On mainstreaming gender perspective in public health care in Bogota: notes for reflection.
Before beginning this article, it is essential to clarify that what is presented here is part of the collaborative work undertaken as part of the public policy for women and gender equality, (2) in the effort to mainstream gender perspective in the government agencies of the city and to develop a theoretical and methodological corpus to achieve this end, implemented by those of us who were responsible for these efforts in the Department of Public Health and in some public hospitals.
It is my intention to list a series of proposals resulting from my three-year assignment as a consultant to incorporate public policy for women and gender equity in Bogota. In this regard, I shall present the most important reflections stemming from my work carried out with a team of women in 13 of the city's public hospitals.
On Public Health
We must begin by examining the difference between the provision of health care, i.e., private (individual) vs. public (collective). With its special characteristics, the latter system must use promotion and prevention as mechanisms to safeguard the public welfare and foster the quality of life of the population.
After profound work within the framework of the city's Strategy for Health and Quality of Life, I believe that public health strengthens the empowerment of individuals and groups on the right to health and the actions that make this right a reality in their daily lives. The information disseminated in this context determines access to and enjoyment not only of healthcare services but the also potential for full human development, hence, my interest in problematizing women's public health care.
The Health of All People
The traditional starting point for conceptualizing health is the premise of the World Health Organization (WHO), which emphasizes that health is biological, psychological and social wellbeing, and not merely the absence of disease. By 1977, this same organization proposed the campaign "Health for All by the Year 2000." This campaign addressed five basic factors related to people's health: biological factors, lifestyle, physical environment, social environment and access to quality health care. Equity, solidarity, rights and freedom were established in as essential to achieving the campaign's goals. However, there were many important questions about the impact of these elements on public health.
To discuss women's rights in the field of health, I find the definition developed by F. Peter to be appropriate. Peter has proposed a third model called "health as freedom," health that creates the conditions for personal freedom, for autonomy, for individual decision-making. And in order to create the necessary conditions, we must address the bio-psycho-social determinants of health, recovering the clinical approach for every human being, listening to the symptoms of the population that public health studies (Valls-Lobet, 2010:110).
As I explained earlier, the public health approach differs from private health care in many ways. For example, public health plans or programs have an emphasis on promotion and prevention. They are also not merely concerned with health but with quality of life and comprehensive health, employing actions that do not focus solely on curative treatment or the disease, but attempt to connect healthcare services with other aspects of life.
Part of the essence of public health is rooted in the generation of alternatives that promote improvements in the population's quality of life from the health system. Directly linked to well-being, "this inclusive concept of human needs breaks with the fragmented and partial conceptions of social realities and develops a continuum of life and its social determinations in all its stages, processes and contexts. It also proposes ways of building collective responses that transcend policies focused on service provision and links economic and social policies to public goals and objectives aimed at transforming the living conditions of the people" (D'Elia et al., 2002:2).
Therefore, we propose that public health is the dimension of the health system with a greater possibility for the empowerment of the population against the risk factors or what are called the "social determinants of health." Based on the potential that promotion and prevention have as cornerstones of interventions, we can construct an ideal scenario to share and build with women the necessary information that will help them take action with regard to the factors that threaten their health and quality of life and to strengthen the notions of people's agency as rights bearers and their experiences in their own well-being. Politically, this is a major contribution to processes of collective action that seek to promote health and quality of life.
As an opportunity for this exchange of resources in the communities, a central point of the following reflections is that the guidelines for public health care need to consider the personal experiences, opinions and social knowledge in their interventions. In terms of the doctor/patient relationship, this applies specifically with regard to the knowledge-power relationship that conditions the exchange. As Foucault says, there may be a "knowledge" of the body which is not exactly the science of its functioning, and a mastery of its forces that is more than the ability to conquer them (Foucault, 1992).
