Follow instructions files

Also, read PP file

Instructions

General Guidelines:

Writing 20%

• Paper meets APA/Graduate School standards; in-text citations and references are properly documented in APA format.
• Paper includes a minimum of fifteen (15) (double-spaced, numbered) pages and at least fifteen scholarly sources.
• Paper is organized; each paragraph flows logically into the next paragraph. Headings and sub-headings are utilized.
• Appropriate terminology it used; writing is clear and concise.
• Proper spelling and grammar is used; sentences are properly constructed.
• Appropriate font (Times New Roman) and font size (12 point font).
• The paper is written in a professional tone. Familiar language is avoided.

Content 80%

• The paper has a strong introduction, main body, and conclusion.
• The topic is introduced, a purpose is clearly evident and an overview of the paper is provided; includes a brief history of the topic/issue, and the importance of studying the topic/issue.
• The research paper goes from general ideas to specific conclusions within each paragraph.  Transitions tie sections together, as well as adjacent paragraphs.  The paper flows logically from one idea to the next.
• Scholarly research is utilized and effectively described in the main body of the paper; information is synthesized throughout the paper; includes a relevant and thorough discussion of sources that relate to the topic/issue and purpose of the paper.
• The paper demonstrates critical and creative thinking skills.
• Concluding paragraphs provide a summary of key points, connects to the introduction, and offers suggestions for future research and/or recommendations for policy changes/considerations.

Week 7 Written Assignment Rubric (Research Paper)

___/20:  Writing/format/title page/length.
___/10:  Introduction/purpose/importance.
___/10:  Organization/transitions.
___/25:  Synthesis of scholarly research.
___/25:  Critical and creative thinking.
___/10:  Conclusions/recommendations.

Gender as Social Determinant of Health

Objectives
Differentiate between sex and gender
Consider the importance of sex and gender as health determinants
Impact on health outcomes
Gender identity and sexual identity impact on health

Sex: biological and physiological characteristics of males and females, such as reproductive organs, chromosomes or hormones.
It is usually difficult to change.
Example: only women bear children, only men have testicular cancer
Gender: norms, roles and relationships of and between women and men. It varies from society to society and can be changed.
Sex and Gender

Gender is socially constructed
Components of gender
Socialization process
Gender Norms
Gender Roles
Gender Relations
Gender Stereotypes
Gender-based division of labor

Gender Norms
Beliefs about women and men
Are passed from generation to generation through the process of socialization
Change over time
Religious or cultural traditions contribute to defining expected behavior of men and women at different ages
Many men and women consider gender norms to be the “natural order of things”
Gender norms lead to inequality if they reinforce:
mistreatment of one group or sex over the other
differences in power and opportunities

Gender roles and relations
Gender roles
What men and women can and should do in a given society
Explain what women and men are responsible for in households, communities and the workplace
Gender relations
Social relations between and among women and men
Can determine hierarchies between groups of men or women based on gender norms and roles
Can contribute to unequal power relations

Gender stereotypes and Labor division
Gender stereotypes
Images, beliefs, attitudes or assumptions about certain groups of women and men
Usually negative and based on assumed gender norms and roles

Gender-based division of labor
Where, how and under what conditions women and men work
Includes formal and informal market activities
Includes work outside the home and tasks in the community and household (paid or unpaid)

Different roles are not the cause of inequality; it is the value
placed on these roles that leads to inequality.
Most societies ascribe a higher value to masculine norms and roles.
Gender norms, roles and relations affect women and men differently.
Norms and roles that undervalue women often lead to:
social exclusion
decreased access to important resources to protect their health.
Many norms encourage men and boys to engage in high-risk behavior that harms both themselves and others.
Pathways to inequality

Gender:
Social Determinant of Health
“… taking action to improve gender equity in health and to address women’s rights to health is one of the most direct and potent ways to reduce health inequities and ensure effective use of health resources.”
“Gender inequality damages the health of millions of girls and women across the globe. It can also be harmful to men’s health despite the many tangible benefits it gives men …. These benefits to men do not come without a cost to their own emotional and psychological health …”
Sen G, Östlin P for the Women and Gender Equity Knowledge Network. Gender inequity in health: why it exists and how to change it. Final report to the WHO Commission on Social Determinants of Health. Geneva, World Health Organization, 2007.

