bly leads to changes in men’s traditional control
over women, particularly over the women of their
households. Men in communities where such
changes have already occurred no longer have
control over women’s bodies, sexuality, or mobil
ity; they cannot abdicate responsibility for house
work and child care, nor physically abuse or
violate women with impunity; they cannor (as is
the case in South Asia at present) abandon or
divorce their wives without providing mainte
nance, or commit bigamy or polygamy, or make
unilateral decisions that affect the whole family.
Clearly, then, women’s empowerment does mean
the loss or the privileged position that patriarchy
allotted to men.
Apomt often missed, however, is that women’s
empowerment also liberates and empowers men,
both in material
and iin psychological terms. First,
-----------
women greatly
<
strengthen the impact of political
movements dominated by
/ men
men —
— not
not just by
their numbers,
-.umbers, but by providing new energy,
insights, leadership, and strategies. Second, astve
saw earlier, the struggles of women’s groups for
access to material resources and knowledge di
rectly be-efit the men and children of their fami
lies anc their communities, by opening the door
ro new ideas and a better quality of life. But most
important are the psychological gains for men
when women become equal partners. Men are
heed from the roles of oppressor and exploiter,
and from gender stereotyping, which limits the
potent.^, for self-expression and personal devel-
opment m men as much as in women. Further
more, experiences worldw.de show drat men dis
cover an emotional satisfaction in sharing respon
sibility and decisionmaking; drey find drat drey
have lost not merely traditional privileges, but
also traditional burdens. As one South Asian
NGO spokeswoman expressed it:
Women’s empowerment should lead to
the liberation of men from false value
systems and ideologies of oppression. It
should lead to a situation where each one
can become a whole being, regardless of
gender, and use their f.illesr potential to
construct a more humane society for all
(Akhtar 1992).
The Process of Empowerment
In order to challenge their subordination,
women mustfirst recognize the ideolog, that legiti
mizes male domination and understand hoL it
perpetuates their oppression. This recognition re
quires reversal of the values and attitudes, indeed
. the entire worldview, that most women have
internalized since earliest childhood. Women have
been led to participate in their own oppression
through a complex web of religious sanctions,
social and cultural taboos^ind superstitions, hier
archies among women in the family (see Adams
and Castle in this volume), behavioral training,
seclusion, veiling, curtailment of physical mobil
ity, discrimination in food and other family re
sources, and control of their sexuality (including
concepts like the “good” and "bad” woman)!
Most poor women have never been allowed to
think for themselves or to make their own choices
except in unusual circumstances, when a male
decision maker has been absent or has abdicated
his role. Because questioning is not allowed, the
majority of women grow up believing that this is
the just and “natural” order.
Hence, the demand for change does .not ttsually begin spontaneously fr'om
i
die condition of
subjugation. Rather, empowerment: must be ex-
tern?Uy induced, by fo rces working with an altered consciousness and
an awareness that the
The Me.-.,Empou.en/ter.:: Me::' Cne.cerT, F-e
)
i
1
Women’s Mobilizing: Anti-Liquor Agitation by Indian Women
“Even a cow must be fed if you want milk. Other
wise it will kick you. We have kicked! W'c will do
anything to stop saara [country liquor] sales here"
(Villager, Totla Cheruvupalli, Andhra Pradesh).
i
The anti-liquor movement that began in die
soudiem Indian state of Andhra Pradesh in 1992
is unusual among popular uprisings. Initiated and
led entirely by poor rural women in a few villages
of one district (Nellore), the movement spread
■ rapidly throughout the state. It has no centralized
’ leadership or base in any political part)', but is led
- entirely by groups of women in each village. It has
' no unified ^ti^ucgy; rather, women use whatever
tactics they find most appropriate. The movement
has been enormously successful, even overcoming
- the state government’s interest in revenues from
taxes on arrack (a crude liquor).
The movement was triggered by the Akshara
Deepam (Light of Literacy) campaign, launched
' by the government and several volunteer organiza
tions in Nellore District. The campaign not only
brought women literacy programs, but also raised
their consciousness about their status and potential
' to act. One of the chapters in the literacy primer
described the plight of a poor woman whose hus
band drank away his wages at the local liquor
shop. Ignited by this story, which mirrored their
own reality all too well, the women readers asked:
How is it that liquor supplies arrive in a village at
least twice a day, but there are always shortages of
feed in the government-controlled ration shops,
kerosene for lighting, drinking water, medicines at
the health center, learning materials for schoolchildren, and myriad other basic essentials?
’• A decade earlier, the party in power in die state
launched the Varuna Vahini (Liquor Flood)
policy, through which the state’s liquor excise
revenues increased from 1.5 billion rupees in
..1981-82 to 6.4 billion rupees in 1991—1992. The
- . state government’s development ouday for 1991- .
y 1992 was 17 billion rupees. Many local employers
■ and landlords pay part of men’s wages in coupons
that can be used at the local liquor shop, further - ;
boosting liquor sales — and ensuring that in most
Ya poor households, men’s.earnings fatten the liquor
-z^lobby
/^lobby and state government, while dieir families •.
•
struggle for daily food and survival. Regular harass
ment and physical abuse by drunken men drives
some women to suicide.
The anti-liquor movement began with a few
women picketing liquor shops and forcing dieir
closure. News spread through die village grapevine
and the media, and soon the whole of Nellore Dis
trict, then the endre state of Andhra Pradesh, was
taken up in the cause. Women used a wide variety
of tacdcs with substantial symbolic import: In one
village, for example, the women cooked die daily
meal, took it wrapped in leaves to die liquor shop,
and demanded that the owner cat all their offerings.
“You have been taking the food from our bellies all
these years, so here, ead Eat until it kills you, the
way you have been killing us!” The terrified propri
etor closed shop and ran, and has not reopened
since.
•
With less arrack being consumed, diere is more
money for food and other essentials-, less physical
and emotional abus; of women, and far less violence
in general. For the most part, men have reacted
surprisingly passively to the whole movement,
perhaps because women directed their outrage
and attacks at the liquor suppliers, rather than at
their men.
. The greatest victory of the movement is that no
politician or party has been able to derail it, nor has
die state government been able to suppress it. It
cannot, after all, be characterized as antigovernment
or seditious, since it is upholc&ng one of the directive
principles of the Indian constitution. However, the
state is trying to repress the movement in more
devious ways. Officials have floated a rumor that
if liquor sales are not resumed, the price of rice will
be increased. Attempts are also afoot to sabotage the
literacy program that gave rise to the movement.
Further, since legal sales have been effectively
stopped, liquor contractors and local officials are
promoting underground sales by smuggling liquor
into villages in milk cans and vegetable baskets.
Though women in the anti-liquor movement
have not direcdy challenged the state, diey have
managed to weaken it by attacking the nexus be
tween the state and the liquor lobby. Poor women
have mobilized and struck a blow for diem^clvcs
and their families.
;
JOSCph 1993
The Meaning of Women’s Empoiuerment: Neiv Concepts from Action
133
^7-
m-mne: as male-dominated capualist societies.
emerging Mnlrila Sangha (women’’ s collective) of
the demand for a separate smashana
one village was
(ctemiuion ground); being scheduled castes, they
said, they were not allowed to use the upper-caste
area. In both cases, external activists were sur
prised by the women’s priorities, which were
quite different from th^se issues the activists
Women’s empowerment will have to lead women
IO address global
__ and (he “new men
nd issues,
including the environment;
concerns ai.^
---id militarism; ethnic, linguistic,
war, violence, an
- racial fanaticism; and population.
religious, or i---Such
Such radical
radical transformations
transformations in
in society obvi
ously cannot be achieved through the
tire struggles of
considered most pressing.
Traditionally, women have made choices
if, indeed, they can be called choices
only
within tight social constraints. For example, a
woman can pay a dowry and marry off her daugh
village or neighborhood women’s collectives Just
as individuafchallenges can be easily crushed, so_
the struggles of small, local collectives of
women be negated by far more powerful and
entrenched socioeconomic and political forces.
ter, or run tire risk that the daughter will remain
unmarried and be a burden to the family; a
In the final analysis, to transform society women s
empowerment must become a political force, that
woman can bear many children, especially sons,
to prove her fertility, or face rejection by her
is, an organized mass movement that challenges
husband and in-laws. Because of the acute poverty and overwhelming work burden of poor
arid transforms existing power structures Em
powerment should ultimately lead to the forma
tion of mass organizations of poor women, at the
women, most activists face a recurring dilemma:
Should they respond towomen’s immediate prob
lems by setting up services that will meet their
regional, national, and international levels. Only
practical needs and alleviate their condition? Or
stmmgic needs, and change both the “condiuon
and the “position” of women. They can form
should they take the longer route of raising con
sciousness about the underlying structural factors
that cause the problems, and organize women to
demand resources and services from the state? Or
should they enable women to organize and man
age their own services with resources from the
then can the poor women of the world hope to
bdn- about the fulfillment of then practical and
strammc alliances with other organizations of the
sud, „ .rale unions, and fc<n«s -d
lenan. farmers poops - and d,ns inoolve men m
the change process a%well. Most important, these
state and themselves?
federations must remain wholly autonomous an
maintain a suprapolitical stance to prevent the co-
A New Understanding of Power
opration and dilution of the empowerment pro
cL by pervasive patriarchal forces. This does not
Empowerment should also generate new no
tions of power. Present-day notions of power
have evolved in 'hierarchical, male-dominated
societies and are based on divisive, destructive,
and oppressive values. The point is not for women
to take power and use it in the same exploitative
and corrupt way. Rather, women’s empower
ment processes must evolve a new understanding
of power, and experiment with ways of democra
tizing and sharing power — building new mecha
nisms for collective responsibility, decisionmaking,
2nd pccountability.
Similarly, once women have gained control
over resources, they should not use them in the
same shortsighted and ecologically destructive
2Z3
mean that women leaders who emerge throug
grassroots empowerment cannot participate in
political processes like elections; on the contrary
they can, and have done so. However, they should
run as candidates of existing parties, not as repre
sentatives of autonomous women s derations
This way, the latter can play a vigilant ro earn.
to account its own members if they betray
women’s aspirations and needs irr-their pel or
mance of other roles.6
,
xtrm
■ In a study of selected South Asian NGOs
(nongovernmental organizations) engaged in
women’s empowerment, 1 was able to gat er an
review project reports and other published an
unpublished material, discuss the empowerment
question with project leaders and field workers,
and visit with field organizers. Tnree major ap
proaches to women’s empowerment were identi
fiable: integrated development programs, eco
nomic development, and consciousness-raising
and organizing among women. These are not
mutually exclusive categories, but they help to
distinguish among the differing interpretations of
I
the causes of women’s powerlessness and, hence,
among the different interventions thought to lead
>
»
to empowerment.
’ fhe integrated development approach ascribes
women’s powerlessness to their greater poverty
and lower access to health care, education, and
survival resources. Strategies are focused on pro
viding services and enhancing economic status;
some NGOs also emphasize awareness building.
)
This approach improves women’s condition
mainly by helping them meet their sunaval and
)
)
)
livelihood needs.
The economic development approach places
women’s economic vulnerability at the center of
)
their powerlessness, and posits that economic
empowerment has a positive impact on other
)
aspects of women’s existence. Its strategies are
built around strengthening women’s position as
workers and income earners by mobilizing, orga
)
)
)
)
)
nizing or unionizing, and providing access to
support services. Though this approach undoubt
edly improves women’s economic position and
condition, it is not clear that this change necessar
ily empowers them in other dimensions of their
lives.
The consciousness-raising and organizing ap
proach is based on a more complex understand
ing of gender relations and women s status. This
method ascribes powerlessness to the ideology
)
and practice of patriarchy and socioeconomic
inequality in all the systems and structures of
society. Strategies focus more on organizing
women to recognize and challenge both genderand class-based discrimination in all aspects of
their lives, in both the public and tire private
spheres. Women are mobilized, to struggle for
greater access to resources, rather than passively
provided with schemes and services, d Ins ap
proach is successful in enabling women to address
their position and strategic needs, but may not be
as effective in meeting immediate needs. A more
detailed analysis of rhe goals, strategies, and di
lemmas of each of these approaches is contained
in Box 2 (on next page).
Lessons for a Women’s
Empowerment Strategy
ISio one magic formula or fail-safe design exists
for empowerment. Nonetheless, experience clearly
shows that empowerment strategies must inter
vene at die level of women’s “condition” while
also transforming their position, thus simulta
neously addressing both practical and strategic
needs. Within die conceptual framework devel
oped in the first part of this chapter, several
elements appear essential. They are designed to
challenge patriarchal ideology, and to enable poor
women to gain greater access to and control over
both material and informational resources. Al
though these elements are set out below in a
particular sequence, they may be reversed or
.interchanged, or several may be undertaken con
currency, depending on the context.
An organization concerned with bringing
about women’s empowerment must begin by
locating the geopolitical region (urban or rural) in
which it wants to wo^c, and identifying the
poorest.and most oppressed women in that area.
Activists then have to be selected and trained.
Intensive preparatory training is critical it must
impart to activists an awareness of the structures
and sources of power, especially gender, and it
must equip them with skills needed to mobilize,
while learning from, die women whose con
sciousness they plan to raise. In general, female
activists are preferable, since they are in a better
posidon to initiate the empowerment process
with other women, notwithstanding differences
in class, caste, or educational background.
In the Field, die activists encourage women co
set aside a separate time and space lor themsels es
__ as disempowered women rather than as passive
recipients of welfare or beneficiaries Oif programs
Action
The Meaning of Women s Empowet■rment: New Concepts from
135
-
■xV."
<
• -■ •
••••
— - » «* ■- * * • 1
/*—• i
’r
Empowerment: Three Approaches
Three experimental approaches to empow
ering women have been undertaken in South
Asia: integrated development, economic em
powerment, and consciousness-raising. While
these approaches differ from each other in
concept, most organizations working on the
ground take a mix of approaches. Common to
all three is the importance placed on group
formation to build solidarity among women.
The i7Uegrated.Jr.’:Lri.ient approach views
women’s development as key to the advance
ment of family and community. It therefore
I
;
provides a package of interventions to alleviate
i
j
poverty, meet basic survival needs, reduce gender discrimination, and help women gain self-
j
j
esteem. This approach proceeds either by forming women’s collectives that engage in devel-
j
i
opment activities and tackle social problems
such as dowry, child marriage, and male alco^
holism (Proshika in Bangladesh; RD RS in
Rajasthan, India), or by employing an “entry
point” strategy, using a specific activity, such as
a literacy’ class or health program, to mobilize
women into groups (Gonoshastya Kendra in
Bangladesh, United Mission to Nepal, Redd
I
Barna in Nepal):
The economic empowerment approach at
tributes women’s subordination to lack of eco
nomic power. It focuses on imp roving women s
control over material resources and strength
J
j
I
Bangladesh, Program of Credit for Rural/.
Women in Nepal); or by occupation or loca7_don (SEWA in India, Proshika). These groups
may work in a range of areas, including savings
and credit, training and skills development,..
new technologies or marketing, as well as providesuclr ancillary supports as child care, health
services, literacy programs, and legal education
and aid.
■
■
■
The consciousness raising approach asserts-that women’s empowerment requires aware^;
ness of the complex factors causing women’s..
subordinadon.-Tlris approach organizes women ,
into collecdves that tackle the sources of subor-,
dination (ASTHA, Deccan Development So' ciety,MahilaSamakhya,WOPinlndia;Nijeram
Kori in Bangladesh). Education is central and r,
is defined as a process of learning that leads to
a new consciousness, self-worth, societal and/.
gender analysis, and access to skills and mfor-^: ..
mation. In this approach, the groups them^
selves determine their priorities.yWomerfsiV
knowledge of their own bodies and ability; to.ff
control reproduction are also considered
The long-term goal is for the women’s groups
to be independent oftiie initiating NGQ- Thug
approach uses no particular service “entry pomR^
and attempts to be open-ended, and;nori^d
-directive. It gives considerable, emphasiseto£
fielding.“change.agents,” who are trained-^;
ening women’s economic security. Groups are
catalyze women’s thinking without determm^;
ing the directions in which a particular group^r
formed using two me tiro dr: organizing women
around savings and credf.., income generation,
or skill training activities (Grameen Bank in
mZfSo.
conceptions. The activists also help women col
— collectively’ to question their situation and
develop critical thinking. These forums should
enable women to evolve from an aggregate of
individuals into a cohesive collective, wherein
i
they can look at themseives and their environ
ment in new ways, develop a positive self-image,
recognize their stiengths, and explode sexist mis-
156
2^
Pc:pu!.~:ioii Policies Reconsidered
lectively to claim access to new information and
knowledge, and to begin
begin to develop a critical
understanding of the ideology-ef gender, the
systeir.s and insdtutions through which it is perpetuated ana reinforced, and the structures of
power governing their lives. This is the process
3
□
D
□
that expands women’s awareness beyond their
‘'condition” to their position.
and collective
With a growing consciousness
<
’
s
groups
prioritize
the problems
strength, women’s _
like- to tackle. They begin to confront
thev woulId-----' ; and situations both inside
oppressive practices
nd outside the home, and gradually to alter their
own attitudes and behavior; this often includes
changing their treatment oftheir girl children and
asserting their reproductive and sexual rights. In
D
the course of both individual and collective
struggles for change, women also build their skills
ofcollective decisionmaking, action, and accountability and they may forge new strategies and
methods, sucn as forming alliances with other
groups of exploited and oppressed people, or
3
■%
J
absence of a democratic environment. An em
powerment process of the kind outlined here is
impossible without democratic space for dissent,
struggle, and change. Theocratic, military', or
other kinds of authoritarian states, based on ide
ologies of dominance and gender subordination,
simply will not allow radical women’s empower
ment movements to survive. Perhaps for this
-reason, many approaches co empowerment in
South Asia tend to avoid overtly political activi
ties; activists provide women with opportunities
and services, and encourage a certain level of
awareness, but avoid more serious challenges to
the dominant ideology or power structures.
A. second, more pervasive, obstacle is a frag
mented understanding of the concept and process
involving sympathetic men of their own commu
nities. With the help of training and counsel
provided by the NGO or activists working with
them, they also acquire real skills — vocational
and managerial know-how, literacy and arith
of empowerment itself, with an accompanying
lack of clarity about the nature of power, patriar
chy, and gender. Male domination and gender
discrimination tend to be oversimplified, equated
with conspicuously oppressive practices like child
metic competence, basic data collection tech
niques for conducting their own surveys — that
marriage, dowry demands, wife beating, bigamy
and polygamy, and denial of women s rights to
equal food, employment, education, or physical
enhance their autonomy and power.
These women’s collectives then begin to seek
access to resources and public services indepen
dently, demanding accountability' from service
providers, lobbying for changes in laws and pro
grams that are inaccessible or inappropriate, and
negotiating with public institutions such as banks
and government departments. Collectively they
may also set up and manage alternative services
and programs, such as their own child care cen
ters, savings banks, or schools. Finally, village- or
neighborhood-level women’s collectives may form
associations at the local, regional, national, and
global levels, through which poor women can
more effectively challenge higher-level power
structures and further empower themselves for
the well-being of society' as a whole.
.mobility. The resultant approach focuses on
women’s practical rather than strategic needs.
The organizing and consciousness-raising ap
proach has come somewhat closer to a holistic
strategy of empowerment, but still needs to solve
many methodological problems before the com
plexities of the social construction of gender .—
and the ways in which family, class, caste, reli
gion, and other factors perpetuating women, s
subordination — can be changed.
Notes
1 This chapter is based on the author s study of empower
ment programs in three South Asian countries, entitled
“Women’s Empowerment in South Asia: Concepts and
Practices” (forthcoming), sponsored by the Freedom
from Hunger Campaign and Asia couth Pacific Bureau
of Adult Education).
Conclusion
Grassroots experiments in empowerment have
made considerable headway since the mid-1980s,
but it is clear — at least in ^uth Asia — that they
have a long way to go. One obvious reason is the
2 This has come through clearly in my' interactions in
South Asia with nongovcrnrncncal organizations
(NGOs), international aid agency representatives, aca
demics, women’s activists, government bureaucrats, and
others.
The Meaning of Women’s Empowerment: New Concepts from Action
2-Zt
157
Development Alternatives with Women for a New Era,
a South-driven network of feminist scholars and women s
Hawkcswonh. M. E. 1990.
Frm,r.^
theory andpoUFcnl strategy. Ncw\ork: Continuum.
groups, formed in 1984 in Ba-galorc, Indra.
Joseph, A. 1993- Brewing trouble. The Hindu, March 7.
The promotion of religious obscurantism in India, with
Kannabiran, K. (a feminist activist of ASM1TA, a women’s
resource center in Hyderabad. India). 1993. Personal
its accompanying redefinition of Hinduism, is a case in
point. We in the subcontinent arc experiencing the
revival and spread of a whole ideology, which culmi
nated in the destruction of the Babri Mosque on Decem
communication.
Misra, A. 1978. Chipko movement: Uttarakhand women’s
bid to save forest wealth. New Delhi: People’s Action.
ber 6, 1992.
Molyneux, M. 1985- Mobilization without emancipation?
S
Arrack is a form of country liquor.
;
In India, members of a peasant and landless women s
federation in southern Maharashtra, and of an urban
slum women’s federation (with chapters in 10 major
i'..‘._-s) have access fully contested and won elections to
municipal and local government bodies with different
party platforms. The federations thereafter exercised the
right to monitor their performance vis-a-vis the agenda
for women’s advancement, thus continually pressuring
the concerned political parties to take up such issues.
References
Akhtar, F. (UBINIG, an NGO engaged in empowerment of
rural women, Dhaka). 1992. Personal communication.
Anveshi. 1993. Reworking gender relations, redefining poli
tics: Nellore village women against arrack. Hyderabad.
Women’s interests, the state, and revolution in Nicara
gua. Feminist Studies 11.2.
Moser, C. 1989. Gender planning in the Third World:
Meeting practical and strategic needs. World Develop
ment 17:1799-1825.
Nelson, C. 1974. Public and private and politics: Women m
the ’Middle Eastern world. American Ethnologist
l(3):551-563.
Rodda, A. 1991. Women and the environment. London: Zed
Books.
Schuler, M., and-S. Kadirgamar-Rajasingham. 1992. Legal
literacy: A tool for women’s empowerment. Nev.’ York:
UNIFEM.
Sen, G , and C. Grown. 1985. Developmentaltemttives with
women for a new era: Development crises and alternative
Badiwala.S. 1994 (forthcoming). Women’s empowerment in
South Asia: Conceptsandpractices. New Delhi: Food and
Agricultural Organization/Asia South Pacific Bureau of
Adult Education (FAO/ASPBAE).
visions. London: Earthscan.
Sharma, K. 1991-1992. Grassroots organizations and
women’s empowerment: Some issues in the contcmpo-
rary debate. Samya Shakti 6:28-43.
Brydon, L., an^ S. Chant. 1989- Women in the Third World:
Gender issues in rural and urban areas. New Brunswick,
N.J.: Rutgers University Press.
Forga.cs, D. (ed.). 1988. An Antonio Gramsci reader: Selected
writings, 1916-1935. New York: Schocken Books.
Freire, P. 1973. Pedagog)'ofitheoppressed.Uc\'rTotV: Scabuiy
Press.
Gupte, M., and A. Borkar, 1987. Women’s work, maternity
and access to health care: Socioeconomic study of villages in
Pune District. Bombay: Foundation for Research in
Communit}' Health.
Stacey, M.» and M. Price. 1981. Women, power, andpolitics.
London and New York: Tavistock Publications.
Walters, S. 1991 - Her words on his lips: Gender and popular
eduction in South Africa. ASPBAE Courier 5TA /.
Young, K. 1938. Gender and development: A. relational
approach. Oxford: Oxford University Press.
. st A
Pendse, V. (2001). Maternal deaths
e +- it
Int!‘an HosPital:A decade of no change? Reproductive Heatt
Matters. Special Supplement on Sale Motherhood Initiatives. Critical Issues, pp. 119-126.
Maternal Deaths in an Indian HospitalA Decade of (No) Change?
^/naya Pendse
in ChiIdbirth in Zanans -4pto/ a
specSXS!nS
=SH^
.
SS=H^=SS=S=-
Mund condition who could not be saved
preventable causes of death than in td
n
and outside hospitals.
AsaKzxsstr* °'work ■
Post-graduate trainino between itZ d9 my
and in mv early vearc as ?! !
and 1968
colleges (1969-1980)^ r
medical
of maternal dea h ^2TT 3
nUmber
at the hos^
Y' m°re °fthem succumbed toclea--v
years ago.
contlnue to die needlessly in childbir■
within
deliveries in a health facility (n 6 oer cpnfl
dunng the same year. More than 40 J cent
sr-v »-■«+- “
untrained persons
J- Bajas,tan.
Per Cent by other
second'h* hUr‘n9 the Peri°d 1982-86- was the
‘ n ni9"est the country.1-2 Durina-iqqo
93, antenatal coverage in Rabsthnn
9 .
one contact with a trained
attached tn
trained nurse-midwife
» “nt
rh-»to.„Ire.
Head Tthe T aPP°inted 3S Profesor and
eaa of the Department of Obste-cs and
G.vnaecology at the RNT Medical Collece and th
position, the emergency maternity care available
deliveries annually. Howexer^m^nunbe^of
delnenes being conducted had crossed 4.000 by
119
liBz
i
.. J
-
Pcndse
Cf>ncomitanta increase1''719 'O r'Se rapidly with no
sPace. Indeed th
u
:.2'■v^en having tuba,
■»
lhe women coming in "
*n rnanPower
bpd
at
thc
time
of qn,
responsible for
V rnatc'rnal death
»aSob"’,- about
the woman who d "^ additional dc,^S
earmarked for
Present at the meedng T
her nelativeT S
r 40■ cent of° non-teaching
staff and aX 09 S‘aff'as Weli'a°
ward3'5 °n the f,o°- puX
Wh° had he
"ard, and women with seo
6 was n° septic
accommodated in the T
nd °thers were all
There was aiso a
essential drugs an °equipnient.'The lahb°orta9e °f
had no proper L
ue labour room
r00m attached to it
or Preparation
operating theatre for^^ Was
one common
coi°gical cases and
0;:,st«ric
■ns Th5™' 9ynae’
<he number of d dSter',,Sati°nns-The increase in
• and tremendous
\vomen with serious
-1 rural areas,
obstetric cm.
emergency senrceT 1 of the hospital's
hJPh rates of
resulting in the
hospital. - maternal mortal^ obs-- /ed in the
h was .during
(’
1983-85
document thT'-a/™ that I decided to
’
happening in tf]maternal
a' (deaths
which were
dnm'ing public attenX
hospital,
aP with
to
attention
- ■ ausview
Pr^pared a report
in 198-to0 this
th'S serio
issue I
^port mhX
]985 on W0
Wo
had died in Zanana
who
would attend the
,
POSt’9raduatesturi
discussions.
6 mee"nps and ParticipateTn t?
The analysis
b«pe””Sn“s„°'Ste«
XT
““
s«mis bav, remai'eT
»>»« XXT8”5XXhprlm,”y™’bb“
WoX9XnT'CO',eCtedinfoi
who died from 'cmation c°n a further
^nana Hospital.
government ministers°spital,' which
Wh'Ch I mailed to
maternal
-t causes in
found fhat despite
federal and stem
aa
ministrators at
^nnainistr;
mprovements inside
and
me number of
de th 0 the h0SpitaJmaternal
hospital had not
i
in th j S£?en in t,le
199s- At the samedeclined
time h'O'vevt
the^ 'T t0
women who were dvinq did
h profile of
ohanged. 771e
' paper i
tO ha''e
a'ySe
POSS
'We the
und^ngof
U' ;fhese'
aneSe (^anngeasttaTdPtthe
h»™ or.x,
"«• .i
the hospital's
emergencies,
constructed, a
additional staff were'em9!” WaS
set up and
anderlying factors
1 whether or r-
;-s“.r£»~-J.
, - ->an, Or even inX^trX"31 deathS m
Zanana Hospital.
he dlstricts
Ii,tricts served by
!
I
I
!
I
brmgmg about imornv
b”:rs'"cy "b»« 'X“ t"" h"« "
neld monthly, and all J’
Meetings were
Previous month were anal
31 deaths m the
reXClaSS,fiedaS'av°feaWe XT
d'SCUSSed.
i
The fi^uXvaVb"1'*3*'0"5
cases of maternal dJ T °n W° c
Udaipur, Rajasthan be^5 3t 2ananaconsecutive
a hospital,
uary 1983 and
tde same
7X2OSt'9radUate -dent XX onX
120
i
audit of all
1 hospital,
d treaf
ment and
treatment
In both instances.
in addition
to medical
e
.1' •
..
Safe Motherhood Initiate i- -. Critical Issues
death was
ional details
t relatives, to
aff as well as
uate students
Licipate in the
nteraction in
erably better
emergencies
s in services,
ties has also
zks and conurt genera
ls and strikes
[en are a few
been rapid
? of Rajasthan
ifrastructural
matched by
/ health care;
s only a small
lages with a
t to 20.5 per
n on a further
nal causes in
hat despite
the hospital,
seen in the
?cade 1985 to
the orofile of
:>ec
o have
n attempt to
iges and the
t seeks to
re has been
mal deaths in
ts served by
) consecutive
ma Hospital,
lary 1983 and
in the same
h 1994 and 30
00 maternal
i to medical
history, information on each patient's socio
economic status and place of residence, the
nature of any care received prior to hospital
admission was recorded, the distance covered to
reach the hospital, and the nature of and
expenditure on getting to the hospital. Cases in
which any of these details could not be obtained
were excluded from the analysis.
Neither data set has information on the
population from which the women who died
came. In the absence of this information, it is
not possible to make observations regarding
changes in the maternal mortality rate or in
the relative risk of maternal death based on
characteristics of the women. The analysis is only
indicative, but it throws up some interesting
hypotheses regarding the factors underlying the
changes in the profile of maternal deaths in the
hospital during the decade concerned.
A context of poverty and gender
discrimination
A major factor underlying many avoidable
maternal deaths is the combination of gender
discrimination and poverty, which begin to have
an effect from birth for girls. Higher female infant
mortality (92 per 1000) than male (88 per 1000) in
Rajasthan (1992), a differential which continues
through the adult years, is a clear indicator of
this. Rajasathan also has the highest gap within
India between female and male mortality rates in
the 20-24 age group, with female mortality 1.7
times greater than male mortality.2 Furthermore,
there is also evidence to suggest that gender
discrimination, rather than diminishing over
time, may in fact be increasing. Thus, the ratio of
female to male child mortality rates increased
from 1.11 in 1982-84 to 1.16 in 1994.
Education of girls is rare, despite the increase
in the number of villages which have a primary
school. Rajasthan has the lowest female literacy
rate in the country, 21 per cent, while the male
literacy rate is 55 per cent.' The gender gap in
educational status is likely to continue for many
more decades, given that the primary school
enrolment rate for girls in 1991 was only 50.1 per
cent as compared to 106.7 for boys.8
Even today, mass child marriage ceremonies
arranged by parents, where hundreds of boys
and girls wed each other, are very common. The
mean age at marriage for women (16.1 yrs) is
among the lowest in the country.' Once a girl
goes to her marital home, it is her duty to
beget a child as soon as she can. Her sex life
therefore starts immediately or soon after menarche, and in some cases, even earlier.
Forcing early pregnancies and motherhood
on teenage girls under the banner of social
custom and family is tragic. Ng: much has
changed in Rajasthan in the past decade with
respect to frequent childbearing and grand
multiparity. Fertility rates remain nigh, with a
total fertility rate in 1991 of 4.7 as compared to
3.9 for the country as a whole. Coming to the
hospital in an obstetric emergency will not help
prevent the deaths of women who are in a
vulnerable state of health to begin whh. Maternal
mortality is thus, in addition to a health services
and poverty issue, also a gender issue.
Yet another factor is the nature of 'develop
ment' that has taken place in the state of
Rajasthan and the rest of the country’ over the
last decade. Few jobs and income earning
avenues appear to be percolating down to the
rural areas, but prices of essential commodities
and especially food have increased several fold.
It would appear that economic inequality
has increased, with the lion's share of benefits
of technological and economic development
cornered by the urban middle and upper classes.
Findings
Demographic characteristics and socio-economic
status
There were more maternal deaths (12 per cent) in
women aged 18 or less in 1994-96 than in 1983-85
(7 per cent). In both series, nearly one fourth of
the deaths were in women over 30 years of age, a
trend similar to other Indian states. Twenty-one
per cent of deaths in 1983-85 and 24 per cent in
1994-96 occurred in women of gravidity five and
above.
A greater proportion of maternal deaths in
1994-96 (68 per cent) occurred in women of the
'very poor' or 'poor' groups, as compared to ten
years earlier (55- per cent).9 Further, a slightly
higher proportion of women who died in 1994-96
(88 per cent) were illiterate as compared to those
who died a decade earlier (82 per cent), and
fewer (4 per cent) had more than five years of
schooling than those who died a decade earlier (9
percent).
121
2-^0
-
-
^22
K-".
->
Pendse
There was a statistically significant increase in
1994-96 as compared to 1983-85 in the per
centage of those belonging to the 'Scheduled'
castes and 'Scheduled' tribes - among the most
economically and socially marginalised groups
in India (74 per cent vs. 45 per cent). The
proportion of maternal deaths among those
belonging to higher castes declined to less than
half of what it had been in the earlier series.
Interestingly, the decline in the number of
maternal deaths was not uniform across the
various 'higher' caste groups. The number of
maternal deaths among the 'Rajput' caste women
remained almost unchanged, from 18 in the
1983-85 study to 14 in the 1994-96 study, while
deaths among other 'higher' castes declined
from 35 to only 8.
28 per cent to 50 per cent. However, on further
exploring the nature of the care received by the
two groups of women, we found that the only
major change observable was that more women
had received tetanus toxoid injections during
pregnancy in 1994-96 than in 1983-85 (52 as
compared to 32). There was only a very marginal
increase (10 per cent vs. 6 per cent) in the
proportion who had received adequate antenatal
care (comprising four contacts with a health
worker, immunisation against tetanus and
anaemia prophylaxis). Eighteen per cent had
Anaemia
Characteristics of the women
Overall, the haemoglobin levels of women who
died in 1994-96 were much worse than those
observed in women who died a decade before.
Every one of the women (100 per cent) who died
from maternal causes in 1994-96 suffered from
anaemia (Hb < 10.1 gm %), while the proportion
was 83 per cent in the earlier series. In particular,
the proportion in the 1994-96 series with very
severe anaemia (Hb < 4 gm%) was three times
greater, from 11 to 34 per cent.
When the haemoglobin level is less than 4
gm%, the risk of sudden heart failure is very high
(up to 40 per cent of all cases).10 Available blood
was preventing some of these deaths in 1983-85.
However, administrative and managerial pro
blems related to blood transfusion in acutely
anaemic patients have multiplied since 1992. with
the advent of newer risks of bloodborne infection
- HIV, hepatitis B, syphilis and malarial parasites,
and screening for these infections has become
mandatory since then. This has frequently
resulted in the hospital being unable to provide
blood for transfusion because the equipment or
supplies to carry out the mandatory tests were
not available. Blood donation by relatives con
tinues to be rare. All these factors have
contributed to maternal deaths related to
anaemia in the 1994-96 series.
Antenatal and delivery care
I
The proportion of women who had received any
primary-level antenatal care had increased
statistically significantly during the decade, from
Table 1. Changes in the profile of women dying in
childbirth at the Zanana Hospital, Udaipur,
Rajasthan, India, 1983-85 and 1994-96
No. of cases
(n=100)
1994-96
(n=100)
7
21
21
82
53
12
22
22
88
22 *
Poor and very poor
45
52
75 *
68
Moderate to severe anaemia (Hb < 8 gm%)
49
78 ’
68
32
10
72
15
60
52
5
50
7
11
27
26
3
20
62
38
12
25
28
23
4
4
4
34
13
31
24
7
15 ?
1983-85
Age 18 years and below
Age 31-40 years
Gravidity 5 +
Illiterate
Belonging to higher castes
Belonging to Scheduled castes/
Scheduled tribes
TBAthe main person responsible for
antenatal & intra-natal care
Tetanus toxoid immunisation
Booked cases
No primary care
Women from the city
Women who travelled 100 km to reach
hospital
Transported by jeep
Transport expenditure Rs. 201- 500
Transport expenditure Rs. 501 >
Mortality within 4 hrs of hospital admission
Eclampsia cause of death
Haemorrhage cause of death
Severe anaemia cause of death
Ruptured uterus cause of death
Septic induced abortion cause of death
*
p < .01, highly significant
** p < .05, significant
Z
11 cases of sepsis and 4 cases of haemorrhage
122
i
.... 2il
■■
Upf
.
I
Pendse
1
i
5
Causes of death
Some changes in the pattern of direct causes of
death over the period from 1983 to 1996 can be
observed. Some of these are positive. For
example, although the number of women
admitted with pregnancy-induced hypertension
remained more or less the same, the proportion
of deaths due to eclampsia dropped from 28 per
cent in 1983-85 to 13 per cent in 1994-96. This is
directly due to hospital policy since 1990 of
timely administration of magnesium sulphate to
all women with suspected cases of eclampsia
except those who had received other drugs prior
to admission.
On the other hand, it was disturbing to find
that malaria was probably responsible for the
deaths of 17 women in the 1994-96 series, of
whom 9 women had a confirmed diagnosis of
malaria. In contrast, there were no deaths related
to malaria in the 1983-85 series. Further, there
was a six-fold increase in the number of deaths
due to severe anaemia (Hb < 6 gm%), probably all
related to malaria. Deaths due to ruptured uterus
were also slightly higher (7 per cent as compared
to 4 per cent), but this was not statistically
significant.
124
lx
An equally disturbing finding was a signifi
cant increase in the proportion of deaths from
complications of induced abortion. There were
15 maternal deaths related to induced abortion
during 1994-96, as compared to only 4 during
1983-85. Of these, cases of septic abortion were
three times higher in 1994-96 than in 1983-85 (11
vs. 4), and four women died from haemorrhage
following induced abortion in 1994-96 as
compared to none in 1983-85. All the abortion
deaths in both series resulted from abortions
carried out by unregistered and unskilled
practitioners, sought because of the absence of
proper abortion services, even at district referral
hospitals.
A decade of (no) progress?
Since it opened in 1959, Zanana Hospital in
Udaipur has remained the only tertiary care
hospital in southern Rajasthan to render proper,
specialist emergency obstetric services to the
women not only of Udaipur city, but also
Udaipur district, adjacent districts and the
adjoining state of Madhya Pradesh. Although
there are two other government health centres in
Safe Motherhood Initiatives: Critical Issues
further
by the
he only
re women
during
(52 as
■ marginal
in the
°ntenatal
health
is and
cent had
ivmg in
ses
1994-96
(n=100)
12
22
22
88
22 *
75 *
68
78 *
60
52
5
50 **
7
20
62
38
12
34
13
31
24
7
15 #
received erratic antenatal care (one or two
contacts with a health worker when the latter
chooses to make a domiciliary visit) or inade
quate antenatal care (falling short of one or more
components), while 50 per cent had received no
antenatal care at all in the 1994-96 series, as com
pared to 4 per cent and 72 per cent respectively
in the 1983-85 series.
Traditional birth attendants still remained the
main people responsible for delivery care for 60
per cent of the women in 1994-96, as compared
to 68 per cent in 1983-85.
Distance and mode of transport to the hospital
With the improvement in roads and transport
facilities which took place in the years between
the two studies, an increased number of women
who died in the hospital had travelled from
distant places and had arrived at the hospital
with the hope of surviving. The proportion of
women who had travelled more than 100 km
almost doubled, from 11 per cent during 1983-85
to 20 per cent during 1994-96. At the same time,
the proportion of maternal deaths from among
women from Udaipur city had been halved, from
15 per cent during 1983-85 to 7 per cent in
1994-96.
Because of the hilly terrain and poor (even if
improved) roads for the long distances, delays in
bringing women to the hospital, leading to
deterioration in the woman's condition, were
always a strong possibility in the majority of the
cases.
As regards means of transport, the most
noticeable change was that many more women
who died in the 1994-96 group (62 per cent) had
travelled in by jeep as compared to those in the
past (37 per cent). This vehicle, suitable for rough
and bumpy roads, has gained popularity as a
mode of private transport because it is far less
expensive than a private taxi, and faster than
other traditional modes of transport available at
the village level. There was not much change in
the other modes of transport used, which
included buses, trucks and the age old bullock
cart. Three-wheeler taxis (auto-rickshaws) were
available for transport in Udaipur city.
Eight women in the 1994-96 group were
carried manually on a cot or on someone's back.
More than one third of the women had used
more than one mode of transport to reach the
hospital. Often, a woman would be carried on a
cot or on someone's back from her village to the
nearest motorable road. From there a passing
private bus, minibus or truck would be flagged
down and asked to transport her to some part of
Udaipur city, and then a three-wheeler would be
hired to reach the hospital. Distance and lack of
transport together may have contributed to far
more maternal deaths in the community than
among women who reached the hospital.
Only 8 percent of the women in the 1994-96
study and 6 per cent in the 1983-85 study were
transported by hospital ambulance. Despite the
passage of ten years and repeated requests and
reminders from us at Zanana Hospital, there has
as yet been no policy directive from the Health
Department regarding the transport of emer
gency maternity cases from rural areas to hospi
tal. Transport is not provided by the government,
even for serious cases referred from primary
health centres in the district.
Expenditure on transport
All but those who used hospital ambulances had
to hire private transport and pay for it. The
exorbitant amounts they had to pay are of great
concern, given that the majority of them were
extremely poor.
The average expenditure on transporting the
dying woman in each case had doubled in the
period between the two studies, from Rs. 150 to
Rs. 300. This may partly be due to the increased
cost of fuel and the longer distances travelled.
However, more families in 1994-96 had ventured
to come to the hospital from longer distances, in
the hope of saving the woman's life. We gathered
that many of the families had to borrow from a
local moneylender or pawn some of their belong
ings before undertaking the journey. The whole
experience left them poorer both materially and
emotionally, especially when, despite their des
perate efforts, the woman's life could not be
saved.
Interval between hospital admission and death
Twenty-one per cent of the women in 1994-96, as
compared to 13 per cent in 1983-85, died within
two hours of admission, which indicates that
their condition was so bad that nothing could be
done for them in the way of hospital emergency
care. While this was also true in the past, the
number of women arriving in a moribund
condition was much higher in the 1994-96 series.
123
f
Safe Mothurh^d :-tiativcs: Critical Issues
g
t
<■
is a signifiieaths from
Fhere were
?d abortion
.y 4 during
jrtion were
1983-85(11
emorrhage
994-96 as
ie
jrtion
i abortions
unskilled
absence of
net referral
Hospital in
rtiary care
ier proper,
ces to the
but also
: and the
Although
i centres in
the city, these only provide outpatient services
whether more women were having induced
and have not been upgraded to offer emergency
abortions than m the past, or whether more
obstetric care.
women who developed complications were able
What have we at fthe Zanana Hospital learned
to reach the hospital or v.ere being brought in
from this comparison of the
profile of women
for treatment in 1994-96 than in the past
dying from complications of
„„ lI,
pregnancy, birth
Although
there is little hard data, access to
and induced abortion during the mid-1990s with
induced
abortions
from trained providers is
those who died in the mid-1980s? A larger
mainly
available
only
in large public and private
proportion suffered from infections and were
hospitals in India, which means that poor, rural
SeV71oonanaerniC than their counterparts in the
women have little or no easy access and continue
mid-1980s. Nearly half of them did not receive
to rely on unskilled providers and dapgerous
any antenatal care, and the care received by most
methods. In any case, the proportion of deaths
Of the rest was erratic and inadequate.’.Many
oue
to illegal abortions in recent years is
more had travelled longer distances and their
unacceptable
in a country where abortion has
amihes had spent more money getting them to
been legal since 1972.
the hospital. Many more arrived in a condition
These problems must be added to the fact that
where nothing could be done to save them
the
health services at prma.w and referral level
Finally, more of them lost their lives from clearly
have
not been improved sufEciently to safeguard
preventable causes than the women who died in
w
omen
s lives until they can reach our hospital in
the decade before them. i.e. complications
cases
of
emergencies. Hence, although our
resulting from illegal abortions, and severe
efforts within the hospital to improve emergency
anaemia and malaria.
obstetric care have made a difference in terms of
As regards socio-economic status, the women
saving some women's lives, we are able to
Who died in 1994-96 were less educated and
succeed only up to a point.
poorer, and more of them belonged to socially
These observations, based on experience are
disadvantaged groups compared to those who
mostly corroborated by data available for' the
had died in 1983-85. with one exception, l^ere
state of Rajasthan, and suggest the following.
was a continuing high representation of Rajput
e health status of the population has not
19OT Z M?On9 maternal deaths both during
improved
in crucial aspects, including maternal
1983-80 (18 per cent) and 1994-96 (14 per cent)
mortality.
The
resurgence of malaria has taken a
while that among other caste groups declined
heavy toll of lives during the present decade and
dramatically (from 3o per cent to 8 per cent) "
IS especially dangerous in pregnancy. Further
Rajputs are a comparatively affluent and poli
Since 1993-94. the state has also witnessed a
tically powerful caste group, but the women are
[e!Ur9enCe of viral hepatitis which has also been
subject to more restrictions than in other higher
associated with maternal deaths in rcc
caste groups. This includes norms of purdah
-------- •*! recent years.
although precise figures for these are not
segregation of women at social gatherings, salt
available.
(self-immolation at the death of the husband),
Health service infrastructure has improved
ema e infanticide and non-acceptance of
only marginally. Access to antenatal care has
Widows remarrying, which are still very com
improved mainly with respect to immunisation
monly practised among them. The relationship
against
tetanus. The overall quality of antenatal
between these manifestations of a high level of
care
remains
poor or is inaccessible. Worsp still
gender discrimination and the continuing high
abortion
services
as well as emergency obstetric
proportion of maternal deaths among Rajput
senices remain almost unavailable to the vast
women, warrants further scrutiny.
majority of rural women. Women who want to
As regards causes of death, 'the increase in
space
pregnancies do so at great risk to their
anaem.a is directly related to an increase in
lives. This also points to the failure of the family
the frequency of malaria caused by Plasmodium
planning programme to meet women's need for
falciparum, which is
more often fatal than other
birth
spacing methods.
kinds of malaria, and is 1
becoming increasingly
The
only positive change brought about by
resistant to chloroquine.1dexelopment' has been improvements in the
It is not possible to determine from the data
network of roads and access to public transport.
125
23A
■
' ... .
Pcndsc
In addition, there has been a general improve
ment in the level of awareness of the people,
probably because of seasonal migration to urban
areas in search of work, as more of them seem to
know about the emergency obstetric services
available at our hospital.
The consequence is what is reported here:
many of the women who would have died at
home in the past, and whose deaths would never
have been counted, are now arriving at our
hospital. However, because the problems of
transport, money and distance remain so large
for them, we are unable to prevent their deaths.
Hence, the number of maternal deaths taking
place m the hospital remains unabated after a
decade.
To the extent that more women are now
coming to the hospital from farther away and
from poorer and lower caste groups, the changes
m the profile of women dying over the past
decade may be viewed as positive. However,
unless and until all the factors contributing to the
continuing high numbers of maternal deaths are
put right, starting from the social and economic
inequalities which place women at a disad
vantage even before they become pregnant,
women will continue to die needlessly in
childbirth, both within and outside hospitals.
Correspondence
Dr Vinaya Pendse, 10/11 P
____
v
Ban
era ;;
House,
Fatehpura, Udaipur 313004. Rajasthan. India'
References and Notes
i
1 • The per capita income for
6. During 1981-1991, there were
Rajasthan was Rs. 3983 in 1990several major improvements in
91 (current prices), as compared
the state's infrastructure and in
to Rs. 4325 for India as a whole.
that of Udaipur district. The
Department of Family Welfare,
proportion of villages in the
1992. Family Welfare
district connected by public
Programme in India - Year Book
transport increased from 21 per
1991-92. New Delhi.. Ministry of
cent to 37 per cent. Villages with
Health and Family Welfare,
a primary school increased from
Government of India.
46 per cent of all villages to 73
2. The infant mortality rate for the
per cent. Office of the Registrar
state was 90 per 1000 live births
General, India, 1993. Census of
in 1992, the fourth highest in the
India, 1991. District Census
country. Office of the Registrar
Abstract, Udaipur district. New
General, Vital Statistics Division,
Delhi, Ministry of Home Affairs,
(various years). Sample
Government of India.
Registration System: Fertility and
7. Office of the Registrar General,
Mortality Indicators. New Delhi,
India, 1991. Provisional
Ministry of Home Affairs,
Population Totals, Census of
Government of India.
India. 1991. Paper 1 of 1991.
3. International Institute for
Series 1. New Delhi, Ministry of
Population Sciences. 1995.
Home Affairs, Government of
National Family Health Survey:
India.
India, 1992-93. Introductory
8. Department of Education, 1993.
Report. Bombay.