Gender as a Category of Analysis in Health: Putting the Public Health Response into Practice
In order to incorporate gender analysis into the health services, it is essential to consider gender as more than a demographic variable that perceived the existence of men and women in the interpretation of the population. A more nuanced understanding would indicate progress towards mainstreaming this category conceptually speaking and specifically with regard to the implementation of interventions, assuming that these readings take into account the diversity of women. And this implies addressing women in all the stages of their life cycle and in every generation.
The following is a proposal of analytical categories from a perspective of women's rights and gender for different public health interventions:
--The first category, since historically a woman's body does not belong to her, it is not appropriated but is vulnerable, a condition inherent to being female and being recognized, accepted and valued socially.
--As a privileged setting of subjectivity, one of the main difficulties in women's health is the perception of the body by the service provider.
--It is here that we find evidence of a fundamental reflection that permeates all areas of women's health promotion and prevention: the tension between individual beliefs and the wellbeing of others, i.e., the collective wellbeing.
--This analysis links with human development opportunities for women who are involved in most of the public health interventions because of the possibilities of exercising autonomy, freedom and decisions in their own lives.
--Assumed as the representation of traditional patterns by which it is assigned to women as an innate condition.
--Economy of Care: The work of caregiving and reproductive work are not considered productive work in terms of economic capital.
--Triple workday for women.
--Specialization of the care that the woman gives herself, rather than just self-care, means that the woman herself is involved in the recognition and indentification of women's role in the healthcare scenario.
--Differentiation between care for women (a demographic variable) and attention with a perspective of women's rights (a category of analysis).
--Sexual and reproductive healthcare services.
--Voluntary interruption of pregnancy.
--Pregnancy in adolescent girls and young women vs. human development.
--Women's individual decision about fertility regulation and the method of contraceptive best for her.
--of people with disabilities;
--of others in the family; and
--as the broad majority of healthcare personnel.
--Cervical cancer and breast cancer.
--Violence against women and the enforcement of Ley 1257 of 2008.
--Implementation of programs for women in situations of displacement under Auto 092.
--Inclusive Language and Acuerdo 361 of 2009.
Naturalization of Gender Patterns
--Male superiority in keeping with the sociological category of male domination (cf. Pierre Bourdieu) gives rise to the social constructions of femininity, which are perpetuated through a series of oppositions (strong--weak, brave fearful; oppressor--oppressed).
Women's Historical Tension with the Family
--Historically, women's subordination to the domestic sphere has been a mechanism to weaken them as rights bearers; it makes it easier to belittle their status as rights bearers; and it makes the exercise of their rights and public policies to close these gaps less important.
--Identifying women's health care with family health care alone is a sociological and anthropological shortcoming and reveals a gender bias in the understanding of social realities. Individual treatment cannot be lumped in with care for a group; neither the analysis of health nor quality of life will be similar, when one is speaking of individuals or of the social institution of the family.
Women and Reproduction
--An in-depth look at motherhood allows us to see a number of variables in women's historical relegation to reproductive functions, the restriction of their bodies in this merely biological capacity, and thus, the overriding of their citizenship in view of being mothers, caregivers and those responsible for domestic work.
Equal Opportunity--Affirmative Action
--In the interest of gender equality (understood as the generation of resources for the underprivileged, in this case, women), affirmative action policies are tools that can promote scenarios for development opportunities that perceive and consider women as rights bearers and give new meaning to their potential in all walks of society.
--Transversal incorporation of gender perspective, recognizing women's diversity in the categories employed in the population approach including age, social and economic conditions, diversity and identity. This involves the perception that women may be touched by all these human possibilities. Therefore, it is necessary for each woman to be taken as an individual with her own life story and special needs understood from a gender perspective.
Mainstreaming a Women's Rights Perspective in Some Public Health Interventions: Points for Discussion
Here, the emphasis and analysis is placed on unconventional scenarios of psychosocial care, especially in terms of clinical treatment; it also involves overcoming the reductionist relationship between women and the family.