Health Differences
Women live longer than men, an average of 5 years longer, but they tend to be “sicker” than men
When social discrimination decreases, women’s life expectancy increases

Men have higher rates of fatal illnesses
Men have more toxic occupational exposure
Men have higher rates of injuries (both intentional and non-intentional)

Gender inequality
High gender equality is associated with:
Low child mortality, low rates of stunting and wasting
Higher rates of health care utilization for maternal, child, and reproductive health services (including STI/HIV)
Lower rates of maternal mortality
Lower rates of gender-based violence
High gender inequality is associated with lower health outcomes
Gender Inequality is a driver of many health outcomes such as, global AIDS epidemic

The reason we must think about gender and M&E is because it has a powerful impact on health status outcomes. Studies for 25 years have documented that gender, measured in a variety of ways, influences a range health outcomes, including HIV/AIDS. This effect has shown to be independent of other factors.
In other words, these health outcomes are influenced by gender equality regardless of economic and educational status, age, religion, urban or rural residence and a host of other factors. These factors mediate the effect of gender. For example, in the Indian state of Uttar Pradesh, it was observed that poor women with low autonomy are less likely to use antenatal and delivery care than are their wealthier counterparts with low autonomy, but poor women with higher autonomy were more likely to use maternal health services than richer women with low autonomy.
This applies to almost any health outcome studied. We next focus on HIV/AIDS.
*

Sex/Gender Differences in Cardiovascular Disease
Figure 1. Annual number of adults having diagnosed heart attack or fatal coronary heart disease (CHD) by age and sex.
Mosca, L., Barrett-Connor, E., & Kass Wenger, N. (2011). Sex/gender differences in cardiovascular disease prevention: what a difference a decade makes. Circulation, 124(19), 2145-2154.

*

Women’s Health Initiative
Originally enrolled 161,808 women aged 50-79 between 1993 and 1998. Now extended to 2020.

Regitz-Zagrosek V. (2012). Sex and gender differences in health
Science & Society Series on Sex and Science. EMBO reports, 13(7), 596-603.

Gender and health care

Gender Disparities and society

Gender Pay Gap

Gender gap in pension plan

Employment

What is Gender Analysis?
Gender analysis draws on social science methods to examine relational differences in women’s and men’s and girls’ and boys’
roles and identities
needs and interests
access to and exercise of power
and the impact of these differences in their life and health.

*
Refer to what participants have shared, and note that in short, gender analysis is the process of identifying gender inequalities and determining their programmatic and developmental implications. That is, gender analysis identifies and examines the social constructions of what it means to be a woman and girl or man or boy and how these impact the lives and health of women and girls and men and boys.

To understand gender relations …
Examine different domains of gender relations

Practices, Roles, and Participation
Knowledge, Beliefs, and Perceptions
Access to Resources
Rights and Status

POWER
POWER

*
To understand gender relations more concretely, gender analysis approaches (and tools) often choose to focus on specific “aspects” or “slices” of social and cultural relations in a given context. The specific “aspects” or “slices” of social and cultural relations chosen for focus in an analysis are referred to as “domains.” Domains frequently analyzed in reproductive health programming include practices, roles, and participation; knowledge, beliefs, and perceptions (many of which are normative—that is, provide norms for what is appropriate behavior for women and men); access to assets; rights and status; and (related to all of these) power.
Note: PEPFAR also has specified key areas of gender relations that need to be addressed to meet PEPFAR goals. These areas highlight specific concerns related to these broader domains. [Note to facilitator—if PEPFAR and HIV programming is a focus for participants, add a slide after this one that outlines the focus areas in the new legislation.]

Different Contexts
Gender constraints and opportunities need to be investigated in specific contexts, as they vary over time and across …
Social Relationships
Partnerships
Households
Communities
Civil society and governmental organizations/institutions
Sociocultural Contexts
Ethnicity
Class
Race
Residence
Age

*
Remind participants that although we have been talking about gender and power relations, gender relations are linked to a host of other power relations at work in a specific context—such as power relations of ethnicity, class, race, and age. Gender relations also vary by context—that is, the type and degree to which a woman (or man) experiences gender constraints may be very different in a household and in a work context.
Thus, gender relations and gender analysis vary according to the specific context in which they are occurring. Therefore, although some gender patterns may appear remarkably similar across contexts, it is critical to understand the specific relations (and ongoing changes and contradictions in these relations) across time, in different organizational contexts, and in different sociocultural contexts.