Selected Educational Statistics:
4. International Institute for
1990-91. New Delhi, Ministry of
Population Sciences. 1994.
Human Resources Development,
National Family Health Survey:
Government of India.
India. 1992-93. Bombay.
9. The definitions of poor' and
5. Mari Bhat PN. K Navaneetham.
'very poor' are as follows: Those
S Irudaya Rajan. 1992. Maternal
who are very poor are those
Mortality in India: Estimates
with no regular employment or
from an Econometric Model.
source of income and no assets.
Dharwad, Population Research
The 'poor' are defined as those
Centre, Working Paper 24
whose household income is less
(January).
than Rs. 1600/- per month (USS
126
I
I
2^5
40) in 1994-96, which is below
the 'poverty line' income
specified by the Planning
Commission of India as 3s.
2600/- per capita per month (US
S65). For 1983-85, the poor were
defined as those with a
household income of less than
Rs. 500 per month at current
prices.
10. World Health Organization,
1992. The Prevalence of C
Nutritional Anaemia in Women:
A Tabulation ofAvailable
Information. Geneva.
WHO/MCH/MSM/92.3.
11. Rajputs are a warrior caste who
rank immediately below the
Brahmins in the caste hierarchy
and form the top rung of the
economic and political
hierarchy.
12. World Health OrganizationSouth East Asia Regional Office,
1999. Health situation in the
South East Asia Region 19941997.
13. See for example Gupte M,
BandewarS, Pisal H, 1997.
Abortion needs of women in
India: a case study of rural
Maharashtra. Reproductive
Health Matters. No. 9IMay)-7786.
Krieger. N. (2003). Genders, sexes, and health: What are the connections — and why does it matter:
International Journal of Epidemiology. 32, pp. 652-657.
TUTORIAL
henaers, sexesf and heaith: what are the
connections and why does it matter?
Nancy Krieger
Accepted
18 February 2002
Open up any biomedical or public health journal prior to the 1970s. and one term
will be glaringly absent: gender. Open up any recent biomedical or public health
journal, and two terms will be used either: (1) interchangeably, or (2) as distinct
constructs: gender and sex. Why the change? Why the confusion?—and why does
' it matter? After briefly reviewing conceptual debates leading to distinctions
between 'sex' and 'gender' as biological and social constructs, respectively, the
paper draws on ecosodal theory to present 12 case examples in which gender
relations and sex-linked biology are singly, neither, or both relevant as independent
or synergistic determinants of the selected outcomes. Spanning from birth defects
to mortality, these outcomes include: chromosomal disorders, infectious and noninfectious disease, occupational and environmental disease, trauma, pregnancy,
menopause, and access to health services. As these examples highlight, not only
can gender relations influence expression—and interpretation—of biological traits,
but also sex-linked biological characteristics can, in some cases, contribute to
or amplify gender ciu'crentials in health. Because ou. sJuncc v.i’i only be as clear
and error-free as our thinking, greater precision about whether and when gender
relations, sex-linked biology, both, or neither matter for health is warranted.
Keywords
Epidemiological methods, epidemiological theory', gender, men's health, sex,
women's health
_________________________
Open up any biomedical or public health journal prior to the
1970s, and one term will be glaringly absent: gender. Open up any
recent biomedical or public health journal and two terms will be
used either: (1) interchangeably, or (2) as distinct constructs:
gender and sex. Why the change? Why the confusion?—and why
does it matter?
As elegantly argued by Raymond Williams, vocabulary
involves not only 'the available and developing meaning of
known words' but also 'particular formations of meaning—
ways not only of discussing but at another level seeing many of
our central experiences' (ref. 1, p. 15). Language in this sense
embodies 'important social and historical processes', in which
new terms are introduced or old terms take on new meanings, and
often 'earlier and later senses coexist, or become actual alter
natives in z hie:: p:cbk::.r of cv •■emcc:belief and affiliation
are contested' (ref. 1, p. 22).
So it is with 'genderi and 'sex'.2,3 The introduction of
'gender' in English in the 1970s as an ahernative to 'sex' was
expressly to counter an implicit and often explicit biological
determinism pervading scientific and lay language.2-8 The new
term was deployed to aid clarity of thought, in a period when
academics and activists alike, as part of and in response to that
era's resurgent women's movement, engaged in debates over
whether observed differences in social roles, performance, and
non-reproductive health status of women and men—and girls
and boys—was due to allegedly innate biological differences
('sex') or to culture-bound conventions about norms for—and
relationships between—women, men. girls, and boys ('gender')
(I^ble 1). For language to express the ideas and issues at stake,
one di-encompassing term—'sex'—would no longer suffice.
Thus, the meaning of 'gender' (derived from the Latin term
'generate', to beget) expanded from being a technical grammatical
Department of Health and Sodal Behavior. Harvard School of Public Health.
677 Huntington Avenue. Boson. MA 02113. USA- E-mail: nLneger^hsph.
harvard.edu
term (voic.'.
: •■'•sU.tiici'nouns
aiia
were 'masculine' or 'feminine') to a term of sodal analysis
(ref. 1, p. 285; ref. 4. p. 2; ref. 5, pp. 136-37). By contrast, the
meaning of 'sex' (derived from the Latin term secas or sexus.
referring to 'the male or female section of humanity’ [ret 1.
p. 283]) contracted. Specifically, it went from a term describing
distinctions between, and the relative status of, women and
men (e.g. Simone DeBeauvoir's The Second Sex9) to a biological
652
22)6
GENDERS. SEXES. AND HEALTH
Tabie 1 Defir.iuons of 'sex’ and 'Rend
653
. From A Giosary fiv Social t-ridemioiogy2
Term
Definition
Gender, sexism, 8- sex
Gender refers io a social construct regarding culture-bound conventions, roles, and behaviors for. as well as
relations between and among, women and men and boys and girls. Gender roles vary across a continuum and
both gender relations and biologic expressions of gender vary within and across societies, typically in relation
to social divisions premised on power and authority (e.g., class, race/ethnicity, nationality, religion). Sexism, in
tum. involves inequitable gender relations and refers to institutional and interpersonal practices whereby
members of dominant gender groups (typically rr.cn) accrue privileges by subordinating other gender groups
(typically women) and justify these practices via ideologies of innate superiority, difference, or deviance. Lastly,
sex is a biological construct premised upon biological charaaeristics enabling sexual reproduaion. Among
people, biological sex is variously assigned in relation to secondary sex-charaaeristics. gonads, or sex
chromosomes; sexual categories include: male, female, intersexual (persons bom with both male and female
sexual charaacrisu’cs), and transsexual (persons who undergo surgical and/or hormonal intervenuons to
reassign their sex). Sclinked biological charaaeristics (e.g., presence or absence of ovaries, testes, vagina, penis;
various hormone levels; pregnancy, etc.) can, in some cases, contribute to gender differentials in health but can
also be construed as gendered expressions of biology and erroneously invoked to explain biologic
expressions of gender. For example, associations between parity and incidence of melanoma among women
arc typically attributed to pregnancy-related hormonal changes; new research indicating comparable associations
between parity and incidence of melanoma among men, however, suggests that social conditions linked to
parity, and not necessarily—or solely—the biology of pregnancy, may be actiologically relevant.
Sexualities & heterosexism
Sexuality refers to culture-bound conventions, roles, and behaviors involving expressions of sexual desire,
power, and diverse emotions, mediated by gender and other aspects of social position (e.g., class, race/cthnidty,
etc.). Distinct components of sexuality include: sexual identity, sexual behavior, and sexual desire.
Contemporary 'Western' categories by which people self-identify or can be labeled include: heterosexual,
homosexual lesbian, gay, bisexual 'queer', transgendered, transsexual and asexual Heterosexism, the type of
discrimination related to sexuality, constitutes one form of abrogation of sexual rights and refers to institutional
and interpersonal practices whereby heterosexuals accrue privileges (e.g.. legal right to marry and to have sexual
panners of the 'other' sex) and discriminate against people who have or desire samc-scx sexual panners, and
justify these practices via ideologies of innate superiority, difference, or deviance. Lived experiences of sexuality
accordingly can affect health by pathways involving not only sexual contact (e.g.. spread of sexually-transmitted
disease) but also discrimination and material conditions of family and household life.
term, referring to groups defined by the biology of sexual reprocucdon (er
n.csmr.g of 'having sex', to interactions involv
ing sexual biology) (ref. I, p. 285; ref. 4, p. 2; ref. 5, pp. 136-37).
As the term 'gender' began to percolate into everyday use,
however, it also began to enter the scientific literature,5-8'10
sometimes with its newly intended meaning, other limes as a
seemingly trendy substitute for 'sex'—with some articles11 even
including both terms, interchangeably, within their titles! Other
studies, by contrast, have adhered to a stria gender/sex
division, typically investigating the influence of only one or the
other on particular health outcomes.5-810 A new strand of
health research, in tum, is expanding these terms from singular
to plural by beginning to grapple with new construas of
genders and sexes now entering the scientific domain, e.g.,
'transgender', 'transsexual', 'intersexual', which blur bound
aries not only between but also within the gender/sex
dichotomy (Table I).8 The net result is that although ludd
analyses have been written on why it is important to distinguish
between 'gender' and 'sex',4-8 epidemiological and other health
research has been hampered by a lack of clear conceptual
models for considering both, simultaneously, to determine their
relevance—or not—to the outcome(s) being researched.
Yet. we do not live as a 'gendered' person one day and a
'sexed' organ'm the next; we are both, simultaneously and for
any given health outcome, it is an empirical question, not a
philosophical principle, as to whether diverse permutations of
gender and sex maner—or are irrelevant. Illustrating the im
portance of asking this question, conceptually and analytically.
Table 1 employs an ecosocial epidemiological perspeaive2*12 to
delineate 12 examples,15-24 across a range of exposure—
outcome associations, in which gender relations and sex-linked
’1%7
biology are singly, nc .her. or both rcle’ an- as independent or
synergistic determ:r?.r.<s.
These examples were chosen for
two reasons. First, underscoring the salience ot considering
these permutations for any and all outcomes, the examples range
from birth defeas to mortality, and include: chromosomal
disorders, infeaious and non-infeaious disease, occupational
and environmental disease, trauma, pregnancy, menopause,
and access to health services. Second, they systematically
present diverse scenarios across possible combinations of gender
relations and sex-linked biology, as singly or jointly pertinent or
irrelevant. In these examples, expressions of gender relations
include: gender segregation of the workforce and gender
discrimination in wages, gender norms about hygiene, gender
expeaations about sexual condua and pregnancy, gendered
presentation of and responses to symptoms of illness, and
gender-based violence. Examples of sex-linked biology include:
chromosomal sex, menstruation, genital secretions, secondary
sex charaaeristics, sex-steroid-sensitive physiology of nonreproductive tissues, pregnancy, and menopause.
As examination of the 12 case examples makes clear, not
only can gender relations influence expression—and inter
pretation—of biological traits, but also sex-linked biological
charaaeristics can. in some cases, contribute to or amplify gender
differentials in health. For example, as shown by case No. 9,
not recognizing that parity is a social as well as biological
phenomenon, with meaning for men as well as women, means
imponant clues about why parity might be associated with
a given outcome might be missed. Similarly, as shown by case
No. 11, recognition of social inequalities among women (includ
ing as related to gender disparities between women and men)
can enhance understanding of expressions of sex-linked biology.
6 54
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Table 2 Selected examples of differential roles of gender relations and sex-linked biology on health outcomes: only gender, only sex-linked
biology, neither, end both
Case Diagrammed illustration_________
1
gender
relations
exposure
2
gender
relations
exposure
3
gender
relations
exposure
gender
relations
exposure
5
gender
relations
exposure
6
gender
relations
exposure
sex-linked biology
health outcome
sex-linked biology
health outcome
sex-linked biology
health outcome
sex-linked biology
health outcome
sex-linked biology
health outcome
sex-linked biology
health outcome
Relevance of:________
Sex-linked
biology
E x posu re—o u tco m e
association
Gender
relations
Greater prevalence
of HIV/AIDS due to
needle-stick injury
among female
compared with male
health care workers
providing patient
care13
Yes: for
exposure
No
• Gender relations: determinant of risk
of exposure (needle stick injury), via
gender segregation of the workforce (e.g.
greater likelihood of women being nurses)
• Sex-linked biology: not a determinant of
risk of exposure
• Risk of outcome, given exposure: risk
of seroconversion same among women
and men
Greater prevalence of
contact lens microbial
keratitis among male
compared with female
contact lens wearers14
Yes
No
• Gender relations: determinant—among
those wearing contact lenses—of risk of
exposure to Improperly deaned contact
lenses (men less likely to properly clean
them than women)
• Sex-linked biology: not a determinant
of exposure
• Risk of outcome, given exposure: risk of
contact lens microbial keratitis same
among women and men, once exposed
to improperly deaned contact lenses
Greater prevalence of
short stature and
gonadal dysgenesis
among women with
Turner's syndrome
compared with
unaffected women 15
No
Yes: lor
exposure
• Gender relations: not a determinant of
exposure (X-monosomy. total or mosaic,
or non-functional X chromosome)
• Sex-linked biology: determinant of
exposure
• Risk of outcome, given exposure: not
influenced by gender relations
Both similar and
different adverse
health outcomes among
women and men due
to ubiquitous exposure
to cooking oil
contaminated by
polychlorinated
biphenyls (RGB)
('Yusho' disease)16
No
Yes: once
exposed
• Gender relations: not a dtte:.«;r«am of nsk
of exposure (ubiquitous exposure to the
contaminated cooking oil, in staple foods)
• Sex-linked biology: not a determinant of
risk of exposure
• Risk of outcome, given exposure: partly
influenced by sex-linked biology, in that
although both women and men
experienced chloracne and other dermal
and ocular lesions, only women
experienced menstrual irregularities
Higher risk of stroke
among both women
and men in the US
'stroke belt' in several
Southern states,
compared with women
and men in other
regions of the US (as
distinct from differences
in risk for women and
men within a given
region)17
No
No.
• Gender relations: not a determinant
of risk of exposure (living in the
US 'stroke beit’)
• Sex-linked biology: not a determinant
of risk of exposure
• Risk of outcome, given exposure: neither
gender relations nor sex-linked biology
determine regional variation in stroke
rates among men and among women
(even as both may contribute to
within-region higher risks among
men compared with women)
Higher risk of
hypospadias among
male infants bom to
women exposed io
potential ctiaccnnedisrupting agents at
work18
Yes: (or
exposure
Yes: once
exposed
• Gender relations: a determinant of risk of
exposure, via gender segregation of the
workforce (e.g. high level of phthalate
Explication
mainly
• Sex-linked biology: not a determinant
of risk of exposure
• Risk of outcome, given exposure: different
for women and men. and for female and
male fetus, as only women can be
pregnant, and adverse exposure can lead
to hypospadias only' among fetuses
with a penis
________ _________
GENDERS. SEXES. AND HEALTH
655
Tabic 2 continued
Relevance of:
Case Diagrammed Illustration
7
gender
sex-linked biology
relations
exposure
8
gender
relations
exposure
9
gender
relations
->>- health outcome
sex-linked biology
health outcome
sex-linked biology'
Exposure—outcome
association
Gender
relations
Sex-linked
. Explication
biology
Geographical variation
in women's rates of
unintended pregnancy
as linked to variation
in state policies re
family planning19
Yes: for
exposure
and once
exposed
Yes: once
exposed
• Gender relations: a determinant, at societal
level, of risk of exposure, i.e. state policies
and spending for family planning
• Sex-linked biology: not a determinant, at
individual level of the girl or woman at
risk of pregnancy, of state policies and
spending for family planning
• Risk of outcome, given exposure: gender
relations, at the individual level influence
women's access to—and ability to act on
information obtained from—family
planning programs, and sex-linked
biology is a determinant of who can
get pregnant
Earlier age of human
immunodeficiency
virus infection among
women compared
with heterosexual men
(in the US)20
Yes: for
exposure
Yes: for
exposure
and once
exposed
• Gender relations: a determinant of age of
sexual panner and risk of unprotected sex
(e.g. gender power imbalance resulting in
sex between older men and younger
women, the latter having a lesser ability
to negotiate condom use)
• Sex-linked biology: a determinant of
exposure, via genital secretions
• Risk of outcome, given exposure:
sex-linked biology a determinant of greater
biological efficiency of male-to-female,
compared with femalc-to-male. transmission
Parity among both
women and men
associated with increased
risk of melanoma21
Yes: for
exposures
Yes: for
exposure
• Gender relations: a determinant of parity
(via expectations of who has children.
at what age)
• Sex-linked biology: a determinant of
who can become pregnant and pregnancylinked hormonal levels
• Risk of outcome, given exposure:
decreased risk of melanoma among
nulliparous tvomen and men indicates
that non-reproductive factors linked to
parity may affect risk among both
women and men. even as pregnancyrelated hormonal factors may also affect
women’s risk
Greater referral of men
compared with women
for interventions for
acute coronary
syndromes22
Yes: for
exposure
and once
exposed
Yes: for
exposure
• Gender relations: a determinant of how
people present and physicians interpret
symptoms of acute coronary syndromes
• Sex-linked biology a determinant of
age at presentation (men are more likely
to have acute infarction at younger ages)
and possibly type of symptoms
• Risk of outcome, given exposure: gender
relations are a determinant of physician
likelihood of referral for diagnostic and
therapeutic interventions (women Jess
likely to be referred, especially at
younger ages)
Earlier age at onset of
perimenopause among
women experiencing
greater cumulative
economic deprivation
over the life course21
Yes: for
exposure
Yes: as
outcome
• Gender relations: a determinant of poverty,
across the life course, among women (via
the gender gap in eamings and wealth)
• Sex-linked b
rr-.
who can expenence prnmenvpa
• Risk of outcome, gjven exposure: risk of
earlier age at perimenopause among
women subjected to greater economic
depri'.ation across the life course.
including non-smokers, may reflect
impact of poverty on oocyte depletion
exposure (a)---- '►-health outcome
exposure (b)
iu
gender
relations
sex-linked biolog}'
/
\. exposure--------health outcome
11
gender
relations
sex-linked biology
\
exposure
health outcome
656
INTF.RNzXTlONAL JOURNAL OF EPIDEMIOLOGY
Table 2 continued
Relevance of:
Case Diagrammed illustration
gender
relations
12
sex-linked biology
exposure-------- >- health outcome
- ---------
Exposure—outcome
association
Gender
relations
Sex-linked
biology
Greater rate of
mortality among
women compared
with men due to
intimate partner
violence24
Yes; for
exposure
Yes: for
exposure
and once
exposed
Explication
• Gender relations: a determinant of
likelihood of men versus women using
physical violence against intimate
panners. plus being encouraged to and
haring access to resources to increase
physical strength
• Scx-linkcd biology: a determinant of
muscle strength and stamina, at a given
level of training and exenion, and also
body size
• Risk of outcome, given exposure: risk
of lethal assault related to on-average
greater physical strength and size
of men. and gender-related skills and
training in inflicting and warding
off physical attack
KEY MESSAGES
•
Gender, a social construct, and sex, a biological construct, are distinct, not interchangeable, terms; the two
nevertheless are often confused and used interchangeably in contemporary scientific literature.
•
The relevance of gender relations and sex-linked biology to a given health outcome is an empirical question, not
a philosophical principle; depending on the health outcome under study, both, neither, one, or the other may be
relevant—as sole, independent, or synergistic determinants.
•
Clarity of concepts, and attention to both gender relations and sex-linked biology, is critical for valid scientific
research on population health.
e.g. age ar perimenopause. Because cur science will only be as
clear and error-free as our thinking, greater precision about
whether gender relations, sex-linked biology, both, or neither
matter for health is warranted.
7 Doyal L. Sex. gender, and health: the need for a new approach. BMJ
2001;323:1061-63.
Acknowledgements
10 Institute of Medicine, Committee on Understanding the Biology of
Sex and Gender Differences. Wizemann TM. Pardue M-L (eds).
Exploring the Biological Contributions to Human Health: Does Sex Matter?
Washington, DC: National Academy Press, 2001.
8 Pausto-Sterling A. Sexing the Body: Gender Politics and the Construction of
Sexuality. New York, NY; Basic Books. 2000.
9 DeBeauvoir S. The Second Sex. NY: Vintage Books, 1974 (1952).
Thanks to Sofia Gruskin for helpful comments. This work was
not supponed by any grant.
References
1 Williams R. Keywords: A Voasbulary of Culture and Society. Revised Edn.
NY: Oxford University Press, 1983.
2 Krieger N. A glossary for social epidemiology. J Epidemiol Community
Health 2001; 55:693-700.
3 Krieger N, Fuc E. Mcii-maue medicine and women's health: the
biopolitics of sex/gendcr and race/ethnicity. Int J Health Serv
1994:24^265-83.
11 Boling EP. Gender and osteoporosis: similarities and scx-spcdfic
differences. J Cend SpcdfMed 2001;4:36-43.
12 Krieger N. Theories for social epidemiology in the 21st century: an
ccosocia! perspective. Int J Epidemiol 2001;30:668-77.
13 Ippolito G. Puro Y Heptonstall J. Jagger J, De Carli G. Petrosillo N.
Occupational human immunodeficiency virus infection in health care
workers: worldwide cases through September 1997. Clin Infea Dis
1999;28:565-63.
14 Liesegang
TJ. Contact lens-related microbial keratitis: Part 1:
Epidemiology. Cornea 1997;16:125-31.
4 Oudshoom N. Beyond the Natural Body: An Archeology of Sex Hormones.
London: Routledge, 1994.
15 Ranke MG. Saengcr P. Turner's syndrome. Lanett 2001;358:309-14.
5 Hubbard R. Constructing sex differences. In: Hubbard R. The Politics of
Women's Biology. New Brunswick. NJ: Rutgers University Press, 1990.
pp. 136—40.
,6Aoki Y. Polychlorinated biphenyis, polychlorinated dibenzo-pdioxins. and polychlorinated dibenzofurans as endocrine disrupters—
what we have learned from Yusho disease. Environ Res 2001;86c2-11.
6 Schiebinger L. Nature's Body: Gender in the Making of Modem Science.
Boston: Beacon Press. 1993.
17 Pickle LW. Gillum RE. Geographic variation in cardiovascular disease
mortality in US blacks and whites. J Nad Med Assoc 1999;91:54 5-56.
2-40
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21 Kravdal O. Is the relationship between childbearing and cancer
incidence due to biology or lifestyle? Examples of the importance of
using data on men. /■•tt J E^derr.:^! 1995:4:477-84.
18 Van Ton ger cn M, Nieuwenhuijsen , MJ, Gardiner K ff fl/. A jobexposure matrix for potential endocrine-disrupting chemicals
developed for a study Into the association between maternal
uccupationai c.xposuie and hypospadias, r'nn Crccap Hyg 2002;46:
•465-77.
22 Feldman T, Silver a. Gender dilfercnces and the outcome of inter
ventions for acute coronary syndromes. Cardiol Rev 20C0;8:240-'47.
19 Melvin CL Rogers M, Gilben BC et al. Pregnancy intention: how
PR/\MS
<^n inform programs and policy. Matem Child Health J
2000;4:197-201.
25 Wise LA. Krieger N. Zierler S. Harlow BL. Lifetime socioeconomic
position in relation to onset of pcrimenopause: a prospective cohort
study. J Epidemiol Community Health 2002:56:851-60.
20 Hadcr SL Smith DK. Moore JS. Holmberg SD. HIV infection in
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1
Acknowledgements
g o
As usual, the creation of this book was a more collective enterprise
than appears from the front cover. Much of the work was completed al
the University of the West of England and I owe many thanks to
colleagues there. The Women and Writing Group in the Faculty of
IIcallh and < ’ommunily Studies was a continuing source of inlcllcctual
nourishment, good food and lots of laughs. Philip Wookcy made it
possible for me to have a much needed sabbatical. Arthur Keefe look
on a lot of extra work so that the book could be completed and was
always there when the going got lough. Malcolm McEachran tolerated
my tcchnophobia. helped me search out obscure references and allowed
me to have more than my fair share of inter-library loans. Helen
Jackson came to the project late but with great enthusiasm, helping me
during those final and painful stages of the birthing process.
Outside the university. Carol Marks worked with great skill to
transform my scribbles into a legible document while Kale Woodhouse
CD
so
so
5
on
__
2
Introduction
£ 5
o’
There is a widespread belief that doctors are the ‘real’ experts on
r ?r
z-
women's health and that biomedicine holds the key to improving it.
This book demonstrates the limitations of such an approach. Instead of
exploring the interior of female bodies, it steps outside to investigate the ways in which women’s lives can make them sick. Through OQ
O)
- 5
a
s
examining economic,, social and cultural influences on their well-being
S’
it identifies the major obstacles that prevent women from optimising
their health.
3 £
<s.
There are obvious differences between male and female patterns of
cd
Whalley. Sue Lees. Kale Young, Mary llaslum. Tamsin Wilton and
Norma Daykin all made extremely valuable comments which helped to
along the ‘fault line’ of gender and this loo has a profound effect on the
improve the final text. Steven Kennedy was an understanding and
supportive publisher whose gastronomic generosity and skills also
well-being of both men and women (Moore, 1988; Papanek. 1990).
Sophie Watson. Ann Hammarslrom. Nancy Worcester. Marianne
-contributed significantly to the eventual outcome.
His fish pies sometimes rescued me from the worst depths of despair
while our debates about question marks raised (he art of punctuation
to new heights. Hannah Doyal matured with the book and her
solidarity and friendship made a major contribution to its develop
ment. Finally, without Len Doyal’s faith, love, feminism, determina
tion, word processing skills and dogged commitment to intellectual
rigour none of this would have come Io fruition
Thanks to all ol them.
1.1 si i > Doyai
\5
X'
XII
sickness and health. Not surprisingly, these stem in part from biological
complex than might al first appear. All societies continue to be divided
Gender differences arc especially significant for women, since they
§r:
usually mean inequality and discrimination. Though female subordina
My son Dan Wilsher continues to be an unfailing source of support.
N
zr
CD
2 >
4’ 5differences between the sexes. But as we shall see. the situation is more
7
checked both the text and the references with consummate dedication.
!
In Sickness and in Health
tion can lake many forms it is an extremely pervasive phenomenon,
demonstrating ‘both endless variety and monotonous similarity’
(Rubin, 1975). This does not, of course, mean that all women are
worse off in every way than all men. But it remains true that in most
societies the male is valued more highly than (he female. Men arc
usually dominant in the allocation of scarce resources and (his
structured inequality has a major impact on women’s health.
Material discrimination against women has been extensively docu
mented. Worldwide, they do more work than men. yet their labour is
seen to be of less value. Typically they receive about 30-40 per cent less
pay than men if employed and no pay at all for most domestic work.
They hold only 10 20 per cent of managerial and administrative jobs
and arc very poorly represented in the ranks of power, policy and
decision making (United Nations. 1991. p. 6). As a result, many face
I
I
a
u
CL
a
□
Cl
TJ
r/
B-
a
z□
c
3
c
ir/mi .ima.'a if /
Si, k
In Suknc.w and in Health
major challenges in acquiring the material resources needed for
healthy life.
a
Cultural devaluation is also impt'rlani. though more difficult to
map. All social groups operate through a variety of discourses that
naturalise gender differences and inequalities. Women have to create
their identity - their sense of themselves
within the framework of
these culturally constructed and sometimes conflicting definitions of
w'omanhood (Martin. 1987; Ussher. 1989). They may be revered as
*5
mothers for instance, or as the guardians of morality, while also being
regarded as ‘sickly’, neurotic, polluted or just fundamentally less
valuable than men. I he dominant message is that women are not just
different, but physically, psychologically ami socially inferior. In a
world defined by and for men. women are ‘the other’ (de Beauvoir.
1972). Under these circumstances it is hardly surprising that many find
it difficult to develop the feelings of competence and self-worth
associated with positive mental health.
Howcvci liie.se similarities do not mean that women constitute a
unified and homogeneous group. Though they share a gender identity
and a common biology, women are differentiated by factors such as
age. sexual preference, race, class and. very importantly, geopolitical
status
the wealth or poverty of the countrv m which they live.
because she is female. Ideologies of w'omanhood have as much to do
it is the
intersections of the various systemic networks of class, race.
(helcro)sexualily and nation
. .
that
position us as women
(Mohanly. 1991. pp. 12 13).
These differences between women arc clearly signalled in both national
and international health statistics (Momscn and Townsend,
19X7;
Seagcr and Olson. I9K6; United Nations. 1991).
This book will describe variations in patterns of health and illness
between women and men. as well as identifying the inequalities in
health status and access to medical care that separate croups of women
from each other. Il will then explore the complex processes shaping
these biological and social realities. If they arc to be effective, strategies
:i
This is not a -book a bou t t h c hcal t h o f bortr^sexesr“ft“q uTtc
unapologetically a book about women. Though men arc present, they
appear mainly as actors in women’s lives rather than as subjects of the
analysis itself. However this should not be taken to imply that men’s
health is unimportant or that it cannot be subjected to the same
methods of analysis. Indeed it would be one measure of the book's
success if the framework presented here were adapted for a similar
study of the influence of gender divisions on male health problems.
Neither is this a book about women and medicine. A comprehensive
treatment ol (his important topic would require a very different
approach with extensive coverage of issues that have hardly been
addressed here (Lupton. 1994; Marlin. 1987). in particular it would
include a more detailed analysis of how doctors and other health
workers treat women in the context of individual medical encounters
(Miles. 1991. Ch. 6; Roberts. 1985; I'ishcr. 1986).
Instead (he analysis will locus on two specific aspects of modern
medicine, hirst, knowledge generated within a biomedical framework
will be combined with that Iroin other disciplines to develop a more
holistic understanding il women's health and illness. Second, the
no-one ‘becomes' a woman (in Simone de Beauvoir's sense) purely
with race and class as they have to do with sex . .
What Iliis Book Is and Is Not About
for improving women s health must be based on a clear un<k*rs(andmg
of how these differences arc created and sustained The remainder of
this chapter provides a preliminary framework lot developing such an
analysis.
impact ol medical practices on women's health will be critically
reviewed and compared with that ol other factors influencing their
wellbeing
lor good or ill. Though doctors sometimes play an
important role in their lives, we will see that modern medicine is
rarely the major determinant of women's health status.
This analysis will not produce a detached and objective account of
women s health problems
if such a thing were even possible. Instead
it will be explicitly feminist in the broadest sense. This claim to
feminism docs not derive from the use of specific methods of data
collection or particular styles of argument (Harding. 1986; Harding.
1987; Maynard and Purvis. 1994). Indeed the evidence marshalled
throughout is eclectic, both in its disciplinary orientation and in the
manner ol its collection and presentation. It includes both quantitative
and qualitative data, some ol which have been produced by people who
would not dclmc themselves as in an) sense feminist. However, the
analysis itself is shaped bv a fundamental concern to identify - and
change
those aspects of women's lives that cause them serious harm.
Physical and mental health arc basic human needs set they remain
unmet lor millions ol women As we shall sec. the reasons for this arc
rarely ‘natural
in the sense that lhev are unavoidable; loo often they
.3
4
What Make,
/omen Sick
arc. quite literally, ‘man-made’, requiring feminist imaginalion(s) for
As we shall see. there arc very marked inequalities in the health
status of women from dilferent classes and racial backgrounds and
one’s feminism in the 1990s requires further elaboration. In particular
it necessitates a clear statement on the thorny question of ‘difference’,
these will be explored in detail as the book progresses. However the
greatest disparities arc those that divide the majority of women in the
In this analysis of women’s health we will reject both crude
universalism and crude difference theories. Instead we will attempt to
identify the commonalities in women's situations while al the same
u<
time remaining sensitive Io the complex social, economic and cultural
variety of their lives. In other words, we will focus on their ‘common
H-
difference (Joseph and Lewis. 19X1). Only in this way can we construct
i
5
their understanding and ultimately their transformation. But to declare
which has been al the heart of recent feminist debates.
-)
In Sickness and in Health
a theory that makes both moral and political sense.
developed countries from the majority of those living in what is often
called the ‘third world'. Though the diversity of social forms in ‘third
world
countries is immense, they arc similar enough to generate
comparable patterns of disease and death for the mass of their female
populations. It is important therefore that we specify these common
features, as well as defining the term ‘third world’ more precisely.
About (wo thirds of the world’s women live in countries where per
capita income is low and life expectancy relatively short, where the
fertility rale continues to be high and a comparatively small percentage
of (he paid labour force is female, where class and gender inequalities in
! ‘
income and wealth continue to be very great and the state provides few
•
Rejecting Crude Univci sidis/n
i
During the last decade, women from many different constituencies
working-class women, lesbians, black women, women with disabilities
and women from third world countries
have challenged the white,
western, middle-class domination of feminist theory and practice
(Kumm. 1992, Ch. 5; Lovell. 1990; Segal. 19X7; McDowell and
Pringle, 1992). In particular they have been critical of those feminists
who prioritise gender over other social divisions, representing all
women as members of the same oppressed group, unified by their
experience of male domination and their uniquclx lemale emotionality.
This political critique has been reinforced by a shift towards post
modernism in much feminist thinking. Women working in this
tradition have emphasised (he dangers of inaccurate and inappropri
ate generalisations, stressing instead, (he importance of hearing many
voices’(Barrett and Phillips. 1992; Braidotli ci <d.. 1994; Mohanty cl
al., 1991; Nicholson. 1991).
In response to these arguments, many feminist writers arc now
placing much greater emphasis on (he differences between women.
Rejecting the ideas of universal sisterhood that characterised much
feminist thinking in (he 1980s. they have begun to develop a more
sophisticated understanding of the relationships between race, class
r
and gender. The analysis conjaincd in (his book should be seen as a
contribution to that process, with the social construction of health and
sickness offering important examples of how such links arc forged in
concrete historical circumstances.
MV
health and welfare services. Though they arc both culturally and
materially heterogeneous most of these countries do share common
experiences of colonialism and imperialism, which have resulted in
varying degrees of subordination within the world economic system.
Geographically they are located in the southern part of the globe in the
Latin American, Caribbean. African. Asian and Pacific regions.
All the terms currently used to summarise the complex reality of
these economic and social divisions arc problematic. They tend
inevitably towards over simplification - there arc huge differences for
instance, between the newly industrialising nations of Asia and Latin
America and the majority of African countries. Such terms also have
the potential to reinforce economic, cultural and ideological hierarchies
(Mohanty, 1991). Yet it is difficult to avoid their use altogether. ‘Third
world is probably the most frequently used and widely understood of
currently available options (Mohanty. |991, p. 75, note I; Sen and
Grown. 19XX. p. 9. note 3). It also continues to be employed as an
affirmative identification by many political activists around the world,
and will therefore be used here (with care) to locate women’s lives
within a broader geopolitical context.
However we need to acknowledge that this categorisation of global
reality into first and third worlds excludes those countries that used to
be called ‘second world' but arc now ‘post-communist’ or ‘desocialis
ing . A number of recent texts have made the lives of women in Central
and Eastern Europe much more visible outside their own countries
(Buckley. 1989; Corrin. 1992; Funk and Mueller. 1993). Though health
has not been their major locus, most of these accounts imply that (he
What Makes IV
6
In Sickness and in Health
n Sick
rapid social changes now taking place in this part of the world have
measure of all - survival. According to some writers even the category
been detrimental to women's well-being.
‘woman’ is itself so culturally variable
Both the political realities of flic recent past and the economic and
so discourse - specific - that it
is not a useful category for social analysis. Thus the very project of
social pressures of the present have contributed to a situation where the
feminism is called into question as women are seen to have radically
life expectancy of women in the countries of Central and Eastern
different interests.
I'urope is five years less, and that of women in the Newly Independent
States (the former Soviet Union) six years icss. than that of women in
This has led in some parts of the world to a political paralysis that is
becoming increasingly intolerable (Maynard and Purvis, 1994; Rama-
the European Union (WHO. 1994, p. 4). In some of these countries life
expectancy has declined further since 1991. and female deaths from
cardiovascular disease arc a particular cause for concern (ibid. p. 6).
zanoglou. 1993). Despite their undoubted heterogeneity, women do
have important things in common. All share broadly similar bodily
Attempts to make sense of these differences and to explore more
experiences, even though the meanings they attach to them may vary
dramatically (Martin. 1987). Their bodies are not merely social
qualitative aspects of women's health are now beginning, but detailed
constructs as some post-modernist writers seem to imply (Haraway,
evidence remains sparse. Hence women in the second world are
seriously underrepresented both in this text and in most other
discussions of women's health.
1991). Nor arc they infinitely malleable. Bodies do impose very real
(though varying) constraints on women’s lives as well as offering
enormous potential, and this is evidenced by the fact that the fight for
Retecting Crude Differcnee Theories
across very different cultures (Jacobus ct al., 1990; Lupton. 1994, Ch. 2;
bodily self-determination has been a central feature of feminist politics
Morgan and Scott, 1993; Pringle. 1992).
It is clear that women’s lives vary enormously and recognition of this
reality must remain al the heart of any analysis of their health and
Women also share the reality of occupying (more or less) subordi
nate positions in most social and cultural contexts. Though this
welfare. However this rejection of crude universalism docs not mean
subordination is linked in complex ways with divisions of race, class
that we should deny
and nationality, women do have common experiences as the objects of
that we should embrace crude difference instead
any possibility of women having beliefs, values or interests in common.
sexist practices. Some of these are psychological, as women struggle to
A number of strands in contemporary women’s studies contain
construct their sense of themselves in the face of cultural messages
within them the implication of radical difference, the belief that we
about their intrinsic ‘otherness’ and inferiority. However they also have
cannot make meaningful judgements about the relative situations of
women in different cultures. For some, this relativism reflects a
a material dimension as women deal with the consequences of poverty
political commitment to the acceptance of all ‘other’ cultural beliefs
different cultures have identified similar processes of gender discrimi
and practices. To do otherwise is said to denigrate those who live their
nation as powerful obstacles to their achievement of both mental and
lives in accordance with values that are different from our own. In the
physical well-being.
context of women s health, this can mean a refusal to cneagc with the
As we shall sec. it is a common recognition both of their need for
control over their own bodies, and of the social origins of many of their
hazards of procedures such as genital mutilation because they arc
defined as ‘traditional’ practices. It has also led in some instances to a
and economic inequality between the sexes. Again, women in very
reluctance to condemn male violence in cultures where it is widely
health problems, that has led many women into political action.
Physical and menial health aie universal and basic human needs and
condoned.
all women have an equal right to their satisfaction.
Similar tendencies arc evident in the work of some post-modernist
writers (Maynard and Purvis. 1994; Nicholson, 1991). Their rejection
of any universal criteria for delcrming what is right or wrong, good or
Why Is Health Important?
bad, real or unreal, implies that the situations of women in different
cultures cannot be compared in any meaningful way. I hus even ‘worse’
or ‘belter’ health cannot be measured, except perhaps b) the crudest
At first sight the answer to this question might seem obvious. Even
minor illness can be temporarily distressing, while serious illness can
In
o
!
H'IKlf
(ik
• • >h
, Su K
have a devastating impact on how individuals feel about themselves,
others and the world. Indeed it may eventually kill them. I’or someone
to be‘happy’ and to be seriously ill is usually a contradiction in terms.
Illness is feared not just for its physical consequences but also because
of the distress - the pain, fear, anxiety and depression - it can engender.
It is not surprising, therefore, (hat health is generally regarded as a
‘good thing' - a state of being that everyone would wish to achieve and
maintain. However the benents conferred go beyond immediate
feelings of subjective well-being.
In order for women or men to nourish they, must interact with
others. It is only through social participation that people learn what
(hey are capable of and how these capabilities may best be used (Sen,
1985). Personal identity is forged through family relationships, friend
ships, waged work and a variety of other communal activities
(Braybrookc, 1987). Any artificial and sustained constraint on an
individual’s ability to relate to people in these and other areas of social
life will constitute serious and objective harm. This harm derives not
, just from any subjective feelings of pain and unhappiness they might
have about their situation, but also from the fact that arbitrary limits
have been placed on the realisation of their capabilities - on their
potential as human beings..
IIcallh and Human Needs
Whatever (heir culture, individuals have at least two basic needs that
must be met if they arc to minimise such harm (Doyal and Gough.
1991). Their first and most immediate need is to survive and be
physically healthy. Death is clearly the ultimate harm, while physical
disease may seriously impair both (heir ability to interact with others
and their capacity to benefit from it. But physical health is not enough.
Both men and women will also be prevented from realising their
potential when their need for mental health is unsatisfied. This will
occur when their ability to make informed choices and to act upon
them is limited over sustained periods of lime by their cognitive and or
emotional incapacity to negotiate physical and social realities.
Thus inequalities in health between social groups arc not simply
inequalities in desired states of subjective well-being. They also
represent objective inequalities in the capacity of individuals to play
an active part in social and community life
to realise their own
potential and help others to do (he same. I’or those who wish to
!n sickness and in lieah/i
9
improve the situation of women, physical and mental health are
therefore strategic issues. They are important goals to be sought in
their own right, but they also provide the key to women's effective
participation in attempts to create a fairer and healthier society.
Comparing Health /I cross Cultures
Cultural variations in concepts of sickness and health arc now well
documented and their significance will be obvious in future chapters
(Baer, 1987; Kleinman, 1988; Lock and Gordon, 1988; Lupton, 1994;
Whelchan, 1988; Wright and Treacher, 1982). However they do not
mean (hat we cannot compare the health status of women in different
societies. This can still be achieved if we distinguish as clearly as
possible between the objective manifestations of ‘disease’ and the
subjective experience of‘illness’ (Eisenberg, 1977). These two elements
will certainly be inextricably intertwined in the minds and bodies of
particular individuals. Yet we can still measure the social distribution
of disease and death while also understanding and respecting the
cultural relativity of illness.
Women in different cultures who contract tuberculosis or pelvic
infection for instance may well experience these diseases in very
different ways. However they will also have a great deal in common.
Some will die, most will ‘feel ill' (in some sense or other), all will show
similar physiological signs (albeit in varying degrees) and all will
respond in broadly similar ways to scientifically tested treatments such
as antibiotics. It is these commonalities that we can measure, and use to
compare the health status of different social groups (Doyal and Gough,
1991, pp. 56-9).
What western medicine defines as mental illness poses more difficult
problems of interpretation and measurement since usually there arc no
objective ‘signs’ independent of the subjective symptoms. But again,
similarities in its effects can be identified across cultures. Whatever the
form of their distress, or the words and concepts used to describe it,
women with poor mental health will all experience a significant
reduction in their capacity for successful participation in their
culture. Though each will have their own contribution to make, all
will be disabled to a greater or lesser extent in the exercise of their
cognitive and emotional capabilities. Il is this disability that can be
compared between societies (Doyal and Gough. 1991, pp. 62-3).
10
Whm Makes II
.ch Si( k
A Picture of I Icalth?
All women whose physical or mental health is damaged will therefore
be harmed in broadly similar ways, and morbidity and mortality rales
can give us a preliminary indication of the global distribution of this
harm. Of course such statistics can provide only a partial picture since
they are not measuring the subjective or experiential aspects of illness.
Moreover they offer a negative view of sickness and death rather than a
positive picture of well-being. However they do represent important
points of reference between societies and social groups as well as
offering clues to structural factors underlying any perceived inequal
ities.
Inequalities in Mortality
I
dJ
In most of the developed countries women can now expect to survive
for about 75 years (United Nations, 1991. p. 55). However this average
conceals significant variations in life expectancy between women in
different social groups. In Britain women married to men in semi
skilled or unskilled jobs are about 70 per cent more likely to die
prematurely than those whose husbands are professionals (OPCS.
1986). Similar social divisions arc apparent in the United States, where
black women now have a life expectancy of 73.5 years compared with
79.2 for white women while their risk of dying in pregnancy or
childbirth is three and a half limes greater (US National Institutes of
Health, 1992. pp. 8, 13). In most underdeveloped countries the social
inequalities in health arc even more dramatic.
There arc also major differences in mortality rales between rich and
poor nations. In Latin America and the Caribbean average life
expectancy is lower than in developed countries but still relatively
high at around 70. In Asia and the Pacific it is 64 and in Africa as low
as 54 (UN, 1991, p. 55). The lowest rales recorded for individual
countries are in Afghanistan. East Timor. Ethiopia and Sierra Leone,
where women can expect to live for only about 43 years (ibid.) These
inequalities arc at their most extreme in deaths related to childbearing.
In developed countries mortality of this kind is rare, with less than Live
deaths for every 100000 live births. In South Asian countries, on the
other hand, the rate is more than 650 deaths per 100000 with the
African average a close second at around 600 deaths (UN. 1991. p. 56).
Though these figures arc extremely dramatic they do not show the
true extent of the inequalities in reproductive hazards facing women in
In Sickness and in Health
dillercnl parts of the world. The maternal mortality rate reflects the
risk a woman runs in each pregnancy. However we also need to
examine fertility rates to assess the lifetime risk to an individual woman
of dying of pregnancy-related causes. Recent estimates suggest that for
a woman in Africa this risk is I in 23 compared with only I in 10 000 in
developed countries (Rooney. 1992). Pregnancy causes almost no
deaths among women of reproductive age in developed countries but
between a quarter and a third of deaths elsewhere (Fortney et al.,
1986). Reproductive deaths are therefore an important indicator both
of the different health hazards facing men and women and also of the
heterogeneity of women's own experiences.
Turning from mortality to morbidity statistics - from death to
disease - we arc immediately faced with what appears to be a paradox.
Around the world, women usually live longer than men in the same
socio-economic circumstances. In most of (he developed countries the
gap between male and female life expectancy is about 6.5 years (UN,
1991, p. 55). In Latin America and the Caribbean it is 50 years, in
Africa 3.5 years and in Asia and the Pacific. 30 years (ibid.) Only in a
few countries in Asia do women have a lower life expectancy than men.
Yet despite their generally greater longevity, women in most commu
nities report more illness and distress. This pattern of excess female
morbidity is reasonably well documented in the developed countries
and we examine that evidence first. The more limited information on
women in third world countries will be considered later.
Sickness and Affluence
A number of studies in the United Kingdom have found that women's
own assessment of their health is consistently worse than that of men
(Blaxtcr. 1990; Whitehead. 1988). Similar findings have emerged from
studies in the United Stales (Rodin and Ickovics. 1990; Verbruggc.
1986). US women arc 25 per cent more likely than men to report that
their activities arc restricted by health problems and they arc bedridden
lor 35 per cent more days than men because of acute conditions (US
National Institutes ol Health. 1992. p. 9). In community surveys
throughout the developed world, women report about twice as much
anxiety and depression as men (Paykcl. 1991; Weissman and Klcrman.
1977).
Women also use most medical services more often. This fact cannot
be taken as a slraightlorward indicator of the relative well-being of the.
two sexes since admitting illness may well be more acceptable for
s
12
In Sickness and in Health
IVhat Mak . IVontcn Sick
women than for men. However it docs highlight certain important
features of women’s health status. The most immediate reason for their
greater use of medical care is longevity. Deteriorating health and
increasing disability are a frequent, though not inevitable accompani
ment of the ageing process and women make up a large proportion of
the elderly in the population - especially the ‘old old’ (Doty, 1987). In
the United States 72 per cent of those over 85 arc female (US National
Institutes of Health, 1992, p. 8). Older women appear to receive less
assistance from relatives and friends than older men of the same age,
despite lhe fact that (hey suffer higher rales of certain disabling
diseases, including arthritis, Alzheimer’s Disease, osteoporosis and
diabetes (Heikkinen el al., 1983; Verbruggc, 1985).
Because of the incorporation of birth control and birthing itself into
the orbit of doctors, younger women loo make more use of medical
services. This is not usually associated with organic pathology but
reflects the growing role of medicine in the management of the ‘normal’
process of pregnancy and childbirth (or its prevention). Women also
appear to experience more problems with their reproductive systems
than men, and again this is likely to bring them into more frequent
contact with the formal health care system.
Finally, evidence from across the developed world suggests that
more women than men consult doctors about psychological and
emotional distress. In the United Kingdom, female consultation rales
with general practitioners for depression and anxiety arc three limes
and nearly two and a half times, respectively, those of males (Office of
Health Economics, 1987; UK Royal College of Practitioners, 1986).
Over the course of a year one British woman in every twenty aged
between 25 and 74 seeks help for emotional problems from her GP.
compared with one in fifty men. There is also evidence from a range of
countries that women arc at least twice as likely as men to be prescribed
mild tranquillisers (Ashton, 1991; Baller el al.. 1984).
Broadly speaking then, the picture in the developed countries is one
where women live longer than men but appear ‘sicker’ and suffer more
disability. They are ill more often than men and use more medical
services. Men do not suffer such frequent illness though their health
problems are more often life-threatening. But sex and gender arc not
lhe only factors influencing women’s health status, as we can sec if we
look again a', the differences between women themselves.