As a result, the incorporation of gender as a social determinant of health would require a number of elements in biomedical treatment, such as:
--The recognition of violence against women as a public health and human safety problem worthy of urgent attention.
--The investigation of the causes of violence against women and its impact on their daily lives. For example, the fact that through various socially validated mechanisms, these forms of violence are seen as a natural or integral part of romantic relationships.
--The elimination of barriers to care imposed by personal notions about sexual abuse or violence against women. One of the tensions evident in the public sphere refers to the lack of distinction between the personal rights of those who provide certain services and their obligation to ensure service users' right to health; women are especially impacted because their social status is already a barrier to the exercise of their rights and opportunities.
--The focus of treatment on the woman, not on her family, her sons, daughters or partner. Rather than a competition for the exercise of the right to health, this simple proposition turns our attention to addressing women's needs in the complex situation of being rights bearers, recognizing both their individual stories and the fact that they participate in other social dynamics that include their partners, families, church and school, but without homogenizing them as responsible for these other areas or reducing them to those scenarios alone.
The recognition of the dynamics of women's lives when proposing treatments, for example: the difficulties they face for taking time off of work; their workload within the home and at work (triple workday); the variables involved in the care of others.
--Violence against women that takes the form of sexual abuse "is a crime that being restricted to the private sphere, was not significantly made visible, and the women and girls who were victims were less likely to report it. In this sense, no matter how much progress has been made in the defense of human rights, the distinction between public and private remains in effect, and the violations of rights that occur in public, whose victims are for the most part men, are more visible and important ..." (3)
The generation of conceptual revisions that propose--from the women's rights perspective--treatment for violence based on the victims, rather than where it took place or the type of aggression, since these variables can apply to the same case and do not account for the complexity of the situation that the victim experienced and, therefore, the care they need. For example, domestic violence is linked to the place in which it is exercised but sexual violence can occur within the home, the workplace or the street.
--In the approach to eating disorders like anorexia and bulimia, it is important to focus on the stigmatization of women's bodies as objects of consumption based on aesthetic standards that make it more socially recognized and valued. Starving or binge eating result in health problems in which social constructions of perfect bodies become to become key factors determining women's health and wellbeing.
--Recognition of the dynamics of women's lives in which stress and emotional reactions become key elements of the manifestations of malaise, social suffering and disease.
Sexual and Reproductive Health
To provide care with a women's rights perspective, sexual and reproductive health services must question women's second-class citizenship evident in their decision making about themselves and about their bodies, since in this area, the processes of women and men are confused with more serious results.
--To provide directed care for men and women in sexual and reproductive health, it is important to consider each component separately, specifically by recognizing the historic domination of women with regard to decisions such as the number and spacing of children or methods of fertility regulation.
--Talking about sexual health means talking about sexuality as a possibility of development in the lives of women who traditionally have been denied this experience because their body is restricted to private spaces, limited by the permission that others give them and burdened by taboos that limit their autonomy.
--It must be recognized that the promotion of condom use is not a favor or giving in to women but a mechanism for preventing pregnancy and the transmission of STIs and HIV.
--It is essential to separate sexuality from reproduction in which, for quite obvious reasons, women are always counted as the leading clients by the healthcare or social welfare services. Once again, we see the difference between treating women or offering a women's rights approach in the healthcare services.
--Services designed for women must be based on autonomy and the possibility to make decisions about their own bodies, the procedures to be performed on it (e.g., tubal ligation, the use of the pill or the use of subdermal methods of birth control) and the relevance they have in their lives and their personal histories.
--Reproductive health services for women must ensure access to the voluntary interruption of pregnancy as a decision of the women themselves (not of the professional who is treating them), in which they are informed and their decision is not manipulated. At the same time, the public healthcare services must recognize their obligation as entities of the public sector with regard to the fulfillment of Sentencia c-355, 2006, and later rulings, and must acknowledge the right to access VIP as a fundamental right of women in Colombia, based on Sentencia T585/10. In addition, Colombia's legal framework requires compliance with these regulations.