Power
Gender relations influence people’s ability to freely decide, influence, control, enforce, and to engage in collective actions.
Decisions about …
One’s body
Children
Affairs of household, community, municipality, and state
Use of individual economic resources and income
Choice of employment
Voting, running for office, and legislating
Entering into legal contracts
Moving about and associating with others

*
Power
Taken together, these four domains ultimately affect the ability of people to decide, influence, control, and enforce a decision—that is, the ability of people to have the power to make decisions freely and to exercise power over one’s body and within an individual’s household, community, municipality, and the state. This includes the capacity of adults to decide about the use of household and individual economic resources, income, and their choice of employment. It also encompasses the right to engage in collective action, including the determination of rights to and control over community and municipal resources. Finally, it includes the capacity to exercise one’s vote, run for office, be an active legislator, and to enter into legal contracts.
Specific areas of control over decisions include
One’s body
Children
Affairs of the household, community, municipality, and state
The use of individual economic resources and income
Choice of employment
Voting, running for office, and legislating
Entering into legal contracts
Moving about and associating with others

Are there any other domains of decision making that are not included on this list but may impact on (the area of reproductive health being considered for the training, such as safe motherhood), as well as broader health and well-being?
For instance, how do power relations—or constraints to the ability to make decisions—affect (the program areas being considered, such as safe motherhood)?
What are some examples from the cases already discussed in the training and in participants own experiences of a lack of power and control? How do these affect (the program area being considered, such as safe motherhood)?
How does gender-based violence relate to power and control? How does it impact (the program area being considered, such as safe motherhood)?

In short, Gender Analysis reveals …
= gender relations
(in different domains) that facilitate men’s or women’s access to resources or opportunities of any type.
= gender relations
(in different domains) that inhibit men’s or women’s access to resources or opportunities of any type.
Gender-based Opportunities
Gender-based Constraints

*
Summarize that, in short, gender analysis seeks to systematically reveal the gender-based constraints (and sometimes opportunities) to achieving a particular program objective. To systematically reveal these constraints and opportunities, gender analysis usually focuses on specific domains (such as the 4 we have just reviewed).

Gender Analysis Example: AIDS
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR): Five Key Legislative Issues
Increasing gender equity in HIV/AIDS activities and services
Reducing violence and coercion
Addressing male norms and behaviors
Increasing women’s legal protection
Increasing women’s access to income and productive resources

*
The five cross-cutting, strategic areas reflect language in the original PEPFAR legislation from 2003.
Specifically, PEPFAR asks that programs
Increase gender equity in HIV/AIDS programs;
Reduce violence and coercion;
Address male norms and behaviors;
Increase women’s legal rights; and
Increase women’s access to income and productive resources.

Interventions in these areas are described in the COP activity narratives and coded by area.

PERFAR
Increased gender equity: PEPFAR-supported programs should promote proactive and innovative strategies to ensure that men and women and girls and boys have access to prevention, care, and treatment services. This includes tailoring services to meet the unique needs of various beneficiary groups.
2. Addressing male norms and behaviors: Men can play a critical role in promoting gender equity, preventing violence, and promoting sexual and reproductive health. Recognizing that men can either impede or promote health interventions, PEPFAR encourages country teams to develop programs that promote positive male engagement and behavior change.

PERFAR
3. Reducing violence and coercion: Women who live in fear for their lives (and their children’s lives) and who are unable to make their own decisions about sex are at a greatly increased risk of becoming infected with HIV. … Reducing violence against women increases their access to services and their ability to negotiate safer sex and take advantage of education and employment activities.
4. Increasing access to income and productive resources: PEPFAR recognizes that women’s and girl’s lack of economic assets increase their vulnerabilities to HIV. Providing women with economic opportunities (increasing access to employment, training, and microfinance activities) empowers them to avoid high-risk behaviors, seek and receive healthcare services, and better care for their families.