Even within developed countries there arc major variations in the
health of women in different social groups. In the United Slates,
strokes occur twice as often in black women as in while women, and
B
(hey have lhe highest incidence of gonorrhoea and syphilis (US
National Institutes of Health, 1992, p. 13). Though black women
have a lower incidence of breast cancer than white women it is
significant that they are more likely to die from it (ibid.) In lhe
United Kingdom women in lhe lowest social class are much more likely
to experience chronic illness than their more affluent counterparts. In a
national survey 46 per cent of unskilled and semi-skilled women aged
between 45 and 64 reported a long-standing illness compared with 34
per cent of professional and managerial women (Bridgewood and
Savage. 1993). Women in lhe lowest social groups were also more likely
than those in the professional and managerial groups to report that
illness limited their daily activities (30 per cent in comparison with 20
per cent) (ibid.)
Sickness and Poverty
However it is in the poorest countries that the state of women's health
is at its worst. Though some affluent women arc as healthy as those in
the developed countries, it is clear that millions of others live in a stale
of chronic debility, afllictcd by the diseases of poverty and the hazards
of childbearing (Jacobson, 1992; Smyke, 1991). Estimates suggest that
lor every one of the half million women who die of pregnancy-related
causes each year, at least 16 suffer long-term damage to their health an annual total of about eight million (Royston and Armstrong, 1989,
p. 187). Reproductive tract infections arc also extremely common
(International Women’s Health Coalition, 1991). In some African
countries gonorrhoea is estimated to affect as many as 40 per cent of
women (WHO, 1992). These diseases arc not just distressing and
disabling in themselves, but often result in chronic infection with
serious effects on women’s overall well-being.
Millions ol women in third world countries also have to cope with
the broader health consequences of poverty communicable diseases
and undernutrition. While they risk contracting the same endemic
diseases as men. both biological and social factors may increase their
exposure or worsen the effects. Malaria, hepatitis and leprosy, for
instance, can be especially dangerous during pregnancy, while women's
responsibility for domestic tasks increases their chance of contracting
water-borne diseases.
The extent of undernutrition in girls and women is dramatically
documented in the incidence of anaemia. Estimates suggest that at least
44 per cent of all women in third world countries are anaemic compared
14
What Makes Womc
cick
with about 12 per cent in developed countries (WHO. 1992, p. 62). In
India the figure is as high as 88 percent (World Bank. 1993. p. 75). This
is an important indicator of general health status, suggesting that many
women are chronically debilitated, never reaching the levels of good
health that most women in the first world take for granted.
In these conditions of poverty, deprivation and disruption, mental
distress is clearly a major risk. Though there is little statistical evidence
of its prevalence, most community surveys show a pattern similar to
that of developed countries, with more women than men reporting
feelings of anxiety and depression. However the pattern of treatment is
very different, with many more men than women receiving psychiatric
help (Paltiel, 1987). Indeed evidence from many third world countries
suggests that women receive less medical treatment of all kinds than
men, despite their greater need. Rural women in particular arc often
unable to gain access to modern services, even for obstetric care.
Around 75 per cent of all births in South Asia and 62 per cent in Africa
still take place without a trained health worker, compared with about 1
per cent in the developed countries (UN. 1991, p. 58). While this
reflects very low levels of health spending overall, it also suggests a
particular reluctance to invest in the health of women and girls.
Though female life expectancy continues to rise in most third world
countries, the ‘harsh uecadc' of the 1980s and the economic rigours of
structural adjustment policies have meant deteriorating health for
many women (Smykc, 1991; Vickers. 1991). The number of those
who are malnourished has risen, resulting in an increased incidence of
high-risk pregnancies and low birth-weight babies. Diseases of poverty
such as tuberculosis are rc-cmcrging while the so-called ‘diseases of
affluence' arc beginning to proliferate, with cancer already one of the
leading causes of death for women between the ages of 25 and 35:
Environmental degradation has made many women's lives harder and
millions are without access to clean water or sanitation. Yet fewer
resources are available to care for them. In recent years a real decline in
per capita health spending has been documented in three quarters of
the nations in Africa and Latin America and women appear to have
been the major losers (UNICEF. 1990).
/// Sick/less mul in Health
15
expectancy than men? Why do women in some countries live nearly
twice as long as those in others? Why do rates of morbidity and
mortality vary between social classes and ethnic groups? Why do so
many women still die in childbirth? Why do women report more
sickness than men? How does their race or their culture affect women’s
experiences of health and health care? As we shall sec. medical science
can offer only limited resources cither for answering these questions or
for changing the reality that they represent.
The Biomedical Model'
Western medicine offers a powerful framework for describing and
classifying much of the sickness afflicting individuals. Using this
‘biomedical model' doctors have developed the means to prevent or
cure many diseases and to alleviate the symptoms of others. However
many other health problems have remained resistant to their ministra
tions. This has drawn increasing attention to the limitations of the
conceptual schema employed by doctors and other health care
providers to understand complex human phenomena. Two aspects of
medical practice have come under particular scrutiny: its narrowly
biological orientation and its separation of individuals from their wider
social environment (Busficld, 1986. p. 28).
Il is no longer appropriate (if it ever was) to categorise western
medicine as a monolithic unified institution devoted only to hard
science and high technology. Recent years have been marked by a
revival of interest in public health and a ‘humanisation’ of some areas
of research and clinical practice. Yet the natural sciences continue to be
seen as the only ‘real’ basis of medicine, with attention focused
predominantly on the internal workings of the human body.
Health and disease are still explained primarily through an engineer
ing metaphor in which the body is seen as a scries of separate but
interdependent systems (Doyal and Doyal. 1984). Ill health is treated as
the mechanical failure of some part of one or more of these systems and
the medical task is to repair the damage. Within this model, the
complex relationship between mind and body is rarely explored and
individuals arc separated from both the social and cultural contexts of
their lives:
Docs Medicine Have (he Answer to Women's Health Problems?
This brief sketch has generated a wide range of questions about
women's health. Why do women in most countries have a longer life
The notion of disease itself refers to a process that unfolds and
develops within the individual and what occurs within the individual
and what the individual docs is the prime subject of medical interest
cA
and endeavour, rather than the individual’s relationship to others or
to the environment or vice versa (Busficld, 1986, p. 25).
This biological and individualistic orientation of modern medicine has
led to enormous successes in our understanding of different types of
disease and their treatment. Indeed it was precisely the concentration of
effort made possible by this explanatory model that led to major
achievements such as anaesthesia, antisepsis, antibiotics, analgesia and
a wide range of other therapies that most people in developed countries
now take for granted. The ‘magic bullet' that works is a powerful
weapon indeed. However its obvious success has led to a neglect of
prevention and an over-reliance on this curative model, both in
explaining the causes of disease and in exploring the different ways
in which illness is experienced.
Perils of Reductionism
i
p
cn
0
In Sickness and in Health
What Makes Women Sick
16
Attempts to explain the causes of disease primarily by reference to
specific biological hazards arc too limited. They rarely examine the
social and economic aspects of the environments within which such
pathogens flourish. Hence they can offer little help in understanding
why some individuals or groups arc more likely to become sick than
others. We have also seen that there is more to poor health than
disease. The subjective experience of illness is the product of complex
processes involving the interaction between the whole person and their
social and cultural environments. Because the biomedical model
focuses almost exclusively on the material rather than the mental
dimension of the ‘patient’, it can offer little help in clarifying and
explaining such experiences. In particular it is often of little use in
understanding psychological distress and disability.
This tendency of modern medicine to reduce the complexity of
sickness and health to matters of specific biological causation has
limited its potential cither to understand or to ameliorate the ills of
both sexes. But the interests of women have been especially damaged
by the narrowness of this approach (Birkc, 1986). Their higher rates of
depression for instance have often been blamed on hormonal distur
bance, leading not only to inappropriate treatment but also to a
mistaken naturalisation of gender divisions that arc essentially social in
origin. Too often women’s problems have been blamed on their
reproductive systems when it is the social relations of both production
and reproduction that need further examination.
17
Gendered Research
However it is not just its narrowly biological orientation that limits the
capacity of medicine to deal with women’s health problems. Even
within its own terms there is growing evidence that both the priorities
and the techniques of biomedical research reflect the white male
domination of the profession (Kirchslein, 1991). Bias has been
identified in the choice and the definition of problems to be studied,
the methods employed to carry out the research, and the interpretation
and application of results (Cotton, 1990; Rosser, 1992, pp. 129-30).
While women are in the majority as health care providers, they
continue to be in the minority as practising doctors (Doyal, 1994a;
Lorbcr. 1984). They hold few positions of power and therefore have
little influence on how funds arc allocated or research carried out
(Rosser, 1992; US National Institutes of Health, 1992; Witz, 1992).
There has been relatively little basic research into non-reproductive
conditions that mainly affect women - incontinence and osteoporosis
for instance. In the United States, Congressional Hearings in 1990
showed that only 13 per cent of government research funds were spent
on health issues specific to women (US National Institutes of Health,
1992). Even the menstrual cycle itself has not been extensively
researched. Hence we have little detailed knowledge about an
extremely important aspect of women’s bodily functioning that
generates a large amount of distress and many medical consultations
(Koblinsky et al., 1993). Where health problems affect both men and
women, few studies have explored possible differences between the
sexes in their development, symptoms and treatment (American
Medical Association. 1991).
Researchers working on coronary heart disease, for example, have
continued to act as though it were only a ‘male’ problem, despite the
fact that it is the single most important cause of death in post
menopausal women, killing half a million a year in the United States.
The Physician Health Study, which demonstrated the effectiveness of
daily aspirin consumption in preventing cardiovascular disease, had a
sample of 20000 men but no women, while the sample in the ‘Mr. Fit
study of the relationship between heart disease, cholesterol and lifestyle
consisted of 15 000 men (Freedman and Maine, 1993, p. 165). AIDS,
loo, has been treated for research purposes as a predominantly male
disease. Though it is now growing faster among women than among
men, we still know very little about the differential effects it may have
on them (Bell, 1992: Dcnenbcrg. 1990b: Kurth. 1993).
18
What Makes
Sick
As long as most biomedical research continues to be based on male
samples there will be significant gaps in our knowledge about women.
Even more importantly, treatments tested only on men will continue to
be given to women, when they may not be appropriate to their needs
(Hamilton, 1985). There have recently been indications, for example,
that anti-depressant drugs can have very different effects on men and
women and may affect women differently during the various phases of
the menstrual cycle. However preliminary testing excluded women,
despite lite fact that they are the major users of the drugs (ibid.)
It is clear that biomedicine has generated valuable knowledge that
has been used to improve the health of individual women. But as we
have seen, this understanding is often partial and sometimes erroneous.
This is because research has selectively ignored many of the biological
differences between the sexes while paying little or no attention to the
particularity of women's psychological and social circumstances.
Hence it can offer little help in answering the questions posed at the
beginning of this section.
In order to remedy these deficiencies we need to move beyond the
boundaries of biology. No single discipline will provide an adequate
conceptual framework for understanding the complex relationship
between women's health and the quality of their daily lives. Instead
methods and insights from a variety of disciplines, including history,
sociology, psychology, economics, anthropology and cultural studies
need to be combined with more traditional biomedical and epidemio
logical approaches to create an interdisciplinary and interactive
framework of analysis (Lupton, 1994, Ch. 1; Turner, 1992:, Ch. 4).
The value of bringing the work of natural and social scientists together
in this way can be illustrated by a brief history of differences in male
and female life expectancy.
Are Women Really the Weaker Sex?
Women have not always been longer lived than men. Indeed what little
evidence we have from the pre-industrial period suggests that in most
places they had a shorter life expectancy (Shorter. 1984). In Europe and
the United Slates the female advantage over men first became apparent
in the latter part of the nineteenth century as the life expectancy of both
sexes increased. This gap between the sexes has continued to widen ever
since (Hart, 1988, p. 117). In most countries women now experience
greater longevity than men, with the size of their advantage being
A
In Sickness and in Health
19 .
proportional to the life expectancy of the population as a w'holc. Ohly
in a few countries do men continue to live longer than women. As we
shall sec, these major historical changes in life expectancy cannot be
explained by reference to cither biological or social factors alone.
Biological and Social Advantages of Females
Far from being the ‘weaker sex', women do seem to begin life with a
biological advantage over men (Waldron. 1986a). Around the world,
significantly more male than female foetuses arc actually conceived but
they arc more likely to be spontaneously aborted or to be stillborn
(Hassold et ah, 1983). By the time of birth the ratio is down to about
105 males to every 100 females and in most societies the excess of male
mortality continues to be especially marked during the first six months
of life (Kynch. 1985: Waldron. 1986a, p. 66).
• The reasons for this inherently greater ‘robustness’ of girl babies are
not entirely clear but they seem to include sex differences in
chromosomal structures and possibly a slower maturing of boys'
lungs due to the effects of testosterone (Waldron, 1986a, p. 66). In
adult life too. women may have a biological advantage - at least until
menopause - as endogenous hormones protect them from ischaemic
heart disease. Thus biological factors do confer an initial advantage on
females. However social factors also make a major impact on their
longevity. In some societies these factors enhance inherent biological
advantage but in others they reduce it or even cancel it out.
European experience suggests that the gap between male and female
life expectancy grew as economic development and social change
removed two major risks to women’s health. As food became more
widely available, most women were assured of adequate diets. This
improved nutrition contributed in particular to a reduction in female
mortality from infectious diseases such as tuberculosis (Hart. 1988). At
the same time reduced fertility and safer childbirth combined to lower
the maternal mortality rate.
Even before these female hazards began to decline, changes in the
sexual division of labour meant that men were taking on new risks. The
reasons for this arc complex, but two factors arc especially significant.
The emergence of the male ‘breadwinner’ in industrial economics led to
more men than women taking on potentially life-threatening jobs. At
the same lime their increased command over resources and their
greater freedom contributed to men’s more frequent pursuit of
dangerous pastimes, including the use of hazardous substances (ibid.)
I
in
cl
20
i
IV/iai M
H
Sick
Young men now run a much greater risk than young women of
dying from accidents (especially in motor vehicles) and violence. In the
United Stales in particular, gunshot wounds arc now a major cause of
male deaths, especially among African Americans. In the United
Kingdom, accidents and violence cause 70 per cent of deaths of men
under the age of 35, compared with only 35 per cent of female deaths.
Later in life men die more often of coronary heart disease and lung
cancer. Both of these arc influenced by occupational factors but are
mainly due to smoking, which has traditionally been heavier among
men than among women. According to one estimate, 50 per cent of the
entire sex differential in life expectancy in the United Stales and
Sweden can be attributed to (past) gender differences in smoking
(Waldron, 1986b). Men s higher rates of alcohol consumption also
contribute to their higher mortality rales at all ages.
It would appear therefore, that as many societies have industrialised,
a variety of social and cultural factors have combined to allow
women’s inherent biological advantage to emerge. The hazards of
infectious diseases and the dangers of childbearing have been reduced,
and certain male risks have increased, giving women longer • though
not necessarily healthier - lives. However there arc important excep
tions to this pattern, showing how biological and social factors may
interact in very different ways.
The Impact of Discrimination on Life Expectancy
I
tn
In certain countries in South Asia, including Bangladesh, men outlive
women, while in India and Pakistan the tw'o sexes have almost equal
life expectancy (UN, 1991, p. 69). In these societies there is an excess of
female deaths both in childhood and in the childbearing years, which
most researchers have attributed to material and cultural discrimina
tion against girls and women. In the most extreme cases this sexism
leads to female infanticide cither during pregnancy or after birth.
However it more commonly involves chronic neglect. In childhood,
girls may receive less care than boys in a variety of different ways
(Sundari Ravindran, 1986; UNICEF, 1990; WHO. 1992. pp. 17 26).
They tend to be breastfed less often than boys and for shorter periods,
and throughout their childhood receive less food and medical care
(Koenig and d'Souza. 1986; Kynch and Sen, 1983; Sen. 1988). In some
populations this lifelong discrimination has reached the point where
the ratio between men and women has become unbalanced.
In Sickness and in I'ealth
21
In India, for instance, the sex ratio fell from 972 women per
thousand men in 1901 to 935 per thousand in 1981, while the ratio
of women to men was increasing in most other parts of the world
(Kynch and Sen. 1983. p. 377; Sen. 1990b). In these ‘classic
patriarchies’ the biological advantage of most women is therefore
cancelled out by their social disadvantage (Kabcer, 1991). This offers a
sharp reminder that there is no reason to assume that economic
development will necessarily allow women more opportunity to
nourish. While discrimination continues, their life chances will be
diminished in comparison with those of men:
Women arc biologically stronger, live longer than men and naturally
outnumber them. Where they do not it is only because of the effects
of war. or if they have been forced to migrate in search of work or
because they have suffered severe and systematic discrimination
(Scagcr and Olson, 1986, p. 12).
Redefining Women's Health
If the biological finality of death can only be explained in a wider social
context then the complex realities of women’s sickness and health must
be explored in similar ways. In order to do this, traditional epidemio
logical methods have to be turned on their head. Instead of identifying
diseases and then searching for a cause, we need to begin by identifying
the major areas of activity that constitute women’s lives. We can then
go on to analyse the impact of these activities on their health and well
being.
Any attempt to separate the various parts of women’s lives in this
way is, of course, fraught w ith difficulty. The balance of these activities
varies both within and between different societies as well as changing
over the lifetime of individual women. Moreover, in many social
contexts it is precisely the inseparability ami co-mingling of their
various tasks that lends to differentiate women’s lives from those of
men:
Working in production and reproduction are increasingly simulta
neous superimposed occupations for women
held in an uneasy
tension, misleadingly called the ‘double day’ because there is never
any neat division where one job ends and the other begins
(Pctchesky. 1979).
2r
•' c-'
7l
^hat Makf yomrn Sick
Us the cumulative effects of these various labours that arc the major
deternnnants of women’s states of health. This is true even in old age
when many of these activities will themselves have ceased but their
impact on well-being becomes increasingly evident. However, we need
to begm by examining each aspect of women’s lives separately This
wi I enab e us to identify some important similarities between women,
but it will also highlight some of the major differences.
An analysis of this kind offers the opportunity’ to explore the
complex interactions between social, psychological and biological
rontex't'with 7
A‘ ,hC n’aCr0-,cvcl wc
<l«cribc the material
77, I
WOn’Cn S hCallh is r<’rmcd’ Wc c;ln illso identify
he cultural constraints within which they can make choices affecting
he'nhTi
7ln8' H°rVCr WC nCCd 10 rcl:,lc thesc broader issu«
he physical and psychology! state of individual women - to their
lived experience of health and illness.
At present the conceptual tools for such an analysis remain
significantly underdeveloped and continue to be the subject of debate
(DiG.acomo. 1992; Schepcr-Hughes and Lock. 19X7) How for
mskince, do we make sense of the complex relationship between the
womL
UC"On Orn;Othcrh00d ln di^rent societies and individual
mod I 7777?
P0Stna,al dcPrcssion? How do we develop a
Zt h°r‘he Z i 7d'rrcrenl mod« of economic organisation
fSchen C Hm'n,dru b?dr'CS
WOmCn lryine to nlake ends meet’’
pro5 ah the
7 • l987,■
r0"°Win8 i,nalysis can'’°>
prov de all the answers but H can frame some of the questions more
clearly, provide relevant empincal data and indicate important areas
lor future investigation.
work Around <?h*lr>tCr ~ 'sl111 ,ln cxP|oration of women's domestic
uork. Around the world the most fundamental feature of women’s
CVaCringforCarndrcSPOnSibhily 7
hoUSehold lab—
Caring for and caring about others is a central feature of these activities
wherever m the world they arc carried out. However the content of (he
work itself will vary s.gnificantly between rich and poor countries rur d
pioduZion?^5 and induSlria,iscd and "on-industrialised modes of
In developed countries women are primarily responsible for what is
traditionally referred to as ’housework’, using a variety of purchased
goods to cook clean and wash for their immediate family group ' In
a wilZ Zco ’WOrd thCy may haVC 10 Pr°ducc lbc f-ZhemseV
mav also be^'''"8 7 ' '■Vi',Cr
0"’Cr pl,ysical necessities. Home
mas also be the workplace m which women curry out a variety of
In Sickness and in Health
economic activities to help their families survive (Young. 1993, Ch. 6).
A ma jor theme of our discussion will be the health implications of these
cross-cultural similarities and differences in the nature of domestic
labour.
Despite its variety ol forms in different societies, the household also
remains the basic unit within which most women’s labour is rewarded both materially and emotionally (ibid. Ch. 7). Yet there is substantial
evidence to show that despite the ‘caring* image of the family, resources
may not be distributed according to need (Bruce and Dwyer, 1988;
bolbre, 1988; Kabccr. 1991). If there are men in the household they
usually acquire the greater share of income and wealth as well as
emotional support, status and decision-making power. Very impor
tantly they usually monopolise physical power loo, putting many
women al serious risk of violence. We will therefore examine both the
physical and the psychological consequences of the unequal distribu
tion of resources within families. The analysis will place particular
emphasis on menial health, since for many women the nature of their
labour combined with their limited access to household resources
constitute a potential threat to their emotional well-being.
Having opened the door to domestic life, subsequent chapters will
look in more detail at the different aspects of sexuality and reproduchon that are usually (but not always) contained within the household.
Chapter 3 explores the relationship between sex and health. As well as
being a significant source of pleasure, sexual activity can also
contribute to emotional well-being. However it is increasingly evident
that sex with men can sometimes pose a serious threat to women's
health. This applies not just to rape and sexual abuse but also to
consensual sex. As the AIDS epidemic has spread it has highlighted the
continuing constraints both on women's capacity to determine their
own sexuality and sexual practices, and on their ability to protect
themseb'es from sexually transmitted diseases. These issues are
discussed in more detail in an analysis of the health hazards of
hctcroscx.
For many women the conceiving of a child is a desired outcome of
heterosexual intercourse. However others will wish to separate sex and
reproduction entirely during their fertile years. They will scck,eilhcr to
prevent conception or. if necessary, to interrupt an established
pregnancy, and it is thesc strategics for birth control that we exafnine
in Chapter 4. An inability to determine her own pattern of procreation
will severely limit a woman’s capacity to control the rest of her life. Yet
as wc shall see. man) are still constrained in their ability to make ^*0
N:’
24
i ■
i
r
N
ui
Whal Make, '/amen Sick
In Sickness and in Health
informed choices by material, social, cultural and religious pressures. If
women do seek medical help in controlling their fertility, doctors may
be reluctant to acknowledge their right to choose and the techniques
offered may themselves be hazardous to health.
Whatever their circumstances, the vast majority of the world's
women do embark, al some point in their lives, on the road to
motherhood. In Chapter 5 we discuss the ways in which the social
context of this childbearing can have a major impact on their health.
Indeed it may determine whether they live or die since for overworked
and undernourished women, motherhood can be fatal. Il is. of course,
this potential for biological reproduction that separates women’s
health needs most clearly from those of men. But as we have seen, it
also separates women most markedly from each other, with the risk of
death or disability varying dramatically between rich and poor
countries.
Women’s relationship with organised medicine is one of the key
factors influencing their experiences of pregnancy and childbirth. If a
pregnancy goes wrong, lack of access to obstetric care can be fatal and
in many third world countries this is the situation many millions of
women face each year. In developed countries, on the other hand,
doctors are often accused of dominating childbirth to the detriment of
mothers and babies. This paradox will be explored as we place
contemporary childbearing in its broader social and economic context.
Many millions of women combine motherhood and their domestic
responsibilities with economic activities both inside and outside the
home. Officially 40 per cent of women around the world arc now in the
labour force, though this is clearly an underestimate since many arc
unrecorded, especially in the informal sector or in casualised work
(Rowbotham and Mittcr, 1994; UN. 1991; Young. 1993). As Chapter 6
will demonstrate, many employed women improve their general well
being through greater access to the basic necessities for physical health,
through enhanced social status and through their involvement in wider
support networks.
However the circumstances of some women’s employment will limit
the potential health benefits of waged work. Because they usually
retain responsibility for domestic labour, many women workers
become physically and emotionally exhausted. This is especially true
of those with the least material and social support. The nature of the
work itself can also be hazardous. Employment has brought many
women into contact with the same hazards that men have faced for
generations. Meanwhile there is growing evidence that what is regarded
as women s work may involve risks ol its own. The impact of
women s economic activity on (heir health therefore needs very careful
assessment.
An examination ol these dilferent dimensions of women’s lives offers
a framework for understanding the social context of their health and
illness. When these various activities are put alongside each other, it
becomes clear (hat for many women the pressures of demanding work
under conditions ol inequality and discrimination may lead to
considerable distress. During (he childbearing years (hey may have
very little time for rest or renewal, always feeling themselves to be
carrying a significant burden of responsibility. Later in life, poverty,
isolation and poor health may make relative longevity a dubious
benefit. In Chapter 7 we explore some of the means by which women
have sought to alleviate the negative feelings associated with these
experiences.
Psychoactive substances of one kind or another are available in most
societies and men have usually been the major users. However the last
two decades have seen a marked rise in substance use and misuse by
women, often with negative effects on their health. There is evidence of
a huge increase in women’s consumption of cigarettes and their abuse
of alcohol is now becoming visible. In developed countries there has
also been an epidemic of tranquilliser use, as some doctors have
colluded with women in the creation of a dependency that can have
both physical and psychological consequences. This provides us with a
further opportunity to assess women’s complex relationship with
organised medicine and the contradictory effects it may have on (heir
health.
Much of this book will be concerned with women's troubles - with
the ways in which (heir attempts to realise their own potential and (hat
ol others can be damaging to their well-being. However its major
purpose is to contribute to (he process of making (heir lives healthier.
The tinal chapter will therefore highlight the many strategics adopted
by women around the world to promote their own health and that of
their families. This will inclucle a discussion of campaigns for reforming
medical care. However it will also cover much broader issues, including
(he fight for reproductive rights and occupational health and safely, the
struggle against violence against women, and the role of women in
broader environmental and development politics. It will explore the
potential contribution ol both (reformed) biomedicine and wider social
change in promoting women’s health.
25
W ■ ■
Verheij, R. A. (1996). Explaining Urban-Rural Variations in Health: A Review of Interactions betwt i
Individual and Environment. Social Science and Medicine, 42(6), pp. 923-935.
i
. Pcrgamon
I
0277-9536(95)00190-5
Soc. Sci. Med. Vol. 42, No. 6, pp. 923-935, 1996 .
Copyright © 1996 Elsevier Science Ltd
Printed in Great Britain. AH rights reserved
0277-9536/96 SI5.00 + 0.00
I
EXPLAINING URBAN-RURAL VARIATIONS; IN HEALTH:
A REVIEW OF INTERACTIONS BETWEEN ]INDIVIDUAL
AND ENVIRONMENT
ROBERT A. VERHEIJ
Netherlands Institute of Primary Health Care, PO Box 1568, 3500 BN Utrecht, The Netherlands
has been primarily on urban constraints rather than opportunities Positive ioects of t.rh?
often rnsufficiently appreciated. Second, positive and negative
ha«
health that is often dependent on individual characteristfcs The ex-ent’tc•
influence on a person’s health is dependent on that peX“'
^nE,
ff O"
I
I
Key words—urbanization, mental health, well-being, perceived health
I
INTRODUCTION
Health is believed to be influenced by both ecological
(aggregate) as well as individual characteristics, yet
much large scale sociological and geographic research
focuses on either the individual or his environment.
Until recently the division between these two levels
was unsurmountable because of methodological stat
istical problems. With the increasing use of multilevel
modelling techniques into health research, however,
L has become possible to do justice to ’this basic
understanding. Individual and environmental deter
minants of health can be studied simultaneously [1].
Multilevel modelling is a relatively new technique
that provides some new possibilities for exploration
of human-environment relations. The theoretical
bases for multilevel modelling are still being formu
lated. We begin by critically renewing recenfresearch
- in a quest for answers to the question: What is the
role^ of the environment in explaining the health of
individuals?
The environmental characteristic that, is antral in
this paper is urbanicity, which is meant to indicate
the extent to which a piace is urban or rural. It should
not be confused with urbanization which refers to
the process of a place becoming urban. While urban
ization is still a major concern in developing
countries, in the Western world urbanicity is more
important. For example, the weighted average annual
growth rate of urban population in OECD countries
S'T 198rt,a"id ,99,W/-:‘^parable figure for low and middle income economics’
y
I
j
%
923
was 6.3%. On the other hand, the 1991 weighted
average urban population was 77% in OECD
countries and 46% in low and middle income
countnes. In this paper we will concentrate on
urbanicity in OECD countries [2],
There are two interconnected reasons for focusing
on urbanicity: the popularity of ^e subject, com
bined with the feck of understanding of its impact
on health. First, urbanicity constitutes indeed one of
the most often employed environmental features in
health research. In many cases it is in fact the only
ecological variable that is taken into account and
usually is the only ecological variable that does have,
at least to some extent, a universal meaning (contrary
to, for instance, the variable ‘region’). Furthermore,
popularity of the concept of urbanicity can be illus
trated by the fact that the World Health Organization
(WHO) has been developing a Healthy Cities Project
that aims at improving the health of u^an residents.
A large number of European dues are today partic
ipating in this project Within this project a socioecological mode! of health is fundamental [3,4].
As yet, however, insight into the mechanisms behind
this ecological approach is lacking and, moreover,
it is unclear if urban residents are indeed less healthy
than others.
This leads us to the second reason for focusing
on urbanidty: the vagueness of the concept. As
Hoggart [5] writes: “I do not mean (..) that there are
no differences between (most) rural and urban places,
but rather that in .he ma;n th-a-r,
----------- •'€ generated by the
uneven presence of some known causal factor *X't as
i
1
I
7I
'i I
2-55 ,
924
Robert A. Vcrheij
opposed to either rurality or urbanity. The obvious
follow up p01nt 1S that for theory to prepress we
cs
should focus on‘JT’” (d 251) Admik
• •
bv Wehh FA1. “ r
A Similar point is made
b) nebb [6] as far as the differential prevalence
ZT '’h ? SharC 2 high leVe! of ec°nomic developof mental disorder is concerned, the rural-urban of hX)1^or °ne °f
PrinC1'PaI dete™^
armble has little utility", and "Rather the area being between urh ° - T"'
°f the ^ationship
between urbamzat.on and health in developin'.
d.ed must be defined in terms of more relevant
criteria, especially the detailed composition of the H.X (t ""fa “ ref'™‘ “ “•«»> P) .nd j
population . In other words, we should concentrate
n the content of the concept of urbanicity. Later
on it will be shown that this is more than just the
theoretical framework
j.
composmon of the population. In order to gain
Before presenting a review of the literature on the
ore insight into the content of urbanicity we will
relation
between urbanicity and health, a brief jntro. emphasize the relation between individual and
1’ction
made to possible mechanisms behind ’
environment.
spatial vanations in health: the breeder aad drifolole bren’n W‘?Ka ShOrt descnPt'on of the methodhypotheses (Table 1).
ology, followed by an introduction to the existing
,
the drif< hypothesis (see for exampt Lewis
heory of spatial variations in health. In the latter
the re,evance of interaction effects is also explained’ et aJ [9]) there ls a notion of selection processes that
result m a higher concentration of either ilB people
We- then
-.-.1 examine the literature on mental health,
w< ’* ‘
(direct
selection) or in a spatial concentration of
ell-being, and physical health, followed by a
more
susceptible
persons (indirect selection)). Direct
discussion of.
-- the
...c more important findings and their
selection
may
take
place because healthy people stav
implications for the present research.
and ill people move, or the other way around.
way around.
ndlrect selection takes place if people with certain
METHODS
health related characteristics move to on- from
specific places. An empirical confirmation of ^e drift
For our purposes, a distinction is made between
ypothesis- would be that' urban/rural differences
three aspects of health: mental health, physical
would not persist when accurate measures of .pat and
health, and well-being’. A discussion of whether
pr«enl illness, together with past and presene other
nealth is the absence of illness, or something else
individual
determinants of health are incliuied in
beyond the scope of this article. Well-being is
analytic
models.
regarded as a combmation of the absence of physical
It is not surprising thaKery little is know-n about
a fter
ter"1985
sV was gathered from various international
Polished the importance of direct and indirect section,
n order to investigate direct selection efiecds lonmdata bases,' such as Medline, PsychLit, Sociofile
tudmal
data are needed about large numtes of
^.conht SG! and GSI, using the keywords morbidity
individuals,
mcluding mobility and (past) Sin,and epidemiology together with the keywords urban
behaviour. Only seldom (if ever) are these dianancT
Ne.hT d
a'S° SearChcd lhE catal°g”e °r the
met. Pre-1985 literature, such as reviewed .in Jones
XS Thu °f Pn'mary Health Care and
Moon [1°, Chap. 5], often has the actional
( IVEL). This search produced a large number of
problem
of being based on aggregate data. AU-hough
udies in which comparisons are made between
more
often
based on individual data, recentt sudies
' urban.and nira! health. In the interest of space
still
have
a
cross-sectional design, and mo study
rmalTTk 1,terature dealing with cither urban or
-ontains detailed variables on spatial mobilittj or on
rural health was not included, even though a com
past illness, making it virtually impossible no detect
parison of these studies are in themselves interesting.
united our review to papers that deal with selection effects if they are present.
Two studies were found in which an attempt was
explicit studies of interaction effects. We also
made
to control for selection effects (within ;a crossdeluded studies on mortality and research from
sectional
design). Both of these tend to reject ttte drift '
our '
? C0UntrieS’ The reason for limiting
hypothesis.
In Blazer er al. [9], evidence is foJnd
our searcn to. these nations is that there is at least
against
the
drift hypothesis, as far as degressive
some, common agreement among them of what
symptomatology is concerned. They tried to get a
va.-ia,ions in heallh
SDacial canrrntr«*:^__ r
___
...
Drift hvnothe$:
•.TJX.
Urban-rural variations in health
i
925
grip'on migration by asking respondents whether not experienced equally by all residents. For some
they had moved in the last 5 years. “When categories of people the positive sides may prevail,
moving within the last five years is controlled (. .), the while for others the negativ? sides are more
urban/rural effect remains” (p. 655). Another attempt important. Some environments may, for instance, be
is provided by Lewis et al. [II], who employed ? characterized as ‘tolerant’, but this is only beneficial
model including cannabis use, parental divorce, and to those who deviate from what is normal. Good air
family history of psychiatric disorder, and concluded quality may serve as another example. It was
that being raised in a city increased the odds of observed by Jones et al. [13] that the lung capacity of
becoming a schizophrenic by 57%, thereby giving non-smokers was negatively related to the urbanicity
of residence, while such negative relationship was
support to the breeder hypothesis.
However, the study by Blazer et al. [9] provides absent in smokers. While showing the importance of
only circumstantial evidence against (in)direct selec- •* looking at sub-populations, these examples also
l.on, because no information is included concerning demonstrate th-1 tH importance of sub-populations
the respondent’s personal and illness characteristics will only appear by contrasting such populations.
before migrating. Furthermore, they do not take Sub-populations should be compared with other sub
account of the fact that a relatively hrge
of all populations. Therefore, the remainder of this paper
migration takes place within cities. The- study by will be primarily concerned with interaction effects
/^-ewis suffers from the fact that no comparison is found in the literature.
ade between the influence of place of upbringing
and place of residence (which is probably the same
MENTAL HEALTH
in many cases). Large scale longitudinal studies are
There is •’n abundance of literature on the relation
necessary to test the drift hypothesis but have yet to
ship between mental health and urbanicity. The
take place.
Behind the breeder hypothesis again two mechan literature discussed here is not a complete review, but
isms may be at work. First, there may be certain it provides insight into the current understanding of
environmental factors to which people are directly urban-rural variations in mental health. For this
exposed. Obvious examples of the physical environ review we attempted to find all post-1985 literature
ment are the negative externalities of nuclear plants, that involved screening instruments like GHQ and
high traffic densities, high levels of noise and pol CES-D, and the more symptom-oriented approach
lution. Also, the social environment may be import of DSM-III and PSE.
Very little attention will be paid to the incidence of
ant: exposure to activities of other persons that are
specific to certain environments. For example, high specific diagnoses. The reason for this is that most of
levels of social support are often thought to be a these studies deal with so-called ‘revealed incidence’,
particular aspect of rural areas. Exposure to stress is inevitably mixing utilization and health. Especially
another important example of the breeder hypothesis. milder forms of psychiatric morbidity will often
The stress-hypothesis [7] that is frequently used to remain undetected, and because of geographical
explain urban-rural differences in mental health differences in provision of health care, this omissi cn
and veil-being can be regarded as another example will not be equally distributed O'Mr space.
Though some attention will be paid to studies that
}f exposure. According to this hypothesis urban
V residents are more frequently and more severely deal with aggregate data, the larger part of the
confronted with stressors than rural residents, literature discussed below builds on individual data.
resulting in higher levels of psychiatric morbidity. First, the main determinants of mental illness used
The second mechanism is associated with ceriain in empirical studies will be discussed. Second, the
types of illness-related behaviour. Smoking, drinking emphasis will be on interaction effects between these
and substance abuse are examples of health determinants and urbanicity. Table 2 gives an
behaviour that is (somewhat) more common in urban overview of findings from studies in which significant
residents [12]. The distinction between exposure and interaction effects were found. This table shows the
behaviour is somewhat artificial since one fill of most important individual determinants of mental
the population may be exposed to the behaviour of illness. It has long been recognized that mental
another part (e.g. passive smoking, unsafe driving, illness is to some extent associated with demographic
crowded housing). A combination of both mechan variables like age and gender, as well as socio
isms is evident in the -stress-hypothesis: stress can economic variables. It is not surprising to find that
be attributed to one’s own behaviour, but also to such variables are most commonly taken into
account. Differences exist concerning the inclusion of
exposure to the behaviour of others.
According to Marsella [7], studying urban-rural race, health behaviour, social support variables and
differences alone does not materially advance our mobility measures. Race is included only in studies
knowledge and future research should focus on in which there is a substantial amount of variation
specific sub-populations. To appreciate this, one only in race, which is usually not the case in European
nas to
mau muii
uvuv»4uvuu> have positive
___
studies. Among measures of health behcv'our drink- .
has
to reanze
realize that
most Cenvironments
and negative qualities but that these qualities are . ing seems to matter [14]. Social support variables
!
I
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1
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i'l'
d|
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?
i.i-i
V- I
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Robert A. Verheij
926
Tabic 2. Urbanicity and mental htaith: main eiTecB and interactions with urbanicity rounc in en.piric.1 re,catch after .9^-------
Interaction urbanicity
u.jih
------------------- ---------- ------------ -------------------- -
Source
Country
Health measure
(17)
US
depression (CES-D)
age, gender, race, income,
education, mari al status,
length of residence
race
fewer oppo.'tunities in
rural areas and in
black people -* learned
helplessness, especially in
rural black people -*
depression
PO)
US
depression (CES-D)
age, gender, race,
unemployment,
family status, education,
income, urbanicity
race, gender, family status,
race/genaer, gender/family
status
ghettos relatively
unhealthy
(22)
GB
psychiatric caseness
(GHQ)
gender, unemp’oyment,
urbanicity
unemployment
more social support and
informal employment in
rural
[23]
NL
depressive symptoms
(self reported)
demographic-, financial-,
network variables,
type of worries,
aspects of unemployment
duration of unemployme’nt,
type of financial worries
more stigmatization in
rural
US
depression (CES-D)
gender, age, race, income,
education, marital status,
religious commitment,
drinking behaviour
life changes/drinking
behaviour
• not given
IH)
(15)
NZ
psychiatric caseness
(PSE/GHQ)
age, gender, SES,
unemployment,
social networks,
past sexual abuse
age, marital satus,
unemployment
social buffering in rurrl,
tolerance in urban
(16)
US
major depression
(DIS/DSM'-III)
age, gender, race, SES,
family status,
social network variables,
mover, urbanicity
age
social change more
negative effects in
young people in
urban areas
!
US
somatization (DIS)
•*ge, gender, race, educa
tion, marital status, health
care utilization, urbanicity
gender, education
(25)
more role conflicts in
urban females
I
US
existence of menu!
health problems
gender, age, stressful life *
events, urbanicity
type of stressful life
events
not given
(27)
may concern the “availability and adequacy of
and attachment” [15], byt also
social integration
i
more simple measures like the availability - of a
[16]. Mob.hty
Mobility ts
is usually
measured
confidant [16],
usuany m=
a5u.cu by
u,
asking whether or not one has recently moved (se
(see.,
r:
•
Mechanism behind
interaction effect
Model main effects
education, unemployment, marital status, physical
health, occurrence of stressful life events, and drink
ing behaviour. These will be discussed below.
Neff and HusainiJ[17] found
urbanicity_race
(CES-D). Black
f° It is often ’found that urban residents are in
in respondents had higherJettvels of depressive symptoms
worse mental shape. There are many exceptions, overall and ess postali affect than white partici
many exceptions,
in the rural sample, while race
however. A Finnish study by Joukamaa et al. [18] pants.^" C
differences in positive affect were absent in the urban
found no effect of urbanicity on mental health. sample. “Race differences were largely specific to
Reitzes et al. [19] found no direct effect or urbanicity
the rural sample, and urban-rural differences were
on mental health in an elderly population, controlling largely specific to black participants” [17], (p. 531).
for personal and social characteristics, network Neff and Husaini challenged the stress-hypothesis
and activity variables (interaction effects found
and state that besides more stress and disorganis
by these authors will be discussed below). Also, ation, the city also provides more freedom and other
among children in Sweden no urbanicity-effect opportunities. They suggest a ‘learned helplessness’
was found regarding depressive symptoms [20].
hypothesis that states that the rural lack of opportu
Another study involving New Zealand women failed
nities and lacka of freedom stimulates helplessness
to show any urban/rural differences in mental ar i thereby depression. A similar causation is fol
health [15]. The oft-cited conclusion drawn by
lowed to- account for race differences. Biack persons
Dohrenwend and Dohrenwend [21] that the level of
experience fewer opportunities than white persons, so
mental problems is on the whole higher in urban that negative stimuli are concentrated in black urban
areas can not be maintained on the basis of recent
persons, explaining the relatively high depression
literature.
scores of black rural residents. Although Neff and
Husaini offer the valuable insight that urban stress
—besides these main effects, interaction effects may be counterbalanced by urban opportunities, the
were observed between urbanicity and race, gender.
y.:
ta1 .
is
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i
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<
Urbar.-ruial variations in health
i
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927
question of which of these prevails in which cases
offered by Neff and Husaini. However, Tousignant
remains to be answered.
and Kovess [24] in their study among urban and rural
The relationships described above were only
alcoholics found that borderline personality traits
found- for depressions, not for general well-being
were found only among the urban samples, which led
and physiological symptoms. Assuming that both
them to conclude that alcoholism is better tolerated
depression and Ipw well-being are caused by stress, in rural areas and, therefore, drinkers are not pushed
the authors make a distinction between acute and into deviant behaviour. A possible side effect may
chronic stressors, Depressive symptoms are in their be that the presumed depression-buffering effect of
view caused by chronic stressors (such as caused alcoholism is
------------ .s more prevalent in rural communities.
by living in a ghetto) and general well-being is mostly
Romans-CIarkson et al. [15] qIso find interesting
influenced by acute stressors (transient life events),
interactions: age and unmarried were found to be
which are more evenly distributed among urbanicassociated with psychiatric problems in urban but
ity/race categories. Although not specifically linked
not in rural women. Urban elderly women and rural
to one type of disorder, this distinction is also made divorced and separated .women were more likely
by Harpham (8J. On the basis of such suggestions it
to exhibit psychiatric disorders than other women.
. is clear that future research into urban-rural vari
According to the authors, elderly women find it
ations should benefit from the inclusion of explicit
easier to cope with travails in a rural environment.
stress measures and that a distinction between An urban environment tends to be more tolerant of
'hronic and acute stressors might be useful. One of a variety of behaviours.iese stressors is unemployment.
Crowell et a.. [L] found an association between
Also, the relation between unemployment and the
urbanicity and age. Younger residents in urban areas
incidence of depression has been found to vary
appeared to.be at greater risk for major depression,
according to urbanicity [22]. Contrary to what might
while in rural areas it we.s the older residents who
have been expected, Harding and Sewel [22] found
that unemployment among urban men has a more were at greater risk, controlling for the other indepen
dent variables. Apparently the depression buffering
negative effect on mental health than among rural
quality of rural areas and the depression enhancing
men. Two possible explanations are offered. First,
quality of urban areas is something that mostly
there may be a higher level of social •
support in affects younger people. This may be related to the
the rural area that counteracts the negativV effects
possibility viiat social change in general is experienced
of unemployment. Second, the distinction.between
i first and most rapidly in urban areas, particularly by
employment and unemployment may be sharper in
urban areas than in rural areas. In the particular young adults. If the rural-buffer hypothesis is correct,
their rural counterparts would be less prone to
research-setting, rural areas, may have more opportu depression.
nities for informal employment, which may dampen
Research by Swartz et ab [25] indicates that the
the effects of formal unemployment.
effects of urban residence on somatization differs by
It was hypothesized by Leeflang et al. [23] that the
influence of unemployment on general health would gender and education. They measured somatization
with the Diagnostic Interview Schedule, which indi
differ from urban to rural areas. This, generally
cates the extent to which people tend to translate
speaking, appeared not to be the case in their study:
psychiatric problems into somatiA problems. In
: “interaction effects were found in none of the demo
rural areas, somatization decreases with education. <
graphic variables, so we can assume that existing
In urban areas this relationship is almost absent.
differences between employed and unemployed are
According to the authors education was less effective
the same in the rural and in the urban area” (p. 345).
in reducing somatization in urban areas. Apparently
However, the power of certain variables in explaining
there are environmental pressures on more highly
dep^ sive symptoms did differ from urban to rural
educated urban respondents that counteract the effect
areas. In rural areas these symptoms were tto a ’higher
' '
of education [25] (p. 51). Urban women exhibit
extent dependent on not being able to provide for
somatization symptoms than rural women. As the
dwelling costs and to a lesser extent on the duration
authors interpret this it may be due to the possibility
of the unemployment.
that urban women experience more role conflicts.
Besides demographic and socio-economic charac
Why these mechanisms would trigger more somatiz
teristics the effect of certain types of health behaviour
ation (instead of direct psychiatric complaints)
may vary between urban and rural areas. Neff remains unclear.
and Husaini [14] concentrated on the urban-rural
Yet another urbanicity—education interaction was
differences in the effects of alcohol consumption on
found by Carpiniello et al. [26]. Less educated elderly
depressions. The buffering effect of alcohol consump
tion on the relationship between depression and life women living in urban areas were especially more ’
often depressed than their rural counterparts. The
events appeared only to be significant in rural areas.
authors see this result as confirming the urban stress
Translating this into a chusal relationship would
hypothesis. Even with respect to the impact of stress
mean that drinking helps against depressions, but ful life events it seems to make a difference whether
only in the countryside. An explanation for this is not
Women live in .an’ urban or a rural community [27],
■f-
$
I
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jj
41
4
Eli
:
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H.:
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1;
• - ’;4-
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I-
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92S
Robert A. Verhcii
In a rural sample of women the total number of
stressful events was an indicator of mental health
problems, while m the urban sample this was replaced
by the number of negative stressful life even’s. An
explanation for this intriguing result is not offered.
black Americans arc happier-in rural areas, while
poor white Americans are happier in urban areas [30].
In yet another study urbanicity-race interaction
effects on well-being were absent. Neff and Husaini
[17] did not find any urbanicity-race interaction with
Well-being
happiness, but they did find such an interaction with
depression. They explain this by suggesting that
It is of course hard, if not impossible, to give an
depression is mostly related to chronic stressors
objective definition of well-being. We use the term
while well-being is more related to acute stressors’
here only as a means to group and discuss jointly
These acute stressors (transient life events) are more
those studies that have some health measure that is
evenly distributed among urbanicity-race categories.
self assessed and does not directly refer to either
Amato and Zuo [30] report that it feels worse to be
mental or~ physical health. Such health measures
poor
in a rural than an urban area. In addition, an
may be reierred to as happiness, life satisfaction or
urbanicity-race interaction effect on happiness was
well-being. Again we will first pay some attention to
found. Poor African Americans seem to be happier
the mam determinants before turning to interaction
(and less depressed!) in rural areas, while poor white
effects with urbanicity.