--Services must provide comprehensive information about the impact of adolescent pregnancy on the life of a young woman. The usual practice is to focus on women's fertility or reproductive capacity, but not the consequences of this event in terms of human development, the chance of pregnancy and motherhood as a condition of early life.
Sexual health also involves the recognition of freedom choice with regard to women's sexual orientation and gender identity, with respect for diversity. This understanding implies the consideration of sexual practices that involve different care for their bodies, e.g. in the prevention of STIs and HIV, in cancer screening, in the use of condoms. In this regard, reproductive health care should be adapted to the practices to which the women refer.
In the interest of equity, sexual and reproductive healthcare services also need to specialize with regard to men:
--Recognition that women have autonomy in decision-making processes that directly concern their body, which does not belong to their spouse, boyfriend, parent, grandparent, etc. And recognition that the exercise of sexuality is not a sign of virility or male power necessarily related to the exercise of intercourse or dominance over another person.
--Promotion of the use of condoms as an autonomous and responsible act, not a show of solidarity with women or another responsibility assigned to women in the context of care.
--Recognition that care for men's bodies has been assigned and assumed, in large part, by women--mothers, wives, grandmothers, etc.--which complicates men's access to and expectations of health services. Hence, the creation of strategies to promote men's self-care is another challenge in the health sector, since it has been labeled as women's work, therefore, as improper for men. A convergence of factors strongly question masculinity and force the exercise of sexuality that is exclusively heterosexual.
Thus, it is essential to promote freedom of choice in terms of sexual orientation for men in the sexual health services, so that transphobia or homophobia do not have an impact on their care.
Maternal and Child Health
From a women's rights approach, it is essential to see the strategy of the familia gestante (pregnant family) from a different perspective.
--This would open reflection on the guarantee of women's rights and the need for shared responsibility in pregnancy and the changes implied and that women should not be solely responsible for the care required by this situation. This would also draw necessary attention to the tools that women are provided with (or not provided with) for perceiving and understanding the "warning" signs and changes in their bodies that do not recognize, among other factors, the multiculturalism of the women who live in the city.
--Attention is not given to fact that the body affected (in a broad and non-pejorative sense) by pregnancy is the woman's body, which is changing, transforming and should be cared for because of the impact of this situation.
--Since maternal mortality is a major cause of death for women in Colombia, and even in Bogota, it is essential to recognize that society overvalues motherhood and women's role as mothers and, thus, problematize the practices that derived from this attitude and which limit women's access to health. For example, the possibility of deciding the number of children, the most appropriate method of family planning, the timing of pregnancy or one's own care in light of the impact of pregnancy has on the body and one's well-being become elements that are decided by others and that limit the realization and promotion of women's autonomy. In turn, personal ideas about motherhood influence the care given to women in order to perpetuate their reproductive role.
Chronic Disease Prevention, Promotion of Physical Activity and the Situation of the Disabled
Historically, the care of others has been culturally assigned to women, who have been made responsible for what are known as the household activities of the domestic sphere, which are not shared, since this dynamic is understood as a sort of collaboration related to a woman's maternal duties.
It is important to generate proposals that include information processes in which women reconstruct the traditional allocation of domestic responsibilities regardless of their stage in the life cycle, so that the responsibility of caring for the home and others does not put them at a major disadvantage as well as have a serious impact on their health.
We can see examples of the construction of gender in society in a number of different scenarios. One of them is the historic assignment of women to the domestic realm, the private sphere and the care of others, in a kind of naturalization of reproductive work stemming from their role of mother, to which they always been subjected.
Currently in the city, as a result of the public policy for women and gender equity, a number of reflections are examining the economy of care, i.e., the recognition of the social value and contribution to the national economy and GDP of the work entailed in caregiving and social production/reproduction provided by women. Likewise, it is essential to support women in their reflections related to their confinement in these traditional areas of care, the domestic sphere, and whether they limit the exercise of their autonomy and lead directly to the failure to care for themselves. This understanding is a fundamental element of the social determinants of women caregivers' health, whether this work is remunerated or not.
