Women's health at risk in Africa

Women all through the continent suffers from lack of control over own sexuality. Between one and two million women in 28 African countries undergo the cruel practice of Female Genital Mutilation each year. Women are also subjected to stigma and discrimination in relation to AIDS. They are blamed for the spread of disease though the majority have been infected by only partner/husband.

Women's right to safe sexuality and to autonomy in all decisions relating to sexuality is respected almost nowhere. As it is intimately related to economic independence, this right is most violated in those places where women exchange sex for survival as a way of life. And we are not talking about prostitution but rather a basic social and economic arrangement between the sexes which results on the one hand from poverty affecting men and women, and on the other hand, from male control over women's lives in a context of poverty. By and large, most men, however poor can choose when, with whom and with what protection if any, to have sex. Most women cannot.

Women have little or no control over own sexuality and sexual relationships. They suffer from poor reproductive and sexual health, leading to serious morbidity and mortality. Rates of infection in young (15-19) women are between 5 and 6 times higher than in young men (recent studies in various African populations) .

Women's health needs, nutrition, medical care etc., are widely neglected, and their access to care and support for HIV/AIDS is much delayed (if it arrives at all) and limited. Family resources are nearly always devoted to caring for the man. Women, even when infected themselves, are providing all the care. Furthermore, the clinical management is based on research on men. 

All forms of coerced sex - from violent rape to cultural/economic obligations to have sex when it is not really wanted, increases risk of micro lesions and therefore of STI/HIV infection. In addition women are objects of lots of harmful cultural practices,  from genital mutilation to practices such as "dry" sex. 

Stigma and discrimination in relation to AIDS (and all STIs) are much stronger against women who risk violence, abandonment, neglect (of health and material needs), destitution, ostracism from family and community. Furthermore, women, are often blamed for spread of disease, always seen as the "vector" even though the majority have been infected by only partner/husband. 

There is now evidence that sexual abuse is an underestimated mode of transmission of HIV infection in children (even very small children). Adult men seek ever younger female partners (younger than 15 years of age) in order to avoid HIV infection, or if already infected, in order to be "cured". 

Disclosure of status, partner notification, confidentiality. These are all more difficult issues for women than for men; and it is a fact that women have usually been infected by their only partner/husband.

Female Genital Mutilation (FGM)
There are different types of female genital mutilation known to be practiced today. They include: 
Type I - excision of the prepuce, with or without excision of part or all of the clitoris; 
Type II - excision of the clitoris with partial or total excision of the labia minor;
Type III - excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation); 
Type IV - pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above. 

The most common type of female genital mutilation is excision of the clitoris and the labia minor, accounting for up to 80% of all cases; the most extreme form is infibulation, which constitutes about 15% of all procedures.

Health Consequences of FGM
The immediate and long-term health consequences of female genital mutilation vary according to the type and severity of the procedure performed. 

- Immediate complications include severe pain, shock, hemorrhage, urine retention, ulceration of the genital region and injury to adjacent tissue. Hemorrhage and infection can cause death. More recently, concern has arisen about possible transmission of the human immunodeficiency virus (HIV) due to the use of one instrument in multiple operations, but this has not been the subject of detailed research.

- Long-term consequences include cysts and abscesses, keloid scar formation, damage to the urethra resulting in urinary incontinence, dyspareunia (painful sexual intercourse) and sexual dysfunction and difficulties with childbirth. 

-Psychosexual and psychological health 
Genital mutilation may leave a lasting mark on the life and mind of the woman who has undergone it. In the longer term, women may suffer feelings of incompleteness, anxiety and depression.

The age at which female genital mutilation is performed varies from area to area. It is performed on infants a few days old, female children and adolescents and, occasionally, on mature women.

The reasons given by families for having FGM performed include:

- psychosexual reasons: reduction or elimination of the sensitive tissue of the outer genitalia, particularly the clitoris, in order to attenuate sexual desire in the female, maintain chastity and virginity before marriage and fidelity during marriage, and increase male sexual pleasure; 

- sociological reasons: identification with the cultural heritage, initiation of girls into womanhood, social integration and the maintenance of social cohesion; 

- hygiene and aesthetic reasons: the external female genitalia are considered dirty and unsightly and are to be removed to promote hygiene and provide aesthetic appeal; myths: enhancement of fertility and promotion of child survival; 

- religious reasons: Some Muslim communities, however, practice FGM in the belief that it is demanded by the Islamic faith. The practice, however, predates Islam. 

Most of the girls and women who have undergone genital mutilation live in 28 African countries, although some live in Asia and the Middle East. They are also increasingly found in Europe, Australia, Canada and the USA, primarily among immigrants from these countries.

Today, the number of girls and women who have been undergone female genital mutilation is estimated at between 100 and 140 million. It is estimated that each year, a further 2 million girls are at risk of undergoing FGM.