Arpericans seem to be happier in urban areas. The
It is not surprising to also find evidence of effects
authors
explanation of this is that harsh inner-city
of demographic and socio-economic variables. Conliving conditions are more important to poor blacks.
s^ering our definition of Well being it is also not
They note that it is not surprising that poor African :
surprising to find that health statis plays an important
Americans experience a particularly low level of
e-plwatiry role. Social network variables are also
psychological well-being in urban areas. This popu
sometimes included [19,28], Health behaviour vari
lation is concentrated in inner-city neighbourhoods
ables, such as drinking, smoking, etc., are usually not
characterized by substandard housing, inferior
considered to relate to well being. Some puzzling
the
nnccihiu
•
"
s<'hooIs’ hiSh cnme rates, poor services, and ininteraction effects and 1tL■ L. mechan,sms adequate transportation. For the more dispersed
behind them will be discussed below. •
poor white population, the rural environment has a
Pahsi et al. [29] report on heafth-urbanicity
detrimental influence on happiness because of stigmarelations involving race. They find a consistent
tization. However, this argument runs counter to
negative relation between urbanicity and happiness
Palisi s relative deprivation hypothesis, which main
among white people, but no significant relation ltains that urban blacks would be relatively happier
among black people (though this may also be due 1
than urban whites. Perhaps the reason for this contra
to smaller numbers). They come up with a relat’ve
diction is that Amato and Zuo’s study concentrates
deprivation hypothesis according to which people
on poor people and Palisi’s does not.
tend to judge their happiness by comparing it with
. Amato and Zuo’s study shows that the relation
others in their vicinity (and. of their own colour).
ships of urban-rural poverty also differ by family
Though black people in urban areas usually live in
status and gender. Poor urban married women with
unhealthy ghetto-like neighbourhoods, they will hot
out children show high levels of well-being (and low
regard themselves very unhappy, because their neigh
depression scores) compared to their rural counter
bours and friends live in the same circumstances.
parts. The authors explain this quite tautologically by
The reverse would then be true for urban white
slating that poor urban women are better off with
persons, who live more dispersed. A study conducted a husband, without the respi&sibility for children. On
among poor Americans, however, reports that poor the other hand poor rurarsingle
_ : men show relatively
•X.f.
!
I
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i
Table 3. Urbanicity a..d u-cll-bcmg: main effects and intenctiuns with urbanicity found in the lit, rature
i
Interaction urbanicity
Mechanism behind
________________________ interaction effect
physical health status
fewer open spaces,
multistorey
buildings in urban
physical health
public transport absent in
suburban
Source
Country
Health measure
(28)
GB
life satisfaction scale
health status, social
activities, social net
work variables
H9]
US
well-being (Affect
Balance Scale)
physical health, wealth,
education, marital
status, social network
variables, social activities
(30]
US
happiness
gender, race,
employment status,
family status, age,
education, family
income, urbanicity
race
ghettos relatively vnhcalthy
a£e, gender, race,
education, unemployment,
urbanicity ■
race
relative deprivation
(one item scale)
(^
us
happiness
Model main effects
4'
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• J
!
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2_6o
Urban-rural variations in health
x
929
low scores on well-being. Rural family orientation
physical health. This health measure will be
may have something to do with this phenomenon
discussed first, followed by five broad categories of
leaving rural single men relatively isolated.
1rSJ- CanCer’ r^Piratory diseases, musculo
Also, the relation between health status and well
being seems to vary according to urbapicity. One skeletal disorders, sexually transmitted diseases and
study earned out by Bowling el al. [28], reports that cardiovascular diseases.
General physical health. General physical health is
health} status is a better predictor of life satisfaction
in urban than in rural areas. Apparently, physical usually measured in terms of‘self assessed health’ or
functional ability’. Multivariate individual-based
impairment has more serious consequences in urban
studies
have found varying results. In some studies,
than m rural areas. The authors suggest that poor
health ts a greater handicap for elderly people living taking into account confounding variables, higher
in densely populated areas with mr
higher traffic densities and fewer possibilities for
relaxation m open spaces. On the other hand, retired Finnish Study, by Vuorinen et al. [31] reports a smaller '
suburban men with poor health in the U.S have number o. restricted activity days in children on the
periphery compared to children in the core area (but
par" n? Th®
C0Untparts [ 9], The authors suspect that the loss of no difference in chronic diseases). In a Dutch study
physical mobility associated with poor health makes [32] urbanicity was regarded as an unimportant but
the use of automobiles more difficult and bridging not negligible factor compared to gender, marital
distances more problematic. Differences between the status, and level of education. A British study based
- an
ng and in the availability of public trans- on the National Household Survey [33] revealed
unexplained urban-rural variation in perceived
portation may account for these differing results
In the study by Bowling, a well developed se.ni-rura! health in a controlled study. On the other hand
area with relatively good public transport was com- Krom ^.adjusting for age, gender, race, living
The ? h V5 i denSe'y P°Puiated
in London. arrangement, marital status and several SES
measures, did not find significant residential differ
The study by Renzes concerned a national U.S
sample in which central city, suburban and non-' ences in health despondency and self-assessed health
metropolitan areas were compared. Indeed public m elderly people. Also, in a sample of elderly in
ransport ln general is not as readily available in the ,Finland no significant differences were found
for gender [35], In Northern England, the
U.S. as a whole and especially not in suburban areas. controlling
,
relationship between urbanicity and health at the
Physical health
ward level weakens when wealth is controlled for [361.
in conclusion, there seems to be a tendency
_ Compared to the measures of well-being and
towards
better perceived health in rural areas, but
mental health discussed above, it is much more
difficult to conduct large scale population surveys on this tendency disappears in many studies when con
istinct physical health problems. The incidence or trolling for demographic variables such as gender and
age and enabhng variables likeXpcioeconomic status.
thrTh06 r 8UreS 310 O''ten Simply 100 low t0
this. Therefore, in. this area of research, aggreaate We will enlarge upon these results below, paying
Stud.es are more common and it does not make sense additional attention to interaction effects.
Using a rather unusual combine^ urbanicity
to limit ourselves to population based surveys The
measure
that includes population characteristics
exception ts perhaps the area of self-assessed general
as well as characteristics of the physical environTable 4. U.-banici.y a„d physical health: main effau
Source
pa]
(29]
(37J
(23J
;
and interactions with urbanicity found in the literature
Country
Health measure
UK
Model main effects
self reported morbidity
age, gender, SES,
car availability, region,
socioeconomic ward
classification
US
NL
-NL
self reported^ health
perceived health
somatic symptoms
(self reported)
’For acute sickness only.
’ i
Interaction urbanicity
u',th
gender*
not given
socio-economic status
relative deptivalion
age, gender, social contacts,
social participation,
marital status, SES,
r tedical consumption,
urbanicity
gender
not given
demographic-, financial-,
network variables,
type of wornc*,
aspe its of unempIoyrnent
not having partner,
duration cf unemployment,
type of financial problems
lower tolerance in rural
age, gender, race,
education, unemployment,
neighbourhood fear,
urbanicity
Mechanism behind
interaction effect
i
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h-
//
930
Robert A. Verheij
■ ment, Haynes [33] reports lower age and gender
standardized acute and chronic morbidity figures
in high status vards (which are non-urban). An inter
action eiTect was found where women in inner city
areas are often confronted with acute sickness. The
weakness of social supportive networks in inner city
areas with transient populations is one example of a
possible, previously ignored link with the perception
of illness [33] (p. 366). Why this link would be
particularly important to women remains unclear.
Also Perenboom et al. [37] found significant
urban/rural differences in perceived health, especially
for elderly women (as opposed to elderly men). Rural
elderly rated their health better than urban elderly,
rural elderly also have fewer problems with ADL,
and there are no apparent explanations for differ
ences between rural and urban elderly in income,
social contacts, social participation, or availability of
community care or medical consumption. This find
ing refutes the suggestion made by Haynes [33] that
urban-rural differences may be exj lained away by
taking account of social networks.
Another Dutch study, by Leeflang et al. [23]
reports that the importance of variables in explaining
somatic symptoms in unemployed people varies
between rural and urban areas. Long duration of
unemployment and financial problems are more detri
mental to one’s health in the urban area, while rural
.unemployed men suffer more from not having a
partner. According to the authors, rural people are
less tolerant of deviant behaviour.
An interaction effect between urbanicity and
education was found by Palisi et al. [29] who found
that lower educated people have slightly better health
when they reside in an urban area. For higher
educated people this rural-urban difference was
absent. They found a similar interaction when
looking at happiness and suggest a similar ‘relative
deprivation’ hypothesis.
Cancer. Concerning urban-rural differences in the
risk of cancer the literature is quite unequivocal. For
most types of cancer higher incidence rates were
found in urban areas. The models that are used to
explain variations in cancer incidence usually include
only age, gender, and place of residence. Interaction
effects were seldom investigated, and one might well
ask: would the results differ if other variables were
included in the analysis?
Greenberg et al. [3S] found higher incidence rates
in urban black people in Georgia, adjusting for age
and gender. Hoe’er al.' [39], using a four group
categorization of urbanicity based on population
density, found higher incidence rates of various types
of cancer in urban counties, controlling for age,
gender and race composition of these counties. This
is consistent with Doll [40] who compared incidence
rates of several types of cancer in several countries
and found higher incidence rates in urban areas.
Interaction-effects were found between urbanicity
and gender by Doll [40], Urban excesses in the
I
prevalence of cancer are more often observed in men
than in women, and in men the urban-rural differ
ence is larger, with almost no exception. This may
be due to differences in the (etiology of) the type
of illness under study or the confounding factor
of gender-related health habits like drinking and
smoking.
There are other examples of gender/urbanicity
interactions. Schouten et al. [41], controlling for age
composition, found higher urban incidence rates for
cancer in all sites in men but only cancers of the
respiratory tract in women. A French study [42] on
liver cancer found higher incidence rates in urban
areas in men but no differences in women. Colorectal
cancer in men also show's higher incidence rates in
men in urban areas, while there is no such difference
in women. An American study by Masca et al. [43]
showed a higher urban excess in cancer incidence
figures in males than in females. Similar results were
found in Denmark [44].
There are some exceptions to the excess in urban
cancer incidence generally found. Higher ageadjusted rural incidence rates were found for cancer
of the oesophagus in men in France [44]. This was
partly explained by regional differences in agricul
tural employment, level of education, and housing
quality. This conclusion is, however, challenged by
Doll [40] who found an excess incidence of cancer of
the oesophagus among urban men.
Leukemia and Hodgkin’s disease also seem to
be exceptions to the rule of higher cancer incidence
in . urban areas. Alexander et al. [45,46] found the
highest incidence rates for both diseases among
children in wards that were farthest away from
urban centers with high socio-economic status.
According to the authors urban-rural status
functions as an inadequate proxy for isolation. Life
style in isolated communities is conducive to an
unusual exposure to some specific infectious agent
or to general infections, and this exposure in turn
increases the risk of childhood leukaemia. Other
exceptions are, according to >oll [40], cancers of the
lip and eye, which are more .common in rural areas.
Confounding factors are, according to Doll, more
pipe smoking and exposure to UV-light in rural
areas.
Respiratory problems. Concerning respiratory
problems the picture is again diffuse. In some studies
a belter health status was found in urban areas
and in other studies in rural areas. The analytical
models-usually include age, gender, and—less often—
smoking habits.
A Swedish study and two studies in the U.S. come
to the conclusion that asthma and chronic bronchitis
are more prevalent in urban areas [47-50]. The same
applies to allergic rhinitis in the U.S. [51] and COPD
in Greece [52]. Higher levels of pollution are often
thought to account for this difference. The possibility
that the differences are due to migration is usually
regarded as only marginal [50, 53].
H
-i?
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4:-
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X
Urban-rural variations in health
j
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931
On the other hand, no urban-rural differences become more viable with the introduction of multi
were observed in non-allergic nasal complaints in level modelling techniques. The central qiestion in
Sweden [54], in respiratory allergies in Austria [55], in this r'aper was: What is the role of the environment in
COPD in the Netherlands [56]. nor in the U.b. for age explaining the health of individuals? The focus was on
and smoking adjusted figures on chronic rhinitis, urbanicity as it is one of the most commonly used
asthma, chronic bronchitis and chronic cough [51]. ecological variables in empirical research, while at the
The only study in which interaction effects were same time the mechanisms behind its impact are not
explicitly investigated was by Spinaci ei al. [57] but an well understood.
effect of gender/geographic area on children’s lung
To explore the possible answers to this question
function was not found.
a jhort introduction was given on possible reasons
Musculoskeletal disorders. Literature on urban- behind geographical disparities in health. The breeder
rural differences m musculoskeletal disorders concen hypothesis points to exposure and behaviour, while
trates almost exclusively on hip fractures. Among the the drift hypothesis refers to movements of specific
broad category of musculoskeletal disorders, hip categories of people. It was subsequently concluded
fractures are the most popular when urban-rural that it does not pay to focus on the drift hypothesis
comparisons are concerned. With some exceptions because stud:?* ’n
the drift hypothesis could
the studies were carried out in Scandinavian countries be investigated are very rare. Longitudinal data are
[58-63]. Ail studies showed significantly more hip needed but not available. It was decided that—in
fractures in urban areas. This difference is usually order to address our question by means of a review—
attributed to lower bone mineral content in urban it was best to focus on the breeder hypothesis,
areas and a higher tendency to fall [61]. Causes of hip controlling as much as possible for the compositional
fractures in urban areas more often concern traffic differences resulting from indirect selection effects.
accidents [63], a finding that is consistent with Thouez It was argued that interactions between aggregate
et al. [64], who found higher urban incidence from and individual level deserve special attention. Living •
non-severe car accidents.
in a particular type of area (rural or urban) seems
Interaction-effects were found between urbanicity to be. related to other demographic variables as they
and gender, especially in elderly persons. Urban affect health. The impact of the envirenment may
excess morbidity appeared most strongly in (elderly) vary from person to person, or the impact of individ
women [63, 65] as compared to elderly men.
ual variables may vary from place to place. It will
Sexually transmitted diseases. Most sexually trans therefore only be possible to tease out the relevant
mitted diseases are regarded as typically urban prob health related aspects of urbanicity by investigating
lems. In the case of AIDS and HIV infection, the interaction effects. A summary of interaction effects
major associations are substance abuse, prostitution, that were found in the literature is given in Table 5.
and prevalence of homosexuality. The literature also Caution should be used with interpreting the signs.
describes other modes of transmission [66]. Diffusion They indicate only the relative position of urban vs
may be partly due to urban emigration of HIV- rural residents in the same demographic or be
i.ifected persons. Other sexually transmitted diseases havioural category.
that are linked to urbanicity, include chlamydia infec
Beginning with physical health, the most convinc
tions [67], gonococcal infections [68], hepatitis B [69], ing interaction is between urbanicity and: gender.
cervical condylomas [70], and syphilis [70]. In all cases Urban-rural health differences seem to be particu
higher incidence rates were found in urban areas, but larly prevalent in women. One author contended
interaction effects were not explicitly investigated. that this may be due to the presumed weakness
Circulatory system /cardiovascular diseases. Hyper of supportive networks in cities. This would imply,
tension in young adults was investigated by Thomas however, that social networks are more important for
and Groer [71]. High systolic blood pressure is women’s health than for men’s health. This could not
associated with age, gender, body mass and urban be corroborated with other literature. An alternative
residence. Urban residence was the strongest explanation for this is perhaps found in an article by
predictor of female systolic pressure. Hypertension in Gabe and Williams [73]: if .here are health differences
elderly people was studied by Weiler and Lubben [72]. that can be attributed to environmental differences,
They also found higher hypertension prevalence in these health difierences should be observable particu
urban areas. Finally, in a Swedish study among bus larly in those groups that are most tied to the house
drivers, myocardial infarction was more common in and immediate neighbourhood: women.
urban areas. Interaction-effects were not explicitly
Regarding stress-related variables such as
investigated..
unemployment, financial problems and low edu
cation (which stands for low SES) it must again be
concluded that they are not only associated with
SUMMARY AND CONCLUSIONS
urbanicity but that their influence also differs
The central issue in this paper is the relation according to urbanicity of residence.
between individual and ecological variables in
Regarding cancer we may conclude that most types
explaining health. Analyzing these relations has are more common in urban areas, with the exceptionJ'
'!f
7
1
932
Robert A. Verhrij
Table 5. Interaction effects fc und in the literature and their explanations
Health problem
Mental health
Interaction
urbanidty with
race [17]
unemployment [22]
alcohol consumptior [14]
age [16]
marital status [15]
Well-being
physical health status [28]
family status [30]
race [30]
Physical health
gender [33; 37]
not having a partner [23]
low education [29]
s
— bad ph. health urb. —
+ bad ph. health rur. +'
. + married no children urban +
— married with children urban —
— poor black urb. —
+ poor white urban +
+ poor black rur. + — poor while rural —
— female urban + female rural +
+ single urban +
— single rural —
4- low education urban +
— low education rural —
Explanation
learned helplessness
informal employment possibilities in
rural areas, social support
not given
social change
stigma tization/tolerancc
constraints in physical environment
street violence, traffic
ghettos relatively unhealthy
women higher exposure to unhealthy
dtylife
stigma tization/tolerance
relative deprivation
Signs indicate the relative position of urban versus rural'residents in the same (demographic or behavioural) category. + indicates better
health status, —indicates worse health status.
of leukemia, Hodgkin’s disease and possibly cancer -that offers better opportunities to cope with divorce
of the oesophagus. Furthermore, for most types of via a higher tolerance and less stigmatization towards
cancer urban excess is typical of men. This is prob the unusual, as well as offering more opportunities
ably due to gender-differences in lifestyle. Much can to meet new partners, thereby limiting the negative
be improved regarding the models that are used. health consequences of divorce. Another example of
A first step in the right direction is including more urban-rural differences in possibilities for coping
individual-based data. Including lifestyle character with individual trouble is learned helplessness which
istics is another step, though this is easier said than is suggested to prevail among black rural residents
done: the time lag between, for instance, smoking and and not in black urban residents and which counter
cancer is unknown. With regard to musculoskeletal balances the fact that urban blacks tend *.o live in
disorders, urban morbidity is higher than rural mor relatively unhealthy environments. Negative aspects
bidity as far as women are concerned. No explanation, of city life may be present in the stress resulting
for this finding was offered. Concerning the circular from social change and limited informal employment
system again urban excess morbidity was found, but possibilities. The first would then explain a higher
interaction effects were nowhere explicitly investi prevalence of mental problems in young city residents
gated. The most important conclusion regarding the as compared to older city residents.
broad categories of physical disorders considered
Similar conclusions may be drawn from looking at
here must be that very little attention is paid to well-being: here too urbanicity moderates the relation
interaction effects and that especially in this field between stressors and health. The evidence is rather
much remains to be done.
convincing regarding*physical health as a stressor.
Regarding the relation between mental health and Physical health problems clearly constitute a meaning
urbanicity the stress-hypothesis is most popular, con for well-being that differs from city to countryside.
tending that the urban environment is more stressful, Factors that make living with a physical handicap
leading to higher levels of mental disorder. Evidence more problematic, like stairclimbing or crossing busy
is found by several authors in the fact ♦hat there is r^ads. occur much more frequently in urban areas.
a direct effect of stress-indicating variables that are Regarding race there is less agreement among
indeed associated with city life.
. authors. Race-urbanicity interactions arc found but
However, the frequent occurrence of interaction not consistently so. The distinction between chronic
effects shows that this is too simple an explanation. and acute stressors is important to remember, the
Indeed we have seen that the impact of stress •hypothesis being that well-being is largely affected
variables themselves varies according to urbanicity. by acute stressors, while mental disorders are more
In Table 5 there are two urban conditions that associated with chronic stressors.
may prove to be important: stigmatization/tolerance
Regarding the three aspects of health two
important conclusions can be drawn. First, based
and learned helplessness. Divorce can, for instanc'
be regarded as a stressor that is strongly associated on the fact that very often bivariate analyses have
with city life. At the Same time, however, it is city life shown an urban disadvantage regarding health, the
I
■
’r
I* I
:‘i
Specification
+ black urban +
— black rural —
— urban men —
+ rura’ men +
— urban drinkers —
+ rural drinkers +
+ e'derly urban + — young urban —
— elderly rural — + young rural +
+ urban divorced +
— rural divorced —
□
!
T ..
»
Bl
'•S’-'’
2-fe^f
i
Urban-rural variations in health
933 ■
a.
urbanicity
health related
macro conditions:
constraints and
opportunities
■p- health
b.
urbanicity
health related
macro conditions:
constraints and
opportunities
—[7 health
k individual health
____
y related conditions
1
Fie. I. Two simple explanatory models.
emphasis has been primarily on urban constraints
instead of opportunities. Possibly combined with the
18th century pastoral romanticist ideology regarding
the purity and salutary qualities of rural societies the
result has .been an insufficient appreciation of the
positive aspects of urban living. Second, it is import
ant to note that these environmental constraints and
opportunities have an effect on health that is in many
cases dependent on the person who is living in that;
environment.
The extent to which the environment exerts
its influence on a person’s health is dependent on
that person’s individual characteristics. Much
previous work on urban-rural differences has con
ceptualized this relation as depicted in Fig. 1(a).
The current review, however, suggests to replace
this by Fig. 1(b), in which interactions between
the individual level and environment are more fully
appreciated.
However, these conclusions are important only for
further investigating the breeder hypothesis. In order
to gain more insight into the drift hypothesis much
more work remains to be done. A start can.be made
with gathering population based longitudinal data in
which breeder and drift hypotheses can be examined
together.
Acknowledgements—The author would like to thank Dinny
de Bakker, Peter Groenewcgen and Paulus Huigen for their
comments on an earlier version of this paper. Paul ten
Zijthoff should be mentioned for his valuable work gather
ing much of the literature. This study was supported by a
grant from the Netherlands Organisation for Scientific
Research.
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1
1-Y-
2.66
r
1
FUNDAMENTAL RIGHTS (From Part III of THE
CONSTITUTION OF INDIA)
Right to Equality
ARTICLE
14.
Equality before law.
15.
Prohibition of discrimination on grounds of religion, race, caste, sex or place
of birth.
16.
Equality of opportunity in matters of public employment.
17.
Abolition of Untouchability
18.
Abolition of titles.
Right to Freedom
ARTICLE
19.
Protection of certain rights regarding freedom of speech, etc.
20.
Protection in respect of conviction for offences.
21.
Protection of life and personal liberty.
22.
Protection against arrest and detention in certain cases.
Right against Exploitation
ARTICLE
23.
Prohibition of traffic in human beings and forced labour.
24.
Prohibition of employment of children in factories, etc.
Right to Freedom of Religion
ARTICLE
25.
Freedom of conscience and free profession, practice and propagation of
religion.
1
26.
Freedom to manage religious affairs.
27.
Freedom as to payment of taxes for promotion of any particular religion.
28.
Freedom as to attendance at religious instruction or religious worship in
certain education institutions.
Cultural and Educational Rights
ARTICLE
29.
Protection of interests of minorities.
30.
Right of minorities to establish and administer educational institutions.
31.
[Repealed.]
Saving of Certain Laws
ARTICLE
31A.
Savings of laws providing for acquisition of estates,etc.
31B.
Validation of certain Acts and Regulations
31C.
Saving of laws giving effect to certain directive principles
31D.
[Repealed.]
Right to Constitutional Remedies
ARTICLE
32.
Remedies for enforcement of rights conferred by this Part.
32A.
[Repealed.]
33.
Power of Parliament to modify the rights conferred by this Part in their
application to Forces, etc.
34.
Restriction on rights conferred by this Part while martial law is in force in
any area.
35.
Legislation to give effect to the provisions of this Part.
2
PART in
FUNDAMENTAL RIGHTS
General
ARTICLE
12. Definition
13. l aws of inconsistent with or in derogation pf the fundamental rights
Right to Equality
ARTICLE
Equality before law.
V 15. pr(’hiOition of discrimination on grounds of religion,race,caste.sex or place of birth.
16. Equality of opportunity in matters of public employment-
17. Abolition of Untouchahility
18. Abolition-oCtitles.
Right to Freedom
ARTICLE
19. Protection of certain rights regarding freedom of speech, etc
20. protection in respect of conviction for offences
21. Protection of life and personal liberty.
22. Protection against arres
nd detention in certain cases.
Right against Exploitation
ARTICLE
23. Prohibition of traffic in human beings and forced labour.
24. PjrQhitdttQiLQfeniplQymeiLt^f^hH
Right to Freedom of Religion
ARTICLE
^70
25. Freedom of conscience and free profession, practice and propagation of religion.
26. Freedom to manage religious affairs.
27. Freedom as to payment ofJaxes for promotion of any particular religion.
28. Freedom asJo_attend_ance^treligiousjnstru_ctiQnQrxeligious worship in certain edneatjon
institutions.
Cultural and Educational Rights
ARTICLE
29. Protection of interests of minorities.
30. Right of minorities to establish and administer educational institutions.
31. [Repealed.)
Saving of Certain Laws
ARTICLE
31A. Savings i>flaws providing for acquisition of estates.efe
Validation of certain Acts and Regulations
31C. Saying of laws giving effect to certain directive principles
31D. [Repealed.)
Right to Constitutional Remedies
ARTICLE
32. Remedies for enforcement of rights conferred by this Part.
32A. (Repealed.)
33. Power of Parliament to modify the rights conferred by this Part in their application to Forces,
etc.
34. Restriction on rights conferred by this Part while martial law is in force in any area.
35. Legislation to give effect to the provisions of this Part
Universal Declaration of Human Rights
Adopted and proclaimed by General Assembly resolution 217 A (III) of 10
December 1948
V
On December 10, 1948
-- the
General Assembly of the United
Nations
adopted
and
proclaimed
Human Rights the full text’of^ch^ppeaZ^i^Si”^00
text of which appears in the
following pages. Following this historic ; ' “
yP011 a11 Member
— countries to publicize the text of
the Declaration and r"‘to
*
cause it to be disseminated,
isplayed, read and expounded principally in schools and
other educational institutions, without distinction based
the political status of countries or territories.”
PREAMBLE
™mhpaZ ZC^nh°n °f ?e .int’e^e^, di9nity and of the equal and inalienable rights of all
worid6
f
hUman fam'y 'S the foundation of freedom, justice and peace in the
Whereas d|sregard and contempt for human rights have resulted in barbarous acts which
have outraged the conscience of mankind, and the advent of a worid in which human
hppn9n f ei^y freedorT’ of sPeectl and belief and freedom from fear and want has
been proclaimed as the highest aspiration of the common people,
Wiereas it is essential, if man is not to be compelled to have recourse as a last resort to
rele onaw93'051 ‘yranny and Oppression-that human ri9hts should be protected by the
Whereas it is essential to promote the development of friendly relations between nations.
10s<'cla, wess
^emb®r States have pledged themselves to achieve, in co-operation with the
and SndaSJS?' "
reSPeaM °bS'S'va"ce
i^nnrtX3 ?OTO,n iynderstandin9 °f these rights and freedomsls of the greatest
importance forthe full realization of this pledge,
Now, Therefore THE GENERAL ASSEMBLY proclaims THIS UNIVERSAL
declaration of human rights
as a common standard of achievement for all
peoples and all nations. to the end that every individual and every
Z72-
organ of society, keeping this Declaration constantly in mind, shall
strive by teaching and education to promote respect for these rights
and freedoms and by progressive measures, national and international,
to secure their universal and effective recognition and observance,
both among the peoples of Member States themselves and among the
peoples of territories under their jurisdiction.
Article 1.
All human beings are born free and equal in dignity and rights.They are endowed with
reason and conscience and should act towards one another in a spirit of brotherhood.
Article 2.
Everyone is entitled to all the rights and freedoms set forth in this Declaration, without
distinction of any kind, such as race, colour, sex, language, religion political or other
opinion, national or social origin, property, birtti or other status. Furthermore no
distinction shall be made on the basis of the political, jurisdictional or international status
of the country or territory to which a person belongs, whether it be independent, trust,
non-self-governing or under any other limitation of sovereignty.
Article 3.
Everyone has the right to life, liberty and security of person.
Article 4.
No one shall be held in slavery or servitude; slavery and the slave trade shall be
prohibited in all their forms.
Article 5.
No one shall be subjected to torture or to cruel, inhuman or degrading treatment or
punishment.
Article 6.
Everyone has the right to recognition everywhere as a person before the law.
Article 7.
All are equal before the law and are entitled without any discrimination to eqi^l protection
of the lawAHare entitled to equal protection against any discrimination in violation of t i
Declaration and against any incitement to such discrimination.
Article 8.
Everyone has the right to an effective remedy by the competent national tnbunals for acts
violating the fundamental rights granted him by the constitution or by law.
Article 9.
2^12)
No one shall be subjected to arbitrary arrest, detention or exile.
Article 10.
Everyone is entitled in full equality to a fair and public hearing by an independent and
impartial tribunal, in the determination of his rights and obligations and of any criminal
charge against him.
Article 11.
(1) Everyone charged with a penal offence has the right to be presumed innocent until
proved guilty according to law in a public trial at which he has had all the guarantees
necessary for his defence.
S?al1 beheld guilty of ar|y Penal offence on account of any act or omission
which did not constitute a penal offence, under national or international law, at the time
when it was committed. Nor shall a heavier penalty be imposed than the one that was
applicable at the time the penal offence was committed.
Article 12.
No one shall be subjected to arbitrary interference with his privacy, family, home or
correspondence, nor to attacks upon his honour and reputation. Everyone has the right to
the protection of the law against such interference or attacks.
Article 13.
(1) Everyone has the right to freedom of movement and residence within the borders of
each state.
(2) Everyone has the right to leave any country, including his own. and to return to his
couniry.
!
Article 14.
per^xition6 h3S th6
t0 Seek
t0 enj*°y in °ther countries asy,um from
(2) Jins nght may not be invoked in the case of prosecutions genuinely arising from nonpo itical comes or from acts contrary to the purposes and principles of the United Nations.
Article 15.
(1) Everyone has the right to a nationality.
nationality Shal1
arbitrarily dePrived of h'S nationality nor denied the right to change his
Article 16.
2-7 Zj
>•
(1) Men and women of full age, without any limitation due to race, nationality or religion,
have the right to marry and to found a family. They are entitled to equal rights as to
marriage, during marriage and at its dissolution.
(2) Marriage shall be entered into only with the free and full consent of the intending
spouses.
(3) The family is the natural and fundamental group unit of society and is entitled to
protection by society and the State.
Article 17,
(1) Everyone has the right to own property alone as well as in association with others.
(2) No one shall be arbitrarily deprived of his property.
Article 18,
Everyone has the right to freedom of thought, conscience and religion; this right includes
freedom to change his religion or belief, and freedom, either alone or in community with
others and in public or private, to manifest his religion or belief in teaching, practice,
worship and observance.
Article 19,
*
Everyone has the right to freedom of opinion and expression; this right includes freedom
to hold opinions without interference and.to seek, receive and impart information and
ideas through any media and regardless of frontiers.
Article 20,
(1) Everyone has the right to freedom of peaceful assembly and association.
(2) No one may be compelled to belong to an association.
Article 21.
(1) Everyone has the right to take part in the government of his country, directly or
through freely chosen representatives.
(2) Everyone has the right of equal access to public service in his country.
(3) The will of the people shall be the basis of the authority of government; this will shall
be expressed in periodic and genuine elections which shall be by universal and equal
suffrage and shall be held by secret vote or by equivalent free voting procedures.
Article 22.
Everyone, as a member of society, has the right to social security and is entitled to
realization, through national effort and international co-operation and in accordance with
Z75
the organization and resources of each State, of the economic, social and cultural rights
indispensable for his dignity and the free development of his personality.
Article 23.
(1) Everyone has the right to work, to free choice of employment, to just and favourable
conditions of work and to protection against unemployment.
(2) Everyone, without any discrimination, has the right to equal pay for equal work.
(3) Everyone who works has the right to just and favourable remuneration ensuring for
himself and his family an existence worthy of human dignity, and supplemented, if
necessary, by other means of social protection.
(4) Everyone has the right to form and to join trade unions for the protection of his
interests.
Article 24.
7
Everyone has the right to rest and leisure, including reasonable limitation of working
hours and periodic holidays with pay.
Article 25.
(1) Everyone has the right to a standard of living adequate for the health and well-being
of himself and of his family, including food, clothing, housing and medical care and
necessary social services, and the right to security in the event of unemployment,
sickness, disability, widowhood, old age or other lack of livelihood in circumstances
beyond his control.
(2) Motherhood and childhood are entitled to special care and assistance. All children,
whether born in or out of wedlock, shall enjoy the same social protection.
Article 26.
I
(1) Everyone has the right to eduoaiien. Education shall be free, at least in the
elementary and fundamental stages. Elementary education shall be compulsory.
Technical and professional education shall be made generally available and higher
education shall be equally accessible to all on the basis of merit.
(2) Education shall be directed to the full development of the human personality and to
the strengthening of respect for human rights and fundamental freedoms. It shall promote
understanding, tolerance and friendship among all nations, racial or religious groups, and
shall further the activities of the United Nations for the maintenance of peace.
(3) Parents have a prior right to choose the kind of education that shall be given to their
children.
Article 27.
(1) Everyone has the right freely to participate in the cultural life of the community, to
enjoy the arts and to share in scientific advancement and its benefits.
(2) Everyone has the right to the protection of the moral and material interests resulting
from any scientific, literary or artistic production of which he is the author.
Article 28.
Everyone is entitled to a social and international order in which the rights and freedoms
set forth in this Declaration can be fully realized.
Article 29.
(1) Everyone has duties to the community in which alone the free and full development of
his personality is possible.
(2) In the exercise of his rights and freedoms, everyone shall be subject only to such
limitations as are determined by law solely for the purpose of securing due recognition
and respect for the rights and freedoms of others and of meeting the just requirements of
morality, public order and the general welfare in a democratic society.
(3) These rights and freedoms may in no case be exercised contrary to the purposes and
principles of the United Nations.
Article 30.
Nothing in this Declaration may be interpreted as implying for any State, group or person
any right to engage in any activity or to perform any act aimed at the destruction of any of
the rights and freedoms set forth herein.
Z77
UNITED
NATIONS
Economic and Social
Council
Distr.
GENERAL
E/C. 12/2000/4, CESCR
General comment 14
4 July 2000
Original: ENGLISH
The right to the highest attainable standard of health . 11/08/2000.
E/C.12/2000/4, CESCR General comment 14. (General Comments')
COMMITTEE ON ECONOMIC, SOCIAL
AND CULTURAL RIGHTS
Twenty-second session
Geneva, 25 April-12 May 2000
Agenda item 3
SUBSTANTIVE ISSUES ARISING IN THE IMPLEMENTATION OF
THE INTERNATIONAL COVENANT ON ECONOMIC, SOCIAL
AND CULTURAL RIGHTS
General Comment No. 14 (2000)
The right to the highest attainable standard of health
(article 12 of the International Covenant on Economic, Social and Cultural Rights)
1. Health is a fundamental human right indispensable for the exercise of other human rights.
Every human being is entitled to the enjoyment of the highest attainable standard of health
conducive to living a life in dignity. The realization of the right to health may be pursued through
numerous, complementary approaches, such as the formulation of health policies, or the
implementation of health programmes developed by the World Health Organization (WHO), or
the adoption of specific legal instruments. Moreover, the right to health includes certain
components which are legally enforceable. (.1)
2. The human right to health is recognized in numerc u. international instruments. Article 25.1 of
the Universal Declaration of Human Rights affirms: ' everyone has the right to a standard of
living adequate for the health of himself and of his family, including food, clothing, housing and
medical care and necessary social services”. The International Covenant on Economic, Social and
Cultural Rights provides the most comprehensive article on the right to health in international
human rights law. In accordance with article 12.1 of the Covenant, States parties recognize "the
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STAG 2001 report: 8.1 women ‘s perspectives and gender issues
I
DRAFT STAG REPORT 2001
8.1 Women’s perspectives and gender issues
Training initiative in gender and reproductive health
This training initiative, which is a collaborative effort between WHO, the
Women's Health Project at the University of the Witwatersrand (South Africa)
and the Frangois Xavier Bagnoud Centre for Health and Human Rights
(Harvard School of Public Health, USA), is moving into its final phase during
this Biennium. (Please refer to the Annual Technical Report 1999 for a full
description^f-the-afmsj of the initiative.)
During 1999 four regional institutions ran a regionally adapted version
of the^ourse. These institutions are: Centre for African Family Studies
(CAPS), Nairobi, Kenya (October); Centre for the Study of State and Society
(CEDES), Buenos Aires, Argentina (August); Key Centre for Women’s Health
in Society, University of Melbourne, Australia (July); and Yunnan
Reproductive Health Research Association (YRHRA), Kunming Medical
College, Kunming, China (Septerr.hur). In March 2000, representatives from
these training institutions attended a workshop together with the international
coordinating committee to evaluate the experience and to select case studies
and approaches that had been successful in the regional courses, for
inclusion in the final curriculum. As a result of the evaluation, extensive
revisions were proposed to the curriculum, particularly in the level of detail
given and in the content and approach of some sessions.
Between March and August these revisions were incorporated by an
editor, Dr Sundari Ravindran who is a member of the coordinating committee.
The revised curriculum was then tested at the South African course on
2. •< <
Gender and Reproductive Heath in September',' by trainers who had not
previously taught the course. Key sessions of the course were also presented
to the staff of/h^RHR for comment and input. As a result of these field tests,
some revisions were again made to the curriculum which, at the time of
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writing, is under review by all the collaborating institutions and three outside
reviewers. The training manual, entitled Transforming health systems: gender
and rights in reproductive health, will be published in 2001.
The centres in Australia,yand Kenya ran the course for the second time
in 2000, and-tn-ChinarYRHRA ran the course twice - once in-February and
once in September. (.?). All of the courses”run-irr2G00 met with positive
response. In South Africa/4Gf-insteneeymany of the those attending the
course were responsible for ensuring that gender issues are addressed in
their institutions. They were therefore urgently seeking tools to help them do
this, and found the course timely and relevant.
All four centres expect to run the course in 2001, and the South African
course will be run for the fifth time. CEDES and YRHRA, will translate the
revised curriculum into Spanish and Mandarin respectively, with support from
WHO and (in the case of China) the Ford Foundation.
The Course is a major contribution to making the concepts and practice
of gender equality and reproductive rights accessible to health programme
managers. Considerable interest in the course has been generated over the
four years of its development and testing. In the coming year and over the
next Biennium, the Department plans to give technical support to five
J
additional regional centres to run the training course. In order to facilitate this,
it will support a high-level “training of trainers" team composed of members
from the five regional institutions collaborating with the initiative, to provide
training to these new centres. The curriculum will also be made available in
electronic.form, and further translations supported if there is a demand.
kL-
right of everyone to the enjoyment of the highest attainable standard of physical and mental,
health", while article 12.2 enumerates, by way of illustration, a number of "steps to be taken by
the States parties ... to achieve the fall realization of this right". Additionally, the right to health is
recognized, inter alia, in article 5 (e) (iv) of the International Convention on the Elimination of
All Forms of Racial Discrimination of 1965, in articles 1 l.l (f) and 12 of the Convention on the
Elimination of All Forms of Discrimination against Women of 1979 and in article 24 of the
Convention on the Rights of the Child of 1989. Several regional human rights instruments also
recognize the right to health, such as the European Social Charter of 1961 as revised (art. 11), the
African Charter on Human and Peoples' Rights of 1981 (art. 16) and the Additional Protocol to
the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights
of 1988 (art. 10). Similarly, the right to health has been proclaimed by the Commission on Human
Rights, (2) as well as in the Vienna Declaration and Programme of Action of 1993 and other
international instruments. (3)
3. The right to health is closely related to and dependent upon the realization of other human
rights, as contained in the International Bill of Rights, including the rights to food, housing, work,
education, human dignity, life, non-discrimination, equality, the prohibition against torture,
privacy, access to information, and the freedoms of association, assembly and movement. These
and other rights and freedoms address integral components of the right to health.
4. In drafting article 12 of the Covenant, the Third Committee of the United Nations General
Assembly did not adopt the definition of health contained in the preamble to the Constitution of
WHO, which conceptualizes health as "a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity'". However, the reference in article 12.1 of the
Covenant to "the highest attainable standard of physical and mental health" is not confined to the
right to health care. On the contrary, the drafting history and the express wording of article 12.2
acknowledge that the right to health embraces a wide range of socio-economic factors that
promote conditions in which people can lead a healthy life, and extends to the underlying
determinants of health, such as food and nutrition, housing, access to safe and potable water and
adequate sanitation, safe and healthy working conditions, and a healthy environment.
5. The Committee is aware that, for millions of people throughout the world, the full enjoyment
of the right to health still remains a distant goal. Moreover, in many cases, especially for those
living in poverty, this goal is becoming increasingly remote. The Committee recognizes the
formidable structural and other obstacles resulting from international and other factors beyond the
control of States that impede the lull realization of article 12 in many States parties.
6. With a view to assisting States parties' implementation of the Covenant and the fulfilment of
their reporting obligations, this Genera! Comment focuses on the normative content of article 12
(Part I), States parties' obligations (Part II), violations (Part III) and implementation at the
national level (Part IV), while the obligations of actors other than States parties are addressed in
Part V. The General Comment is based on the Conunittee's experience in examining States
parties' reports over many years.
I. NORMATIVE CONTENT OF ARTICLE 12
7. Article 12.1 provides a definition of the right to health, while article 12.2 enumerates
illustrative, non-exhaustive examples ol States parties' obligations.
8. The right to health is not to be understood as a right to be healthy. The right to health contains
both freedoms and entitlements. The freedoms include the right to control one's health and body,
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including sexual and reproductive freedom, and the right to be free from interference, such as the
right to be free from torture, non-consensual medical treatment and experimentation. By contrast,
the entitlements include the right to a system of health protection which provides equality of
opportunity for people to enjoy the highest attainable level of health.
9. The notion of "the highest attainable standard of health" in article 12.1 takes into account both
the individual's biological and socio-economic preconditions and a State's available resources.
There are a number of aspects which cannot be addressed solely within the relationship between
States and individuals; in particular, good health cannot be ensured by a State, nor can States
provide protection against every possible cause of human ill health. Thus, genetic factors,
individual susceptibility to ill health and the adoption of unhealthy or risky lifestyles may play an
important role with respect to an individual's health. Consequently, the right to health must be
understood as a right to the enjoyment of a variety of facilities, goods, services and conditions
necessary for the realization of the highest attainable standard of health.
10. Since the adoption of the two International Covenants in 1966 the world health situation has
changed dramatically and the notion of health has undergone substantial changes and has also
widened in scope. More determinants of health are being taken into consideration, such as
resource distribution and gender differences. A wider definition of health also takes into account
such socially-related concerns as violence and armed conflict. (4) Moreover, formerly unknown
diseases, such as Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome
(HIV/AIDS), and others that have become more widespread, such as cancer, as well as the rapid
growth of the world population, have created new obstacles for the realization of the right to
health which need to be taken into account when interpreting article 12.
11. The Committee interprets the right to health, as defined in article 12.1, as an inclusive right
extending not only to timely and appropriate health care but also to the underlying determinants
of health, such as access to safe and potable water and adequate sanitation, an adequate supply of
safe food, nutrition and housing, healthy occupational and environmental conditions, and access
to health-related education and information, including on sexual and reproductive health. A
further important aspect is the participation of the population in all health-related decision
making at the community, national and international levels.
.12. The right to health in all its forms and at all levels contains the following interrelated and
essential elements, the precise application of which will depend on the conditions prevailing in a
particular State party:
(a) Availability. Functioning public health and health-care facilities, goods and services, as well
as programmes, have to be available in sufficient quantity within the State party. The precise
nature of the facilities, goods and services will vary depending on numerous factors, including the
State party's developmental level. They will include, however, the underlying determinants of
health, such as safe and potable drinking water and adequate sanitation facilities, hospitals, clinics
and other health-related buildings, trained medical and professional personnel receiving
domestically competitive salaries, and essential drugs, as defined by the WHO Action Programme
on Essential Drugs. (5)
(b) Accessibility. Health facilities, goods and services (6) have to be accessible to everyone
without discrimination, within the jurisdiction of the State party. Accessibility has four
overlapping dimensions:
Non-discrimination: health facilities, goods and services must be accessible to all, especially the
most vulnerable or marginalized sections of the population, in law and in fact, without
discrimination on any of the prohibited grounds. (7)
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Physical accessibility: health facilities, goods and services must be within safe physical reach for,
all sections of the population, especially vulnerable or marginalized groups, such as ethnic
minorities and indigenous populations, women, children, adolescents, older persons, persons with
disabilities and persons with HIV/AIDS. Accessibility also implies that medical services and
underlying determinants of health, such as safe and potable water and adequate sanitation
facilities, are within safe physical reach, including in rural areas. Accessibility further includes
adequate access to buildings for persons with disabilities.
Economic accessibility (affordability): health facilities, goods and services must be affordable for
all. Payment for health-care services, as well as services related to the underlying determinants o
health has to be based on the principle of equity, ensuring that these services, whether privately
or publicly provided, are affordable for all, including socially disadvantaged groups Equity
demands that poorer households should not be disproportionately burdened with health expenses
as compared to richer households.
Information accessibility; accessibility includes the right to seek, receive and impart information
and ideas (8) concerning health issues. However, accessibility of information should not impair
the right to have personal health data treated with confidentiality.
(c) Acceptability. All health facilities, goods and services must be respectful of medical ethics and
culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoples and
communities, sensitive to gender and life-cycle requirements, as well as being designed to respect
confidentiality and improve the health status of those concerned.
(d) Duality As well as being culturally acceptable, health facilities, goods and services must also
be scientifically and medically appropriate and of good quality. This requires, inter alia, skilled
medical personnel, scientifically approved and unexpired drugs and hospital equipment, safe and
potable water, and adequate sanitation.
13. The non-exhaustive catalogue of examples in article 12.2 provides guidance in defining the
action to be taken by States. It gives specific generic examples of measures arising from the broad
definition of the right to health contained in article 12.1, thereby illustrating the content of that
right, as exemplified in the following paragraphs. (9)
I
Article 12.2 (a). The right to maternal, child and reproductive heakh
14 "The provision for the reduction of the stillbirth rate and of infant mortality and for the
healthy development of the child” (art. 12.2 (a)) (J Q) may be understood as requiring measures to
improve child and maternal health, sexual and reproductive health services, including access to
family planning, pre- and post-natal care, (11) emergency obstetric services and access to
information, as well as to resources necessary to act on that information. (12)
Article 12.2 (b). The right to healthy natural and workplace environments
15. "The improvement of all aspects of environmental and industrial hygiene" (art 12.2 (b))
comprises inter alia, preventive measures in respect of occupational accidents and diseases; the
requirement to ensure an adequate supply of safe and potable water and basic sanitation; the
prevention and reduction of the population's exposure to harmful substances such as radiation and
harmful chemicals or other detrimental environmental conditions that directly or indirectly impact
upon human health. (13) Furthermore, industrial hygiene refers to the minimization, so far as is^
reasonably practicable, of the causes of health hazards inherent in the working envaonment. (14)
Article 12.2 (b) also embraces adequate housing and safe and hygienic working conditions, an
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adequate supply of food and proper nutrition, and discourages the abuse of alcohol, and the use of
tobacco, drugs and other harmful substances.
Article 12.2 (c). The right to prevention, treatment and control of diseases
16. "The prevention, treatment and control of epidemic, endemic, occupational and other
diseases" (art. 12.2 (c)) requires the establishment of prevention and education programmes for
behaviour-related health concerns such as sexually transmitted diseases, in particular HIV/AIDS,
and those adversely affecting sexual and reproductive health, and the promotion of social
determinants of good health, such as environmental safety, education, economic development and
gender equity. The right to treatment includes the creation of a system of urgent medical care in
cases of accidents, epidemics and similar health hazards, and the provision of disaster relief and
humanitarian assistance in emergency situations. The control of diseases referslo States’
individual and joint efforts to, inter alia, make available relevant technologies, using and
improving epidemiological surveillance and data collection on a disaggregated basis, the
implementation or enhancement of immunization programmes and other strategies of infectious
disease control.
Article 12.2 (d). The right to health facilities, goods and sendees (15)
\/ 17. "The creation of conditions which would assure to all medical sendee and medical attention in
the event of sickness" (art. 12.2 (d))» both physical and mental, includes the provision of equal
and timely access to basic preventive, curative, rehabilitative health services and health
education; regular screening programmes; appropriate treatment of prevalent diseases, illnesses,
injuries and disabilities, preferably at community level; the provision of essential drugs; and
appropriate mental health treatment and care. A further important aspect is the improvement and
furtherance of participation of the population in the provision of preventive and curative health
services, such as the organization of the health sector, the insurance system and, in particular,
participation in political decisions relating to the right to health taken at both the community and
national levels.
Article 12. Special topics of broad application
*
r
Non-discrimination and equal treatment
18. By virtue of article 2.2 and article 3, the Covenant proscribes any discrimination in access to
health care and underlying determinants of health, as well as io means and entitlements for their
procurement, on the grounds of race, colour, sex, language, religion, political or other opinion,
national or social origin, property, birth, physical or mental disability, health status (including
HIV/AIDS), sexual orientation and civil, political, social or other status, which has the intention
or effect of nullifying or impairing the equal enjoyment or exercise of the right to health. The
Committee stresses that many measures, such as most strategies and programmes designed to
eliminate health-related discrimination, can be pursued with minimum resource implications
through the adoption, modification or abrogation of legislation or the dissemination of
information. The Committee recalls General Comment No. 3, paragraph 12, which states that
even in times of severe resource constraints, the vulnerable members of society must be protected
by the adoption of relatively low-cost targeted programmes.