In relation to other areas of health care, certain elements that appear to be obvious, but which are denied in women's care, take center stage. One of them is oral health care, in which we see how women put off their own care; as they assume responsibility for the care of others, they put themselves last.
In the appropriation of wellbeing and comprehensive health, it is equally important to link oral health care in all the stages of the cycle.
--The recognition one's own body from the very dimension of corporeality, that is, the social and cultural relations that have to do with the body and have an impact on our daily lives.
--That women take care of themselves.
--The recognition that mental, oral and physical health are all parts that make up a whole--the body and its possibilities--not isolated aspects of traditional medical consultation.
--The perception of the prevention as a protective element of self-care, keeping in mind that society has defined women as the quintessential and natural caregivers of others, ignoring the possibility of recognizing in themselves the need for care and wellbeing.
--The recovery of physical activity as something separate from domestic work and accompanied by a profound reflection on and awareness of the body as an autonomous territory for decision making, empowerment and promotion of health in a comprehensive manner.
Health and Work
The rigorous reading of statistics makes clear the impact of gender factors in opportunities in the labor market for men and women, with regard to access to jobs and level of pay, as well as in the type of jobs that society sees as appropriate for women and men.
From an early age, children clearly face these dynamics, which define key trends evident in child labor, as mentioned in the section on violence. Typically, most caregiving jobs are assigned to girls along with their induction to working in the home. Other work that involves use of strength, carrying or spatial ability are given to boys.
Regional peculiarities, which sometimes determine nuances in gender assignments and activities developed by families and communities, also come into play. And of course, this dimension is also related to the reflection on the economy of care and women's triple workday.
Situations of Displacement
Currently one of the key objectives in the country is to meet the provisions of Auto 092 to ensure a women's rights perspective in health care, thus diminishing the disproportionate impact of forced displacement. (4)
In this sense, the most important guidelines are related to the difference between a women's rights approach and the family-based approach. Clearly, women are part of the family, but this fact should not conflict with her right as a rights bearer to receive individual treatment. It is worrying that the care of women and the care of families become the same "subject," as the Constitutional Court expressed when it highlighted the need to overcome the family-based approach that is so often used to address women's care, which is a denial of women's status as rights bearers that threatens their autonomy and their welfare.
This element is common to the various programs that were created for the specific care of women in the context of the disproportionate impact of armed conflict.
Promotion and Prevention of Cervical and Breast Cancer
This area of intervention also opens a dialog on women health care, primarily a reflection on women's bodies and the numerous taboos associated with on it, a reflection of the control over women's bodies exercised by others. Rather than positioning the body as an object of care, women must be encouraged to be the subject of their own care and to appropriate the body that belongs to them.
Cancer of the breast and cervix are two diseases that claim many lives of Latin American women, and the focus of prevention has been on diagnostic examines or false responsibilities assigned to women in the context of the medical consultation. Here, the key is to discuss how the actions of promotion and prevention should address, conceptually and methodologically, the real causes of infection, as in the case of cervical cancer, and the difficulties of self-exams because of taboos that women have been taught from a very young age. These taboos are so strongly anchored in our minds that the notions of exploring, feeling, touching one's own body are meaningless words and an impractical approach for many women and, therefore, elements that are useless for the prevention of diseases with such serious impact.
--One of the main lessons is the conviction of the need to incorporate a women's rights perspective in public health services as non-negotiable.
--While there have been important gains in terms of the gradual incorporation of gender into healthcare policies in the cities,5 there may be a limitation on this progress and on the ability of women to exercise these rights, if gender is not understood as a category of analysis, a way to understand social realities, but only employed semantically to argue that men and women enjoy the same opportunities and that women's subjugation is a thing of the past.