PERFAR
5. Increasing legal protection: Many of the norms and practices that increase women’s vulnerability to HIV and limit their capacity to deal with its consequences are reinforced by policies, laws, and legal practices that discriminate against women. Women denied enforceable legal rights and protections, including property and inheritance rights, are often unable to meet the basic needs of survival for themselves and their children, increasing their vulnerability to HIV.

Gender / Sexual identities
Gender Expression: External appearance of one’s gender identity, usually expressed through behavior, clothing, haircut or voice, and which may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine.
Gender Identity: One’s innermost concept of self as male, female, a blend of both or neither – how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different from their sex assigned at birth.
Sexual orientation: An inherent or immutable enduring emotional, romantic or sexual attraction to other people.
Transgender: An umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth. Being transgender does not imply any specific sexual orientation. Therefore, transgender people may identify as straight, gay, lesbian, bisexual, etc.

Gender Identity Development
Gender identity is developed in three stages:
Construction (ages 0–5 years)
Consolidation (ages 5–7 years)
Integration (ages 7 years and up)
Some research suggests that three external factors may influence how a person develops and ultimately expresses their gender identity:
Centrality
Evaluation
Felt pressure

During construction, children seek information about gender and do not necessarily react strongly to norm violations (e.g., a boy may play with a Barbie doll). In the consolidation phase, children have well-developed gender stereotypes and show rigidity about their gender beliefs (e.g., a boy may avoid or refuse to touch a Barbie doll). Lastly, in the integration phase, children may show more flexibility and individual differences in how they think about gender (e.g., a boy may choose to play with certain types of dolls).
REFERENCES:
Lurye, L.E., Zosuls, K.M., & Ruble, D.N. (2008). Gender identity and adjustment: Understanding the impact of individual and normative differences in sex typing. In M. Azmitia, M. Syed, & K. Radmacher (Eds.), The Intersections of Personal and Social Identities: New Directions for Child and Adolescent Development, 120, 31–46.
*

Health concerns
MSM and other LGBT people have similar health concerns as others, as well as some additional concerns
Important to engage the whole person, not a collection of risk factors
Important to understand that LGBT life issues are similar to others, but also unique:
Families, Coming Out
Long Term Relationships
Reproduction, Parenting
Mental Health
Chronic Diseases
Communicable Diseases

LGBT Disparities: Healthy People 2020
LGBT youth
2 to 3 times more likely to attempt suicide.
More likely to be homeless (20-40% are LGBT)
LGBT populations have the highest rates of tobacco, alcohol, and other drug use
Gay men are at higher risk of HIV/STDs, especially among communities of color.
Lesbians are less likely to get preventive services for cancer.
Lesbians and bisexual females are more likely to be overweight or obese.

*

LGBT Disparities: Healthy People 2020
Transgender individuals have a high prevalence of HIV/STI’s, victimization, mental health issues, and suicide.
They are less likely to have health insurance than heterosexual or LGB individuals.
Elderly LGBT individuals face additional barriers to health because of isolation and a lack of social services and culturally competent providers.

Mental Health
A study that examined the risk of psychiatric disorders among individuals with same-sex partners found that, during the previous 12 months, women with same-sex partners experienced more mental health disorders–such as major depression, phobia, and post-traumatic stress disorder–than did women with opposite-sex partners.
Studies have found that lesbians are between 1.5 and 2 times more likely to smoke than heterosexual women.
A number of studies have also suggested that lesbians are significantly more likely to drink heavily than heterosexual women.
Bisexual women report more hazardous drinking than heterosexual or lesbian women.