19. With respect to the right to health, equality of access to health care and health services has to
be emphasized. States have a special obligation to provide those who do not have sufficient
means with the necessary health insurance and health-care facilities, and to prevent any
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discrimination on internationally prohibited grounds in the provision of health care and health
services, especially with respect to the core obligations of the right to health. (16) Inappropriate
health resource allocation can lead to discrimination that may not be overt*.For example,
investments should not disproportionately favour expensive curative health services which are
often accessible only to a small, privileged fraction of the population, rather than primary and
preventive health care benefiting a far larger part of the population.
Genderj^rspectiye
20. The Committee recommends that States integrate a gender perspective in their health-related
policies, planning, programmes and research in order to promote better health for both women
and men. A gender-based approach recognizes that biological and socio-cultural factors play a
significant role in influencing the health of men and women. The disaggregation of health and
socio-economic data according to sex is essential for identifying and remedying inequalities in
health.
Women and the right to health
21. To eliminate discrimination against women, there is a need to develop and implement a
comprehensive national strategy for promoting women’s right to health throughout their life span.
Such a strategy should include interventions aimed at the prevention and treatment of diseases
affecting women, as well as policies to provide access to a full range of high quality and
affordable health care, including sexual and reproductive services. A major goal should be
reducing women’s health risks, particularly lowering rates of maternal mortality and protecting
women from domestic violence. The realization of women's right to health requires the removal
of all barriers interfering with access to health services, education and information, including in
the area of sexual and reproductive health. It is also important to undertake preventive, promotivc
and remedial action to shield women from the impact of harmful traditional cultural practices and
norms that deny them their full reproductive rights.
Children and adolescents
22. Article 12.2 (a) outlines the need to take measures to reduce infant mortality and promote the
healthy development of infants and children. Subsequent international human rights instruments
recognize that children and adolescents have the right to the enjoyment of the highest standard of
health and access to facilities for the treatment of illness. (1_7)
The Convention on the Rights of the Child directs States to ensure access to essential health
services for the child and his or her family, including pre- and post-natal care for mothers. The
Convention links these goals with ensuring access to child-friendly information about preventive
and health-promoting behaviour and support to families and communities in implementing these
practices. Implementation of the principle of non-discrimination requires that girls, as well as
boys, have equal access to adequate nutrition, safe environments, and physical as well as mental
health services. There is a need to adopt effective and appropriate measures to abolish harmful
traditional practices affecting the health of children, particularly girls, including early marriage,
female genital mutilation, preferential feeding and care of male children. (18) Children with
disabilities should be given the opportunity to enjoy a fulfilling and decent life and to participate
within their community.
j
23. States parties should provide a safe and supportive environment for adolescents, that ensures
the opportunity to participate in decisions affecting their health, to build life-skills, to acquire
appropriate information, to receive counselling and to negotiate the health-behaviour choices they
make. The realization of the right io health of adolescents is dependent on the development of
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youth-friendly health care, which respects confidentiality and privacy and includes appropriate
sexual and reproductive health services.
24. In all policies and programmes aimed at guaranteeing the right to health of children and
adolescents their best interests shall be a primary consideration.
Older persons
25. With regard to the realization of the right to health of older persons, the Committee, in
accordance with paragraphs 34 and 35 of General Comment No. 6 (1995), reaffirms the
importance of an integrated approach, combining elements of preventive, curative and
rehabilitative health treatment. Such measures should be based on periodical check-ups for both
sexes; physical as well as psychological rehabilitative measures aimed at maintaining the
functionality and autonomy of older persons; and attention and care for chronically and terminally
ill persons, sparing them avoidable pain and enabling them to die with dignity.
Persons with disabilities
26. The Committee reaffirms paragraph 34 of its General Comment No. 5, which addresses the
issue of persons with disabilities in the context of the right to physical and mental health.
Moreover, the Committee stresses the need to ensure that not only the public health sector but
also private providers of health services and facilities comply with the principle of non
discrimination in relation to persons with disabilities.
Indigenous peoples
>
27. In the light of emerging international law and practice and the recent measures taken by States
in relation to indigenous peoples, (.19) the Committee deems it useful to identify elements that
would help to define indigenous peoples* right to health in order better to enable States with
indigenous peoples to implement the provisions contained in article 12 of the Covenant. The
Committee considers that indigenous peoples have the right to specific measures to improve their
access to health services and care. These health services should be culturally appropriate, taking
into account traditional preventive care, healing practices and medicines. States should provide
resources, for indigenous peoples to design, deliver and control such services so that they may
enjoy the highest attainable standard of physical and mental health. The vital medicinal plants,
animals and minerals necessary to the full enjoyment of health of indigenous peoples should also
be protected. The Committee notes that, in indigenous communities, the health of the individual is
often linked to the health of the society as a whole and has a collective dimension. In this respect,
the Committee considers that development-related activities that lead to the displacement of
indigenous peoples against their will from their traditional territories and environment, denying
them their sources of nutrition and breaking their symbiotic relationship with their lands, has a
deleterious effect on their health.
Limitations
28. Issues of public health are sometimes used by States as grounds for limiting the exercise of
other fundamental rights. The Committee wishes to emphasize that the Covenant's limitation
clause, article 4, is primarily intended to protect the rights of individuals rather than to permit the
imposition of limitations by States. Consequently a State party which, for example, restricts the
movement of, or incarcerates, persons with transmissible diseases such as HIV/AIDS, refuses to
allow doctors to treat persons believed to be opposed to a government, or fails to provide
immunization against the community's major infectious diseases, on grounds such as national
security or the preservation of public order, has the burden of justifying such senous measures in
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for the promotion of the general welfare in a democratic society.
29 In line with article 5.1, such limitations must be proportional, i.e. the least restrictive
alternative must be adopted where several types of hmitations are available Even where such
limitations on grounds of protecting public health are basically permitted, they shou
eo
limited duration and subject to review.
II. STATES PARTIES' OBLIGATIONS
n
General legal obligations
30 While the Covenant provides for progressive realization and acknowledges the constraints due
to the limits of available resources, it also imposes on Slates pames vanous obligations which are
of immediate effect. States parties have immediate obligations in relation to the right to health
such as the guarantee that the right will be exercised without discrimination of any kind (art. 2.2)
and the obligation to take steps (art. 2.1) towards the full realization of article 12 Such steps must
be deliberate, concrete and targeted towards the full realization of the right to health. (^0)
31 The progressive realization of-thc right to health over a period of time should not be
interpreted as depriving States parties' obligations of all meaningful content. Rather, progressive
realization means that States parties have a specific and contmuing obligation tc> move as
expeditiously and effectively as possible towards the full realization of article 12. (J.)
32. As with all other rights in the Covenant, there is a strong presumption that retrogressive
measures taken in relation to the right to health are not permissible. If any deliberately
retrogressive measures are taken, the State part}' has the burden of proving that they have been
introduced after the most careful consideration of all alternatives and that they are duly justified
by reference to the totality of the rights provided for in the Covenant in the context of the full use
of the State party's maximum available resources. (22)
33 The right to health, like all human rights, imposes three types or levels of obligations on
States parties: the obligations to respect, protect andfulfil. In turn, the obligation to fulfil contains
obligations to facilitate, provide and promote. (23) The obligation to respect requires States to
refrain from interfering directly or indirectly with the enjoyment of the right to health. The
obligation to protect requires States to take measures that prevent third parties from interfering
with article 12 guarantees. Finally, die obligation to fulfil requires States to adopt appropriate
legislative, administrative, budgetary, judicial, promotional and other measures towards the full
realization of the right to health,
Sp^LficJegaLobligatioiis
34. In particular, States are under the obligation to respect the right to health by, inter alia,
refraining from denying or limiting equal access for all persons, including prisoners or detainees,
minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative healt
services; abstaining from enforcing discriminatory practices as a State policy; and abstaining
from imposing discriminatory practices relating to women's health status and needs. Furthermore,
obligations to respect include a State's obligation to refrain from prohibiting or impeding
traditional preventive care, healing practices and medicines, from marketing unsafe drugs and
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from applying coercive medical treatments, unless on an exceptional basis for the treatment of
mental illness or the prevention and control of communicable diseases. Such exceptional cases
should be subject to specific and restrictive conditions, respecting best practices and applicable
international standards, including the Principles for the Protection of Persons with Mental Illness
and the Improvement of Mental Health Care. (24)
In addition, States should refrain from limiting access to contraceptives and other means of
maintaining sexual and reproductive health, from censoring, withholding or intentionally
misrepresenting health-related information, including sexual education and information, as well
as from preventing people's participation in health-related matters. States should also refrain from
unlawfully polluting air, water and soil, e.g. through industrial waste from State-owned facilities,
from using or testing nuclear, biological or chemical weapons if such testing results in the release
of substances harmful to human health, and from limiting access to health services as a punitive
measure, e.g. during armed conflicts in violation of international humanitarian law.
35. Qbligatioris^to protect include, inter alia, the duties of States to adopt legislation or to take
otherm^suresensuring equal access to health care and health-related services provided by third
parties; to ensure that privatization of the health sector does not constitute a threat to the
availability, accessibility. accejrtability and quality of health facilities, goods arid services; to
confr^nifeHTiaSeting^bTnredicarequipment and medicines by third pities; and to ensure that
medical practitioners and other health professionals meet appropriate standards of education, skill
and ethical codes of conduct. States are also obliged to ensure that harmful social or traditional
practices do not interfere with access to pre- and post-natal care and family-planning; to prevent
third parties from coercing women to undergo traditional practices, e.g. female genital mutilation,
and to take measures to protect all vulnerable or marginalized groups of society, in particular
women, children, adolescents and older persons, in the light of gender-based expressions of
violence. States should also ensure that third parties do not limit people's access to health-related
information and services.
36. The obligation to fulfil requires States parties, inter alia, to give sufficient recognition to the
right to health in the national political and legal systems, preferably by way of legislative
implementation, and to adopt a national health policy with a detailed plan for realizing the right to
health. States must ensure provision of health care, including immunization programmes against
the major infectious diseases, and ensure equal access for all to the underlying determinants of
health, such as nutritiously safe food and potable drinking water, basic sanitation and adequate
housing and living conditions. Public health infrastructures should provide for sexual and
reproductive health services, including safe motherhood, particularly in rural areas. States have to
ensure the appropriate training of doctors and other medical personnel, the provision of a
sufficient number of hospitals, clinics and other health-related facilities, and the promotion and
support of the establishment of institutions providing counselling and mental health services, with
due regard to equitable distributipn throughout the country. Further obligations include the
provision of a public, private or mixed health insurance system which is affordable for all, the
promotion of medical research and health education, as well as information campaigns, in
particular with respect to HIV/AIDS, sexual and reproductive health, traditional practices,
domestic violence, the abuse of alcohol and the use. of cigarettes, drugs and other harmful
substances. States are also required to adopt measures against environmental and occupational
health hazards and against any other threat as demonstrated by epidemiological data. For this
purpose they should formulate and implement national policies aimed at reducing and eliminating
pollution of air, water and soil, including pollution by heavy metals such as lead from gasoline.
Furthermore, States parties are required to formulate, implement and periodically review a
coherent national policy to minimize the risk of occupational accidents and diseases, as well as to
provide a coherent national policy on occupational safety and health services. (25)
37. The obligation to fulfil (facilitate) requires States inter alia to take positive measures that
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sEESESSSBSBSSr^
fostering recognition of factors favouring positive health results, e.g. researc i and P™v‘sl^ °f
seMees; (iv) supportins people in making infomed eho.ces abou. ter heaUh.
International obligations
38 In its General Comment No. 3, the Committee drew attention to the obligation of all States
-art es to take steps individually and through international assistance and cooperation, especi y
parties to take steps, mui w
realization of the rights recognized in the Covenant,
Spee,f,« protons^of
essential .ole of international cooperation
developed and developing countries, as well as within countnes, is poditicaHy, soc a y
economically unacceptable and is, therefore, of common concern to all countnes. (26)
39 To comply with their international obligations in relation to article 12, States; parties; have m
resnect the enjoyment of the right to health in other countries, and to prevent third parties from
violating the right in other countries, if they are able to influence these third parties by way of
ol noliticfl means in accordance with the Charter of the United Nations and applicable
international law. Depending on the availability of resources, States should facilitate access to
pccential health facilities goods and services in other countries, wherever possible and provi
the necessary aid when required. (27) States parties should ensure that the right to health is given
due attentio? in international agreements and, to that end, should consider the deveiopmen o
Irther leeal instruments. In relation to the conclusion of other international agreements State
narties should take steps to ensure that these instruments do not adversely impact upon the ng i
m health. Similarly, States parties have an obligation to ensure that their actions as members
international organizations take due account of the right to health. Accordingly, S a^ Pa ■
which are members of international financial institutions, notably the International Monetary
Fund the World Bank, and regional development banks, should pay greater attcn‘l°"
protection of the right to health in influencing the lending policies, credit agreements and
international measures of these institutions.
40 States narties have a joint and individual responsibility, in accordance with the Charter of the
United Naflons and relevant resolutions of the United Nations General Assembly and of the
World Health Assembly to cooperate in providing disaster relief and humanitarian assistance!
times of emergency including assistance to refugees and internally displaced persons. Each S
hTuldI comribute to this task to the maximum of its capacities. Priority in the provision of
international medical aid, distribution and management of resources, such as safe an p
w“od and medical supplies, and financial aid should be given to the most vulnerable or
marginalized groups of the population. Moreover, given that some diseases are easily
tranfmissible beyond the frontiers of a State, the international community has a collective
responsibility to address this problem. The economically developed States parties have a special
responsibility and interest to assist the poorer developing States in this regar .
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41. States parties should refrain at all times from imposing embargoes or similar measures
restricting the supply of another State with adequate medicines and medical equipment.
Restrictions on such goods should never be used as an instrument of political and economic
pressure. In this regard, the Committee recalls its position, stated in General Comment No. 8, on
the relationship between economic sanctions and respect for economic, social and cultural rights.
42. While only States are parties to the Covenant and thus ultimately accountable for compliance
with it, all members of society - individuals, including health professionals, families, local
communities, intergovernmental and non-governmental organizations, civil society organizations,
as well as the private business sector - have responsibilities regarding the realization of the right
to health. State parties should therefore provide an environment which facilitates the discharge of
these responsibilities.
Core obligations
43. In General Comment No. 3, the Committee confirms that States parties have a core obligation
to ensure the satisfaction of, at the very least, minimum essential levels of each of the rights
enunciated in the Covenant, including essential primary health care. Read in conjunction with
more contemporary instruments, such as the Programme of Action of the International
Conference on Population and Development, (28) the Alma-Ata Declaration provides compelling
guidance on the core obligations arising from article 12. Accordingly, in the Committee's view,
these core obligations include at least the following obligations:
(a) To ensure the right of access to health facilities, goods and services on a non-discriminatory
basis, especially for vulnerable or marginalized groups;
(b) . To ensure access to the minimum essential food which is nutritionally adequate and safe, to
ensure freedom from hunger to everyone;
(c) To ensure access to basic shelter, housing and sanitation, and an adequate supply of safe and
potable water;
(d) To provide essential drugs, as from time to time defined under the WHO Action Programme
on Essential Drugs;
(e) To ensure equitable distribution of all health facilities, goods and services,
(0 To adopt and implement a national public health strategy and plan of action, on the basis of
epidemiological evidence, addressing the health concerns of the whole population, the strategy
and plan of action shall be devised, and periodically reviewed, on the basis of a participatory and
transparent process; they shall include methods, such as right to health indicators and
benchmarks, by which progress can be closely monitored; the process by which the strategy and
plan of action are devised, as well as their content, shall give particular attention to all vulnerable
or marginalized groups.
44. The Committee also confirms that the following are obligations of comparable priority.
(a) To ensure reproductive, maternal (pre-natal as well as post-natal) and child health care,
(b) To provide immunization against the major infectious diseases occurring in the community,
(c) To take measures to prevent, treat and control epidemic and endemic diseases;
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(d) To provide education and access to information concerning the main health problems in the
community, including methods of preventing and controlling them;
(e) To provide appropriate training for health personnel, including education on health and human
rights.
45. For the avoidance of any doubt, the Committee wishes to emphasize that it is particularly
incumbent on States parties and other actors in a position to assist, lo provide “international
assistance and cooperation, especially economic and technical" (29) which enable developing
countries to fulfil their core and other obligations indicated in paragraphs 43 and 44 above.
III. VIOLATIONS
46. When the normative content of article 12 (Part I) is applied to the obligations of Stales parties
(Part II), a dynamic process is set in motion which facilitates identification of violations of the
right to health. The following paragraphs provide illustrations of violations of article 12.
47. In determining which actions or omissions amount to a violation of the right to health, it is
important to distinguish the inability from the unwillingness of a State part}' to comply with its
obligations under article 12. This follows from article 12.1, which speaks of the highest attainable
standard of health, as well as from article 2.1 of the Covenant, which obliges each State party to
take the necessary steps to the maximum of its available resources. A State which is unwilling to
use the maximum of its available resources for the realization of the right to health is in violation
of its obligations under article 12. If resource constraints render it impossible for a State to
comply fully with its Covenant obligations, it has the burden ofjustifying that every effort has
nevertheless been made to use all available resources at its disposal in order to satisfy, as a matter
of priority, the obligations outlined above. It should be stressed, however, that a State party
cannot, under any circumstances whatsoever, justify its non-compliance with the core obligations
set out in paragraph 43 above, which arc non-derogable,
48. Violations of the right to health can occur through the direct action of States or other entities
insufficiently regulated by States. The adoption of any retrogressive measures incompatible with
the core obligations under the right to health, outlined in paragraph 43 above, constitutes a
violation of the right to health. Violations through acts ofcommission include the formal repeal or
suspension of legislation necessary for the continued enjoyment of the right to health or the
adoption of legislation or policies which are manifestly incompatible with pre-existing domestic
or international legal obligations in relation to the right to health.
49. Violations of the right to health can also occur through the omission or failure of States to
take necessary measures arising from legal obligations. Violations through acts of omission
include the failure to take appropriate steps towards the full realization of everyone’s right to the
enjoyment of the highest attainable standard of physical and mental health, the failure to have a
national policy on occupational safety and health as well as occupational health services, and the
failure to enforce relevant laws.
Violations of the obligation to respect
50. Violations of the obligation to respect are those State actions, policies or laws that contravene
the standards set out in article 12 of the Covenant and are likely to result in bodily harm,
unnecessary morbidity and preventable mortality. Examples include the denial of access to health
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facilities, goods and services to particular individuals or groups as a result of de jure or de facto
discrimination; the deliberate withholding or misrepresentation of information vital to health
* protection or treatment; the suspension of legislation or the adoption of laws or policies that
interfere with the enjoyment of any of the components of the right to health; and the failure of the
State to take into account its legal obligations regarding the right to health when entering into
bilateral or multilateral agreements with other States, international organizations and other
entities, such as multinational corporations.
Violations of the obligation to protect
51 Violations of the obligation to protect follow from the failure of a State to take all necessary
measures to safeguard persons within their jurisdiction from infringements of the right to health
by third parties. This category includes such omissions as the failure to regulate the activities of
individuals, groups or corporations so as to prevent them from violating the right to health of
others; the failure to protect consumers and workers from practices detrimental to health, e.g. by
employers and manufacturers of medicines or food; the failure to discourage production,
marketing and consumption of tobacco, narcotics and other harmful substances; the failure to
protect women against violence or to prosecute perpetrators; the failure to discourage the
continued observance of harmful traditional medical or cultural practices; and the failure to enact
or enforce laws to prevent the pollution of water, air and soil by extractive and manufacturing
industries.
Violations of the obligation to fulfil
52. Violations of the obligation to fulfil occur through the failure of States parties to take all
necessary steps to ensure the realization of the right to health. Examples include the failure to
adopt or implement a national health policy designed to ensure the right to health for everyone;
insufficient expenditure or misallocation of public resources which results in the non-enjoyment
of the right to health by individuals or groups, particularly the vulnerable or marginalized; the
failure to monitor the realization of the right to health at the national level, for example by
identifying right to health indicators and benchmarks; the failure to take measures to reduce the
inequitable distribution of health facilities, goods and services; the failure to adopt a gender
sensitive approach to health; and the failure to reduce infant and maternal mortality rates.
IV. IMPLEMENTATION AT THE NATIONAL LEVEL
7
Framework legislation
• 53. The most appropriate feasible measures to implement the right to health will vary
significantly from one State to another. Every State has a margin of discretion in assessing which
measures are most suitable to meet its specific circumstances. The Covenant, however, clearly
imposes a duty on each State to take whatever steps are necessary to ensure that everyone has
access to health facilities, goods and services so that they can enjoy, as soon as possible, the
highest attainable standard of physical and mental health. This requires the adoption of a national
strategy to ensure to all the enjoyment of the right to health, based on human rights principles
which define the objectives of that strategy, and the formulation of policies and corresponding
right to health indicators and benchmarks. The national health strategy should also identify the
resources available to attain defined objectives, as well as the most cost-effective way of using
those resources.
54. The formulation and implementation of national health strategies and plans of action should
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respect inter alia, the principles of non-discrimination and people's participation. In particular,
the right of individuals and eroups to participate in decision-making processes, which may affect
their development, must b? an integral component of any policy, programme or strategy
developed to discharge governmental obligations under article 12. Promoting health must involve
effective community action in setting pnorities, making decisions, planning, implementing and
evaluating strategies to achieve better health. Effective provision of health services can only be
assured if people's participation is secured by States.
55. The national health strategy and plan of action should also be based on the principles of
accountability, transparency and independence of the judiciary, since good governance is
essential to the effective implementation of all human rights, including the realization of the right
to health. In order to create a favourable climate for the realization of the right, States parties
should take appropriate steps to ensure that the private business sector and civil society are aware
of, and consider the importance of, the right to health in pursuing their activities.
56 States should consider adopting a framework law to operationalize their right to health
national strategy. The framework law should establish national mechanisms for monitoring the
implementation of national health strategies and plans of action. It should include provisions on
the targets to be achieved and the time-frame for their achievement; the means by which right to
health benchmarks could be achieved; the intended collaboration with civil society, including
health experts, the private sector and international organizations; institutional responsibility for
the implementation of the right to health national strategy and plan of action; and possible
recourse procedures. In monitoring progress towards the realization of the right to health, States
parties should identify the factors and difficulties affecting implementation of their obligations.
Right to health indicators and benchmarks
57. National health strategies should identify appropriate right to health indicators and
benchmarks. The indicators should be designed to monitor, at the national and international
levels, the State party's obligations under article 12. States may obtain guidance on appropnate
right to health indicators, which should address different aspects of the right to health, from the
ongoing work of WHO and the United Nations Children's Fund (UNICEF) in this field. Right to
health indicators require disaggregation on the prohibited grounds of discrimination.
58. Having identified appropriate right to health indicators, States parties are invited to set
appropriate national benchmarks in relation to each indicator. During the periodic reporting
procedure the Committee will engage in a process of scoping with the State party. Scoping
involves the joint consideration by the State party and the Committee of the indicators and
national benchmarks which will then provide the targets to be achieved during the next reporting
period In the following five years, the State party will use these national benchmarks to help
monitor its implementation of article 12. Thereafter, in the subsequent reporting process, the State
party and the Committee will consider whether or not the benchmarks have been achieved, and
the reasons for any difficulties that may have been encountered.
Remedies and accountability
59 Any person or group victim of a violation of the right to health should have access to effective
judicial or other appropriate remedies at both national and international levels. (3Q) All victims of
such violations should be entitled to adequate reparation, which may take the form of restitution,
compensation, satisfaction or guarantees of non-repetition. National ombudsmen, human rights
commissions, consumer forums, patients' rights associations or similar institutions should address
violations of the right to health-
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60. The incorporation in the domestic legal order of international instruments recognising the
< right to health can significantly enhance the scope and effectiveness of remedial measures and
should be encouraged in all cases. (3.1) Incorporation enables courts to adjudicate violations of
the right to health, or at least its core obligations, by direct reference to the Covenant.
61. Judges and members of the legal profession should be encouraged by States parties to pay
greater attention to violations of the right to health in the exercise of their functions.
62. States parties should respect, protect, facilitate and promote the work of human rights
advocates and other members of civil society with a view to assisting vulnerable or marginalized
groups in the realization of their right to health.
V. OBLIGATIONS OF ACTORS OTHER THAN STATES PARTIES
63. The role of the United Nations agencies and programmes, and in particular the key function
assigned to WHO in realizing the right to health at the international, regional and country levels,
is of particular importance, as is the function of UNICEF in relation to the right to health of
children. When formulating and implementing their right to health national strategies, States
parties should avail themselves of technical assistance and cooperation of WHO. Further, when
preparing their reports, States parties should utilize the extensive information and advisory
services of WHO with regard to data collection, disaggregation, and the development of right to
health indicators and benchmarks.
64. Moreover, coordinated efforts for the realization of the right to health should be maintained to
enhance the interaction among all the actors concerned, including the various components of civil
society. In conformity with articles 22 and 23 of the Covenant, WHO, The International Labour
Organization, the United Nations Development Programme, UNICEF, the United Nations
Population Fund, the World Bank, regional development banks, the International Monetary Fund,
the World Trade Organization and other relevant bodies within the United Nations system, should
cooperate effectively with States parties, building on their respective expertise, in relation to the
implementation of the right to health at the national level, with due respect to their individual
mandates. In particular, the international financial institutions, notably the World Bank and the
International Monetary Fund, should pay greater attention to the protection of the right to health
in their lending policies, credit agreements and structural adjustment programmes. When
examining the reports of States parties and their ability to meet the obligations under article 12,
the Committee will consider the effects of the assistance provided by all other actors. The
adoption of a human rights-based approach by United Nations specialized agencies, programmes
and bodies will greatly facilitate implementation of the right to health. In the course of its
examination of States parties' reports, the Committee will also consider the role of health
professional associations and other non-governmental organizations in relation to the States'
obligations under article 12.
65. The role of WHO, the Office of the United Nations High Commissioner for Refugees, the
International Committee of the Red Cross/Red Crescent and UNICEF, as well as non
governmental organizations and national medical associations, is of particular importance in
relation to disaster relief and humanitarian assistance in times of emergencies, including
assistance to refugees and internally displaced persons. Priority in the provision of international
medical aid, distribution and management of resources, such as safe and potable water, food and
medical supplies, and financial aid should be given to the most vulnerable or marginalized groups
of the population.
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Adopted on 11 May 2000.
Notes
1. For example, the principle oi non-discrimination in relation to health facilities, goods and
services is legally enforceable in numerous national jurisdictions.
2. In its resolution 1989/11.
3. The Principles for the Protection of Persons with Mental Illness and for the Improvement of
Mental Health Care adopted by the United Nations General Assembly in 1991 (resolution 46/119)
and the Committee's General Comment No. 5 on persons with disabilities apply to persons with
mental illness; the Programme of Action of the International Conference on Population and
Development held at Cairo in 1994, as well as the Declaration and Programme for Action of the
Fourth World Conference on Women held in Beijing in 1995 contain definitions of reproductive
health and women's health, respectively.
4. Common article 3 of the Geneva Conventions for the protection of war victims (1949);
Additional Protocol I (1977) relating to the Protection of Victims of International Armed
Conflicts, art. 75 (2) (a); Additional Protocol II (1977) relating to the Protection of Victims of
Non-Intemational Armed Conflicts, art. 4 (a).
5. See TOO Model List of Essential Drugs, revised December 1999, WHO Drug Information,
vol. 13, No. 4, 1999.
6. Unless expressly provided otherwise, any reference in this General Comment to health
facilities, goods and services includes the underlying determinants of health outlined in paras. 11
and 12 (a) of this General Comment.
7. See paras. 18 and 19 of this General Comment.
8. See article 19.2 of the International Covenant on Civil and Political Rights. This General
Comment gives particular emphasis to access to information because of the special importance of
this issue in relation to* health.
9. In the literature and practice concerning the right to health, three levels of health care are
frequently referred to: primary’ health care typically deals, with common and relatively minor
illnesses and is provided by health professionals and/or generally trained doctors working within
the community at relatively low cost; secondary health care is provided in centres, usually
hospitals, and typically deals with relatively common minor or serious illnesses that cannot be
managed at community level, using specialty-trained health professionals and doctors, special
equipment and sometimes in-patient care at comparatively higher cost; tertiary health care is
provided in relatively few centres, typically deals with small numbers of minor or serious
illnesses requiring specialty-trained health professionals and doctors and special equipment, and
is often relatively expensive. Since forms of primary, secondary and tertiary health care
frequently overlap and often interact, the use of this typology does not always provide sufficient
distinguishing criteria to be helpful for assessing which levels of health care States parties must
provide, and is therefore of limited assistance in relation to the normative understanding of article
12.
htip://www.unhchr.ch/tbs/d.../40d009901358b0e2c 1256915005090be?OpcnDocumen
9.5
15-Dcc-2000
JO. According to WHO, the stillbirth rate is no
longer commonly used, infant and under-five
mortality rates being measured instead.
before and after birth (inmedicaSSic! the^eriJd beST th th^ '° theper,od shor11y
gestation and is variously defined as ending one to four weekZafter biX^'1011
°f
covers the period perlaming to the first four weeks after birth- wh.leXz
\C°ntraSt’
occurrence after birth. In this General Commpm thrs
’
P°S
a denotes
exclusively employed.
Comment, the more generic terms pre- and post-natal are
12. Reproductive health means that women and me
men have the freedom to decide if and when to
reproduce and the right to be informed and to have
acceptable methods of famdy ptamtmj
■
chealth-care
hh“ services
SerV'CeS that will' for
f°r example, enable
•“
-re,yfhro.fgbCXnePyPZ,att
wtTh«^
m anenvironment of a quality that permits a life ofdign%'a“d welWe^TnSit"?’’ °f ''f''
developments in envimn^^SSS^SSS^?'^'
international law inrlnHtrtm r
> a 7 ,>
oe ng ’ as wel1 as °f recent
--healthy
”
14. ILO Convention No. 155, art. 4.2.
15. See para. 12 (b) and note 8 above.
16. For the core obligations, see paras. 43 and 44 of the present General Comments.
17. Article 24.1 of the Conventio>n on the Rights of the Child.
the Convention on Biological Diversity/ (1009^
United Nations Conierence on Environment and Develooment (19971 in
^tlicle 8 Q) of
i
20. See General Comment No. 13, para. 43.
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21. See General Comment No. 3, para. 9; General Comment No. 13,
para. 44.
22. See General Comment No. 3, para. 9; General Comment No. 13, para. 45.
BSSSF
or4allh P:“ al.XS^
b"”s' »r'b' —1
24. General Assembly resolution 46/119 (1991).
such a policy, and the provision of occupational health services with essentiallv nrovonti,,/
ftmcttons. See ILO Occupational Safety and Health Convention, 1981Z> !S/and
Occupational Health Services Convention, 1985 (No. 161).
26. Article II Alma-Ata Declaration, Report of the International Conference on f '
Primary Health
m
’ Series,
S SKSSS?1* 197S’in: 1"“
-Heald, Aii"
27. See para. 45 of this General Comment.
28. Rgport of the International Conference on Population and Development Cairo 5 13
.‘SS£^n("”devd,na,i“S““,ion’Sa'esNo E'95x,n''8)29. Covenant, art. 2.1.
31. See General Comment No. 2, para. 9.
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Right to Health in International Documents
Universal Declaration ol Human Kights, Article 25
Everyone has the right to a standard of ll^ndec'“^es'°g^ediil
SHo
disabiity.... Motberhood^hM^
ans entitled to seecialcareandassisiartce.
(nternadona, Covenanf on Economic, Social and CnifomInterna
the ddht oi everyone to^
Xua.e
and mental health. The steps to be tak^
Qhall include those necessary for th ----- nf all aspects of environmental
healthy development of thechild;
and control of epidemic,
Convention on the Elimination ot AH Forms ot Discrimination Agams.
Convention on
Women, Article 10, 12 and 14
. ed, national informatignto help to
State shall ensure to women
ensure the health and wellbeing of fami
,
against women in health cage
SXtteMS- State shall
to ensure, on a basis °* q'ftn7, IJ..I-',inj "P"i .re appronnate services in
Fhat wmeiliriJuraLare^have
cSaXi>i«es, induding information counseling
services in family planning.
Convention on the —of
States undertake to ehmtnate rac al
Qr ethnic ongin to
^X'bXTL mXt <o pubiic health, medicei care soeiai secunty
social service.
2.98.
Convention on the Rights of the Child, Article 24
.
States recognizes the right of the child the enjoyment of the highest attainab e
standards of health and to facilities for the treatment of illness, and rehabilitation
of health.
Constitutional Provisions Relating to Health
Unfortunately, in the Constitution of India, health is not a fundamental right of the
citizens. The provision of healthcare is contained in the Directive Principles and it
is a duty of the State to raise the level of nutrition and the standard of living and
to improve public health.
Fundamental Rights:
*Article 21: No person shall be deprived of his life or personal liberty except
according to procedure established by law
Directive Principles of State Policy
Article 39: The State shall, in particular, direct its policy towards securing; that
the health and strength of workers, men and women, and the tender age of
children be not abused and that citizens are not forced by economic necessity to
enter avocations unsuited to their age or strength.
Article 41: The State shall, within the limits of its economic capacity and
development, make effective provision for securing the right to work, to education
and to public assistance in cases of unemployment, old age, sickness and
disablement, and in other cases of undeserved want.
Article 42: The State shall make provision for securing just and humane
conditions of work and for maternity relief.
Article 47: The State shall regard the raising of the level of nutrition and the
standard of living of its people and the improvement of public health as among its
primary duties and, in particular, the State shall endeavor to bring about
prohibition of the consumption except for medical purposes of intoxicating drinks
and of drugs which are injurious to health.
CONVENTION ON THE ELIMINATION OF ALL FORMS OF
DISCRIMINATION AGAINST WOMEN
(Adopted by UN General Assembly in 1976)
"...the full and complete development of a country, the welfare of the
world and the cause of peace require the maximum participation of women
on equal terms with men in all fields "
CONTENTS
INTRODUCTION
Content and Significance of the Convention
1
PREAMBLE
4
PART I
Discrimination (Article 1)
’• • • •
Policy Measures (Article 2)
Guarantee of Basic Human Rights and Fundamental Freedoms
(Article 3)
.....
Special Measures (Article 4)
Sex Role Stereotyping and Prejudice (Article 5)
.
Prostitution (Article 6) .................................
6
7
7
7
PART II
Political and Public Life (Article 7)
Representation (Article 8)
Nationality (Article 9)
7
8
8
PART III
Education (Article 10)
Employment (Article 11 ) . . Health (Article 12)
Economic and Social Benefits
Rural Women (Article 14) ...
3
(Article 13)
6
6
8
9
10
10
10
PART IV
Law (Article 15)
Marriage and Family Life (Article 16)
11
12
PART V
Committee on the Elimination of Discrimination against Women
(Article 17)
National Reports (Article 18)
Rules of Procedure (Article 19)
Committee Meetings (Article 20)
Committee Reports (Article 21)
Role of Specialized Agencies (Article 22)
12
14
14
14
14
14
PART VI
Effect on Other Treaties (Article 23)
Commitment of States Parties (Article 24)
Administration of the Convention (Articles 25-30)
15
15
15
8oo
INTRODUCTION
On 18 December 1979, the Convention on the Elimination of All Forms of
Discrimination against Women was adopted by the United Nations General
Assembly.
it entered into force as an international treaty on 3
It
September 1981 after the twentieth country had ratified it. By the
tenth anniversary of the Convention in 1989, almost one hundred nations
have agreed to be bound by its provisions.
The Convention was the culmination
of more than thirty years of
work by the r
United Natiops Commission on the Status of Women, a body
established in
-a 194 6 to monitor the situation of women and to promote
women’s rights. The Commission’s
work has been instrumental in bringing
to light all the areas in which women are
denied equality with men.
These efforts for the advancement of women have resulted in several
declarations
and
conventions,
of
which
the
the
Convention
on
elimination of All T
•
Forms of- Discrimination
against Women is the central
and most comprehensive document.
Among the international human rights treaties,
the Convention
takes an important place in bringing the female half of humanity into
the focus of human rights concerns. The spirit of the Convention is
rooted m the goals of the United Nations:
to reaffirm faith in
fundamental human rights, in
in the dignity,and worth of the human person,
in the equal rights of men and women. The present document spells out
the meaning of equality and how it can be achieved. In so doing, the
Convention establishes not only an international bill of rights for
women, but also an agenda for action by countries to
guarantee the enjoyment of those rights.
In its preamble,
the Convention explicitly acknowledges
that
"extensive
C^J-Scrimination
against women continues
to exist” ,
and
emphasizes
that
such
discrimination
"violates
the
principles
the
of
equality of
<
rights and respect for human dignity
dignity”
”.. As defined in
article 1, discrimination is understood as "any
"any distinction,
distinction, exclusion
or restriction made o.l the basis of sex. ...in
. in the political,
political. economic,
social, cultural, ,
or any other field”. The Convention gives
positive affirmation to the principle of equality by requiring States
parties to take "all appropriate measures, including legislation, to
ensure the full development and advancement of women, for the purpose
of guaranteeing them the exercise and enjoyment of human rights and
fundamental freedoms on a basis of equality with men"(article 3).
The agenda for equality is specified in
in fourteen subsequent
articles. In its approach,
approach, the Convention covers three dimensions of
the situation of women.
women. Civil rights and the legal status of women are
dealt with in great detail. In addition, and unlike other human rights
treaties, the Convention is
is also concerned with the dimension of human
reproduction as well as with the imoact
impact of cultural
cultural factors on gender
relations.
The legal status of women receives the broadest attention,
Concern
over the basic rights of political participation has not
diminished
since the adoption of the Convention on the Political Rights
of Women
in 1952. Its provisions, therefore, are restated in article 7
of the
present document,
^ol
whereby women are guaranteed the rights to vote, to hold public office
and to exercise public functions. This includes equal rights for women
to represent their countries at the international level (article 8) .
The Convention on the Nationality of Married Women
adopted in 1957 is integrated under article 9 providing for the statehood of
women,
irrespective of their marital status, The Convention, thereby, draws
attention to the fact that often women ’ s legal status has been linked
to marriage, making them dependent on their
their husband's
husband's nationality
rather than individuals in their own right. Articles 10, 11 and
13,
respectively,
affirm women's
rights
to
non-discrimination
in
education, employment and economic and social activities. These demands
are <given special emphasis with regard to the situation of rural women,
whose particular struggles; and vital economic contributions, as noted
in article 14, warrant more attention in policy planning. Article 15
asserts the full equality of
of women
women in civil and business matters,
demanding that all instruments
directed at restricting women's legal
instruments directed
capacity ' 'shall be deemed null and void". Finally, in article 16, the
Convention returns to the issue of marriage and family relations,
asserting the equal rights and obligations of women and men with regard
to choice of spouse, parenthood, personal rights and command
over
property.
Aside from civil rights issues, the Convention also devotes major
attention to a most vital concern of women, namely their reproductive
rights. The preamble sets the tone by stating that "the role of women
in procreation should not be a basis for discrimination". The link
between discrimination and women's reproductive role is a matter of
recurrent concern in the Convention. For example, it advocates, in
article 5, ''a proper understanding of maternity as a social function",
demanding fully shared responsibility for child-rearing by both sexes.
Accordingly, provisions for maternity protection and child-care
are
proclaimed as essential rights and are incorporated into all areas
of
the Convention, whether dealing with employment, fami1y law, health
core or education. Society's obligation extends to offering social
services, especially child-care facilities that allow individuals to
combine family responsibilities with work and participation in public
life. Special measures for maternity protection are recommended and
"shall not be considered discriminatory". (Article 4). "The Convention
also affirms women’s right
right to
to reproductive
reproductive choice,
choice. Notably, it is the
only human rights treaty to mention family planning, States parties are
obliged to include advice on family planning in the education
process
(article 1 O.h) and to develop family codes that guarantee
women’s
rights "to decide freely and responsibly on the number
and spacing of
their children and to hove access to the information,
education and
means -*•••to enable them to exercise these rights" (article 16.e).
The third general thrust of the Convention aims at enlarging
enlarging our
understanding of the concept of human rights, as it gives
gives formal
recognition to the influence of culture and tradition on
on restricting
women’s enjoyment of their fundamental rights. These forces take shape
in stereotypes, customs and norms which give rise to the multitude of
legal, political and economic constraints on the advancement of women.
Noting this interrelationship, the preamble of the Convention stresses
"that a change in the traditional role of men as well as the role of
women in society and in the family is needed to achieve full equality
of men and women". States parties are therefore obliged to work towards
the modification of social and cultural patterns of individual conduct
ler to eliminate "prejudices and customary and all other practices
m orc
order
which are based on the idea of the inferiority or the
the superiority of
either of the sexes or on stereotyped roles for men and
and women"
women” (article
5) .
And Article lO.c.
mandates the revision of textbooks,
school
IO. c.
textbooks,
programmes and teaching methods with a view to eliminating stereotyped
concepts in the field of education. Finally, cultural patterns which
define the public realm as a man ' s world and the domestic sphere
as
women's domain are strongly
targeted in all of
the Convention's
provisions that affirm the equal responsibili ties of both sexes in
family lifei and their equal rights with regard to education and
employment.
Altogether,
the
Altogether,
Convention
provides
a
comprehensive
framework for challenging thei various forces that have created and
sustained discrimination based upon sex.
The inpiementation of the Convention is monitored by the Committee
on
the Elimination
of Discrimination against Women ;(CEDAW).
The
Committee's mandate and the administration of the treaty are defined in
the Articles 17 to 30 of the Convention. The Committee is
composed of
23 experts nominated by their Governments and elected by
the States
Pa2-^-^-es as individuals "of high moral standing and conpetence in the
field covered by the Convention".
At least every four years, the States parties are expected to
submit a national report to the Committee, findicating
'’
the measures they
have adopted to give effect to the provisions of the Convention,
---- -- During
its annual session, the Committee members discuss these
reports with
the Government representatives and explore with them areas
for further
action by the specific country. The Committee also
makes general
recommendations
to
the States parties on matters
concerning the
elimination of discrimination against women.
The
full
text
of
the
Convention
set
follow.
out
in
the
pages
that
********************************** w*<.***w***w<<it*w*<<
CONVENTION ON THE
WOMEN
ELIMINATION
OF ALL
FORMS
OF DISCRIMINATION AGAINST
The States Parties to the present Convention,
Noting that the Charter of the United Nations reaffirms faith
in
fundamental human rights, in the dignity and worth of the human
person
and in the equal rights of man
man and
and women.
women. Noting
Noting that
that the Universal
Declaration
of
Human
Rights
affirms
the
principle
Rights
affirms
the
principle
of
the
inadmissibility of discrimination and
and proclaims
proclaims that
that all human beings
are korn free and equal in
in dignity
dignity and
and rights
rights and
and that everyone is
entitled to all the rights
rights and
and freedoms
freedoms set
set forth
forth therein, without
distinction of any
kind,
.
kind, including
including distinction
distinction based
based on
on sex,
sex. Noting
that the States Parties to the International Covenants on Human
Rights have the obligation to ensure the equal right of men and women
to enjoy all economic, social, cultural, civil and political rights.
Considering the international conventions concluded under the auspices
of the United Nations and the specialized agencies promoting equality
of rights of men and women. Noting also the resolutions, declarations
and recommendations adopted by the United Nations and the specialized
agencies promoting equality of rights of men and women. Concerned,
n
t
however,
that
despite
these
various
instruments
extensive
di scrimina tion
against
women
continues
to
exist.
Recalling
tha t
discrimination against women
violates the principl es of equality of
rights
and
respect
for
human
digni ty,
is
an
obstacle
to
the
Participation of women, on equal terms wi th
men, in the political,
social, economic and cultural
life of their countries, hampers the
growth of the prosperity of
society and the family and makes more
dif f icul t the full development of
the potentialities of women in the
service
of
their
countries
and
of humanity,
Concerned
that
in
si tuations of poverty women have
the least access to food,
health,
education, training and
opportuni ties for employment and other
needs,
Convinced that the establishment
of the new international
economic
order based on equity and justice will
contribute sigriificantly towards
the promotion of equality between men and
.
women, Emphasizing that the
eradication
of
apartheid,
of
all
forms
racism,
racial
discriminati on,
colonialism,
neo-colonialism,
aggression,
foreign
occupation and dominati on and
interference in the internal affairs of
States is essential to the
full enjoyment of the rights of men and
women. Affirming that the
strengthening of international peace and
security,
relaxation of international tension,
mutual
tension,
mutual co-operation
among all States irrespective of their social and
social and economic systems,
general and <complete disarmament, and in particular
nuclear
di sarmamen t
under strict•and effective international control, the affirmation
of
the principl.es of justice, equality and mutual benefit in relations
among countries and the
and colonial domination ^nd^r10"
°f peoPles under alien
colonial domination and
and independence
as wel! f°re1^ occupation to self-determinatidn
independence, as well
territorial inteq'ntv will
sovereignty and
integrity,
as a con
Y' will
11 promote social progress and development and
^tween m
W111
to the attainment of full e^al^tv
women
,
a counXy^ thTTelfa^e^of “h that ^he ful1 and COraPlete development
of
the welfare of
xnaximu^ , particZation
the
participation
rticipation of women on equal terms with men in all
fields,
faZZ9 1", T
grSat contribution of women to the welfare
of the family and to the development of society, so far not fully
recognized, the social significance of maternity and the role of both
parents in the
role
of
wZ2 Y and
the upbrdnging of children, and aware that
the
role
of
discrimination bu
that "the^T^10"
"
baSis
responsibilitv
b
t
upbringing
of
children
requires
a sharing
of
chaZe in Z /"aT
“
d S°Ciety aS 3 whole'
and
that a change in the traditional role of men as well as the role of
of
women inmeZaZ
ociety
Y and in
10 tHe
is need
ed to achieve full equality
needed
between men and women,
_____
women, Detprrmnmri
Determined 4-zx
to implement
the principles set forth
in the Declaration
on the Elimination of Discrimination
against Women
and,
for that
PurPose r
to adopt
the measures
required for
the
elimination of such discrimination
in all its forms and manifestations,
Have agreed on the following:
PART I
Article 1.
FOr the purposes
of the present Convention,
the
the term
"discrimination against women"
shall mean any distinction, exclusion or
^-®striction made on the basis of
sex which has the effect or purpose of
impairing or nullifying the r
recognition, enjoyment or exercise by women
irrespective
their marital2 status, on a basis of
equality of men and
women, of human rights and
fundamental freedoms in the political,
economic, social. cultural,
civil or any other field. Article 2. States
S»
Parties condemn discrimination against women in all its forms; agree
to
pursue by all appropriate means
and without delay a policy
of
eliminating discrimination against women and, to this end, undertake(a)
To embody the principle of the equality of men and women in their
national constitutions or other appropriate legislation if not yet
incorporated therein and to ensure, through law and other
appropriate means, the practical realization of this principle;
(b) To adopt appropriate legislative
and other measures, inclndi ng
sanctions where appropriate, prohibiting all discrimination
against women;
(c) To establish legal protection
j_
of the rights of women on an equal
basis with men and to ensure through competent national tribunals
and other public institutions the effective protection of women
against any act of discrimination;
(d) To refrain from <engaging in any act or practice of discrimination
against women and to
-u ensure that public authorities and
institutions shall act in conformity with this obligation;
(e)
To take all <-appropriate
*
measures to eliminate discrimination
against women by
any
person,
- > organization or enterprise;
(f) To take all f
appropriate measures, including legislation, fto modify
’5
or abolish existing laws,, :regulations, customs and practices which
constitute discrimination against: women;
(g) To repeal all national penal provisions which constitute
discrimination against women.
Article 3. States Parties shall take in all fields,
in particular in
the political, social, economic
and cultural fields, all appropriate
measures, including legislation, to ensure the full
development and
advancement of women, for the
purpose of guaranteeing them the exercise
and enjoyment of human tights and fundamental freedoms on a
freedoms
basis of
equality with men.
Article 4.
1. Adoption by States Parties <of- temporary special measures
aimed at a ccelerating de facto equality between
men and women shall not
^>e considered discrimination
i as defined in the present Convention, but
shall in no way entail as a
consequence the maintenance of unequal or
separate standards;
these measures
measures shall
shall be
be discontinued
when the
objectives of equality of opportunity and treatment
have been achieved.
2. Adoption by States
Parties of special measures, including those
measures contained in the present Convention,
aimed at protecting
maternity shall not be considered
--•—I discriminatory.
Article 5.
(a)
3o5
States Parties shall take all appropriate measures:
To modify the social and cultural patterns of <
conduct of men and
women, with a view to achieving the elimination
.1 of prejudices and
customary and all other practices
-- ; which are based on the idea of
the inferiority or the superiority of either of the
sexes or on
stereotyped roles for men and women;
(b)
To ensure that family education includes
a proper understanding of
maternity as a social function and the
recognition of the common
. responsibility of men and women in the
upbringing and development
of their children, it being understood that
L2—c the interest of the
children is the primordial consideration in all
cases.
Article
6.
States
Parties
shall
take
all appropriate measures,
including legislation, to rsuppress all forms of traffic in
women and
exploitation of prostitutiona of women.
PART II
7.
