Introduction

Gender inequality holds back the growth of individuals, the development of countries and the evolution of societies, to the disadvantage of both women and men.

UNICEF/0667/Vilas

Indian girl at work. Lack of support for girls' education limits their future choices.

The facts of gender inequality–the restrictions placed on women's choices, opportunities and participation–have direct and often malign consequences for women's health and education, and for their social and economic participation. Yet until recent years, these restrictions have been considered either unimportant or non-existent, either accepted or ignored. The reality of women's lives has been invisible to men. This invisibility persists at all levels, from the family to the nation. Though they share the same space, women and men live in different worlds.

The first steps have been taken to end this invisibility. In 1979, by adopting the Convention on the Elimination of All Forms of Discrimination against Women, the global community agreed to eliminate gender discrimination. The Convention, which has the force of international law, has now been ratified by 165 of the 188 member states of the United Nations.

Health care and education for girls and women have been the subject of international agreements, notably those reached at a series of world conferences on women beginning in 1975, the World Conference on Education for All in 1990 and the International Conference on Population and Development (ICPD) in 1994.

A rapidly growing number of countries have adopted population and development policies that include measures to meet the health care and education needs of girls and women, including their reproductive health needs. Education and health, including reproductive health, are human rights. Meeting education and health needs and working towards gender equality will also contribute to balanced population growth and economic development.

Most countries have some measures in place to protect women's personal security and their rights in marriage, property, inheritance, political representation and the workplace. Those measures are being expanded and increasingly enforced.

The impact of women's empowerment on the rights and roles of men is being considered. Efforts to bring women into the mainstream of development now emphasize partnership between women and men.

"Gender issues" are not the same as "women's issues": understanding gender means understanding opportunities, constraints and the impact of change as they affect both women and men. It is increasingly understood that partnership between women and men is the basis for strong families and viable societies in a rapidly changing world.

Equal partnership is also the aim of women's organizations, which are rapidly growing in number and strength in many countries of Asia, Africa and Latin America. The advantages of partnerships between official organizations and women's groups are increasingly recognized.

Yet gender inequality remains pervasive. It is a public concern, but it also relates to private behaviour, and therefore has not yet been fully discussed, especially where male dominance is the basis of family life. Elsewhere, though unequal restrictions on women may be outlawed or condemned, they persist in forms that have been rendered more socially acceptable.

This year's State of World Population report makes the case for bringing gender inequality fully into the light and treating it as a matter of urgency affecting both human rights and development priorities. Gender discrimination will not end until all eyes are opened to its inherent contradictions, and countries, communities and families take action to end it.

Box 1: Discrimination and Poverty Go Hand in Hand

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Summary

More equal power relations between men and women, combined with increased access to good reproductive health care, would save the lives of hundreds of thousands of women, including many of those who die from pregnancy-related causes. If women had the power to make decisions about sexual activity and its consequences, they could avoid many of the 80 million unwanted pregnancies each year, 20 million unsafe abortions, some 500,000 maternal deaths (including 78,000 as a result of unsafe abortion), and many times that number of infections and injuries. They could also avoid many of the 333 million new sexually transmitted infections contracted each year. Adolescent girls are particularly vulnerable (Chapter 2).

Violence against women also takes a steep toll on women's health, well-being and social participation (Chapter 3). Men must involve themselves in protecting women's reproductive health as a matter of self-interest and to protect their families, as well as for its own sake (Chapter 4).

The equality of women and men is integral to development (Chapter 5). It is also a human right (Chapter 6). Governments must take the fundamental decisions. Donor countries have agreed to support these priorities, but donors in the 1990s have not met even half of the agreed resource targets in the area of population and reproductive health (Chapter 7).

Gender and Health (Chapter 2)

Quality reproductive health services enable women to balance safe childbearing with other aspects of their lives. The International Conference on Population and Development and the United Nations' "ICPD+5" five-year review recognized the important relationship between gender and reproductive health. Gender-sensitive programmes listen to clients and involve them in programme and service design.

Components of reproductive health

About one third of pregnancies–about 80 million a year–are believed to be unwanted or mistimed. The number of users of family planning services in developing countries–assuming services can be provided–is expected to increase by more than 40 per cent by 2015: 742 million compared with 525 million in 2000. Just over half of the increase will be due to rising numbers of women of reproductive age (15-49) in these countries. This group will grow by more than one fifth in the next 15 years, to 1.55 billion. The rest of the increase in users will result from increased demand as the proportion of people using contraception rises.