Many factors affect the mental and emotional health of lesbian women. For example, a research study found that adverse, punitive, and traumatic reactions from parents and caregivers in response to their children’s sexual orientation were closely correlated with poor mental health and an increase in substance use.
Studies have found that lesbian and bisexual women consult general practitioners for emotional reasons more often than heterosexuals if their primary care physician is aware of their sexual orientation. However, not all lesbian and bisexual women want to disclose their sexual orientation.
REFERENCES:
Ryan, C., Huebner, D., Diaz, R.M., Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in White and Latino lesbian, gay, and bisexual young adults. Pediatrics, 23(1), 346–352.
Gilman, S.E., Cochran, S.D., Mays, V.M., Hughes, M., Ostrow, D., & Kessler, R.C. (2001). Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the national comorbidity survey. American Journal of Public Health, 91, 933–939.
King, M., & Nazareth, I. (2006). The health of people classified as lesbian, gay, and bisexual attending family practitioners in London: A controlled study. BMC Public Health, 6, 127.
*

Suicide
Results from an anonymous survey administered in 33 healthcare sites across the United States found that:
Lesbian and bisexual women who were “out” experienced more emotional stress as teenagers and were 2 to 2.5 times more likely to experience suicidal ideation in the past 12 months than heterosexual women; and
Lesbian and bisexual women who were not “out” were more likely to have attempted suicide than heterosexual women.

This survey also showed that sexual orientation was associated with higher levels of emotional stress and other types of mental health disorders.
REFERENCES:
Koh, A.S., & Ross, L.K. (2006). Mental health issues: A comparison of lesbian, bisexual and heterosexual women. Journal of Homosexuality, 51(1), 33–57.
*

Substance Abuse
Some studies show that gay men use substances, including alcohol and illicit drugs, at a higher rate than the general population.
Many studies also indicate that gay men use tobacco at much higher rates than straight men—reaching nearly a 50 percent difference in some cases.

Recent studies have improved our understanding of substance use in the gay community. Higher substance abuse rates have been found among gay men in many places, not just in larger communities such as New York, San Francisco, and Los Angeles.
REFERENCES:
Ostrow, D.G., & Stall, R. (2008). Alcohol, tobacco, and drug use among gay and bisexual men. In Wolitski, R. J., Stall, R., & Valdiserri, R. O., (Ed.) Unequal opportunity: Health disparities affecting gay and bisexual men in the United States. New York: Oxford University Press.
Centers for Disease Control and Prevention. (2010). CDC fact sheet, substance abuse among gay and bisexual men. Atlanta: Author.
Irwin, T.W., Morgenstern, H., Parsons, J.T., et al. (2006). Alcohol and sexual HIV risk behavior among problem drinking men who have sex with men: An event level analysis of timeline follow-back data. AIDS and Behavior, 10(3), 299–307.
Wong, C.F., Kipke, M.D., Weiss, G. (2008). Risk factors for alcohol use, frequent use, and binge drinking among young men who have sex with men. Addictive Behaviors, 33(8), 1012–1020.
Stall, R., Paul, J.P., et al. (2001). Alcohol use, drug use and alcohol-related problems among men who have sex with men: The Urban Men’s Health Study. Addiction, 96(11), 589–601.
Padilla, Y., Crisp, C., & Rew, D.L. (2010). Parental acceptance and illegal drug use among gay, lesbian, and bisexual adolescents: Results from a national survey. Social Work, 55(3), 265–275.
Halkitis, P.N., Mukherjee, P.P., & Palamar, J.J. (2009). Longitudinal modeling of methamphetamine use and sexual risk behaviors in gay and bisexual men. AIDS and Behavior, 13(4), 783–791.
Lee, J.G., Griffin, G.K., et al. (2009). Tobacco use among sexual minorities in the USA, 1987 to May 2007: A systematic review. Tobacco Control, 18(4), 275–282. From http://tobaccocontrol.bmj.com/content/18/4/275.long (accessed June 1, 2011).
Gruskin, E.P., Greenwood, G.L., Matevia, M., Pollack, L.M., & Bye, L.L. (2007). Disparities in smoking between the lesbian, gay, and bisexual population and the general population in California. American Journal of Public Health, 97(8), 1496–1502.
Greenwood, G.L., Paul, J.P., et al. (2005). Tobacco use and cessation among a household-based sample of U.S. urban men who have sex with men. American Journal of Public Health, 95(1), 145–151. From http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449276/pdf/0950929 (accessed June 1, 2011).
*

Conclusions
Develop indicators for analysis, monitoring and evaluation
Data disaggregated by sex and analyzed from a gender perspective
Disseminate information on gender and health
Train health workers to employ a gender perspective
Increase women’s participation in:
Defining health priorities
Planning solutions, policies and programs
Demanding accountability

*