States Parties shall take all
appropriate measures to
eliminate discrimination
against women in the political
and public life
of the country and, in
Particular, shall ensure to women, on equal
terms with men,the right:
(a) To vote in all
; ’ ' elections and public referenda and to be
eligibl e
for election
- to all publicly elected bodies;
(b) To participate in the formulation .
of government policy and the
inpiementation thereof and to hold
public office and perform all
public functions at all levels of government;
(c) To participate in r— --non-governmental organizations ;and associations
concerned with the public
. ‘ "Ij and political life of the
—e country.
Article 8. States Parties shall take all
appropriate measures to ensure
women, on equal terms with men and without
to women,
any discrimination, the
opportunity to represent their Governments at
and to participate in the work of international the international level
organizations.
Article 9.
1. States Parties shall
acquire, change
particular that
that
grant
women
equal
rights
nationality-
with
men
to
shall ensure in
change the nationality of the wife, render he- stateless or force
upon her the nationality of the husband.
2. States Parties shall grant
women equal rights
respect to the nationality of their children.
with
men
with
PART III
Article 10. States Parties
shall take all aPP^opriate measures to
eliminate discrimination
against women in order to ensure to them equal
eights with men in ^e field of education
and in particular to ensure
on a basis of equality of men and women:
a) The same <conditions tor
for career and vocational
guidance,
for
access
to
studies and for the achievement of
diplomas
in
educational establishments of all
categories in rural as well as
in urban areas; this equality shall
ensured in preschool,
general, technical, professional and higher technical
as well as in all types of vocational training;
education,
b) Access to the same curricula,
the same examinations,
teaching
staff with qualifications
of
the same
standard and
school
premises and equipment of the same quality;
c)
The elimination of any stereotyped concept of the roles of men
and women at all levels and in all forms of education by
encouraging coeducation and other types of education which will
help to achieve this aim and, in particular, by the revision of
textbooks and school programmes and the adaptation of teaching
methods;
d) The same opportunities
study grants;
to
benefi t
from
scholarships
and
other
e) The same opportunities for access to programmes of continuing
education including adult and functional literacy programmes,
particularly those aimed at reducing, at the earliest possible
time , any gap in education existing between men and women;
f)
The
reduction
of
female
organization of programmes
school prematurely;
g) The same opportunities
physical education;
to
student
drop-out
rates
for girls and women who
participate
actively
in
and
have
the
left
sports
and
h) Access to specific educational information to help to ensure the
health and well-being of families,
families,
including information and
advice on family planning.
Article 11. 1. States Parties shall take all appropriate measures to
eliminate discrimination against women in the field of employment in
order to ensure, on a basis of equality of ]men and women, the same
rights, in particular:
(a)
The right to work as an inalienable right of all human beings;
(b) The right to the same employment opportunities, including the
aPPlication of the same criteria for selection in matters of
einpl oyme nt;
(c)
The right to free choice of profession and employment, the right
to promotion, job security and all benefits and conditions of
se2rvice and the right to receive vocational training and
retraining, including apprenticeships, advanced vocational
training and recurrent training;
(d) The right to equal remuneration, including benefits, and to equal
treatment in respect of work of equal value, as well as equality
of treatment in the evaluation of the quality of work;
(e) The right to social security, particularly in cases of retirement,
unenployment, sickness, invalidity and old age and other
incapacity to work, as well as the right to paid leave;
307
■?
(f) The right to protection of health iand’ to
‘
safety in working
conditions, including the safeguarding of the function
--------------------------- -V A 1
O
reproduction.
2. In order to prevent discrimination against women on the grounds of
marriage or maternity and to ensure their effective right to work.
States Parties shall take appropriate measures:
(a) To prohibit, jsubject to the imposition of sanctions, dismissal on
the grounds of pregnancy or of maternity leave and discrimination
in dismissals <on the basis of marital status;
(b) To introduce maternity
i
•
leave with pay or with comparable social
benefits without loss
former employment, seniority or social
--- of
_ ------allowances;
(c) To encourage the provision of the necessary supporting social
services to enable ]parents
-to combine family obligations with work
responsibilities and participation in public life/ in particular
through promoting the establishment and development of a network
of child-care facilities;
(d) To provide special protection to women- during pregnancy in types
of work proved to be harmful to them.
3. Protective legislation relating to matters covered in this article
shall
be
reviewed periodically
in
the light of
scientific
and
technological knowledge and shall be revised, repealed or extended as
necessary.
Article 12. 1. States Parties shall take all appropriate measures to
eliminate discrimination against women in the field of health care
in
order to ensure, on a basis of equality of men and women, access
to
health care services, including those related to family planning.
*
2. Notwithstanding the provisions of paragraph 1 of this article,
States Parties shall ensure to women appropriate services in connexion
with pregnancy, confinement and the post-natal period, granting free
services
where
necessary,
as
well
as
adequate
nutrition
during
pregnancy and lactation.
Article 13. States Parties shall take all appropriate measures
to
eliminate discrimination against
against women in other areas of economic and
social life in order to ensure,
ensure t on a basis of equality of men and
rights t in particular:
women, the same rights,
(a) The right to family benefits;
(b) The right to bank loans, mortgages and other forms of financial
credit;
(c) The right to participate in recreational activities, sports and
all aspects of cultural life.
Article 14.
1.
States Parties shall take into account the particular
problems faced by rural women and
the significant roles which rural
women play m the economic survival
of their families, including their
work in the non-monetized sectors
of the economy, and shall take all
appropriate measures to ensure the application of the
provisions of
this Convention to women in rural areas.
2. States Parties shall take all appropriate
measures to eliminate
discrimination .against women in
rural areas in order to ensure
on a
basis of cequality of men and
women, that they participate in and
benefit from
—i :rural development and. in particular, shall ensure
to such
women the right:
(a) To participate in the
‘
’ ’
elaboration
and implementation of
development planning at all levels;
(b) To have access to adequate health care facilities, including
information, counselling and services in family planning;
(c) To benefit directly from social security
programmes;
) To obtain all types of training and education, formal and nonformal,including that relating to functional literacy, as well as,
inter alia, the benefit of all community and extension services,
m order to increase their technical proficiency;
(e) To organize self-help groups and co-operatives in order to obtain
equal access to economic opportunities through en^loyment or
seif-employmen t;
(f)
To participate in all community activities;
(g) To have access to agricultural credit and loans, marketing
facilities, appropriate technology and equal treatment in land and
agrarian reform as well as in land resettlement schemes;
(h) To enjoy adequate living <conditions,
'
, particularly in relation to
housing, sanitation, electricity and water supply,
, transport and
communications.
PART IV
Article 15.
1■ States Parties shall accord to women equality with
men
before the law.
2. States Parties shall accord to women, in civil
matters, a legal
capacity identical to that of men and the same
opportunities to
e*ercise that capacity. In P^j-ticular, they shall give women
equal
rights to conclude contracts and to administer property and shall
treat
them equally in all stages of procedure
in courts and tribunals.
3. States Parties ragree that all contracts and all other private
instruments of any kind withi a legal effect which is directed at
restricting the legal capacity of women shall be deemed null and void.
4. States Parties shall accord to men and women the same rights with
regard to the law relating to the movement of persons and the freedom
to choose their residence and domicile.
Article 16. 1. States Parties shall take all appropriate measures to
eliminate discrimination against women in all matters relating to
marriage and family relations and in particular shall ensure, on a
basis of equality of men and women:
(a) The same right to enter into marriage;
(b) The same right freely to choose a spouse and to enter into
marriage only with their free and full consent;
Me) The same rights and responsibilities during marriage and at its
dissolution;
w (d) The same rights and responsibilities as parents, irrespective of
their marital status, in matters relating to their children; in
all cases the interests of the children shall be paramount;
(e) The same rights to decide freely and responsibly on the number and
spacing of their children and to have access to the information,
education and means to enable them to exercise these rights;
(f) The same rights and responsibilities with regard to guardianship,
wardship, trusteeship and adoption of children, or si mi lay
institutions where these concepts exist in national legislation;
in all cases the interests of the children shall be paramount;
(g) The same ;personal rights as husband and wife, including the right
to choose; a family name, a profession and an occupation;
(h) The same rights for both spouses in respect of the ownership,
acquisition, management, administration, enjoyment and disposition
property, whether free of charge or for a va 1 nabl e
consideration.
2. The betrothal and the marriage of a child shall have no legal
effect, and all necessary action, including legislation, shall be taken
to specify a minimum age for marriage and to make the registration of
marriages in an official registry compulsory.
PART V
Article 17.
•
For
the
purpose
of
considering
the
progress
made
in
the
implementation of the present Convention, mere
there snaxx
shall i>e
be established
established a
Committee
on
the
Elimination
of
Discrimination
against
Women
Discrimination
against
(hereinafter referred to as the Committee) consisting, at
at the
the time of
entry into force of the Convention, of eighteen and, after ratification
of or accession to the Convention by the thirty-fifth State Party, of
twenty-three experts of high moral standing and competence in the field
covered by the Convention. The experts shall be elected by States
Part*es from among their nationals and shall serve in their personal
capacity,
consideration
being
given
to
equitable
geographical
'blo
distribution
and
to
the
representation
of
the different
civilization as well as; the principal legal systems.
forms
of
2 . The members of the Committee shall be elected by
secret ballot from
a list of persons nominated by States Parties,
Each State Party may
nominate one person from among its own nationals.
3. The initial election shall be held six months after
the date of the
entry into force of the present Convention.
At least three months
before the date of each election the Secretary-General of the United
Nations shall address a letter to the States Parties inviting them to
submit their nominations within two months. The Secretary-General shall
in alphabetical order of all persons thus
States
Parties which have nominated them,
them.
submit it to the States Parties.
prepare a list
indicating the
nominated,
and
shall
4 . Elections of the members of the Committee shall be held at a ]
meeting
of States Parties convened by the Secretary-General at United Nations
Headquarters.
At that meeting,
for
for which two thirds of the States
Parties shall constitute a
quorum,
a quorum, the persons elected to the Committee
shall be those nominees
nominees who
who obtain
obtain the largest number of votes and an
absolute majority of the votes of the representatives
*.
----- • of States Parties
present and voting.
5. The members of the Committee shall be elected for a term of four
years.However, the terms of nine of the members elected at the first
election shall expire at
at the
the end of two years;
immediately after the
first election the names
names of these nine members shall
be chosen by lot
by the Chairman of the Committee.
6. The election of the five additional members of the Committee shall
be held in accordance with the provisions of paragraphs 2, 3 and 4 of
2,
this article, following the thirty-fifth ratification or accession. The
or accession.
terms of two of the additional members elected on this occasion shall
expire at the end of two years, the names of these
two members having
been chosen by lot by the Chairman of the Committee.
*7- For the
has ceased
filling of casual vacancies,
to function as a member of
expert from among its nationals,
Committee.
the State Party whose expert
the Committee shall appoint
subject to the approval of the
8. The members of the Committee shall, with the approval of the General
Assembly,
receive emoluments from United Nations resources on such
terms and conditions as the Assembly may decide, having regard to the
importance of the Committee’s responsibilities.
9.
The
Secretary-General
of
the United Nations
shall
provide
necessary staff and facilities for the effective performance of
functions of the Committee under the present Convention.
the
the
18. 1. States Parties undertake to submit
to the Secretary—
of the United Nations, for consideration by the Committee, a
report on the legislative, judicial, administrative or
other measures
which they have adopted to give effect to he provisions
of the present
Convention and on the progress made in this respect:
Article
31/
(a)
Within
concerned;
and
one
year
the
after
entry
into
force
for
the
State
(b). Thereafter at least every four years and further whenever the
Committee so requests.
2. Reports may indicate factors and difficulties affecting the degree
of fulfilment of obligations under the present Convention.
Article 19.
1. The Committee shall adopt its own rules of procedure.
2. The Committee shall elect its officers for a term of two years.
Article 20. 1. The Committee shall normally meet for a period of not
more than two weeks annually in order to consider the reports submitted
in accordance with article 18 of the present Convention.
2. The meetings of the Committee shall normally be held at United
Nations Headquarters or at any other convenient place , as determined by
the Committee.
Article 21. 1. The Committee shall, through the Economic and Social
Council, report annually to the General Assembly of the United Nations
on its activities and may make suggestions and general recommendations
based on the examination of reports and information received from the
States Parties. Such suggestions and general recommendations shall be
included in the report of the Committee together with comments, if any,
from States Parties.
2. The Secretary-General shall transmit the reports of the Committee to
the Commission on the Status of Women for its information.
Article
22.
The
specialized
agencies
shall
be
entitled
to
be
represented
at
the
consideration
of
the
implementation
of
such
provisions of the present Convention as fall within the scope of their
activities. The Committee may invite the specialized agencies to submit
reports on the implementation of the Convention in areas falling within
the scope of their activities.
PART VI
Article 23. Nothing in this Convention shall affect any provisions that
are more conducive to the achievement of equality between men and women
which may be contained:
(a) In the legislation of a State Party; or
(b) In any other international
force for that State.
convention,
treaty
or
agreement
in
Article 24. States Parties undertake to adopt all necessary measures at
the national level aimed at achieving the full realization of the
rights recognized in the present Convention.
31^
Article 25.
all States.
1.
The present
Convention
shall
be
open
for signature
by
2. The Secretary-General of the United Nations is designated as the
depositary of the present Convention.
3. The present Convention is subject to ratification.
Instruments of
ratification shall be deposited with the Secretary-General of the
United Nations.
4.
Present Convention shall be open to accession by all States.
Accession shall be effected by the deposit of an instrument
accession with the Secretary-General of the United Nations.
of
Article 26. 1. A request for the revision of the present Convention may
be made at any time by any State Party by means
means of
of a
a notification in
addressed to the Secretary-General of the United Nations.
2- The General Assembly of the United Nations shall decide
s^ePs' if any/ to be taken in respect of such a request.
upon
the
Article 27• 1- The present Convention shall enter into force on the
thirtieth day after the date of deposit with the Secretary-General of
the United Nations of the twentieth instrument of ratification or
accession.
2. For each State ratifying the present Convention or acceding to it
after the deposit of the twentieth instrument of ratification or
accession, the Convention shall enter into force on the thirtieth day
after the date of the deposit of its own instrument of ratification or
accession.
Article 28.
1.
The Secretary-General of the United Nations shall
receive and circulate t° all States the text of reservations made by
States at the time of ratification or accession.
2. A reservation incompa
tible with the
incompatible
present Convention shall not be permitted.
object
and
purpose
of
the
3. Reservations may be withdrawn at any time by notification to this
effect addressed to the Secretary—General of the United Nations, who
shall then inform all States thereof. Such notification shall take
effect on the date on which it is received.
Article 29.
1.
Any dispute between
two or more States Parties
concerning the interpretation or application of the present Convention
which is not settled by negotiation shall, at the request of one of
them, be submitted to arbitration, If within six months from the date
of the request for arbitration the parties are unable to agree on the
°^‘Cfanization of the arbitration, any one of those parties may refer the
dispute to the International Court of Justice by request in conformity
with the Statute of the Court.
2. Each State Party may at the time of signature or ratification of
this Convention or accession thereto declare that it does not consider
itself
3(2)
bound by paragraph 1 of this article, The
other States Parties shall
not be bound by that paragraph with respect to
any State Party which
has made such a reservation.
3. Any State Party which has made a
reservation in accordance with
paragraph 2 of this article may at any time withdraw that reservation
by notification to the Secretary-General
- of the United Nations.
Article 30.
The present Convention,
the Arabic,
Chinese
p
French,Russian and Spanish texts of which are equally authenticEnglish,
, shall
be deposited with the Secretary-General of the United Nations.
IN WITNESS WHEREOF the undersigned, duly authorized, have signed the
present Convention.
y
t
.
. .....
...------- ---- - - -- - ---
TARSHI. (2001). Common Ground: Sexuality. Principlesfor Working on Sexuality. New Delhi: TARSHI
and SIECUS, pp. 7-8.
7
(#■
Sexual rights
“Sexual rights are a fundamental element of human rights. They
encompass the right to experience a pleasurable sexuality, which
is essential in and of itself, and, at the same time, is a
fundamental vehicle of communication and love between people.
Sexual rights include the right to liberty and autonomy in the
responsible exercise of sexuality. ”
j
- HERA Statement
Because sexuality is a basic part of being human, the notion of
sexual rights is part of the larger body of human rights. Human
rights affirm the dignity, worth, respect, equality, and autonomy
of all people in all aspects of their lives. Sexual rights are
necessary' in order for women and men to express and enjoy their
sexuality, and promote overall health through access to
information, education and services regarding their sexual health.
Human rights affirm
the dignity, worth,
respect, equality,
and autonomy of all
people in all
aspects of their
lives. Sexual rights
are necessary in
Therefore.
order for women
and men to express
Sexual rights are not privileges or favours, but are
entitlements of all women and men.
and enjoy their
sexuality...
■
?
►
Sexual rights protect the individual as well as the
collective.
The concept of sexual rights, like that of human rights,
provides a framework to ensure non-discrimination, and
therefore cannot be used to privilege any one individual or
group over another.
► Sexual rights are as valid as other rights such as the right to
food, health and housing.
►
Sexual rights affirm entitlements, such as the right to
bodily integrity, as well as rights that protect against
violations, such as the right not to be coerced into sexual
activity.
315
I
8
I
Sexual rights are based on certain ethical principles
(Correa and Petchesky). These are the principles of:
Bodily Integrity - the right to security in and control over
one's body. This means that all women and men have a right
to not only be protected from harm to the bodv but also to
enjoy the full potential of the body.
Personhood - the right to self-determination. This means
that all women and men have a right to make decisions for
themselves.
a
Equality - all people are equal and should be recognized as
such without discrimination based on age, caste, class,
ethnicity, gender, physical ability, religious or other beliefs,
sexual preference, or other such factors.
Diversity respect tor difference. Diversity in terms of
people's sexuality and other aspects of their lives should not
be a basis for discrimination. The principle of diversity
should not be misused to violate any of the pre\ ious three
ethical principles.
•
■
■
■
Sexual Rights Include:
1 . " The right to sexual pleasure without fear of infection, disease, unwanted pregnancy, or harm.
- The right to sexual expression and to make sexual decisions that are consistent with one’s
personal, ethical and social values.
The right to sexual and reproductive health care, information, education, and services.
The right to bodily integrity and the right to choose if, when, how and with whom to be
sexually active and engage in sexual relations with full consent.
The right to enter relationships, including marriage, with full and free consent and without
coercion.
The right to privacy and confidentiality in seeking sexual and reproductive health care
services.
The right to express one’s sexuality without discrimination, and independent of reproduction.
31G
Sami, L. (2001, July-October). A Summary of the National Population Policy and the State Population
Policies of Uttar Pradesh9 Madhya PRadesh, Rajasthan, Maharashtra and Andhra Pradesh. Medico
Friend Circle Bulletin, Special Issue on Population, 286-288-89, pp. 2-6.
2
mfc bulletin / jul-oct 2001
A Summary of the National Population Policy and the
State Population Policies of Uttar Pradesh, Madhya
Pradesh, Rajasthan, Maharashtra, and Andhra Pradesh
''s
.
Leela Sami
? ■ rv.
- -‘
K
This paper seeks to summarize the population
planning, the empowerment of women for
policies of five Indian states; namely, Uttar Pradesh,
population stabilisation, child health and survival,
Madhya Pradesh, Rajasthan, Maharashtra and
collaboration with the voluntary and NGO sector,
Andhra Pradesh. In the year 2000, the Government
and encouragement of research in contraceptive
of India released the National Population Policy
technology.
. ri.~ \•;:
(NPP) docdmenl
document which made an 'explicit
explicit
■J
commitment to” voluntary and informed
infornKd choice and UIInulucl
„lc lIIC
orderlutoplullI
promote
the policy,„itus[s
listsaanumDer
numberOI
of
availmg'of^eproducttyeg f measures; iThese^d^ew^rding of Panchayats
and Child Health (RCH) services and continuation
and Zilla
Zula Parishads
Panshads for exemphry
exemplary performance in jgwL
of the target free approach in administering family
Family Welfare and maternity benefits for mothers ® -5
planning services.”
U/ho O1VP Kirth trt
fife#
who give birth to their first
child after the nna
age nf
of ■f
nineteen. Also, a family welfare-linked social
The NPP also acknowledges a “need to
insurance is to be given to couples below the
simultaneously address issues of child survival,
Poverty Line with two or less children who
maternal health and contraception, while increasing
undergo sterilisation. The government proposes to
outreach and coverage of a comprehensive package
reward couples who marry after the legal age at
of RCH services by government, industry and
marriage, register their marriage, have their first
voluntary NGO sectors working in partnership.”
child after the age of 21 years, accept the small
family norm and adopt a terminal method after the
The NPP lists its objectives in terms of three time
birth of their second child. It is also proposed to
frames: its immediate objective is to address unmet
have a revolving fund for income generating
needs for contraception, healthcare infrastructure
activities by village level self help groups who
and health personnel and to provide integrated
provide community health care services, the
service delivery for basic reproductive and child
establishment of creches and child care centres in
A
health. The medium term objective is to bring the
rural areas and the urban slums, a wide choice of
I
TFR back to replacement level by 2010, through
contraceptives, facilities for safe and legal abortion,
vigorous implementation of intersectoral operational
and vocational training for girls.
2
strategies. The long- term objective is to achieve a
stable population by 2045,at a level consistent with
1
One of the central features of the policy is a
the requirements of sustainable economic growth,
commitment to a target- free approach and a refusal
social development and environmental protection.
to use disincentives or coercion in order to achieve
the demographic goals set by the state. The NPP
In pursuance of these objectives, the NPP lists
also stresses the need for involvement of local
fourteen sociodemographic goals to be achieved at
bodies at the lowest level- i.e. the Panchayati Raj
an all- India level by 2010. These include
Institutions (PRI’s)-in the achievement of the goals
addressing the unmet need for basic RCH services,
that make for population stabilization. It suggests
supplies and infrastructure, increasing access to
the devolution not only of rights, responsibilities and
schooling, reduction in Infant Mortality Rates
powers to the PRI’s but also of funds and resource
(IMR) and Maternal Mortality Ratio (MMR),
generation. This latter is extremely critical in order
uni versalisation of immunization, delayed marriage
for decision making to be truly decentralised. In
for girls, universalising delivery by trained
doing so, the NPP extends the scope of population
*
personnel and increasing the number of institutional
policy to a broader notion of democracy and
deliveries, achieving a delayed average age at
welfare.
marriage for girls, increased access to information
and counselling, universal registration of vital
With the NPP as the background, we move on to
events, control of communicable diseases,
examine the state level policies.
convergence of RCH programmes and Indian
Systems of Medicine and Homeopathy(ISMH), and
convergence of different social sector
Leela Sami is a research scholar. Centre for Social
programmes.
Medicine and Community Health, Jawaharlal Nehru
University, New Delhi
The NPP stresses the need for decentralised
1
_________________ •.
- /•
•«*
•
••
4
I
o
3\7
I
3
mfc bulletin / jul-oct 2001
1.Uttar Pradesh:
1
The population policy of Uttar Pradesh links the
growth of population to pressure on natural
resources, and declares the inability of the state
and its government to improve the quality of life of
the people, in the face of this pressure of population
growth. It mentions the need to address issues of
gender and child development in the attempt to
stabilise population growth.
In terms of its specific objectives, the following are
mentioned:
The need to reduce TFR from 4.3 in 1997 to>2.6
in 2011 -2016.
•
J-,;
i
-■ -i- "-
-
v H
...
Proportionate increases in use of contraceptive
methods by increasing demand for the same. .
Increase in average age of the mother at the birth
of her first child.
Reduction in unmet need for both spacing and
terminal methods.
Reduction in MMR from 707/ 1000,000 live
births in 1997 to 394 in 2010 to below 250 in
2016.
Reduction in infant mortality from 85/1000 live
births in 1997 to 73 in 2010 and 67 in 2016.
Reduction in incidence of sexually transmitted
diseases (STI’s) and reproductive tract infections
(RTFs).
Increase awareness of AIDS.
The strategies to be adopted to improve RCH
include raising the average age of effective
marriage, introducing and focusing on adult
education, empowerment of women and enhancing
the involvement both of the private and voluntary/
NGO sector and the role of PRI’s.
The policy lists a number of incentives and
disincentives to achieve its objectives, which
include some of the following:
Disqualification of persons who marry before the
legal age at marriage from eligibility for
government jobs.
“Performance- based “ disbursement of 10 per
cent of the total financial resources for PRI’s.
Panchayals which “perform” well in the provision
of RCH services will be rewarded. While the total
transfer of funds will amount to only four per
cent of state revenue, the PRI’s are to be entirely
responsible for advocacy, identification of
contraceptive needs and recording of vital events.
2 2^T^eLperformanco of^ m^cal <ficers:and
workers is to be based on their performance m the
RCH programme. While ostensibly, this would
mean more efficient RCH services, it would
perhaps place extreme pressure on health workers
to reach targets with regard to limiting of family
size. Also, linking performance appraisal of
individuals to performance in RCH would
probably result in lopsided health services
provision, leading to an overemphasis on family
planning and a neglect of other aspects of primary
health care such as control of communicable
diseases.
The document also calls for “an active dialogue
with the GQI for wider availability of injectables and
other- new technologies through private,
commercial and government channels in the state”.
The. statelhus i^nfls Jo actively push .the
intr^uction-ofthe^n^
ybuliri
el
1
1; r~-
df
. StfWV.'
Finally, the explicit commitment to charging user
fees ostensibly to improve the quality of services
will place a further burden on the poor to pay for
the entire gamut of health services. The decision of
the government to disallow those who marry
before the legal age and who have more than two
children from government service will adversely
affect women who may have no say in their age at
marriage. In this case, even the implementation of
33% reservation for women in elected bodies and
employment will not necessarily result in greater
gender equity, except in a narrow sense for some
sections of women.
2. Madhya Pradesh
The population policy of Madhya Pradesh stresses
the need to curb high fertility and mortality, which
impinge upon the quality of life and the balance
between population, resources and the
environment. The policy document mentions the
process of democratic decentralisation underway
in the state ancFspeaks of the need to change the
thrust of family welfare from female sterilization to
include raising the age at marriage for women,
provision of RCH services, universalization of
education and empowerment of women.
The specific objectives of the MP policy include:
Reducing total fertility rates from 4 in 1997 to 2.1
in 2011.
Increasing contraceptive usage and sterilisation
services.
Increasing the age of the mother at the birth of her
first child from 16 years in 1997 to 20 years in
2011.
Reduction in MMR from 498 to 220 between
1997 and 2011 through greater registration of
pregnant women, increases ir proportions of
318
4
mfc bulletin / jul-oct 2001
testing*^”3! and tra‘ne<^ de*‘ver*es an<h*regnancy
Reduction in IMR through increases in
Jnp ^T,On’ USerOf OraI Rehydration Solution
(OKS) therapies for diahorrea in rural areas
reduction in incidence of Acute Respiratory
In?Ci!^jS
coverage of pregnant women
u[en WIth Vitamin A, Iron and Folic Acid
(IrA) tablets.
The p^uhnon policy of Rajasthan, like those of i
Madhya Pradesh and Uttar Pradesh, also links d
deceleration in the population growth rate to i
sustainable development. It mentions the need to 1
reduce infant mortality, gender discrimination and 1
undemutntion, and to increase household security. 1
Increases in levels of HIV testing.
With regard to its specific objectives, it mentions
Services for infertile couples.
Universalizing access to primary education by
2005; with a goal of ensuring that 30% of girls in
the age group of 14-15 years in 2005 would
complete elementary education.
The strategies advocated by the policy document
include the need td involve PRTs, and to empower
^omen in the endeavour to reach population
stabilisation. A number of initiatives are suggested
making men realize their responsibility to
empower women.
strengthening local women’s groups.
reducing the burden of housework and drudgery
on women by providing cooking gas connections
and electricity to rural households.
women3'00 °f 3°% of government jobs for
lhe mp P„,icy
disincentives. These include
h„.a number
„mber of
Debarring of persons who marry before the legal
age for marriage from seeking government
employment.
Persons who have more than two children will be
debarred from contesting Panchayat elections.
The provision of rural development schemes in
villages will depend upon the level of family
planning performance by Panchayats. The flow of
resources to PRI’s is also to be linked to
performance in RCH. While there is no specific
commitment to increasing devolution and control
of resources to PRI’s, these institutions are to be
made responsible for the implementation iof the
KCH programme.
^rformance by Panchayats in family planning is
also to be linked to the starting of income
generating schemes for women and poverty
alleviation programmes.
319
I
The need to increase the median age at marriage I
for girls from 15 in 1993 to 19 by 2010 through I
education and increasing awareness.
1
Increase institutional deliveries from 8% in 1995 1
to 35% by 2016 and assistance by trained persons I
in child delivery from 35% in 1995 to 75% iin ff
* 2010.^
V"
Educate all women in the reproductive age
groups about antenatal services and on
establishing linkages between female health
workers, anganwadi workers and trained dais at
the village level.
I
Improved child health is to be achieved through
assuring better quality ARI care, strengthening
links between ICDS and health workers, and
coverage of all children for immunization and
Vitamin A dosage.
With regard to operational strategies, it mentions the
need5° encourage men to use low-cost sterilization
improved. While the thrust of the policy is on
provision of RCH services, improvement of 1
management of service delivery systems a
encouraging involvement of PRI’s, NGO’s the |
private sector,and co-operatives , and on fl
information, education and communication (IEC). 9
There are, however, a number of incentives.and ® \
disincentives mentioned, which include the 1 ’
debarring of persons with two or more children fl
from contesting elections. It is also mentioned that 8
the same provisions can .be considered for other 3
elected bodies like co-operative institutions and as »
a service ^condition for state government
employees.” The policy also states that “the legal
provisions barring people with more than two
cni Idren from election to panchayats and municipal
bodies is a testimony of the firm political will and
commitment to population control.”
The policy is cautious on the question of introducing
new reproductive technologies, although the policy
draft mentions that “ new contraceptive methods,
as and when approved by the GOI will be I
introduced to make new technology accessible.” I
_ mally, it mentions the need to address issues of 1
infertility, RTFs and female literacy.
e
I
I
5
mfc bulletin / jul-oct 2001
4. Maharashtra
1
unemployment. ...there will be serious pressure on
the country’s natural resources causing
deforestation, desertification and more natural
calamities.”
■
The population policy of Maharashtra begins with
a statement of the need to bring down the rate of
population growth. Its specific objectives include:
Reducing TFR to 2.1 by 2004.
The demographic goals as stated in the policy
include:
Reducing CBR to 18 by 2004.
Reduction of natural growth rate from 1.44 in
1996 to 0.80 in 2010 and 0.70 by 2020.
Reducing IMR to 25 by 2004.
Reduction in CBR from 22.7 in 1996 to 15.0 by
2010 and 13.0 by 2020.
Reduction in CDR from 8.3 in 1996 to 7.0 in 2010
and 6.0 in 2020.
Reduction in IMR from 66.0 in 1996 to 30.0 in
2010 and 15.0 in 2020.
j?..
Reduction in MMR from 3.8 in 1996 to 1.2 in
Reducing neonatal mortality to 2 by 2004.
The policy extract lists a number of measures in
order to achieve these objectives. These include:
i
ii
ij
I
The provision of subsidies and perquisites to
government employees is to be linked to
acceptance of the small family norm or Derrno^ent
methods of family planning by couples. "'
Service in government jobs is also to be
dependent on the acceptance of the small family
norm.
Provision of village health schemes will also be
linked to the performance of panchayats in the
RCH programme.
Assessment of medical officers will depend upon
their level of performance in the RCH programme.
Reduction in TFR from 2.7 in 1996 to L5 in 2020
Increase in Couple Protection Rate from 48.8 %
in 1996 to 70 % in 2010 and 75 % in 2020.
I
Other schemes include cash incentives to couples
undergoing sterilization after the birth of one or
more daughters, training of dais, and strict
enforcement of the Child Marriage Restraint Act,
the ban on prenatal sex determination testing, etc.
Also, women’s self- help groups are to be set up
at the village level.
Funding of PRI’s will depend upon performance
in the RCH programme.
I
I
I
1
I
(
I
I
(e)
Eradicating polio, measles and neonatal
tetanus by 1998.
(f)
Reducing diahorreal deaths, deaths due to
ARI’s and incidence of low birth weight babies.
(
(g)
Increasing female literacy levels,
increasing the median age at marriage for girls and
reduction in severe and moderate malnutrition
among children.
Reduction in the incidence of child labour.
(h)
The policy makes no provision for the
representation of women in elected or other bodies.
It also does not mention the devolution of
resources or decision- making powers to PRI’s.
The Andhra Pradesh population policy links
population stabilization to improvements in
standards of living and quality of life of the people.
It states that “production of food may not keep
pace with growing population....pressure on land
and other facilities will increase further, resulting m
social tension and violence... housing in both rural
and urban areas will become a serious
problem...there will be an increase in1
!
These objectives are to be attained by:
(a)
The promotion of spacing, terminal and
male contraceptive methods.
Increasing the coverage of pregnant
(b)
women for TT inoculation and provision of EFA
tablets.
(c)
Increasing the number of trained and
institutional deliveries.
(d)
Strengthening of referral systems and
equity in accessibility of services.
Persons having two or more children will be
debarred from contesting panchayat elections.
5. Andhra Pradesh
i
.
The policy lists a number of operational strategies
relating to promotion of terminal and spacing
methods, ensuring safe deliveries as well as safe
abortions, prevention and management of RTFs
and STD’s, increasing the average age at marriage
of girls, and increasing female literacy and child
survival. It also mentions a role for NGO’s and the
private sector in social marketing of contraceptives
and delivery of health care.
The document explicitly lists a number of incentives
i
32-0
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I
mfc bulletin / jul-oct '2001
lo be used, ity the^achieycment of-its-ot^ectivc&r — (coiit.d-frompage. 14)— - —
These include the following: h < a
development processes have a direct impact on ■
poverty and community health, giving rise to a host :
1) At the community level, performance in RCH
of unmet needs. We would, for example, posit that
and rates of couple protection will determine the
toilet facilities, systematic garbage remove facilities
construction of school buildings, public works
should intrinsically be part of the population policy.
and funding for rural development programmes.
Because the lack of these creates the conditions for
2) Performance in RCH is also to be made the
worsening health conditions.
>
-j
criterion for full coverage under programmes like
TRYSEM, Weaker Section Housing Scheme, and
7. Given the fact that Gujarat has had an abysmal
Low Cost Sanitation Scheme.
record with regard to girl child infant mortality rates ’S
between girls and boys in the age group 0-4.
3) Funding for programmes under the DWCRA
Special care needs to be expended on programmes
and other social groups will be dependent on RCH
that will plug the shocking gap between the deaths
performance.
of boy child and the girl child. This will include j
4) At the individual level, cash prizes will be
social awareness programmers as part of the 1
population policy. It is important to realize that J
awarded to couples adopting terminal methods of
these social awareness programmers.should xjim at |
family planning.
discussidns with men as weli as wopaen. ;
5) Allotment of surplui agricultural land, housing
sites, as well as benefits under IRDP, SC Action
Plan, BC Action Plan to be given in preference to
acceptors of terminal methods of contraception.
6) Special health insurance schemes for
acceptors of terminal methods of family planning.
7) Educational concessions, subsidies and
promotions as well as government jobs to be
restricted to those whb'accept the small family
norm.
8) Cash awards on the basis of performance to
service providers. \
9) An award of Rs. 10,000 each to 3 couples to
be selected from every district on the basis of
lucky dip, from the following categories: (a) 3
couples per district with two girl children
adopting permanent methods of family planning
(b) 3 couples per district with one child adopting
permanent methods (c)3 couples per district with
two or less children adopting vasectomy.
The policy document mentions the need for
involvement of people’s representatives, religious
leaders, professional social bodies, professionals,
chambers of industry and commerce, youth,
women and film actors and actresses. While it
underscores the need for delegation of rights to
PRI’s, there are no provisions for delegation or
devolution of resources to the panchayats.
j
')
To summarize, the National Population Policy lays
the groundwork for a policy of population
stabilization based on the premise that the provision
of health, safety, security and protection of
vulnerable groups is a precondition for population
stability. It also affirms the need for a policy based
on the ethics of informed choice and consent. In
doing so, it eschews any measure that would be
ethically hazardous or coerci ve. However, the state
policies all suggest some measure of disincentives
in older to achieve their targets.
5
3-2-1
Rao, M. (2001, July-October). Anti-people State Population Policies. Medico Friend Circle Bulletin,
Special Issue on Population, 286-288-89, pp. 7-8.
7
mfc bulletin / jul-oct 2001 •
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Anti-People State Population policies
.ton.v
• . ■■
................ ..
Mohan Rao
In February last year, the Government of India
adopted the National Population Policy 2000. This
policy is weak on many counts: population is not
integrated with, health, it has population
stabilization rather than the health and well being
of the population as a goal and so on. Yet one
aspect on which the policy is to be hailed is that it
resolutely affirms the “commitment of the
government towards voluntary' and informed choice
and consent of citizens while availing of
reproductive health care services, and continuation
ofthe targetfree approach in administeringfamily
planning services”fIt is thus surprising thpt
several state governments have announced
population policies, which, in very significant
manners, violate the letter and the spirit of the
National Population Policy. Equally distressing is
that several private members bills are pending in
Parliament that seek to reinforce a punitive and
anti-democratic approach to issues ofpopulation.
Before considering why these measures are anti
democratic, it might be pertinent to recall some of
the measures proposed by the states. The Uttar
Pradesh policy, for instance, disqualifies persons
married before the legal age of marriage from
government jobs, as if children are responsible for
child marriages. Further, 10 per cent of financial
assistance to Panchayats is to be based on family
planning performance. Indeed, frightfully recalling
the Emergency, the assessment of the performance
of medical officers and other health workers is
linked to performance in the Reproductive and Child
Health (RCH) programme, the new avatar of the
family welfare programme. The policy also
recommends User Fees for government health
services when it is widely accepted that these are
inaccesible to the poor. And in a daring departure
from other states, the policy recommends the
induction of contraceptives such as injectables and
implants which are both unsafe and dangerous to
the health of women.
Madhya Pradesh, besides debarring
persons married before the legal age at marriage
from government jobs, also forbids them from
contesting Panchyat elections. As in the case of
U.P.. disbursement of resources to PRIs is linked
to family planning performance. In a piquant twist,
the provision of rural development schemes,
income generating schemes for women, and'indeed
poverty alleviation programmes as a whole, are all
linked to performance in family planning.
Rajasthan, besides debarring persons with more
than two children from Panchayat elections, also
bars them from other elected bodies like
cooperative institutions. It makes adherence to a
“two-chiId,norm” a service condition for state
government employees.
‘
In addition to many of the above, the Maharashtra
government in an Order announced the two-child
norm as an eligibility criterion for a range of
schemes for the weaker sections, including access
to the public distribution system and education in
government schools. The Andhra Pradesh
government’s fervour is exhibited by the fact that
performance in RCH and the Couple Protection
Rate will determine construction of school
build!ngs^public works, and funding for rural
development*.'Performance in RCH is also a
criteribW fdrfcbverage under programmes like
TRYSEM, Weaker Section Housing Scheme, Low
Cost Sanitation Scheme and DWCRA. Allotment of
surplus agricultural land, housing sites, benefits
under IRDP, S.C. Action Plan and B.C. Action Plan
are to be given in preference to acceptors of family
planning. Further, educational concessions,
subsidies, promotions and government jobs are to
be restricted to those accepting the small family
norm. In a macabre metaphor of the lottery that is
the life of the poor in the country, awards of
Rs. 10,000/- each are to be given to three couples
per district chosen by lottery. Eligible couples
comprise those with two girl children with the
mother sterilised, those with one girl child with the
mother sterilised and couples two children or less
with the father sterilised.
Newspaper reports indicate that Gujarat, that
crucible of Hindutva politics, has unveiled a
population policy that, besides carrying a range of
disincentives, also explicitly makes a two-child
norm mandatory for all communities.
These state policies are thus in complete
disjunction with the National policy and indeed with
commitments made by the Government of India at
the International Conference on Population and
Development in Cairo. Policy makers so anxious to
control numbers need to be reminded that such
policies are unnecessary as a significant
demographic transition is underway in large parts
of the country. Areas where this transition has
lagged behind need assistance towards
strengthening their health and anti-poverty
programmes and not measures that punish the poor.
As the NPP itself points out, there is a large unniet
need for health and family planning services. In
such a situation, without meeting this unmet need,
to propose punitive measures is both irrational and
absurd.
•
32^
mfc bulletin / jul-oct 2QQ1
8
The disincentives proposed are particularly anti- r
poor, anti-dalit and aritira'divasis^ith these wedcer ;
sections having to bear the brunt of the withdrawal
of a range of subsidies and measures to mitigate
poverty and deprivation. Thp National Family
Health Survey for 1998.-99 shows that the Total
Fertility Rate (TFR) is 3.15 for S.Cs, 3.06 for S.Ts,
2.66 among O.B.Cs and 3.47 among illiterate
women as a whole. In contrast, it is 1.99 among
women educated beyond Class X. Significant
sections among these already deprived populations
will thus bear the brunt of these policies of
disincentives. In addition to privatisation that de
facto deprives S.Cs and S.T.s of jobs in the
organised sector, these explicit policy measures will
further curtail the meager employment
opportunities available to them. Indeed this measure
is pregnant with pro-natalist possibilities.
The disincentives are also anti-women since
women in India seldom decide the number of
children they wish to bear, when to bear them and
indeed have no control over how many will
survive. By debarring such women from contesting
elections makes a mockery of policies to empower
women. Further, they will provide an impetus to
some women to resort to sex selective abortions
and female feticide, worsening an already terrible
sex ratio in the country.
.
The proposals are also anti-minorities since they
ignore the fact that the somewhat higher TFR
among some sections of these communities are a
reflection of their poorer socio-economic situation.
It need hardly be stated that just as the Hindu rate
of economic growth is a chimera, so is a Muslim
rate of population growth.
Finally, the proposals are deeply anti-democratic
and violate several provisions of the Constitution
(the right to livelihood, the right to life, the right to
< privacy, among others) and several International
Covenants that India is signatory to, including the
Rights of the Child.
The fact that structural adjustment policies have led
to the collapse of a weak and underfunded public
health care system, and that these same policies
have also led to an increase of infant mortality rates
in ten of the fifteen major stales of the country, do
not seem to concern our policy makers. So singleminded are they in their short-sighted policies that
they do not realise the appalling fact that it is the
fearsome pursuit of family planning programmes
that has led to the distrust of the health system
among the poor. The fact too is that it was these
same people who brought down a government for
the “excesses" of family planning not too long
back. Is the fear of the poor so strong amoog our
legislators and policy makers that their memories
are so short?
12.2>
!
Khanna, R. (2001, July-October). Women’s Perspective on Population Policies; Feminist Critique o
Population Policies; Population Policy Statementfor Gujarat. Medico Friend Circle Bulletin, Speci ’
Issue on Population, 286-288-89, pp. 15-20.
15
mfc bulletin / jul-oct 2001
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Women’s Perspective on Population Policies: Feminist
Critique of Population Policies; Population Policy
Statement for Gujarat
Renu Khanna
WHOTRAC1
Feminists believe that population policies are
designed to control the bodies, the fertility and the
lives of women, because it is women who bear
children. Population policies have in-built racist and
eugenic ideologies. These ideologies operate
through the process of selection of the ones who
have the right to survive while dismissing the
minorities, the disabled and indigenous people.
They have the goal of eliminating the poor instead
of poverty. Population policies represent the
interests of the privileged elite and a lifestyle of
over-consumption in the countries of the North as
well as the elite of the Third World.
Population policies and programmes of most
countries and international agencies have been
driven more by demographic goals than by quality
of life goals. Population size and growth have often
been blamed inappropriately as the exclusive or
primary causes of problems such as global
environmental degradation and poverty. Fertility
control programmes have prevailed as solutions
when poverty and inequity are root causes that
need to be addressed. Population policies and
programmes have typically targeted low-income
countries and groups, often reflecting racial and
class biases.
Women’s fertility has been the primary object of
both pro-natalist and anti-natalist population
policies. Women’s behaviour rather than men’s has
been the focus of attention. Women have been
expected to carry most of the responsibility and
risks of birth control, but have been largely
excluded from decision-making in personal
relationships as well as in public policy. Sexuality
and gender-based power inequities have been largely
ignored, and sometimes even strengthened, by
population and family planning programmes.
Population control programmes of the 1960s and
70s. devised supposedly for ‘poverty eradication’
subjected women in the South to a whole range of
coercive technologies and methods which have
often ruined their health and their lives. By
presenting population policies as an expansion of
'reproductive choice’ these policies try and cloak
the population control agenda in the language of the
women’s liberation movements. Feminists have
also rejected the tendency of the media to blame
"population explosion” for the economic and
political crises in the Third World. These media
images, feminists state, maintain the domination of
the privileged elite over the marginalised and under
privileged sections of society.
The economic reforms introduced through the
World Bank’s and the International Monetary
Fund’s Structural Adjustment P-ogrammes are
reducing the health and food subsidies for the poor 1
in the Third World. The public health and welfare
infrastructure are being systematically dismantled
and privatized. The reduced health delivery services
are being technologized and the poor in general, and
poor women in particular, are the main victims of
this global policy everywhere. The globalisation of
the world market economy is threatening the food
security of the poor.
The growth oriented development model is leading
to severe environmental degradation in most parts
of the world, which is in turn undermining peoples’
security and livelihoods. Feminists reject the notion
that ‘overpopulation’ has a causal connection with
environmental degradation. The North with 20 per
cent of the world’s people, consumes 80 per cent
of the total resources. One of the key factors
causing environmental destruction is the excessive
use of energy in production and consumption,
energy from non-sustainable resources such as
petrochemical, coal and nuclear energies, extraction
of which itself destroys the environment.
The growth oriented development model has
increased the number of poor, environmental and
political migrants and refugees. The phobia of over
population has not only distracted policies from the
actual causes of migration but has further
victimized the victims. It is estimated that 65 per
cent migrants and 90 per cent of refugees are
women and children. The northern countries in
response to migration issues are making stricter
laws to close their borders, while in the new free
market economy, the resources and capital are
flowing freely from the South to the North,
dragging migrant and low-wage workers with
them. Double standards are practised when it
comes to the movement of the world’s citizens
Renu Khanna is associated with SAHAJ, a health
organisation and WOHTRAC, a women's resource
centre, in M.S. University, Vadodara
H
mfc bulletin / jul-oct 2001
16
between those who are welcome and can afford to
move freely and those who are shunned or
exploited fortheir labour. Goods can move without
restriction whereas migration remains constrained.
Increasinely, reproductive technologies that are
invented that arc controlled by the providers, that
is the physicians, the drug companies and the state.
Contraceptives like the diaphragm, more under the
control of women, are not easily available.
Provider-controlled technologies effectively
undermine women’s control over their lives while
burdening them with full responsibility for fertility
and absolving men of their responsibility.
access to safe contraception, legal and safe abortion
and a wid^jange.gLnrceisa^
good quality.
j
Population Policy Statement for Gujarat
The State Health and Family Welfare Department j
and UNFPA jointly organised a consultative
workshop for the State Population Policy
Development on May 1,2000. This state level
workshop was attended by representatives from <
Government departments, NGOs and institutions
workine in the field of development. The main
objective of this consultative workshop was to
bring together experts from various fields to
deliberate upon issues related to population and ?
In the North, reproductive technologies serve a . development and to suggest major points for
pro-natalist rather than an anti-natalist goal. In
drafting the State Population Policy. Discussion j
Japan, Canada and elsewhere where the fertility
took place on five issues identifieu
working.
rate has fallen, the government and media are stating
group at the state level:
>
that the ‘population’ is endangered by this fall. This
Reproductive and Child Health (RCH); Gender and <
campaign along with the notion that motherhood
development; Decentralisation; Public-private f
must be central to women’s lives places pressure
partnerships and inter-sectoral co-ordination and |
on women to have children.
resource mobilisation, alternative financing, |
incentives and disincentives. A host of |
Insufficient research is directed towards
recommendations emerged, many of which have |
indigenous people’s traditional family planning and
been included in the statement. The state-leve |
health practices. These are discarded in favour of
consultation helped to widen the debate and |
.. modern technology and practices.
generate creative ideas for the contents of the |
policy. But the absence of representatives front the |
Feminists of the South state that women’s basic
departments of education and rural development at |
needs of food, education, health, work, social and
the meetins must be criticised, especially as issues |
political participation, a life free of violence and
of population and development require inter- |
oppression should be addressed on their own merit
sectoral approaches.
|
Meeting women’s needs should be not be linked
with fertility goals and norms. Women should have
-----------------
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Population Policy Statement for Gujarat
I
tr
>
1
of the Board. Towards this end. a population policy is under development.
Goal
In accordance with India’s National Population Policy. Gujarat's population policy will also focus^Prov'ng
women will be an underlying principle of Gujarat s Population Policy.