Good family planning programmes share several characteristics:1

• Government support is strong;
• Providers are well trained, sensitive to cultural conditions, listen to clients' needs, and are friendly and sympathetic;
• Services are affordable and a choice of contraceptive methods is available;
• Counselling ensures informed consent;
• Privacy and confidentiality are ensured;
• Facilities are comfortable and clean;
• Service is prompt.

Figure 1: Family Planning Needs Will Grow as Both Population and Demand Increase

Universal access to sexual and reproductive health care is a central objective of the ICPD Programme of Action. Since the ICPD, many countries have expanded services beyond family planning to care for women's and men's broader reproductive health needs.

One woman a minute dies of pregnancy-related causes. Maternal mortality is preventable by:

• Helping women avoid unwanted pregnancy;
• Ensuring the presence of trained attendants at every birth;
• Providing emergency obstetric care;
• Providing post-natal care–61 per cent of maternal deaths occur after delivery;
• Providing effective post-abortion care–78,000 maternal deaths are due to unsafe abortions, 95 per cent of which take place in developing countries.

Box 2: Most Maternal Deaths Could be Prevented

Some 20 million of the estimated 50 million abortions each year are unsafe; 78,000 women die and millions suffer injuries and illness as a result. Expanded access to family planning would prevent many unwanted pregnancies and many unsafe abortions. In many low-income countries effective post-abortion care would reduce maternal mortality by as much as one fifth.

Sexually transmitted diseases (STDs) afflict five times more women than men. There are an estimated 333 million new cases every year. These diseases cause infertility, pregnancy-related complications, post-partum illness and cervical cancer.

Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) is now the leading cause of death in Africa and the fourth most common cause of death worldwide. At the end of 1999, 34.3 million men, women and children were living with HIV or AIDS, 5.4 millions were newly infected that year, and 18.8 million had already died from the disease. More than 95 per cent of all HIV-infected people live in the developing world.

Women are more vulnerable to infection than men and are becoming infected at a faster rate. In Africa, HIV-positive women outnumber infected men by 2 million. The ICPD+5 review agreed that women need information, education, skills, services and social support to reduce their vulnerability. There should be wider access to male and female condoms, and retro-viral drugs where possible. Information and counselling are needed on sexuality, gender roles and power imbalances, gender-based violence and other issues. Family planning and services for STDs and HIV/AIDS should be integrated within reproductive health services.

Women tend to become infected far younger than men. In several African populations, girls aged 15-19 are five or six times more likely to be HIV-positive than boys their own age. Clearly, older males are infecting teenage girls. Good-quality sex education helps adolescents delay sexual intercourse and increase safe sexual practices.

Worldwide, some 130 million girls and young women have undergone female genital mutilation (FGM). Genital mutilation is extremely painful and may result in severe infection, shock or even death. Survivors experience painful sexual intercourse and may be at greater risk during and after childbirth. FGM can lead to repeated infections and sterility.

Gender biases can also lead to a variety of restrictions on care–for example, restricting certain procedures to doctors, or providing public clinics only for maternal and child health, so men and childless or unmarried women feel uncomfortable going to them for reproductive health services.

Reproductive health services are increasingly recognizing that reproductive health is a matter for men as well as women, including the effect of women's reproductive health on men and men's support for their partners' reproductive health.

Young people's reproductive health

Young men and women face different social pressures and expectations which may work against responsible sexual behaviour. Training young people as peer educators encourages discussion and responsible behaviour. Sometimes, simply calling attention to double standards can lead to improvements.

Many girls and boys, however, are forced into early and unsafe intercourse by sexual abuse, child marriage or poverty. Adults also prevent young people from acting responsibly by limiting their access to information and health services. Parents can learn to be sources of information and counselling to their children. Many other adults in and out of the family can also play a part, especially political and religious leaders, who have a great deal of influence on changing social attitudes.

Men's reproductive health needs

Men are subject to sexually transmitted infections and have other reproductive health problems such as impotence and infertility. Men also want to space their children–and in some developing countries between one quarter and two thirds of men say they want no more children, but neither they nor their wives are using contraception.

Reproductive health services for men have concentrated on treatment and control of STDs. The proportion of contraception attributable to men has fallen in recent years. Information on avoiding pregnancy and preventing infection is still limited among unmarried men. Good programmes can increase men's interest in and their use of contraception.

Migrants and refugees

Migrants and refugees have special reproductive health needs. UNFPA has provided timely emergency assistance in a number of developing countries.

Partnerships for reproductive health

Non-governmental organizations (NGOs) have helped to bring about major shifts in population and development programmes, and have brought gender concerns to the centre of these programmes. NGOs are working for gender equality and engaging in advocacy and policy formulation covering such sensitive topics as unwanted pregnancy, STDs and HIV/AIDS, and adolescent reproductive health, among others.