A definition of violence against women
A group of international experts convened by WHO in February 1996 agreed that the definition adopted by the United Nations General Assembly provides a useful framework for the Organization's activities. The Declaration on the Elimination of Violence against Women (1993) defines violence against women as "any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life." This encompasses, inter alias, "physical, sexual and psychological violence occurring in the family and in the general community, including battering, sexual abuse of children, dowry-related violence, rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women, forced prostitution, and violence perpetrated or condoned by the state." 

Abuse of women are becoming a growing public health concern 
In every country where reliable, large-scale studies have been conducted, results indicate that between 10% and 50% of women report they have been physically abused by an intimate partner in their lifetime.
Population-based studies report between 12 and 25% of women have experienced attempted or completed forced sex by an intimate partner or ex-partner at some time in their lives.
Interpersonal violence was the tenth leading cause of death for women 15-44 years of age in 1998. 
Forced prostitution, trafficking for sex and sex tourism appear to be growing. Existing data and statistical sources on trafficking of women and children estimated 500,000 women entering the European Union in 1995. 

Most studies on violence against women indicate that;
- the perpetrators of violence against women are almost exclusively men; 
- women are at greatest risk of violence from men they know; 
- women and girls are the most frequent victims of violence within the family and between intimate partners 
physical abuse in intimate relationships is almost always accompanied by severe psychological and verbal abuse; 
- social institutions put in place to protect citizens too often blame or 
- ignore battered women. 

Impact of violence against women
- Health status: Violence against women has serious consequences for their physical and mental health. Abused women are more likely to suffer from depression, anxiety, psychosomatic symptoms, eating problems, and sexual dysfunctions. Violence may affect the reproductive health of women through:
the increase of sexual risk-taking among adolescents, the transmission of STDs, including HIV/AIDS, unplanned pregnancies, precipitating various gynecological problems including chronic pelvic pain and painful intercourse. Consequences such as HIV/AIDS or unplanned pregnancies may in themselves act as risk factors for further aggression, forming a cycle of abuse. Effects of violence may also be fatal as a result of intentional homicide, severe injury or suicide.

- Burden on health care system 
Violence presents an undue burden on the health system. Studies from the United States, Zimbabwe and Nicaragua indicate that women who have been physically or sexually assaulted use health services more than women with no history of violence, thus increasing health care costs. 

It is worth while mentioning that the relation between AIDS and violence has been taken seriously in Rwanda and Burundi: The accessibility to health services are improved for women affected by violence, through local capacity-building and institutional-building. Training will now include integrated services addressing the link between HIV/AIDS and violence. 

Women and HIV/AIDS 
Facts and figures 
- there are 33.6 million people living with HIV/AIDS, 14.8 million of whom are women 
- there are 5 million adults newly infected in 1999, 2.3 million of whom are women 
- 2.1 million died of AIDS in 1999, 1.1 million of whom were women 
- there are 12-13 African women currently infected for every 10 African men 
- there are half a million infections in children (under 15), most of which have been transmitted from mother to child 
- 55% of adult infections in sub-Saharan Africa are in women

Modes of transmission 
The AIDS epidemic in women is overwhelmingly heterosexual - almost entirely so in Africa.

Why are women more vulnerable to HIV infection? 

Biologically
- women have larger mucosal surface; micro lesions which can occur during intercourse may be entry points for the virus; very young women are even more vulnerable in this respect. 
- it is more virus in sperm than in vaginal secretions 
- as with STIs, women are at least four times more vulnerable to infection; the presence of untreated STIs is a risk factor for HIV. 
- coerced sex increases risk of micro lesions. 

Economically
- financial or material dependence on men means that women cannot control when, with whom and in what circumstances they have sex 
- many women have to exchange sex for material favors, for daily survival. There is formal sex work but there is also this exchange which in many poor settings, is many women's only way of providing for themselves and their children. 

Socially and culturally
- women are not expected to discuss or make decisions about sexuality 
- they cannot request, let alone insist on using a condom or any form of protection 
- if they refuse sex or request condom use, they often risk abuse, as there is a suspicion of infidelity 
- the many forms of violence against women mean that sex is often coerced which is itself a risk factor for HIV infection 
- for married and unmarried men, multiple partners (including sex workers) are culturally accepted 
- women are expected to have relations with or marry older men, who are more experienced, and more likely to be infected. Men are seeking younger and younger partners in order to avoid infection and in the belief that sex with a virgin cures AIDS and other diseases. 

Women as carers
- women are responsible for the health care of all family members. 
- care is only one of the many productive and reproductive activities of women which include farming, food preparation, collection of firewood and water, child care, cleaning, etc. 
- care is provided free but has a cost! During illness, women's productive labor is lost; this has serious impact on long term well-being of the household. 
- care doesn't end with death of husband/child/sister. Care of orphans lies with grandmothers and aunts. 
- women carers are often HIV positive themselves. 

Making men more responsible
- little attention has been paid to men's participation in efforts to protect women 
- men are hard to reach and educate but some are concerned about sexual health - their own and their partners 
- raising awareness of their own risk has been shown to change certain behaviours 
- interventions must be aimed at men (as well as at women) if women are to be protected. 