Objective
morta!itynand lower fertility, buTalso for its own sake. Universal access to u f.-uy
acnhieC'“ine8nd°eriatter^quires strong support from men and
their participation in women’s empowerment. Women’s health and women s education will be encourage .
Specific Objectives
\ The immediate objective of the State Population Policy is to provide integrated reproductive health services^/
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17
mfc bulletin / jul-oct 2001
addressing ,he unmet .fed
systems to Imp^e ^e«ss m fere £
. * *;
y(.„ 2„
„hie„„g there ohtnelra. -
KZKSSSIS !X - •-* *»” “”de *
I
§
§
§
I
.~SX==S=-==—..............
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Settino quality indicatorsand providing rewardslorPHG onnel for increase quab yand
strengthen thequality of services.
health concerns and the need for supportive action
„rams and communication, education
Gender perspectives will be institutionalized in educatiomand
win be prolected against
and trailing materials will be screened from a
^Xenforced Efforts will be made to increase age at
violence. Laws against sex de“oXtmtion of manages. Tbe government will take a proactive role
marriage for girls, and
’Xly in universalizing primary education for gtrls.
promoting gender equality, and part
y
, 3tive Reform^ alon" with Financial Reforms
i ill
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order to strengthen the potential of this system^ pp
nlob,11Mtion.
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jl
Re5OUreesMuhllire>lwn.AI«™s<reeRnanc,nS’lnsu’i'1
Pudbe, dp.-smp * « -
f ,he sys,em will be Imprered ihruugh
i!
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ss&ssssffi^****
3.2-6
18
Critique of the population policy statement _
The participants at the WOHTRAC meeting came
up with the following critique and
recommendations:
The Government’s initiative to set up a Social
Infrastructure Development Board for achieving
overall development in the State is laudable. Apart
from population stabilization by 2008 being a
priority, it would be useful to know other priorities
of the Board. This would help us to analyse the
total context within which Gujarat’s Population
Policy is being developed and to assess links for
consistency in approach.
The Goal of Gujarat’s Population Policy, with its
focus on improving the quality of life of people,
reducing gender discrimination, empowering
women and respecting reproductive rights of men
and women in addition to ensuring achievement of
replacement level, is also noteworthy. Similarly,
the objectives are impressive: 100 per cent access
to quality and affordable RH Services, the
emphasis on women’s education not just to reduce
IMR and TFR but, also for its own sake, specific
measures to achieve gender equity and equality
and encouraging men’s participation in women’s
empowerment. However, just as the Policy
Statement in its later sections, promotes
partnerships and inter-sectoral co-ordination,
reproductive and sexual health needs to be
contexualised within the framework'of
comprehensive Primary Health Care. In practical
terms, this would entail forging partnerships and
co-ordination links with, for instance,
communicable diseases control programmes,
such as Tuberculosis and Malaria while also
emphasising issues such as water supply,
sanitation and nutrition, among others. Also
gender perspective analysis needs to be applied to
health as a whole and not only to reproductive and
sexual health. The differential impact and outcome
of all diseases on men and women needs be
analysed and responded to accordingly. Thus,
gender analysis needs to be part of the training
and education curricula of all categories of health
care providers and managers.
The paragraph on Specific Objectives reveals a
domination of demographic objectives like Unmet
Need for Contraception, reducing the Total
Fertility Rate (TFR) and increasing Contraceptive
Prevalence Rate (CPR). Other objectives like
increasing safe Medical Termination of
Pregnancies (MTPs), providing quality infertility
services and so on, would better reflect the goal
of improving the quality of lifenf the people and
a shift away from the demographic orientation of
all population policies.
Although the linkages between Nutrition and RCH
mfc bulletin / jul-oct 2001
!
are evident; the high prevalence of under nutrition
nwoin erfland chi Idf^nlxonUauc^ HjOinaZlZ.
challenge, yet the policy gives only a cursory
mention of malnutrition reduction in the context
of population and quality of life improvement.
•5
Paradigm Shift in Reproductive and Child Health:
Gujarat has a rich tradition of self-help, herbal
remedies, other innovations in community health
through mature and experienced community
health and women’s organisations and peoples’
organisations. This section of the Policy
Statement needs to mention how the existing rich
experience will be incorporated in the paradigm
shift of the RCH Services. For example, can
Gujarat’s RCH Programme incorporate
Indigenous Systems of Medicines for
reproductive tract infections? Can some of the
health promoting pregnancy care and post partum
practices be recognised in, the MCH package? Can
the State adopt a formulary consisting of generic
essential drugs?
The section on gender equality, women’s
empowerment and male participation is rather
progressive. None of the other State Population
Policies mention violence against women as a
health issue, or the need to institutionalise gender
perspectives in education and training
programmes and screen educational and IEC
materials from a gender perspective. The
challenge will lie in the translation of these ideas
into operational programmes such that the spirit
and meaning of gender sensitivity is not lost.
The section on Decentralization, points out that
health, family welfare and education are a
responsibility of the village panchayats. The
Policy Statement mentions that appropriate
support will be given to panchayats to carry out
community needs assessments, resource
planning 'and resource mobilisation. It also needs
to mention that special support will be given to
strengthen women’s roles within the panchayat
system both as panchayat members and as
members of the gram sabha.
Partnerships and inter-sectoral co-ordination
between Government Organisations (GO),
NGOs, corporate, co-operative and private
sectors is the need of the hour. Partnerships
should take the form of genuine and mutually
respectful collaboration between all concerned.
The bottom-line of such partnerships should be
clear to all: social and health benefits to the largest
sections of most needy sections of society with
exploitation of none. Mechanisms for monitoring
partnerships should be clearly spelt out right from
the beginning.
The participants at the workshop concluded that
the Population Policy Statement for Gujarat is
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19
mfc bulletin / jul-oct 2001
essentially a ‘progressiVedocumeni’. It has rnpst
of the elements that can form part of a Women’s
Health Policy. In a memorandum to the
Government of Gujarat they urged the
government to move a step forward and, instead
of a Population Policy, bring out a progressive
Women’s Health Policy. Gujarat would perhaps
be the second state in India (Andhra Pradesh
announced a Women’s Health Policy in 1996) to
bring out such a policy, and,the first state to bring
out a progressive Women’s Health Policy. Such a
policy would be more consistent with the stated
goal of improving the quality of life of people. It
would move away from the continuing focus on
controlling women’s fertility to a focus on
improving health services for women
-
;
providing health information for women
addressing sexuality and gender based
power inequities that have been ignored
until recently.
The process being followed by the Government
of Gujarat in formulating the Population Policy,
with its emphasis on a series of consultations, is
also consistent with the process of formulating a
Women’s Health Policy. Brazil, Colombia, South
Africa and Australia, countries that have brought
out Women’s Health Policies in the last decade,
have followed highly inclusive processes.
Decentralised discussions were held with a wide
variety of persons, including representatives of
the women’s movement, health care providers,
researchers and scholars, and men with relevant
grassroots experience. Extensive networking and
consultations ensured that grassroots’ ideas were
incorporated in the proposals.
In conclusion the memorandum reiterated the
salient recommendations from the earlier
sections. Firstly,theeffortof the. Gujarat-------Government should bernotonly On prijvfdnrg^
quality reproductive and sexual health services,
crucial though these are, but also quality
comprehensive and universal Primary Health
Care services including services for nutrition and
control of communicable diseases such as TB
and Malaria. Secondly, the policy statement must
clearly specify the parameters on which the
implementation of the policy will be monitored and
the processes that will be institutionalised for
monitoring.
Government of Gujarat’s Proposal for a
‘Two-child Norm’
Contrary to the generally progressive tone of the
Population Policy Statement, in June 2001, the
Gujarat Government proposed the passing of a bill
and enactment of a law for enforcing the ‘two-child
norm’. The bill would have allowed the
Government to give various incentives and
disincentives for the enforcement of a two-child
norm. The Chief Minister stated in press reports
that the recent poverty and unemployment
increases in the state were a result of the population
growth rate of 22.48 per cent (compared to 21.19
per cent in the preceding decade). The Health
Secretary stated that the disincentives would be for
entire village communities that did not agree with
the two- child norm.
•'ii
In a concerted advocacy campaign, WOHTRAC
made representations to the Chief Minister and the
Health Minister as well gave press releases on its
stand on the two-child norm . The public debate
among several sections of the civil society and the
resultant pressure forced the Government of
Gujarat to withdraw its proposal.
WOIfFRAC’s Perspectives on the Two Child Norm
We. at WOHTRAC strongly oppose this move of the Gujarat Government. Our reasons are as follows
1
The decision on the number of children to have is a personal decision of the family. No government
(i)
can decide how many children anyone can have. Doing so goes against the basic tenets of democracy.
v.z
Introducing incentives and disincentives for the implementation of such a law would in practice
Ui)
amount to coercion, which violates the basic human rights of citizens by denying them autonomous decision
making. Disincentives deprive people, especially the neediest, of the minimum support that is their entitlement,
support in terms of rations, health care, educahon, employment. Both incentives and disincentives lead to
increased corruption in the system.
(iii)
The two child norm would actually be discriminatory. The disincentives against population increase
would be largely applicable to only those couples who already have inadequate exposure to state government
facilities, schemes and aid. Those who practice the two child norm are and will be from the class of people who
do not depend on state government’s facilities WOHTRAC urges the Government to remove incentive and
disincentives either at the individual level or at the level of the community.
(iv)
the two child norm in a society which values sons, would lead to an increase in female foeticide. Ehe
sex ratio in our state has already declined from 1000: 936 in 1991 to 1000 : 919 in 2001—the two child norm J
\would push down the sex-ratio to the 800s in 2011._______________ ___
Hl:
jj
3 2.8
i
__ __
mfc bulletin / jul-oct 2001
20
(v)
the State Govern merits* move is surprising because theCentralGovemmentin itspostICPD agenda
has announced the withdrawal of coercive measures like targets for family planning. The Government of
Gujarat has been a signatory to the ICPD's Plan of Action and has committed itself to upholding the principles
which respect human rights of all individuals and gender equity amongst its citizens.
(vi)
the Government should have a more gender sensitive and women friendly policy.
WOHTRAC endorses the Government’s decision to have a wide ranging debate with representative
of women’s group, NGOs working with women as well as academics from University departments of Sociology,
Women Studies Centres etc. who have been involved in issues related to female foeticide and other similar
practices which discriminate against the female population.
(vii)
(viii)
w e recommend training of doctors, nurses and other health personnel to provide services which arc
humane.
(ix)
we further recommend that copies of die Medical Termination of Pregnancy (MTP) Act as well as the
regulation of the Sex Determination test be prepared in simple and understandable language and are widely
disseminated among women groups, PHCs and other centres where health care is provide.
The Government of India has also in the last one year intervened in certain states like Maharastra and
Rajasthan to have them take back their two child norm policies. Would we. want the Central Government to
intervene in our State on this matter?
. .
. / ’
Can we be progressive and interpret the Vision 2020 for Human Development for our State in a spirit that
upholds the dignity of its citizens?
We would also like to be included in any consultation meetings that the State has in this regard.
References:
Declaration of People’s Perspectives on ‘Population*
Symposium; Comilla, Bangladesh; December 12-15.
1993.
i
1
Women’s Declaration on Population Policies; Women’s
Voices ’94; (In preparation for the 1994 International
Conference on Population and Development)
Renu Khanna and Vaishali Zararia; Report of Meeting
on Women’s Perspective on the Nation Population
Policy (2000) and the Population Policy Statement for
Gujarati WOHTRAC; M.S. University. Baroda. June
2000.
National Population Policy 2000; Government of India.
i
V
>
1
Population Policy Statement for Gujarat: May 11.2000.
Qg -
Maharashtra Population Policy Statement: Vision 2010.
State Level Consultation Workshop for Population Policy
Development - Gujarat, organised by Department of
Health and Family Welfare Government of Gujarat and
United Nations Population Fund (UNFPA), May 1.2000.
Women's Health Policies: Organising for Change by T
K Sundari Ravindran, Reproductive Health Matters, No:
6, November 1995.
The Andhra Pradesh Women’s Heal in Policy: A Review
by M. Prakasamma. Paper presented at the ‘National
Consultation Towards Comprehensive Women’s Health
Policy and Programmes’, VHAI - WAH ’ - DSE. February
18-19,1999.
}
)
■:
‘Salient Features of Population Policies of India. Selected
Statesand Sri Lanka: acomparison*. Dr. Arivind Pullikak
UNFPA. Gandhinagar (undated)
■
5
V
WHO. (2001). Advancing Safe Motherhood Through Human Rights. Occasional Paper 5
WHO/RHR/1.05. Geneva: WHO, 21-48.
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ADVANCING SAFE MOTHERHOOD
THROUGH HUMAN RIGHTS
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THROUGH HUMAN RIGHTS
21
III. Human Rights Affecting Safe Motherhood
This section addresses the range of human rights, whether found in national law or
in regional or international human rights conventions. These rights can be applied
k individually or combined with others to advance safe motherhood. In the legal
' application of human rights, it is important to identify those bound by the legal duty
to observe human rights, such as governmental agencies, those working under the
authority of government, and those carrying out governmental responsibilities.
Human rights not backed by legally enforceable duties remain moral rights, and
various agencies, officers and others can be made morally accountable through their
moral duties to observe them.
The legal challenge islo find not only the human lights breached in unsafe
motherhood, but also the rights that would contribute most effectively to future
remedies. For instance, a woman may have suffered because a family member was
allowed to veto or frustrate her request for necessary care. A remedy may be
approached by ensuring respect for a woman’s confidentiality in requesting health
care, and in applying human rights to achieve women’s economic and social equality
in access to health care.
It is helpful to have an understanding of how courts and tribunals have applied a
particular human right in the past. This understanding will provide an insight into
the potential for success in invoking the right to prevent and remedy a violation
causing a maternal death. Human rights have been applied in recent decades at
national, regional and international levels to secure women’s interests in access to
contraception, voluntary sterilization, safe abortion and reproductive health
information, and in women’s freedom from involuntary sterilization and veto
powers over their requests for care. These developments provide promise of the
capacity of human rights to advance safe motherhood.62
A. Sources of Human Rights
!T'
Ife
I8;
!-•
Sources of human rights to advance safe motherhood are found in all national
constitutions and in international and regional human rights treaties based on the
Universal Declaration of Human Rights, adopted in 194863 (see Appendix 2). The
Universal Declaration itself was not proposed as a legally enforceable instrument,
but it has gained legal acceptance and legal enforceability through a series of
international human rights conventions, which are also called treaties, covenants or
charters. The primary modem human rights treaty concerning women’s rights is
4.
the Convention on the Elimination of All Forms of Discrimination Against
Women (the Women’s Convention).64
•
<7-^
This Convention gives expression to the values implicit in the Universal Declaration
of Human Rights, and reinforces the Universal Declaration’s two initial legallybinding implementing covenants,
-
-•»-7
331
International Covenant on Civil and Political Rights (the Political
. Covenant),65 and
)
ADVANCING SAFE MOTHERHOOD
22
■
the International Covenant on Economic, Social and Cultural Rights (the
Economic Covenant).66
•
Similarly derived from the Universal Declaration are:
•
the International Convention on the Elimination of All Forms of Racial
Discrimination (the Race Convention),67 and
•
the Convention on the Rights of the Child (the Children’s Convention) 68
*
Regional human rights conventions of legal force also draw inspiration from the
Universal Declaration, and they include:
I
I
I
•
the European Convention for the Protection of Human Rights and
Fundamental Freedoms (the European Convention),69
•
the European Social Charter - Revised (the European Charter),70
•
the American Convention on Human Rights (the American Convention),71
•
the Additional Protocol to the American Convention on Human Rights in the
Area of Economic, Social and Cultural Rights (the Protocol of San
Salvador),72
•
the Inter-American Convention on the Prevention, Punishment and
Eradication of Violence Against Women (the Convention of Belem do
Par&),73 and
•
the African Charter on Human and Peoples’ Rights (the African Charter)74
Additional documents (see Appendix 2) reflect widespread international consensus
on issues of women’s health and human rights, notably:
•
the Cairo Programme of Action (the Cairo Programme)75 and the Cairo Plus
Five follow-up docunient76 developed respectively at the 1994 UN
Conference on Population and Development, held in Cairo, and its five year
review; and
•
the Beijing Declaration and Platform for Action (the Beijing Platform),77
developed at the 1995 Fourth World Conference on Women, held in Beijing,
and its five-year review.78
Throughout this discussion document, the international and regional instruments
above will be referred to by the short names that follow them in brackets.
Like national constitutions that have constitutional courts to monitor compliance
with constitutional provisions, the human rights treaties have monitoring bodies to
monitor compliance with treaty provisions. For example, the Women’s Convention
established the Committee on the Elimination of Discrimination Against Women
h
i
•
-
through human rights
23
Covenant established the Human Rights Committee (HRC) to monitor state
compliance and the Committee on Economic, Social and Cultural Rights (CESCR'l
was established to monitor compliance with the Economic Covenant. Unlike
national courts however, which act only on the occasions when parties bring cases
before them, the treaty monitoring bodies receive reports that treaty member states
must submit periodically, usually at three to five year intervals.
!
• Countries that are members of an international human rights convention (see
Appendix 3) are obligated to report on a periodic basis to the respective treaty
monitoring body to provide information on their national performance ^For
example, the reporting procedure of the CESCR .requires States Ranies lofflenn
initial report Avithin two years ofthe Covenant coming into force and thereafter
every five years, or at any other time the Committee deems appropriate «o states
Partiesto the Children’s Convention are similarly required to submit reports to the
CRC two years after the Convention comes into effect for the state concerned, and
every five years thereafter?’ The Committee on the Elimination of Racial
iscnmination (CERD), established under the International Convention on the
imina mn o
Forms of Racial Discrimination, requires states to report within
one year of their ratification and thereafter every two years and whenever the
Committee so requests.82
Article 18 of the Women’s Convention requires States Parties to submit a report
withm one year of the Convention going into effect for the state concerned and every
ur years thereafter, and explains that reports may indicate factors and difficulties
h
T0 °f fbIfi!ment ofob'igations. In the specific area of women’s
f6 rat‘fyins states have committed themselves to report regularly to
CEDAW on what they have done to:
•
TJ aPProPr;ate measures to eliminate discrimination against women
m the field of health care in order to ensure ... access to health care services,
inc u ing t lose related to family planning ... pregnancy, confinement and the
post-natalI penod, granting free services where necessary, as well as adequate
nutrition during pregnancy and lactation.”83
Once a treaty monitoring committee has considered a country report and any
additional information on treaty compliance, and discussed the report with ie
ZseSeS °f nlrep°rt-n8 80Vemment- h issues Concluding Observations,
ctenc k •
-n8iObservatlons note the achievements of the reporting state to take
steps to brings its laws, policies and practices into compliance with its treaty
obligations, and the concerns the committee has with lack of compliance.8^
devXXtCOUntrieS 'r^lfl1 the’r reP°rting obligations, treaty-monitoring bodies ha'
tve
InrinTc 7Rec™^tions or GenerJ Comments (see
under tri 3 w’ i
!Xplain 1116 conten’ and meaning of duties that arise
useful to r3 ‘ 1C-eS’
°Utllne 1116 •kind °f infonrlation dwt treaty bodies find
have ictneH
reporting countries’ compliance records. Committees
have issued general gmdehnes for reporting and guidelines that are specific to
particular articles. In 1995, for instance, HRC amended its general gihdelines for
J
ADVANCING SAFE MOTHERHOOD
14
periodic reports to include, “[fjactors affecting and difficulties experienced in the
implementation of the [Economic] Covenant including any factors affecting the
equal enjoyment by women of that right.”86 CESCR has stressed the importance of
observance of the Economic Covenant’s minimum core obligations in its general
guidelines for reporting.87
With regard to guidance on specific articles of the Women’s Convention, the
CEDAW General Recommendation on Women and Health requires that:
in order to enable the Committee to evaluate whether measures to
eliminate discrimination against women in the field ofhealth care are
appropriate. States Parties must report on their health legislation, plans and
policies for women with reliable data disaggregated by sex on the incidence
and severity of diseases and conditions hazardous to women’s health and
nutrition and on the availability and cost-effectiveness of preventive and
curative measures.”(see Appendix 4, para 90) (emphasis added)
This Recommendation stresses that:
•
!
'
■
[Reports to the Committee must demonstrate that health legislation,
plans and policies are based on scientific and ethical research and assessment
of the health status and needs of women in that country and take into account
any ethnic, regional or community variations or practices based on religion,
tradition or culture.” (see Appendix 4, para 9)
Complaint procedures are available under some of these conventions, such as the
Race Convention,88 or under Optional Protocols to others, such as the Political
Covenant89 and the Women’s Convention.90 These procedures enable individuals or
groups of individuals from ratifying countries to bring complaints to the relevant
treaty body of alleged violations they have suffered, once they have exhausted
available domestic remedies. The decisions of treaty bodies help to develop the
content and meaning of rights. A successful complaint can have the effect of
requiring governments to change or apply laws or to provide remedies that might
benefit individuals as well as groups that are harmed (see Appendix 10).
B. Obligations of Government to Implement Human Rights
i
SLr
Under their national constitutions and regional and international human rights
treaties, governments face a variety of obligations, including general obligations that
can be applied to particular circumstances, core obligations, and immediate and
long-term obligations. The CEDAW General Recommendation on Women and
Health (see Appendix 4) and CESCR’s General Comment on Health (see Appendix
7) explain that governments have three different kinds of general legal obligations to
implement human rights. They are:
•
the obligation to respect rights, which requires states to refrain from
interfering with the enjoyment of rights; •
•
the obligation to protect rights, which requires states actively to prevent
violations of human right by third parties; and
THROUGH HUMAN RIGHTS
•
the obligation to fulfil rights, which requires states to take appropriate
governmental measures toward the full realization of rights.
These obligations are elaborated by treaty monitoring bodies in their development of
General Recommendations or General Comments. For example, the CEDAW
General Recommendation on Women and Health explains the obligations with
respect to Article 12 of the Women’s Convention in the following way:
“The obligation to respect rights requires states parties to refrain from
obstructing action taken by women in pursuit of their health goals. States
parties should report on how public and private health care providers meet
their duties to respect women’s rights to have access to health care.” (see
Appendix 4, para 14)
This General Recommendation explains that states are obliged to change laws or
policies that require women to seek the authorization of their husbands, parents or
health authorities to obtain health services, because such laws or policies obstruct
women’s pursuit of their health goals. The Recommendation also states that the
Women’s Convention may be infringed by “laws that criminalize medical
procedures only needed by women and that punish women who undergo those
procedures.” (see Appendix 4, para 14)
,3
The General Recommendation further observes that:
“The obligation to protect rights relating to women’s health requires states
parties, their agents and officials to take action to prevent and impose
sanctions for violations of rights by private persons and organizations.”(see
Appendix 4, para 15)
The Recommendation explains that the duty to protect rights requires the
“enactment and effective enforcement of laws that prohibit... marriage of girl
children” (see Appendix 4, para 15). The duty of protection also includes
responsibility to develop health care protocols and programmes of gender training
for health care providers and in the provision of health services, in order to identify,
address, prevent and remedy the causes of unsafe motherhood.
The General Recommendation goes on to make clear that:
I
“The duty to fulfil rights places an obligation on States Parties to take
appropriate legislative, judicial, administrative and budgetary, economic and
other measures to the maximum extent of their available resources to ensure
that women realize their rights to health care.” (see Appendix 4, para 17)
The General Recommendation explains that studies that show high rates of maternal
mortality and morbidity, or large numbers of couples who would like to limit their
family size but lack access to contraception, provide important indications about
possible breaches of duties to ensure women’s access to health care.
In addition to these general obligations, CESCR has issued a General Comment
which explains the minimum core obligations of Article 12 on the right to the
L.J
*
26
ADVANCING SAFE MOTHERHOOD
highest attainable standard of health (see Appendix 7). This General Comment
establishes that states have core obligations to provide essential primary health care
in order to satisfy the right to the highest attainable standard of health. The General
Comment explains that “core obligations are not subject to resource limitations or
progressive realization, instead their realization is required immediately” (see
Appendix 7, para 19). The General Comment requires governments at least:
43(w^ “t0 ensure the right of access to health facilities, goods and services on a
non-discriminatory basis, especially for vulnerable and marginalized groups;
(b) to ensure access to minimum essential food which is sufficient, nutritionally
adequate and safe, to ensure freedom from hunger to everyone;
(c) to ensure access to basic shelter, housing and sanitation, and an adequate
supply of safe and potable water;
( (e) j to ensure equitable distribution of ail health facilities, goods and services;
(f) to adopt and implement a national public health strategy and plan of action,
, on the basis of epidemiological evidence, addressing the health concerns of
the whole population; the strategy and plan of action shall be devised, and
periodically reviewed, on the basis of a participatory and transparent process;
they shall include methods, such as right to health indicators and
benchmarks, by which progress can be closely monitored; the process by
which the strategy and plan of actions is devised, as well as their content,
shall give particular attention to vulnerable or marginalized groups;
44(a) i to ensure reproductive, maternal (pre-natal as well as post-natal) and child
health care;
(fd}) to provide education and access to information concerning the main health
problems in the community, including methods of preventing and controlling
them
(e) to provide appropriate training for health personnel, including education on
health and human rights....” (see Appendix 7, para 43-44)
The General Comment explains that immediate obligations with regard to the right
to health include the obligation to eliminate health-related discrimination, for
example in access to health care, and to take no retrogressive measures with regard
to health, including withdrawal of senices.
C. The Application of Human Rights to Safe Motherhood
Safe motherhood may be advanced through several specific legally established
human rights. The choice of which rights to apply will depend on the immediate and
underlying causes of maternal death and ill health.91 Several human rights may be
cumulatively and interactively applied to advance particular interests. The rights
addressed below are not exhaustive but are indicative of rights that may be applied
to promote safe motherhood. Moreover, the discussion is only suggestive of how
27 '
XZXJZS Ssx* aT“appfcd'»
aes?»-^^x^
f•
nghts relating to life, survival and security of the person;
V*
rights relating to maternity and health;
/•
rights to non-discrimination and due respect for difference; and
rights relating to information and education.
•H» d«e™i„a,i»„ of which rights ,o apply
an assessment of how successful their application might be in the future; and
mOrta,ity 311(1 morbidity appear
amenab^TtThu^^
remedy matemaTmoSity^d'morb^Vw-llXX 3!? hUman
t0 P1®™11*
1. Rights relating to life, survival and security
fem inhtmtSXSeXcm^ °f
““ 'h'
'« »'
the national level particularly inlafin .
development is happening at both
international lev s » toC0UrtS>
at 1116 regional and
to promote safe moth^od L
tO
t0 SeCUre the services
applied for this purpose.
’
P hapS
C y t0 ,hlnk about h6w theV cajl be
a. The right to life and survival
The Political Covenant, Article 6(1):
- ---------------- -------------------
nghi smi
risk crying in childbirth due^ol^lT8?1
C0U,d
pr°K“d ty
appUed t0 Pr°tect a woman at
ying m childbirth due to lack of obstetric care. Historically, this right
•D
78
ADVANCING SAFE MOTHERHOOD
generally has been applied legally only to ensure that capital punishment is not
imposed in an arbitrary way. However, judicial tribunals are beginning to apply the
right to life to matters relating to health by addressing the positive nature of the
right, and by providing a context of health and human dignity to the right to life. For
example, HRC has explained that llthe expression ‘inherent right to life’ cannot be
properly understood in a restrictive manner, and the protection of this right requires
that States adopt positive measures.”92 When explaining what positive measures
might be adopted, HRC gave, as an example, measures necessary to reduce infant
mortality and to increase life expectancy.93 HRC has specified through its General
Comment on Equality between Men and Women that States Parties are now
required to provide data on “pregnancy and childbirth-related deaths of women.”
(see Appendix 8, para 10)
In 1991, the European Commission of Human Rights considered a complaint
alleging a state’s violation of the right to life of a woman who had died in
childbirth.94 The Commission held that the complaint was inadmissible on technical
grounds. However, the Commission took the opportunity to emphasize that the right
to life in the European Convention95 has to be interpreted not only to require states
to take steps to prevent intentional killing, but also to take measures necessary to
protect life against unintentional loss. The European Commission had earlier
considered a claim that a governmental vaccination programme that resulted in
damage and death to babies was a violation of the right to life.96 The Commission
found that appropriate and adequate measures to protect life had been taken in this
case. The Commission did explain, however, that had the state not shown that such
measures had been taken, the state would have been found in breach of its duty
under human rights law to safeguard life and health. This shows that states are
bound to explain and justify their efforts to protect their citizens’ lives and health.
ie
>
■F
Given the magnitude of an estimated 1,400 maternal deaths worldwide each day, it
is remarkable that so few legal proceedings have made their way into national courts
to require that governments take all appropriate measures to identify the causes of
maternal mortality in their respective countries, and take precautionary measures
necessary to prevent further maternal deaths. This is due in part to families and
communities in which women have died of pregnancy-related causes not
understanding how governmental neglect of the conditions in which women bear
pregnancies and give birth violates their right to life. Effective protection of the right
to life requires that positive measures be taken that are necessary to ensure “access
to appropriate health-care services that will enable women to go safely through
pregnancy and childbirth and provide couples with the best chance of having a
healthy infant.”97
Positive measures might include progressive steps are taken to ensure an increasing
rate of births are assisted by skilled attendants, as required by the Cairo and Beijing
processes.98 Where such measures are not taken, states need to be encouraged to
take steps to ensure compliance with treaty obligations to protect and promote the
right to life.
i
Some national courts are giving an expanded meaning to the right to life that could
be applied to require ministries of health to address the causes of preventable
maternal deaths. For example, the Supreme Court of India decided that the right to
J
THROUGH HUMAN RIGHTS
■'W
29
life contained in the Indian Constitution^ was breached when various government
hospitals denied a complainant emergency treatment for serious head injuries.100
The Court explained that the state cannot use financial constraints to ignore its
constitutional obligation to provide adequate medical services to preserve human
life, and even detailed which measures the state might take to comply. While this
case addressed emergency medical care to treat head injuries, the reasoning could be
applied to require governments to provide emergency obstetric services where they
are not sufficiently available.
4
4
The Venezuelan Supreme Court recognized the interrelationship between the rights
to life101 and to health102 contained in the Venezuelan Constitution, when ruling in
favour of a claim for HIV treatment.103 In underscoring the positive nature of the
right to life, the Court required the Ministry of Health to:
Trovide the'medicines prescribed by government doctors;
•
cover the cost of HIV blood tests in order for patients to obtain the necessary
anti-retroviral treatments and treatments for opportunistic infections;
k* / devetoP ^ie policies and programmes necessary for affected patients’
treatment and assistance; and
• } make the reallocation of the budget necessary to carry out the decision of the
While the successful claim was brought on behalf of 172 individuals living with
HIV, the Court applied the decision to all people who are HIV positive in
Venezuela.
As a result of these decisions, it is now timely to explore how a claim might be
brought on behalf of women whose lives and health are at risk because of denial or
neglect of life-saving obstetric care. Such a claim would certainly be feasible in
Venezuela, and in light of the Supreme Court of India’s judgement it might be
credible in India and other countries, especially Commonwealth countries.
Governmental health administrations might be wise to plan their resource
allocations and programmes in anticipation ofjudicial sympathy with the courts in
Venezuela and India, and of their need in court to explain the adequacy of their
responses to the requirements of safe motherhood.
4
I
b. The right to liberty and security ofthe person
The Political Covenant, Article 9(1):
Everyone has the right to liberty and security of the person ... No one shall be
deprived of his liberty except on such grounds and in accordance with such
procedure as are established by law.”
The right to liberty and security of the person is one of the strongest defences of
individual integrity and the right of women to free choice of maternity. The right is
being applied beyond its historical prohibition of arbitrary arrest or detention, to
Wk
LT-
E
30
SAFE MOTHERHOO0
l
“The essence of the legal obligation incurred by any oovemment is to
L o^r ST
^--soAts
Tby following
Sucatfo 7hZSnS wT? •the baSiC needs °f health’nutrition and
~
education. The pnonty of the ‘right to survival’ and ‘basic needs’ is a natural
consequence of the right to personal security.”101
-aocounahlX
lhey <lcl'8a,e -Wonsibility to administer
to prov.de eondruons necessary for safe motherhood, they are
d^, 1. may be possible .0 apply .be rieb^
govcmme^s to tmprove services for treatment of unsafe abortion to change
restrictive laws regarding access to abortion and to ensure the provision of8
S=^X^~~^s
violated a woman s right to security of the person.107
k
Provis>on
■
Several constitutional courts, including those of France,1 m Ita|yi09
XoX» P
,f°”d ’b"
lam"<»> ™e„’s
"y
have
'“S
=3^=5““—
alta8h
•ffeeu bod. men
it may deter women from seeking advice and treatment and thereby
adversely affect their health and well-being. Women will be less willing for
t^e o ♦ ^r*
confidenPaJity], to seek medical care for disease!’of
the genital tract, for contraception or for incomplete abortion and ^2s
240
F:
I
THROUGH HUMAN RIGHTS
31
where they have suffered sexual or physical violence.” (see Appendix 4, para
12(d))
Given this clear explanation of the impact of failures to respect confidentiality,
health care administrators and providers can appreciate that the absence of
confidentiality is a contributing factor in maternal mortality and morbidity, and a
violation of a woman’s right to health and wider aspects of security.
The right to liberty and security of the person can be applied to require that positive
measures be taken to ensure respect in the delivery of reproductive health services to
women who are at particular risk. They include women, especially adolescent girls,
presenting with stigmatizing conditions, such as unmarried or extra-marital
pregnancy, or incomplete abortion. Sometimes, adolescents hesitate to seek
reproductive health services because they fear that their confidentiality might be
reached. They fear, perhaps incorrectly, that information^boutlheirsexual
%chav-ioui,-which they have to make for appropriate health care, will be disclosed to
their parents, parents of their partners, teachers and others. As a result, special care
and attention needs to be given to informing adolescents in the community through
positive assurances that confidentiality will be protected, and to training health
personnel appropriately. Clinics may have to withhold information not only of what
treatment their patients have received, but also of who their patients are, although
some disclosure may be required for billing purposes.
ri£ht t0 befreefrom inhuman and degrading treatment
The Political Covenant, Article 7:
~
"
—
^No one shall be subjected to torture or to cruel, inhuman or degrading treatment or
punishment...” |
Decisions of human rights tribunals have required states to ensure that health
services tire provided when their denial would constitute inhuman treatment. The
European Court of Human Rights held that a governmental deportation of a person
at an advanced stage of terminal AIDS to his own country, where he would have no
ope o receiving appropriate care, would constitute inhuman treatment, contrary to
Article 3 of the European Convention.’" Similarly, denying a prison inmate any
adequate medical treatment for his mental condition, even when he was liable to
capital punishment, has been held to constitute inhuman treatment contrary to
Article 7, and denial of respect for the inherent dignity of his person contrary to
Article 10(1), of the Political Covenant.112
Accordingly, a state might be held bound to ensure provision of emergency obstetric
care and treatment for maternal morbidities, because lack of such provision could
constitute inhuman treatment and denial of respect for the inherent dignity of
"omen. Care could provide for a woman’s access to medically indicated treatment,
which may mclude services to treat a high risk pregnancy, and to terminate
pregnancy safely where her life or continuing health, including mental health and
social well-being, are at risk.
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ADVANCING SAFE MOTHERHOOD
HRC addressed the inhuman and degrading nature of maternal death from unskilled
abortion in considering a report submitted by the Government of Peru under the
Political Covenant. When examining what the country had done to bring its laws,
policies and practices into compliance with the Covenant, the Committee addressed
the human rights of women, including the rights denied them by Peru’s restrictive
criminal abortion law. In its Concluding Observations, the Committee expressed its
concern ‘"that abortion gives rise to a criminal penalty even if a woman is pregnant
as a result of rape and that clandestine abortions are the main cause of maternal
mortality.”113 The Committee found that the restrictions of the criminal law
subjected women to inhuman treatment, contrary to Article 7 of the Covenant.
Moreover, the Committee explained that this aspect of the criminal law was possibly
incompatible with Article3, on equal entitlement of men and women to enjoyment
of the rights set forth in the Covenant. The Committee said this would include
Article 6, which protects the. right to life, since men could request medical care of a
life endangering condition without fear that they or their care-providers would face
criminal prosecution.
The Committee recommended that “necessary legal measures should be taken to
ensure compliance with the obligations to respect and guarantee the rights
recognized in the Covenant.”114 Moreover, the Committee explained that the
“provisions of the Civil and Penal Codes [of Peru] should be revised in light of the
obligations laid down in the Covenant,” particularly Articles 3 and 26 requiring that
countries ensure the rights of women under the Covenant.115 'Die requirement that a
country conform to human rights standards, if necessary by aniending national law
to be compatible with individuals’ human rights entitlements, shows that
governments can be expected to comply with the duties they have assumed to
protect women’s rights, including to safe motherhood.
A state is responsible, at a minimum, to require its health care providers and
facilities to ensure women’s reasonable access to safe abortion and related health
services, as its law permits. Moreover, since the law in Peru, which strictly penalised
abortion, was shown to result in inhuman treatment of women and undue maternal
mortality, Peru was held obliged to consider legal reform so that its law would
comply witli human rights standards for women’s health and dignity. A new national
policy could be expressed in law that more adequately balances limitations on
abortion with women’s rights to safe and humane access to health services necessary
to protect their lives and dignity, and their security in health.
2. Rights relating to maternity and health
a. Rights relating to maternity
Rights relating to maternity have been developed through interrelated rights
requiring maternity protection in general, maternity7 protection during employment in
particular, rights to marry7 and to found a family and, for instance, rights relating to
free choice of maternity and to private and family life.
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through human rights
i. The right to maternity protection
The Economic Covenant, Article 10(2):
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take all appropriate measures:
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[t]o ensure that family education includes a proper understanding of
maternity as a social function...”
OfRiEhls ” Articlc 25(2X addressin8 hel"'h a”d
Motherhood and childhood are entitled to special care and assistance.
Dec!arJationl s*™larly recognizes that “[a]ll women, during pregnancy
ThrouehnArtnf 7?°^ k”
t0 SpeC'al Protection> care and aid.’™
Through Article 15 of the Protocol on Economic, Social and Cultural Riehts to the
American Convention, states agree to “provide special care and assistantto
mothers during a reasonable period before and after childbirth.”
Under Article 24(d) of the Children’s Convention, States Parties commit to ensure
appropriate
appropriate prenatal
prenatal and
and postnatal
postnatal care for mothers. Article 12(2) of the Women’s
Convention requires provision of free maternity services where necessaryI
provide these serv.ces in order that they are in compliance with Article 12(2) of the
Women s ConvenUon and Article 24(2) of the Children’s Convention.
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ADVANCING SAFE MOTHERHOOD
Necessary though these provisions are, their focus tends to link protection of
women’s health to motherhood and care of infants and children, reinforcing a
perception that protection of women’s health is an instrumental means of serving
children, rather than an inherent right for women to enjoy for themselves. Whatever
the motivation is for such provisions, they do obligate states to ensure that
motherhood is safe. Legal research is needed to show if and how these provisions
have been or could be applied to ensure women are adequately protected durins
pregnancy.
ii. The right to maternity protection during employment
Article 10(2) of the Economic -.Covjmant .requireslliat “working mothers should be
accorded paid leave or leave with adequate social security benefits” during a
reasonable period before and after childbirth. The maternal health of women during
employment has been an objective of the International Labour Organisation (ILO)
since its establishment in 1919. The Maternity Protection Convention, No. 3
(1919)118 was among the first instruments to be adopted. The 1919 Convention
stipulates in Article 3(c) that the pregnant woman is entitled to free attendance by a
doctor or qualified midwife.
if.
In 1952, this Convention was revised119 to take into consideration developments in
national law and practice. The 1952 Convention, Convention No. 103, began to
reflect the increasing participation of women in the workforce, as w'ell as rising
social expectations regarding the rights of women during their childbearing years,
particularly with respect to a growing commitment to eliminate discrimination in
employment. The 1952 Convention provides in Article 4(1) for the material support
of mother and child through financial benefits and medical care. Article 4(3)
explains that medical care includes “prenatal, confinement and postnatal care by
qualified midwives or medical practitioners as well as hospitalisation care where
necessary; freedom of choice of doctor and freedom of choice between a public and
private hospital” where applicable. The Maternity' Protection Recommendation, No.
95 (1952),120 provides further guidance on the health protection of employed women
wnth regard to conditions of W'ork, such as the prohibition of work prejudicial to the
health of mother and child.
Article 1 of the 1952 Convention suggests that its provisions apply to “women
employed in industrial undertakings and in non-industrial and agriculture
occupations, including women wage earners working at home.” However, the
provisions of domestic laws defining the scope of persons to whom the maternity'
protections apply vary widely from country to country'. Even so, a survey' of
legislation indicates that the scope of women whose maternity' protection is covered
in most countries approaches or exceeds that prescribed by the Convention, and is
moving toward broad coverage for all employed women.121 Women are generally
covered across the industrial and non-industrial sectors, and in both the private and
public sectors.122 However, significant gaps still exist with respect to the agricultural
sector, as well as to part-time workers, home workers, domestic workers, and casual,
contract and temporary workers.123 While these gaps are decreasing, much remains
to be done to ensure that legal protection available in principle becomes effective in
practice.
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The 1952 Convention was further revised by the Maternity Protection Convention
(Revised), 2000.124 In addition, the 1952 Recommendation was revised in 2000.125
These revisions were undertaken, in part, to reflect the growing commitment to
eliminate discrimination in the workforce. Through all of these conventions and
their accompanying recommendations, member states are obligated to devote
attention to the health aspects of maternity protection, since they state that women
have the right to medical care as well as to financial benefits.
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iii. The right to marry and to found a family
The Political Covenant, Article 23:
1. The family is the natural and fundamental group unit of society and is entitled to
protection by society and the State.
2. The right of men and women of marriageable age to marry and to found a family
shall be recognized.
j. No marriage shall be entered into without the free and full consent of the
intending spouses.
4. States Parties to the present Covenant shall take appropriate steps to ensure
equality of rights and responsibilities of spouses as to marriage, during marriage and
at its dissolution. In the case of dissolution, provision shall be made for the
necessary protection of any children.”
The obligations of states to protect the family are found in many human rights
treaties (see Appendix 2). Wording similar to that of Article 23(1) of the Political
Covenant is found in Article 18 of the African Charter requiring protection of the
family. The exact wording of Article 23(1) is repeated in Article 17(1) of the
American Convention. Article 23(2) is slightly revised in Article 17(2) of the
American Convention, to read:
[t]he nght of men and women of marriageable age to marry and io raise a
family shall be recognized...”
V
Article 10(1) of the Economic Covenant stresses the importance of states ensuring
piotection and assistance for the “establishment” of the family and for “the care and
education of dependent children.” It reads:
The widest possible protection and assistance should be accorded to the
family, which is the natural and fundamental group unit of society,
particularly for its establishment and while it is responsible for the care and
education of dependent children. Marriage must be entered into with the free
consent of the intending spouses.”
The Women s Convention stresses the importance of equal rights within the family.
Article 16 reads:
(1) States Parties shall take all appropriate measures to eliminate
discrimination against women in all matters relating to marriage and family
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ADVANCING SAFE MOTHERHOOD
relations and in particular shall ensure, on a basis of equality of men and
women:
(a) The same right to enter into marriage;
(b) The same right to choose a spouse and to enter into marriage only
with their free and full consent;
(c) The same rights and responsibilities during marriage and at its
dissolution...”
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(2) The betrothal and marriage of a child shall have no legal effect, and all
necessary action, including legislation, shall be taken to specify a minimum
age for mamage and to make the registration of marriages in an official
registry compulsory.”
Laws setting a legal minimum age of marriage, if implemented, can help to ensure
that young women are of sufficient age and maturity to be able voluntarily to
consent to marriage, and to avoid the health risks of premature childbearing.
Evidence shows while most countries have set a legal minimum age of marriage,
governments generally do not provide the resources or the leadership for their" ’
effective implementation, for instance through a requirement of marriage licensing
dependent on submission of evidence of age, such as dated certificates of birth. This
is the case in India where marriage registration is not legally required. In their
Concluding Observations on the report of India submitted under the Political
Covenant, the HRC explained that:
“[w]hile acknowledging measures taken to outlaw child marriages (Child
Marriage Restraint Act) [which sets the minimum age of marriage at 18 for
girls and 21 for boys], ... the Committee remains gravely concerned that
legislative measures are not sufficient and that measures designed to change
the attitudes which allow such practices [child marriages] should be taken.
The Committee therefore recommends that the Government take further
measures to overcome these problems....”126
The Committee’s concern about child marriages entered “without free and full
consent of the intending spouses” is underscored by a study in Rajasthan, India
which explained that:
[e]ven today, mass child marriage ceremonies arranged by parents, where
hundred of boys and girls wed each other, are very common. The mean age
at mamage for women (16.1 years) is among the lowest in the country'. Once
the girl goes to her marital home, it is her duty' to beget a child as soon as she
can. ... Forcing early pregnancies and motherhood on teenage girls under the
banner of social custom and family is tragic.”127
The tragedy of child marriages is not unique to Rajasthan. CEDAW expressed
similar concerns in its Concluding Observations on the report of Nepal in noting
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“traditional customs and practices detrimental to women and girls, such as
child marriage, dowry, polygamy, deuki (a tradition of dedicating girls to a
god or goddess, who become “temple prostitutes”, which persists, despite
the prohibition of the practice by the Children’s Act), badi (the etlLiic
practice of forcing young girls to become prostitutes) and discriminatory
practices that derive from the caste system are still prevalent.”128
A'.
“Protection by society and the State”
There is significant scope for the right to marry and to found a family to be applied
to advance safe motherhood, because this right imposes positive obligations on the
state to protect the right. State authorities can be liable for not providing vulnerable
women and girls with effective protection against the acts of private individuals.
Courts of law are, of course, public authorities, and obliged to apply and develop the
law consistently with human rights treaties binding their states. As a result, where
governmental or judicial branches of the state do not constrain those who arrange
marriages of children under the legal age of marriage, or against the will of one of
the parties to the marriage, the government would be accountable for the state’s
violation of Article 23(1) of the Political Covenant
The human right to family life is seriously jeopardised by neglect of the needs of
women who are at risk of maternal death or disability to receive reproductive,
including maternity, care. In addition, the rights to family life of children and fathers
are prejudiced due to the harmful impact of mothers’ deaths on the potential of
surviving infants, children and other family members to lead healthy lives. Children
of women who die following childbirth are “three to ten times more likely to die
within two years than those with both living parents.”129 Preservation of maternal
health and prevention of maternal death are so central to the enjoyment of family life
that they are part of the human rights entitlements not only of women but also of
children and husbands.
“Marriageable age”
The right to marry and to found a family, available to persons of “marriageable age,”
may be applied to achieve the desirable result of adolescent girls marrying later,
giving them more choice over the age at which they have children. The expression
marriageable age” in Article 23(2) of the Political Covenant needs to be interpreted
in light of the Children’s Convention. Article 1 of that Convention explains that “a
child means even' human being below the age of eighteen unless, under the law
applicable to the child, majority is attained earlier.”
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National family laws have traditionally set ages at which adolescents could marry
without parental consent, and even over parental objection. This age often coincided
with the general age of majority (traditionally 21 but now commonly 18). A lower
age was also set at which adolescents could marry provided that their parents
consented, or “emancipated” them. In addition, laws often had an exception
allowing an underage girl to marry if she was pregnant, in order that her child would
be legitimate at birth.
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ADVANCING SAFE MOTHERHOOD
An objection to parental consent laws is that they protect marriages the parents
arrange. Daughters may accept the arrangements as an act of obedience to their
parents rather than of emotional commitment to their husbands and to raising their
own children. Accordingly, the better view may be that the reference in legal
provisions to “marriageable age” not be taken to refer to the minimum age of
marriage with parental consent, but to the age of marriageability without the legal
requirement of emancipation by parents.
This view is reinforced by the health advantages^ for both mothers and children, of
marriages not being undertaken before adolescent girls have achieved sufficient
physical maturity to bear pregnancy and deliver safely, and the emotional and
intellectual maturity for self-care, child-care, and resort to necessary assistance.
Physical maturity can be approximately related to a chronological age, but this age
may not be as reliably related to emotional and intellectual maturity.