--Health care in the public sphere is heavily permeated by religious and moral beliefs that are reflected in barriers to care for women through the naturalization of discrimination in health care evident in everyday life. As a result, the healthcare system also perpetuates the social reproduction of societies' most conservative attitudes.
--Promotion and prevention in the healthcare system have significant potential for women's empowerment (6) in terms of autonomy, their health, their ability to decide and their enjoyment of health as a freedom, "which creates conditions for personal freedom, personal autonomy for individual decision making" (Valls-Llobet, 2009:110).
--Actions to ensure the full exercise of these qualities defined for health would lead to Haraway's proposal that we can and should make women the agents of change ("Manifesto for Cyborgs") and move towards women who are in charge of their health and destiny and not eternal victims at the hands of their aggressors, whether physical, imaginary or symbolic (Haraway, 1995, cited in Valls-Llobet, 2009:27).
--Health services are indebted to women for the advances of the social movement in favor of making the body the focus of the intervention. But not only the biological body, which centralizes the medical debate and that seems an obvious factor in the discussion, but a body, corporeality, from which biomedicine recognizes stories, knowledge, taboos and, above all, the subjectivities of women who have grown up bound by male dominance in every stage of their lives, including obviously, health care.
Alcaldia Mayor de Bogota (2004) Politica publica de mujery genero, ABC de la politica publica de mujery genero. Bogota D.C.
Alcaldia Mayor de Bogota (2004) Plan de Igualdad de Oportunidades para la Equidad de Genero en el Distrito Capital 2004-2016. Bogota, p. 12.
Alcaldia Mayor de Bogota (2007) Politica publica de mujer y genero. "Vivir sin violencias, vivir sin miedo es nuestro derecho." Document presented in the commemoration of November 25, International Day Against Violence Against Women, Bogota.
Bourdieu, Pierre (1970) La Dominacion Masculina. Madrid: Editorial Taurus.
Foucault, M. (1992). Microfisica del poder. 3rd ed., J. V. Alvarez, trans., Madrid: Ediciones de la Piqueta.
Honorable Corte Constitucional de la Republica de Colombia (2010) Sentencia T 585/10 Referenda: Expediente T- 2.597.513 Accion de tutela instaurada por AA contra el Hospital Departamental de Villavicencio E.S.E. Bogota D.C.
Honorable Corte Constitucional de la Republica de Colombia (2006) Sentencia C355/06. Bogota, Colombia.
Organizacion Panamericana de la Salud (2005) Politica de Igualdad de Genero. Washington, D.C.: OPS.
--(2009) Las mujeres y la salud. Los datos de hoy. La agenda del mahana. Washington, D.C.: OPS.
Santos Velasquez, Luis (2009) Masculino y femenino en la interseccion entre el psicoanalisis y los estudios de genero. Botoga: Universidad Nacional de Colombia.
Valls-Llobet, C. (2009) Mujeres, Salud y Poder. Madrid: Ediciones Catedra.
(1.) The author is a sociologist with a Masters in Social Anthropology from the Universidad Nacional de Colombia. She is also a member of the Colectivo Feminista Proyecto Pasos.
(2.) Decreto 166 of 2010. Politica Publica para las mujeres y la Equidad de genero en el Distrito Capital (Public Policy for Women and Gender Equity in the Capital District) Since 2004, efforts in the city have been based on the Plan de Igualdad de Oportunidades para la Igualdad de Genero en el Distrito Capital 2004-2016 (Plan of Equal Opportunity for Gender Equality in the Capital District 2004-2016).
(3.) Alcaldia Mayor de Bogota, 2007, p. 13.
(4.) Dictated by the Constitutional Court, this national guideline aims to restore women's rights in situation of displacement due to the disproportionate impact of gender in the context of armed conflict.
(5.) This is due to the massive mobilization of women in favor of legislation through which to generate collective demands of the government.
(6.) In terms of recognition and enjoyment of their individual freedoms.
by Constance Fletscher Fernandez (1)