Sexually transmitted infections 
Problems specific to women
- women are much more vulnerable biologically, culturally, and in socioeconomic terms
- the majority of sexually transmitted infections (STIs) are asymptomatic in women (60-70% of gonococcal and chlamydial infections) 
- the consequences of STIs are very serious in women, sometime fatal (eg cervical cancer, ectopic pregnancy, sepsis) and in their babies (stillbirth, blindness) 
- women tend not to seek treatment, in addition to having no symptoms, more stigma is attached to STIs in women, who often have neither time nor money for health care. 

Women and poverty
For example, poverty at older ages often reflects poor economic status earlier in life and is a determinant of health at all stages of life. Countries that have data on poverty by age and sex (mostly the developed countries) show that older women are more likely to be poor than older men. But in many developing countries there are often simply no reliable data on poverty tabulated by sex and age.

Poverty is also linked to inadequate access to food and nutrition and the health of older women often reflects the cumulative impact of poor diets. For example, years of child bearing and sacrificing her own nutrition to that of the family can leave the older woman with chronic anemia.

Another determinant of health is education; levels of education and literacy among current cohorts of older women in developing countries are low. Increased literacy for older women will bring health benefits for them and their families. Lack of safe drinking water, a gender-based division of domestic chores (including the carrying of water), environmental hazards, such as contact with polluted water, agricultural pesticides and indoor air pollution, all have a cumulative negative impact on the health of women as they age in many developing countries.

Older women everywhere are far more likely to be widowed than older men and most women can expect widowhood to be a normal part of their adult daily lives. While most women adjust both emotionally and financially to their changed situation, traditional widowhood practices in some countries result in situations of violence and abuse and pose a serious threat to older women's health and well-being.

Widowhood is often being preceded by a period of care giving to the deceased spouse combined in many cases with care giving to dependent parents, grandchildren and other dependent family members. Older women are an important source of care giving and such activities are most often unremunerated. In many countries, access to health care is tied to coverage by national social security and health insurance systems which in turn is linked to employment in the formal sector of the economy. As many older women in developing countries have worked all of their lives in the informal sector or in unpaid activities, access to health care often remains unaffordable and difficult at best.

Women and mental health
In many under-served populations, women have considerable mental health needs. However, until recent years, the conception of women's mental health has been limited as have attempts to protect and promote it. When women's health issues have been addressed in these populations, activities have tended to focus on issues associated with reproduction - such as family planning and child-bearing - while women's mental health has been relatively neglected (WHO, 1993; WHO, 1995).

Women are integral to all aspects of society. However, the multiple roles that they fulfill in society render them at greater risk of experiencing mental problems than others in the community. Women bear the burden of responsibility associated with being wives, mothers and carers of others. Increasingly, women are becoming an essential part of the labor force and in one-quarter to one-third of households they are the prime source of income (WHO, 1995).

In addition to the many pressures placed on women, they must contend with significant gender discrimination and the associated factors of poverty, hunger, malnutrition and overwork. An extreme but common expression of gender inequality is sexual and domestic violence perpetrated against women. These forms of socio-cultural violence contribute to the high prevalence of mental problems experienced by women.

Significant mental disorders and problems experienced by women
In investigating common mental, behavioral and social problems in the community we find that women are more likely than men to be adversely affected by specific mental disorders, the most common being: anxiety related disorders and depression; the effects of domestic violence; the effects of sexual violence; and escalating rates of substance use.

Mental disorders
Prevalence rates of depression and anxiety disorders as well as psychological distress are higher for women than for men. These findings are consistent across a range of studies undertaken in different countries and settings (Desjarlais et al, 1995). In addition to the higher rates of depression and anxiety, women are much more likely to receive a diagnosis of obsessive compulsive disorder, somatization disorder and panic disorder (Russo, 1990). In contrast men are more likely to receive a diagnosis of antisocial personality disorder and alcohol abuse/dependency. The gender differences associated with mental disorders are brought out most clearly in the case of depression (Russo, 1990). Data from the World Bank study revealed that depressive disorders accounted for close to 30% of the disability from neuropsychiatric disorders amongst women in developing countries but only 12.6% of that among men. The disparity in rates between men and women tend to be even more pronounced in underserved populations (World Bank, 1993).

Gender differences in mental disorders
Explanations for the gender differences in mental disorders have been discussed in relation to different help-seeking behaviors of the sexes, biological differences, social causes and the different ways in which women and men acknowledge and deal with distress (Paykel, 1991). Blue et al, (1995) argue that while all these factors may contribute to higher rates of depression or psychological problems among women, social causes seem to be the most significant explanation. Women living in poor social and environmental circumstances with associated low education, low income and difficult family and marital relationships, are much more likely than other women to suffer from mental disorders. They conclude that the combined impact of gender and low socio-economic status are critical determinants of mental ill-health (Blue et al, 1995).