Health and social effects of child marriage
HRC and other treaty monitoring bodies could benefit significantly from the work of
women’s health specialists in adding content and meaning to an understanding of
“marriageable age.” For example, a serious health dysfunction of early marriage and
childbearing is younger girls’ vulnerability to suffer different forms of obstetric
fistulae. A fistula is a maternal disability arising from obstructed labour that has
been reported particularly in Africa and Asia.130 It has been explained that:
“an obstetric fistula is a hole which forms in the vaginal wall communicating
into the bladder (vesico-vaginal fistula - VVF) or the rectum (recto-vaginal
fistula - RVF) or both (recto-vesico-vaginal fistula RVVF),.as a result of
prolonged and obstructed labour... The immediate consequences of such
damage are urinary incontinence, faecal incontinence if the rectum is
affected, and excoriation of the vulva from the constantly leaking urine and
faeces. Secondary amenorrhoea is a frequently associated problem. Women
who have survived prolonged obstructed labour may also suffer from local
nerve damage which results in difficult}' in walking, including foot drop.”131
The social stigma resulting from obstetric fistulae can be devastating to those who
cannot obtain prompt surgical repair. It has been explained that:
“The social consequences of these physical disabilities are severe. Most
victims of obstructed labour in which the fistula subsequently occurred will
also have given birth to a stillborn baby. In some areas, a high percentage of
fistulae occur during the first pregnancy. Women who live in cultures where
childlessness is unacceptable will therefore suffer from this fact alone. As
long as they are incontinent of urine they are also likely to be abandoned by
their husbands on whom they are financially dependent, and will probably be
ostracised by society.”132
Moreover, in many situations the “social isolation compounds the woman’s own
belief that she is a disgrace and has brought shame on her family. Women with VVF
often work alone, eat alone, use their own plates and utensils to eat and are not
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anowed to cook for anyone else. In some cases they must live on the streets and
oeg.
The denial of the right to enjoy marriage and to found a family that failure to prevent
marriage and childbearing. Once adolescent girls are married, states need to ensure
that they obtain the necessary health care to survive pregnancy and delivery In the
event of complications, such as obstetric fistulae, states are obliged to ensure that
they quickly obtain necessary surgical treatment in order that they may found and
enjoy their families.
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“Free and full consent”
1
The burden falls on those employing state authority, whether by enacting legislation
or by takmg executive orjudicial action, to ensure that entry into marriaoe
relationships conforms to human rights standards concerning women’s voluntary
choice to many and protection of their health and welfare.
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CESCR, in its Concluding Observations on the report from Suriname
recommended that “the laws permitting persons to many without the ’
acknowledgement or consent of the partner be abolished.. .”134 its Concluding
Observations on the report of Cameroon, CESCR also deplored “the lack of
g[2reSm?5ade
the Govemment in combating ... the forced early marriage of
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Significantly, the National Court of Justice of Papua New Guinea decided in favour
of a girl who wanted to continue her education and find a job, over her familv’s
opposition, instead of being married involuntarily.^ so doing>
Court dec!ared
unconstitutional the ‘head pay’ custom of providing young women for marriage or
other employment in victims’ families as part of legitimate compensation for ~
causing accidental deaths.
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S Judgement 1S consistent with CEDAW’s General Recommendation on
Equality m Marriage and Family Relations.n^ This Recommendation makes the
following observation on Article 16(1 )(a) and (b) of the Women’s Convention:
A woman’s right to choose a spouse and enter freely into marriage is
central to her life and to her dignity and equality as a human being An
examination of States parties’ reports discloses that there are countries
which on the basis of custom, religious beliefs or the ethnic ongins of
particular groups of people, permit forced marriages or remarriages. Other
coimtnes allow a woman’s marriage to be arranged for payment or
pre erment and in others women’s poverty forces them to many foreign
nationals for financial security. Subject to reasonable restrictions based for
'
e u n 3 Vv0Jnan s y°uth or consanguinity with her partner, a woman’s
eitforced a??56
W^om s^e
marry must be protected and
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This Recommendation has been echoed in HRC’s General Comment 28 Equality of
Rights between Men and Women, which explains that:
F
“States are required to treat men and women equally in regard to marriage in
accordance with article 23.... Men and women have the right to enter into
marriage only with their free and full consent, and States have an obligation
to protect the enjoyment of this right on an equal basis. Many factors may
prevent women from being able to make the decision to marry freely. One
factor relates to the minimum age for marriage. That age should be set by the
State on the basis of equal criteria for men and women. These criteria should
ensure women’s capacity to make an informed and uncoerced decision. A
second factor in some States may be that either by statutory or customary
law a guardian, w'ho is generally male, consents to the marriage instead of
the woman herself, thereby preventing women from exercising a free
choice.” (see Appendix 8, para 23)
iv. The right to free choice ofinaternity/the right to private andfamily life
The Women’s Convention, Article 16(1):
States Parties shall take all appropriate measures to eliminate discrimination against
women in all matters relating to marriage and family relations and in particular shall
ensure...
(e) The same rights to decide freely and responsibly on the number and
spacing of their children and to have access to the information, education
and means to enable them to exercise these rights.
The Political Covenant, Article 17(1):
“No one shall be subjected to arbitrary or unlawful interference wdth his privacy,
family, home or correspondence....”
The right to free choice of maternity is derived from the right to private and family
life and the right to decide on the number and spacing of one’s children. These
rights, however formulated, are found in many national constitutions and human
rights treaties. For example, the 1998 Constitution of Ecuador says that:
“[t]he State shall guarantee the right of persons to decide on the number of
children they w'ant to conceive, adopt, maintain and educate. It is the
obligation of the State to inform, educate and provide means that contribute
to the exercise of this right.”139
i
The implementation of such rights reduces state power to compel individuals to
account to governmental officers for their reproductive choices, and to compel
individuals to employ their reproductive capacities in compliance with governmental
preferences. Free choice of maternity is increasingly recognized as an attribute of
private and family life, in order that individuals may propose whether, when and
how often to have children, without governmental control, accountability or
coercion. The common approach now is that choices on reproductive practice and
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health, including maternity, are private decisions between consenting partners, not
governmental decisions. Accordingly, women may in principle protect their health
in maternity by determining whether and when to plan pregnancy.
The issue of choice of termination of unplanned or health-endangering pregnancy
remains legally contentious in many countries, although countries are progressively
liberalising their laws.140 Governmental agents such as police officers have powers
of enquiry and investigation where criminal abortion is suspected that may prevail
over human rights of privacy. Women are often deterred from seeking health care
v/hen they know that governmental officers could have access to their health care
information. The deterrent effect on women is especially strong when others’
knowledge of their pregnancy, or possible pregnancy, risks their exposure to
disadvantage. They may fear, for instance, loss of personal and family reputation
where pregnancy outside marriage is stigmatized, and subjection to personal
violence, which in some cultures, notwithstanding prohibitive law, may go so far as
to accommodate or only lightly punish a so-called “honour killing.” Further, a
premature end to a pregnancy of which those bound or disposed to notify police
officers are aware may expose a woman, and perhaps others close to her, to
investigation on suspicion of unlawfully inducing abortion.
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Courts respecting women’s choices on pregnancy and childbirth have relied on
rights to private life to prevent potential fathers, whether married or unmarried, from
forcing women to bear children against their will. The European Commission has
held that a husband could not veto his wife’s lawful abortion and force her to endure
pregnancy against her will.141 This decision gives priority to a wife’s right of
decision with respect to childbearing over a husband’s right to family life in the birth
of his child. Husbands’ rights do not include the right even to be consulted about
abortion, because wives’ rights of confidentiality and privacy prevail. This reasoning
supports the argument that the state has no greater interest in the birth of a child than
a husband or biological father. As a result, the state should have no right to prevent
women’s choice about the timing of their families and their full exercise of their
right to private and family life.142
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A 1998 study of maternal mortality in Nepal indicates how the right of women to
privacy is not sufficiently protected by prevailing practices regarding decisions to
seek health care. The Nepalese study demonstrates that the husband is the most
frequent decision-maker in whether to seek hospital maternity care,143 and that delay
in seeking care is a contributing factor to maternal deaths. The husband alone made
the decision to seek care in 42.5% of all families that sought hospital care, and the
husband and family of the husband together made the decision in 39.1% of the
cases. In only 11.5% of cases did maternal family members make the decision. The
Nepalese experience suggests that a great deal of effort is needed to educate
husbands and wives and their families on the importance of seeking maternity care
promptly, and the importance of respecting the woman’s decision to seek care
promptly when she feels in need of assistance.
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b. The right to the highest attainable standard ofhealth
The Economic Covenant, Article 12:
“1 The States Parties to the present Covenant recognize the right of everyone to the
enjoyment of the highest attainable standard of physical and mental health.
2. The steps to be taken by the States Parties to the present Covenant to achieve the
full realization of this right shall include those necessary for:
(a) The provision for the reduction of the stillbirth-rate and of infant
mortality and for the healthy development of the child;
(b) The improvement of all aspects of environmental and industrial hygiene;
(c) The prevention, treatment and control of epidemic, endemic,
occupational and other diseases;
(d) The creation of conditions which would assure to all medical service and
medical attention in the event of sickness.”
The right to health is also protected by other regional and international human rights
instruments (see Appendix 2) as well as by various national constitutions. The
Constitution of the Federative Republic of Brazil is particularly clear in providing
that:
Health is the right of all and the duty of the State and shall be guaranteed by
social and economic policies aimed at reducing the risk of illness and otiier
maladies and by the universal and equal access to all activities and services
for its promotion, protection and recovery.144
The CESCR General Comment on Health significantly develops the understanding
of what is required to implement the right (see Appendix 7). The General Comment
explains that
“the right to health in all its forms and at all levels contains the following
interrelated and essential features:
(dfAvailability - functioning public health and health care facilities, goods
and services, as well as programmes, have to be available in sufficient
quantity within the State party. The precise nature of the facilities, goods and
services will vary according to numerous factors, including the State party's
developmental level. They will include, however, the undeilying
determinants of health, such as safe and potable drinking water and
sanitation facilities, hospitals, clinics and other health-related buildings,
trained medical and professional personnel receiving domestically
competitive salaries, and essential drugs, as defined by WHO's Action
Programme on Essential Drugs.
(b^Accessibility - health facilities, goods and services have to be accessible
to everyone without discrimination, within the jurisdiction of the State party.
Accessibility has four overlapping dimensions:
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Non-discrimination: health facilities, goods and services must be accessible
to all, especially the most vulnerable or marginalized sections of the
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population, in law and fact, without discrimination on
any of the prohibited
grounds.
' Physical accessibility: health facilities, goods and services must be within
safe physical reach for all parts of the population, especially for vulnerable
or marginalized groups, such as ethnic minorities and indigenous
P°pu atl0ns’ w°men> children, adolescents, older persons, persons with
dtsabth tes, and persons with HIV/AIDS. Accessibility also implies that
medical services and underlying determinants of health, such as safe and
potable water and adequate sanitary facilities, are within safe physical reach
'nC “dlng 'n
areas- Accessibility further includes adequate access to
buildings for persons with disabilities.
onomtc aecesstbihty (affordability): health facilities, goods and services
must be affordable for all. Payment for health care services, as well as
services re ated to the underlying determinants of health, have to be based
on
the principle of equity ensuring that these services, whether privately or
publicly provided, are affordable for all, including socially disadvantaged
groups. Equity demands that poorer households should not be
disproportionately burdened with health expenses as compared to richer
households.
Information accessibility: Accessibility includes the right to seek, receive
and impart information and ideas concerning health issues. However
health dbl1^ ° mf0rmiatlon should not impair the right to have personal
health data treated with confidentiality.
jc) Acceptability - All health facilities, goods and services must be respectful
medlcai ethics and culturally appropriate, i.e. respectful of the culture of
n ividuals, minorities, peoples and communities, sensitive to gender and
hfe-cycle requirements, as well as being designed to respect confldentialitv
and improve the health status of those concerned.
(duality - As well as being culturally acceptable, health facilities, goods
_ J6™68
also be scientifically and medically appropriate and of
t jo ^ua..L;. i nis requires, inter aha, skilled medical personnel
scientifically approved and unexpired drugs and hospital equipment safe
and potable water, and adequate sanitation.” (see Appendix 7, para 12)
currendy working to develop indicators to determine how fully the
substantive elements of the right to health services, namely their availability
accessibility, acceptability and quality, are satisfied. Laws and policies that ’
Siwsngh/?11101 r1111
aCCOr'dlng tO theSC Critena would not comPly
health servFe ' gg’ f.law or Pol,cy requiring unnecessary qualifications for
moTerhZr 7" himit aVailabiHty °f 3 service that contributes to safe
XaS° rXT u SUCh P°IicieS
re^re exccssive
reouirp cp OnS i °r 63 r SerVlce Prov>ders to perform caesarean deliveries, and that
of nreon
QS^^Cia !StS to deteiTnine satisfaction of criteria for lawful termination
y’ SUCh P? 1CieS may be ProP°sed good faith in order to ensure
ence in women s health care. However, it is poor policy, and may be a human
353
Rig: .
)
ADVANCING SAFE MOTHERHOOD
44
rights violation where health services are jeopardised, to allow the excellent to be
the enemy of the good, or the good the enemy of the adequate.
Some or all of the standards proposed in the CESCR’s General Conunent on Health
XX general recommendations, such as the CEDAW General Recommendation
on Women and Health, and those arising out of the Cairo Programme and t
Beiiing Platform are used to determine whether states are in compliance or
violation with treaty obligations.^ These standards are also reflected in Ub agency
consensus documents on the major components of a woman s nght to heal^F
example, a report on maternal health care explains that women-fhendly h
I
services should:
®
be available, accessible, affordable and acceptable,
of care by providing a coo.iounm of services m
the context of integrated and strengthened systems,
(iii) be implemented by staff motivated and backed up by supervisory teamteed training, and incentive-linked evaluation of Perf™C^
(iv) empower users as individuals and as a group by respecting their rights
information, choice, and participation.146
Much work is stili required to apply the right to health
velysc, as »
ensure the availability, accessibility, acceptability and quahty of
SC^
in particular countries. However, treaty-monitoring
g
Observations on country reports, have made some signifi
g
lained
example, CESCR, in its Concluding Observation on a report by Gambia, explai
that:
“frlecardina the right to health in Article 12 of the Covenant, the Committee
expresses it’s deep concern over the extremely high maternal mortality rate
1 050 per 100,000 live births. UNICEF identifies the main causes to be
haemorrhage and infection related to the lack of access to [appropriate
services] and poor services.
!i
i
!■
services in particular.
i. Available resources
I Jnder the Economic Covenant, states are required to take immediate and
progressive steps to achieve specific health standards. States
on
extent to which they are moving toward “the realizahon of the right to Ae highes
attainable standard of health. CEDAW’s General
Health nrovides that’ “the duty to fulfil rights places an obligation on States partie
I
I
extent of their available resources to ensure that women realize their ngh
care” (see Appendix 4, para 17).
55^1
THROUGH HUMAN RIGHTS
45 ■■Wk
The Constitutional Court of South Africa has addressed the issue of whether the
government is required under the South African Constitution149 to provide long term
dialysis treatment for a claimant’s chronic renal failure.150 The Court found that the
government is not so required, because the constitutional obligations regarding
access to health care services, including reproductive health care, “are dependent
upon the resources available for such purposes, and ... the corresponding rights
themselves are limited by reason of the lack of resources.”151 The Court stated,
however, that emergency services cannot be denied in situations where a person
suffers a sudden catastrophe which calls for immediate medical attention.”152 Thus,
it would seem that under the South African Constitution, and possibly under similar
provisions of other national constitutions, women seeking emergency obstetric care
have a right of reasonable access to treatment.
A state s willingness in principle to give effect to women’s rights to health and safe
motherhood may be deterred by the fear that full implementation will have
indeterminate economic consequences for the national health budget. A finding in a
World Bank study, however, has “estimated that providing a standard ‘package’ of
maternal and new-born health services would cost approximately $3 [U.S.] per
person per year in a developing country; maternal health services alone could cost as
little as $2 per person.”153
The same World Bank study has also found that family planning and maternal health
services are the most cost-effective governmental health interventions, in terms of
death and disability prevented.154 When a mother dies, the economy loses her
productive contribution to the work force, her community loses the domestic and
wider caring services of a vital member, and her death puts others around her at risk
and impaired capacity to function in social, employment and other roles. Studies
have shown that when their mother dies, the surviving children are three to ten times
more likely to die within two years than children that live with both of their
parents.155
j
The study also explains that the savings resulting from investing in maternal health
and reduction of maternal morbidity are significant.156 The population will have
fewer poor women, and the work force will be healthier and therefore capable of
higher productivity. Reducing maternal mortality and morbidity reduces household
poverty and benefits the health system. Moreover, preventative care mav save
money when there are fewer sick women. Practical and economically viable
solutions to the problem of maternal death and sickness include the purchase of a
community ambulance where resources exist for fuel and maintenance of an
ambulance, or financial help is available to a communit}' to cover emergency
transport costs.
ii. Economic access
Some policy makers advocate that users of services should pay at least partial or
token fees. Their reasons include needs to raise revenues to be available for health
care, but also fears that irrational use may be made of publicly funded health
services. Moreover, there is a perceived need to impress upon users of health
services that their use of services has economic costs. Paying from their own pockets
is believed to bring home this reality to them, and to cause them to question whether
2.55
■ C
’
ADVANCING SAFE MOTHERHOOD
46
their request for services is based on a real health need, or is rather a frivolous
indulgence at others’ expense that they will not allow at their own. There is a
market-based perception that people exercise rationality in expenditure of their own
resources that they do not exercise in expenditure of others’ or of public resources,
and that cost-effective utilization of resources can be achieved by imposition of user
I
fees for services.
v
It is uncertain and problematic what effect the imposition of user fees would have on
safe motherhood among poor people in developing countries, particularly whether
such fees would deter or prevent poor women’s resort to necessary maternity care. A
study on safe motherhood funded by the U.K. Department for International
Development and WHO reported in 1999 that “[t]he paucity of relevant global, let
alone local, information on cost poses a challenge to maternal health planners and
managers in developing countries, for in the development of health financing
schemes, programme costs are critical.”157 Evidence following removal of user fees
by the post-apartheid government elected in South Africa in 1994 “suggests that
gains in maternal health care ... have been relatively modest,” and that more
deliveries within health facilities and improvements in the quality of services are
also required to reduce maternal and perinatal mortality.158
i
i
Contrasting evidence has come from other countries experimenting with general
user fees, including Kenya. A review of safe motherhood there has observed that:
“Cost is known to affect both uptake and delays in seeking care. The GOK
[Government of Kenya] introduced cost-sharing in 1989 for specific
services, but excluding promotive and preventive services, which includes
antenatal care ... Evidence from other developing countries indicates a direct
decline in utilization of maternity services linked with the introduction of
user fees, and this will need to be monitored in Kenya. Fees appear to vary
from facility to facility, but generally women are charged in proportion to the
service rendered. A caesarean section for example, is more expensive than a
normal delivery. This appears logical in terms of the health service inputs
but may also be an important deterrent for poor women seeking care.””159
159
The inability of impoverished families to pay for the full range of safe motherhood
services, including antenatal, delivery and postpartum care, available only by
payment, appears evident. When medical services are themselves free of charge,
however, poverty may remain an obstacle to safe motherhood. It has been observed
that:
“Even when formal fees are low or non-existent, there can be other costs that
deter women from seeking care. These costs may include transport,
accommodation, drugs, and supplies, as well as informal or under the table
fees that may be imposed by health staff. When women lack control over
resources and are dependent on others to provide funds, fees of any kind can
be a serious obstacle to their use of services.”160
I-' :
"■i
I
Proposed options to overcome economic barriers to safe motherhood services
include making medical services free of charge, having means-related sliding fees,
insurance schemes based on community membership or, for instance, employment
■:
35fe
I
1
THROUGH HUMAN RIGHTS
47
and community trust fund or loan schemes, each with advantages and disadvantages
concerning coverage and effectiveness.
I
In responding to the problem of economic barriers to services that promote safe
motherhood, and to economic conditions that aggravate unsafe motherhood,
governments are accountable under the Economic Covenant for denials of the right
to the highest attainable standard of health that are due to individuals’ poverty.
Moreover, Article 12(2) of the Women’s Convention, addressing maternity services,
requires States Parties to grant “free services where necessary.”161 Accordingly,
governments will have to explain the extent to which, in their countries, measures of
what standards of health are attainable include issues of personal poverty and of
national allocation of economic and other resources.
A
g;
Hi. Transparency andfairness in the allocation ofresources
Women whose governments have failed to address their basic obstetric needs in the
allocation of health resources in a fair and transparent way may be able to ground a
complaint in the right to procedural fairness in administrative decision-making.
Courts are slowly applying the right to procedural fairness to require that health
benefits are allocated equitably, or at least are not denied in an unfair or arbitrary
way.162 For example, the European Court of Human Rights has found that a sickness
allowance should not be arbitrarily withdrawn.163 This decision could be applied to
require the restoration of health services, including maternity services, where they
have been withdrawn in an unfair and arbitrary way, and governmental explanation
and justification of policies that disfavour safe motherhood services against other
health expenditures or budgetary allocations. Further, since in the world’s prevailing
global economy few if any countries exercise full fiscal sovereignty, governments
may be amenable to international persuasion and inducement to invest in such
services compatibly with their human rights undertakings.
c. The right to the benefits ofscientific progress
J
The Economic Covenant, Article 15(1 )(b):
The States Parties to the present Covenant recognize the right of everyone... [t]o
enjoy the benefits of scientific progress and its applications.”
Scientific progress can play a vital role in the reduction of maternal mortality and
morbidity rates. One of the most fundamental methods of reducing risk in pregnancy
is to afford women the ability to plan the number and timing of their pregnancies;
this can most easily be accomplished through the use of birth control technologies.
The right to receive the benefits of scientific progress includes a woman’s
entitlement to receive the advantages of better and more acceptable means of fertility
control, including emergency contraception and non-surgical methods of early
abortion.
The right to the benefits of scientific progress can also support the claim that
governments should spend public funds on research designed to benefit the
reduction of maternal mortality. The modem history of ethical regulation of research
involving human subjects originated in the trial of physicians who conducted
48
r
ADVANCING SAFE MOTHERHOOD
inhumane experiments on vulnerable subjects, including inmates of concentration
camps, to serve military and scientific interests in the Second World War. Their trial
before the International War Crimes Tribunal in Nuremberg resulted in the 1947
Nuremberg Code, which invoked concepts of human rights to prohibit nonconsensual medical experimentation. The subsequent decades saw reinforcement of
protections against improper medical experimentation in a series of international
human rights conventions. Under this inspiration, medical research recovered its
moral standing, and its benefits came to be almost universally recognized. In the
1980s it began to be perceived, however, that women were not participating
equitably in these benefits.
Human rights protections had been implemented by rigorously excluding women of
reproductive age from research initiatives, in order to guard against injuring unborn
children. Their exclusion was also economic, since it was costly to have sufficiently
large-scale studies to achieve statistically valid data on women at every stage of their
menstrual cycle. The effect, however, was that women’s health was not seriously
studied, except regarding fertility. The health-related factors that predisposed
women to maternal mortality and morbidity, other than fertility itself and its control,
were under-researched.
In the 1980s it came to be realized, however, that women had been denied their
collective human right to benefits of progress in medical science. Reversing the
Nuremberg-influenced perception that individuals would be protected by their
exclusion from medical studies, women’s groups showed that women’s health
protection depended on scientific research, and that exclusion of research on
women’s health from governmental funding constituted discrimination. Women
allied themselves with AIDS activists to require the conduct of medical research, to
address and remedy causes of mortality and morbidity of special concern to them.
They pointed to states’ legal commitments, made for instance under Article 15 of the
Economic Covenant, to respect their rights “to enjoy the benefits of scientific
progress and its applications.”
d
H
■i;
I!-'
III
I!l
ill i
l|-r
»
i1'
L.
Health care providers can accordingly rely on this right to argue for funding to
achieve equity in the recruitment of members of both sexes into studies, and in the
topics they choose to investigate. Similarly, research agencies, health research
centres and, for instance, governmental health departments should remember human
rights responsibilities to pursue the goal of safe motherhood through sponsorship
and support of appropriate scientific studies. These should include not only
biomedical studies, but also epidemiological or public health research, health
systems research and social science research that could expose and remedy social
causes of unsafe motherhood.
i
!
Family Care International (FCI) and the Safe Motherhood Inter-Agency Group (IAG). (1998). Safe
3^3 Motherhood: A Matter of Human Rights and Social Justice, Safe Motherhood Factsheet. New York: FC
Safe
4
KMotherhood^
< must be seen as integral to reproductive health. But changes in service delivery and accessibility are not ...
5 sufficientThe goals of the Safe Motherhood Initiative will not be achieved until women are empowered
Ondjtiieir human rights ~ including their rights to quality services and information during and after
^Mdciuidbrnh:^
It yT
Cl IVLCICL&T (jT
Huj
Rights
s
Empowering Women, Ensuring
Choices1
r | ’he sluggish'decline in maternal mortaliJL ry and morbidity is rooted in the
'owerlessness of women, and women’s
*^\equal access to resources in families, soci
ety and economic markets. These factors set
the stage for poor reproductive health and
unsafe motherhood even before a pregnancy
occurs, and make it worse once pregnancy
and childbearing have begun.
Women face multiple barriers to attain
ing good health. These include:
□ Limited information and options:
Women’s limited exposure to new ideas
and information means that they are
socialised to accept pain and suffering as
□ Poor quality of interaction with health
choice, and far too many women still have
are reluctant to use health sendees because
far too few choices.
they perceive health care providers to be
rude, patronising and insensitive to the
context in which they live. Interactions
with providers can be threatening and
humiliating, and women often feel pres
sured to make choices that conflict with
their own health and fertility goals.
Empowering women means enabling
care. As a result, many women do not
■
women’s empowerment:
■ Women must have greater freedom to
the areas affecting the most intimate aspect
must have opportunities to learn about
of their lives — their reproductive health.
their rights and their health, to question
Empowerment is critical to securing safe
the acceptability of unfair practices and to
motherhood because it enables women to:
develop a feeling of entitlement to medical
care and other services.
a) articulate (heir health needs and concerns;
b) access services with confidence and with
out delay;
and programme managers, and from gov
medical services.
ernments for their policies;
d) act to reduce gender bias in families,
communities and markets; and
mobility' and access to material resources:
the decision to deliver at home is generally
in the private and public spheres to ensure
es within families and communities; they
and do not know where or when to seek
In some settings in developing countries,
JLwomen, multiple actions will be needed
make fully informed choices, particularly in
c) seek accountability from service providers
women’s decision-making ability, physical
Tn order to address the constraints on
determine their own health and life choic
recognise danger signs during pregnancy,
□ Unequal power relations that constrain
What Can be Done’
them to overcome these barriers and to
women’s “lot”, and they do not perceive
pregnancy as requiring any additional
hood. Central to all empowerment is
care providers: Women in many cultures
e) panicipate more fully in social and eco
nomic development.
n Women must have access to accurate
information about their reproductive
health as well as to high quality, women
centred care.
n Women must have expanded access to
educational and economic opportunities,
and control over economic and other
resources.
□ Adolescents must be offered the opportu
nity to develop life skills, including
self-esteem, so that they can act to protect
made by the husband or other family
Empowering women in the area of
member. Many women need permission
health requires more than simply health-
from their husbands to visit a health facili-
related interventions; it requires social,
ry. Women’s lack of economic resources
economic and cultural conditions in which
constrains their ability' to make indepen
freedom and responsibility are given con
households and communities, and in
dent health-related choices, and to gain
crete meaning. Women must have the
ensuring responsible sexual and
access to health and other social services.
means — both physical and psychological —
family life.
their own health.
■ Men must be sensitised to their role
in expanding choices for women within
to overcome the barriers to safe mother-
SATE MOTHERHOOD FACT SHEET
359
I
i Women must be supported by policies
and laws that promote and ensure safe
motherhood, good quality maternal care
and gender equality; correspondingly,
governments must engage women in
planning, implementing, monitoring and
evaluating health programmes for
women.
^1 Training of providers must stress the
importance of preserving women’s digni
ty; encouraging informed choices;
recognising the realities of women’s lives
and providing sensitive counselling to
uncover and treat the conditions that
women are accustomed to endure.
Reducing inequalities in social and eco
nomic policies, and protecting and
promoting women’s rights, choices and
autonomy, are core public activities. They
are also critical to reducing maternal deaths
and ill-health, achieving the goals of the
Safe Motherhood Initiative, and bringing
about sustainable, equitable development
for all the world’s women and men.
Advance Safe Motherhood
Through Human Rights2
reventing maternal death and illness is
JL an issue of social justice and women’s
human rights. Redefining maternal mortality
from a “health disadvantage” to a "social
injustice” provides the legal and political
basis for governments to ensure maternal
health care for all women — care that will
save their lives. The challenge in applying
human rights to advance safe motherhood
is to characterise women’s multiple disem
powerments — during pregnancy as well as
from birth — as injustices that governments
are obligated to remedy through political,
health and legal systems.
The protection and promotion of the
human rights of women can help ensure
that all women have the right to:
□ make decisions about their own health,
free from coercion or violence, and based
on full information; and
□ have access to quality services and infor
mation before, during and after pregnancy
and childbirth.
<,00
Existing national constitutions and inter
national human rights treaties offer
under-utilised opportunities to advance
safe motherhood. Relevant international
treaties include:
□ Convention on the Elimination of All
Forms of Discrimination Against Women
(the Women’s Convention);
□ International Covenant on Civil and
Political Rights;
□ International Covenant on Economic,
Social and Cultural Rights;
□ Convention on the Rights of the Child;
□ European Convention on Human Rights;
Q American Convention on Human Rights:
and
□ African Charter on Human and Peoples’
Rights.
Each of these treaties has a monitoring
body that develops performance standards
for signatory countries, and monitors their
compliance with these standards. Countries
are to report regularly to the relevant moni
toring bodies on what they have done to
ensure the full development and advance
ment of the rights enshrined in the human
rights treaties they have ratified. The
Women’s Convention, which has been rati
fied by more than 160 countries and is
being used to advance safe motherhood, is
monitored by the Committee on the
Elimination of Discrimination Against
Women-(CEDAW).
The Challenge2
fforts to advance safe motherhood
_L_-/through human rights must build on
the existing framework of human rights
recognised in most national constitutions
and international human rights treaties.
These rights include:
□ rights relating to life, liberty and the
security of the person, which require
governments to ensure access to ap
propriate health care during pregnancy
and childbirth (women’s right to life).
and to ensure women s rights to
decide if, when and how often to bear
children (right to liberty and security
of the person);
□ rights relating to the foundation of fami
lies and of family life, which require
governments to provide access to health
care and other services women need to
establish families and to survive to enjoy
life within the family;
□ rights relating to health care and the bene
fits of scientific progress, including to
health information and education, which
require governments to provide reproduc
tive and sexual health services and
information for women; and
O rights relating to equality and -non
discrimination on grounds such as s
marital status, race, age and class, whii..
require governments to provide access to
services such as education and health
care for women and girls — especially for
women or girls of a particular marital
status, age, minority group or socio-eco
nomic status.
What Can be Done2
A T uch has been achieved in the past ten
JLVJLycars to develop standards of human
rights that support and protect women’s
reproductive health needs. For example, the
Programme of Action of the International
Conference on Population and
Development (1994) states that gov
w
ernments must work to reduce by h:
number of maternal deaths by the year
2000, and then reduce maternal deaths by
another half by 2015.
Three critical actions needed now are:
■ reforming laws that contribute to mater
nal mortality (e.g., laws that require
women seeking health services to obtain
the authorisation of their husbands, and
laws that inhibit access to safe reproduc
tive health services);
■ implementing laws that protect women’s
health interests (e.g., laws that prohibit
child marriages, female genital mutila
tion, rape and sexual abuse); and
f
■ apply^g human rights in national consti. tutions and international conventions to
advance safe motherhood (e.g., by
requiring states to take effective preven
tive and curative measures to reduce
mortality and to treat women with
respect and dignity).
The ICPD Programme of Action in itself
was non-binding; however, in 1995,
CEDAW agreed to use the Programme of
Action in developing performance stan
dards for the Women’s Convention.
Therefore, signatories to the Women’s
Convention are obligated to uphold and
advance the ICPD commitments, including
the right of women and men to decide if,
when and how often to reproduce, and ro
have access to appropriate health services
.hat enable women to enjoy safe pregnancy
^^and childbirth.
States have a legal obligation to account
for their practices regarding human rights
by reporting to human rights treaty bodies.
Where states do not take all appropriate
measures to bring laws, policies and
practices into compliance with the human
rights of women, they have been and can
continue to be held accountable by con
stitutional courts and treaty monitoring
bodies for denying women their human
rights, which arc necessary for their dignity
and empowerment.
Sources:
1. S.J. Jejeebhoy, “Empower Women, Ensure
Choices: Key to Enhancing Reproductive Health”.
Presentation at Safe Motherhood Technical
Consultation in Sri Lanka, 18-23 October 1997.
2. R.J. Cook, “Advancing Safe Motherhood
Through Human Rights”. Presentation at Safe
Motherhood Technical Consultation in Sri Lanka,
18-23 October 1997.
Prepared by Family Care International (FCI) and
the Safe Motherhood Inter-Agency Group (IAG).
The IAG includes: the United Nations Children’s
Fund (UNICEF), United Nations Population Fund
(UNFPA), World Bank, World Health Organization
(WHO), International Planned Parenthood
Federation (IPPF), and the Population Council; FCI
serves as the secretariat.
These fact sheets have also been prepared in a more
abbreviated version for general audiences. For more
information or copies of available materials, contact
any IAG member, or the secretarial aL
Family Care International
588 Broadway, Suite 503
New York, NY, 10012, USA
Tel: (212) 941-5300
Fax: (212) 941-5563
Email: smilO@familycareintl.org
Web site: www.safemothcrhood.org
1998
a6j.
/
■ 0
.Safe Motherhood-
■
-■
/.
>
For a woman to die from pregnancy and childbirth is a social injustice. Such deaths are irooted“in women's
\r
powerlessness and unequal access to employment, finances, education, basic health care and other resources. These^actors set
the stage for poor maternal health even before a pregnancy occurs, and make it worse once pregnancy and childbear
ing have begun.
Making motherhood safer, therefore, requires more than good quality health services. Women must be empowered, and
their human rights — including their rights to good quality services and information during and after pregnancy and
childbirth — must be guaranteed.
rhe Powerlessness of Women1
E5 Millions of women in the developing world do not have
Percentage of Women Aged 15 to 49 With No Education3
the social and economic support they need to seek good
health and safe motherhood. Physical and psychological
too
83%
barriers include:
— Limited exposure to information and new ideas: In many
s
73%
GO
48%
communities pregnancy is not seen as requiring special
care, and women do not recognise danger signs during
pregnancy. Even if they are experiencing pain and suffer
0
38%
•o
TO
&
ing, they may have been taught that these conditions are
O
inevitable, and therefore do not seek medical care.
— Limits on decision-making: In many developing countries,
Burkina
Faso
Pakistan
Egypt
Uganda
n%
io%
g
Mexico Thailand
men make the decisions about whether and when their
wives (or partners) will have sexual relations, use contra
ception or bear children. In some settings in Asia and
■ Health services that arc insensitive to women’s needs, or
Africa, husbands, other family members or elders in the
staffed by rude health providers, do not offer women a real
community decide where a woman will give birth and
choice: In many cultures, women are reluctant to use
must give permission for her to be taken to a hospital.
health services because they feel threatened and humiliated
by health workers, or pressured to accept treatments that
— Limited access to education: In much of Africa and Asia,
conflict with their own values and customs.
75% of women age 25 and over are illiterate? When girls
are denied schooling, as adults they tend to have poorer
HOW CAN EMPOWERING WOMEN MAKE MOTHERHOOD SAFER?’
health, larger families and their children face a higher risk
It enables women to:
of death.
• speak out about their health needs and concerns.
— Limited resources: Poverty, cultural traditions and national
laws restrict women’s access to financial resources and
inheritance in the developing world. Without money, they
cannot make independent choices about their health or
• seek services with confidence and without delay
• demand accountability from service providers, and from governments
for their policies.
• participate more fully in social and economic development.
seek necessary services.
Political Commitment to Safe Motherhood4
■ National policy-makers can establish a legal and political
— Ensuring that all women have the right to make decisions
basis for safe motherhood by defining maternal mortality
about their own health, free from coercion or violence,
as a “social injustice”, as well as a “health disadvantage”.
and based on full information.
By doing so, they will commit their governments to:
— Guaranteeing that all urotnen have access to good quality
— Identifying the powerlessness that women face —
care before, during and after pregnancy and childbirth.
throughout their lives as well as during pregnancy' — as
an injustice that countries must remedy through political,
health and legal systems.
2>^
Using Intemational Human Rights to Advance Safe Motherhood■ International human rights treaties can be used to advance
- Governments participating in the 1994 Intemational
safe motherhood (see below). These documents, as well as
Conference on Population and Development and the 1995
most national constitutions, guarantee:
Fourth World Conference on Women agreed that women
- The right to life, liberty and the security of
and men have the right to decide if, when and how often
ese rights require governments to provide access to
to bear children, and should have access to reproductive
appropnate health care, and to guarantee that citizens can
boose when and how often to bear children.
health services. They also pledged to cut the number of
maternal deaths in half by the year 2000, and in half again
by 2015. Although these commitments are non-binding,
- Rights that relate to the foundation of fantilies and of
fannly l,fe These rights require governments to provide
the Committee on the Elimination of Discrimination
access to health care and other services women need to
Against Women, which monitors the Women’s Convention
establish famil.es and enjoy life within their families.
(see below), is using them as standards for the 161 coun-
tries that signed the Convention.
- Tint right to health services (including information and
e ucatton) and the benefits of scientific progress. These
THE FOLLOWING INTERNATIONAL TREATIES PROVIDE FRAMF
WORKS THAT CAN RE USED TO ADVANCE SAFE MOTHERHOOD-
ng ts require governments to provide reproductive and
sexual health care to women.
’inaVe?«tn
Eliminatim of AU Forms of Dtscrtmtnat,™
Against Women {the Women's Convention);
- The right to equality and nondiscrimination. These rights
• International Covenant on Civil and Political Rights;
require governments to ensure that all women and girls
ave access to services (such as education and health
regardless of age, marital status, ethnicity or socio-
• International Covenant on Economic, Social and Cultural Ri-
ss
• Convention on the Rights of the Child;
• European Convention on Human Rights;
economic status.
• American Convention on Human Rights; and
■ Recent international conferences and conventions set
expl.Cit goals that support and protect women’s reproduc-
• African Charter on Human and Peoples’ Rights
live health needs.
reports provided by each country.
9 Periodic
What Can Be Done
0 Governments must provide
a framework for ensuring safe
Allow tvomen greater freedom to make their own health
motherhood by:
in
and hfe cho.ces, encourage them to question unfair prac
- Kefonni,,/; lau,s aild policies that
tices, and g,ve them opportunities to learn about their
rights and health and to develop a feeling of entitlement
’'•ortahty (e.g. those that restrict women’s access to
reproductive health services and information) and imple-
ie
to medical care and other services.
-nenttng laws and policies that protect women’s health
(such as prohtbttions against child marriage and female
- Help men unde,stand their ivle in expanding choices for
women, and in ensuring responsible sexual and family P'
genital mutilation).
access lo good q,.ality „,ater.
health care and accurate infonnation, and involving
-
■ Everyone, including women’s health advocates and
donors, must:
-onten ,n planmng, implementing, monitoring and eval-
the hutnan rights of their citizens by reporting any viola
■ Community leaders, women’s advocates, private organisa-
j
|
Hold gonenunents accountable for effectively protecting
uatmg health programmes.
I
tions to constnunonal courts and international
monitoring bodies.
lions and individuals must:
Sources:
'
|
?erain
4
ind
as rhe ^'^nat 't'en,hooJ prderjt^ (IPPF). and the Population Council. FCI
f’R
H^lth Sun^
N.^ N„. york
Dc,noV<tphic and
■iwix. wor&i tieauh Organization (VCHQ)
^cn- For more information or copia of'atvilZbi/
trr»*O'» for technical audithe sreretanat at:
COp‘a O' ai^t>le materials, contact any IA C member, or
Care Intemational
I,
iuiie 503
I00I2. USA
Teh (212) 941-5300
Fta: (212) 941-5563
F^rh am, 1 O^famdycareintL
^eb site address^mna. t^rferro
1998
36?>
-or.
duc-
ien\
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5
UNICEF, Regional Office for South Asia. (2003). A Human Rights-based Approach to Programmingfor
Maternal Mortality Reduction in a South Asian Context. A review of Literature. Geneva: UNICEF, pp.
. Ill 100-106.
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Appendix 1:
A Summary of Human Rights701
World Health Organization, Transforming Health
Systems: Gender and Rights in Reproductive Health,
http7/www.who.int/reproductive-health/
Human rights also cover rights and freedoms related to
human dignity, creativity and intellectual and spiritual
development, for example:
Human rights necessary for survival and dignified living
include:
• The right to education and access to information
• The rights to life and liberty
$
• Freedom of association
• The right to participate in the political process
• The right to social protection in times of need
• The right to participate in cultural life
• The right to the highest attainable standard of
physical and mental health
Human rights also include rights necessary for liberty
and physical security, for example:
• The right to work and to just and favourable
conditions of work
• Freedom from slavery and servitude
• The right to privacy and family life
s
• Freedom of religion, opinion, speech and expression
o The right to a standard of living adequate for health
and well-being of the individual and his/her family
• The right to food and housing
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• The right to security of person (physical integrity)
• The right to be free from arbitrary arrest or
imprisonment
• Freedom from torture and from cruel, inhuman or
degrading treatment or punishment
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II
100
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565
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Appendix 2:
Human Rights Affecting Safe Motherhood702
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The following is*a summary of the rights mentioned in
Appendix 1 plus the major articles quoted.
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1. Rights relating to life, survival and security
The right to-many and found a family: ICCPR 23,
ICESCR 10(1), CEDAW 16
• Covers full and free consent to marriage, minimum
These include:
}
The right to maternity protection during employment:
ICESCR 10(2), MPC 1, 4(1 )(3)
• Requires paid maternity leave plus health care
without discrimination
The right to life and survival: ICCPR703 6(1)
• Most obvious right to protect pregnant women
1
age for marriages
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• Requires government to address avoidable deaths by
taking positive measures
• Includes right of children and husbands to family life
with mother/wife
• Includes increasing the rate of births attended by
skilled birth attendants
The right to free choice of maternity/the right to private
and family life: CEDAW 16(1), ICCPR 17(1)
• Includes the right to decide freely and responsibly on
the number and spacing of children
The right to liberty and security of person: ICCPR 9(1)
• Supports women’s free choice of maternity
• Right to have access to the information, education
and means to enable women to exercise these
• Holds governments accountable to provide
conditions for safe motherhood
rights
The right to .the highest attainable standard of health:
• Requires clinic policies and law that ensure
women’s care and confidentiality
• Requires positive measures to ensure respect for
women at particular risk
The right to be free from inhuman and degrading
treatment: ICCPR 7
• Requires states to provide health services when their
denial would constitute inhuman treatment.
ICESCR 12
• Includes essential features such as availability,
accessibility, acceptability, and quality
• Available resources: obliges states to take
appropriate budgetary, economic and other
measures to the maximum extent of resources
« Economic access: requires governments to give
services free if necessary
2. Rights relating to maternity and health
♦ Transparency and fairness in the allocation of
resources: protects women from being arbitrarily
denied resources or services
These include:
The right to maternity protection: ICESCR 10(2),
CEDAW 5(b), 12(2), UDHR 25(2) CRC 24(d)
• Obligates states parties to provide free maternity
services if necessary
The right to the benefits of scientific progress: ICESCR
15(1 )(b)
o Requires that recent advances be made available to
women
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t
This right is Used to argue for funding for appropriate
research on maternal health
4. Rights relating to information and education
These include:
3. Rights relating to non-discrimination and due
respect-for difference
States parties obligations include: ICCPR 2(1),26
c States parties are obliged to change laws and
policies which discriminate on the face (e.g. women,
not men, need spousal consent for health services)
and in effect (e.g. everyone must pay equally
discriminates against the poor)
c Women have distinct interests in safe pregnancy
and childbirth, which if not protected would
constitute discrimination
The right to receive and to impart information:
ICCPR 19
<■ Requires governments to provide information about
how to save lives of women before, during and after
delivery
The right to education: ICESCR 13
♦ Relates to safe motherhood as girls education is
linked to decreased maternal mortality, probably due
to informed choice on timing and number of
pregnancies, awareness of pregnancy complications
and removing misconceptions about pregnancy and
childbirth
Issues to be considered include:
Sex and gender
Sex and gender non-discrimination in the family:
CEDAW 1
Sex and gender non-discrimination in health:
CEDAW 12
• Particular mention of adolescents sexual and
reproductive health education
There is also recognition of the right to specific
educational information to help ensure the health and
well-being of families.
These include:
The right to be free from torture, cruel, inhuman or
degrading treatment or punishment: UDHR 5, ICCPR
7.CRC 37a, CAT 12
Age: CRC 2, 14(2)
Requires governments to provide reproductive health
care to adolescents and to take into due account
the “evolving capacities of the child"
The right to be free from medical or scientific
experimentation against ones will: ICCPR 7
Other status
® Includes rural residence, poverty
• Different forms of discrimination often overlap.
102
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5. Rights relating to physical integrity
Marital status: ICCPR 2(26)
• Requires that there is no discrimination in services
offered to married and single women
Race and ethnicity: ICERD 1
® Requires that attention is given to the distribution of
resources to districts with different racial
composition
r
The right to be protected from violence against women:
CEDAW General Recommendation 12, DEVAW
The right to protection in situations of armed conflict:
PFA 144b, DPWCEAC 4 requires states to protect
women from rape, forced prostitution, persecution,
torture, degrading treatment, violence and any otheir
form of assault and sexual slavery
The right not to be forced to return to a country where
one may be in danger of torture: CAT 3
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6. Rights relating to participation
These include:
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The right to vote in all elections and public referenda
CEDAW 7a
The right to participate in the formulation and
implementation of government policy CEDAW 7b
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The right to participate in development planning and
implementation CEDAW 14.2.a
The right to participate in all community activities
CEDAW 14.2.f
The right to participate in non-governmental
organisations and associations CEDAW 7.c
The right to represent their government at the
international level and to participate in the work of
international organisations CEDAW 8
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Appendix 3:
Ratification of Relevant Rights Documents by
South Asian Countries (May 2003)
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Bhutan
Maldives ”
Pakistan
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....... . R
R
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R
R
Afghanistan
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...........
” ............. .
R
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R = Ratification
S = Signature
Source: http://www.unhchr.ch
- Ratifications as of May 31. 1997, Source: International Women’s Tribune Center, Rights of Women, page 129
# Ratification as of December 31, 1998, Source: http://www.unesco.org
Acronyms:
CRC:
CEDAW:
ICESCR:
MPC:
ICERD:
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Convention on the Rights of the Child
Convention on the Elimination of All Forms of Discrimination against Women
International Covenant on Economic, Social and Cultural Rights
Maternity Protection Convention (Revised)
International Convention on the Elimination of All Forms of Racial Discrimination
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Appendix 4:
Documents Relevant to the Rights Related
to Women’s Health
Universal Declaration on Human Rights
Articles 2, 3, 5, 16, 25
11
International Covenant on Civil and Political
Rights: Articles
17,’23.
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International Covenant on Economic, Social
and Cultural Rights: Articles 2, 10, 12, 15
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Convention on the Elimination of All Forms of
Discrimination Against Women: Articles 1, 2, 3,
5,6,10,11,12,14,15,16
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Convention on the Rights of the Child:
Articles 6, 16, 19, 24,34,37
International Convention on the Elimination of
All Forms of Racial Discrimination: Article 5
International Conference on Population and
Development Programme of Action:
See paragraphs 7.1-7.48; 8.19-8.35; 4.1-4 23- 11 i11.10.
UN Fourth World Conference on Women
Platform for Action
See paragraphs 89-130; 259-285.
CEDAW General Recommendation
No. 12 or 19 on Violence Against Women states
that the Committee considers gender-based violence
to be a form of gender discrimination, and therefore
outlawed by CEDAW
CEDAW General Recommendation No. 14 on
Female Circumcision states the Committee’s view
that appropriate and effective measure must be
taken to eradicate female genital mutilation.
CEDAW General Recommendation No. 15 on HIV/
AIDS requires states parties to include information
on AIDS and its effect on women and recommends
certain national-level action to address such effects.
CEDAW Recommendation No 21. on Equality in
Marriage and Family Relations outlines the
Committee’s views on the importance of women’s
basic rights within the family.
CEDAW General Recommendation No. 24 on
Women and Health affirms the obligation of State
parties to ensure women’s access to health care as
a basic right.705
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Appendix 5:
Conceptual Framework for Assessing and Analysing
the Situation of Children and Women from a Rights
Perspective706
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Level of the Individual
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Desired Outcome
Survival Development
Participation and Protection
Level of the
individual and
the household
Level of the
household and
community
Nutritional
Status
Status of women in society
Caring practices in the family
and community
Intellectual and emotional stimuli
Role of men in the family
and community
Essential Social
Services
(Health.Education,
Sanitation, etc.)
Protection
Participation
Security
Food/Water/Energy
/Shelter
Health Status
Direct
Influences
Underlying
Influences
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Analysis
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Assessment
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Action
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K
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Societal Level
Availability and Control of
Human/Economic/Organisational
Structural
Influences
Resources, Environment
Legal Context
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