health at risk in Africa
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
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
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
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.
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.
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
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
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
Genital Mutilation (FGM)
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.
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.
Consequences of FGM
immediate and long-term health consequences of female genital
mutilation vary according to the type and severity of the
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.
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
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
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;
identification with the cultural heritage, initiation of girls
into womanhood, social integration and the maintenance of
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
religious reasons: Some Muslim communities, however,
practice FGM in the belief that it is demanded by the Islamic
faith. The practice, however, predates Islam.
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
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.
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
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.
studies on violence against women indicate that;
- the perpetrators of violence against women are almost
- 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.
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.
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.
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
- 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
The AIDS epidemic in women is overwhelmingly heterosexual -
almost entirely so in Africa.
are women more vulnerable to HIV infection?
- 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
- coerced sex increases risk of micro lesions.
- financial or material dependence on men means that women
cannot control when, with whom and in what circumstances they
- 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.
- women are not expected to discuss or make decisions about
- 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 are responsible for the health care of all family
- 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.
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
- interventions must be aimed at men (as well as at women) if
women are to be protected.
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
- 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.
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.
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.
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
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.
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.
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).
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).
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.
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.
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,
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).