NGOs' work on violence against women is one of the most important contributions to ending gender-based abuse. National NGOs are promoting reproductive health and women's well-being, providing health care and social services, and participating actively in health reforms.

One of the great strengths of NGOs is their ability to form partnerships and alliances among themselves and with governments. International networks validate and strengthen national groups and raise the NGO profile in international discussion.

Civil society/government partnerships can be highly productive. In Bangladesh, for example, 25 per cent of reproductive health activities are carried out by NGOs. Effective partnerships are especially important where public-sector investments are most limited.

Violence against Women (Chapter 3)

Girls and women worldwide, across lines of income, class and culture, are subjected to physical, sexual and psychological abuse. Violence against women includes rape, genital mutilation and sexual assault; forced pregnancy, sterilization or abortion; forced use or non-use of contraceptives; "honour" crimes; sexual trafficking; and dowry-related violence.

Around the world, at least one in every three women has been beaten, coerced into sex, or abused in some other way–most often by someone she knows, including her husband or another male family member. One woman in four has been abused during pregnancy.

Each year rape and domestic violence cost women worldwide the equivalent of millions of lost years of healthy life. Physical violence is nearly always accompanied by psychological abuse, which can be just as demeaning and degrading.

Many cultures condone or at least tolerate a certain amount of violence against women. Even women often view a certain amount of physical abuse as justified under certain conditions. As many as 5,000 women and girls are killed annually in so-called "honour" killings, many of them for the "dishonour" of having been raped.

The reproductive health consequences of violence include unwanted pregnancies, complications of pregnancy, unsafe abortion and sexually transmitted infections.

An estimated 4 million women and girls are bought and sold worldwide each year, either into marriage, prostitution or slavery. Although the greatest volume of trafficking occurs in Asia, Eastern European women are increasingly vulnerable.

Recognizing the growing use of violence against women as a weapon of war, a conference of the International Criminal Court in 1998 added to its definition of war crimes a statute on gender justice stating that rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilization and other forms of sexual violence are "grave breaches" of the Geneva Conventions against war crimes.2

Men, Reproductive Rights and Gender Equality (Chapter 4)

Gender considerations involve men as well as women, so understanding gender means understanding opportunities and constraints as they affect both women and men. Definitions of gender roles are often rigidly stereotypical, and increasingly fail to correspond to external change. These anomalous expectations are at the root of continuing gender inequality.

Men develop an interest in women's reproductive health when they learn more about how they can help ensure safe pregnancy and delivery. Shared beliefs about marriage and proper behaviour improve the reproductive health of both partners.

The Cost of Inequality (Chapter 5)

Empowerment and equality for women are important human rights aims in themselves, but they are also integral to development. It is more than a matter of economics: in the words of UNFPA's Executive Director, Dr. Nafis Sadik, "Better health and education, and freedom to plan their families' future, will widen women's economic choices, but it will also liberate their minds and spirits."

Much of women's work, paid and unpaid, has an economic impact, though their contribution is rarely noticed or fully quantified. If it were recognized for what it is and supported accordingly, its value would be even greater. Giving women farmers in Kenya the same support as men, for example, would increase their yields by more than 20 per cent; raising Latin American women's wages to men's levels would increase national output by 5 per cent.

One of the keys to sustainable development will be recognizing the costs of gender discrimination and the advantages of equality, making them visible to policy makers and families, and agreeing on action.

Health care and education

The absence of health care has economic as well as personal costs. As much as 30 per cent of economic growth may be attributed to better health and nutrition. On the other hand, life expectancy is shorter in poor nations and among poor people. Cuts in health services such as those imposed after the Asian financial crisis affect the poor most acutely, and poor women in particular, as the heaviest users of public services. Where funding cuts led to fees being imposed, more recovery time was needed after illness, and labour force participation dropped. Poor women were among those most seriously affected.

Limited access to health care among the poor has a greater relative impact on women than on men. In particular, poor women are more likely to die as a result of pregnancy. A mother's death represents more than a personal tragedy: the economic and social costs include the impact on children's health and education, and on the father's ability to hold the family together.

Like maternal death and disability, HIV/AIDS has a heavy economic and social cost, in part because deaths are concentrated in the early to mid-adult years, when family responsibilities are greatest and earning power highest. Partly as a result of gender inequality, women are now more likely than men to contract HIV infection. Economic costs may amount to a loss of 0.5 percentage points in annual gross domestic product (GDP) growth, a considerable burden where growth is already slow.

Gender violence also imposes costs, from the cost of caring for the injured to the cost of family dissolution; indirect costs include missed opportunities for women and their children. Inequality also has psychological costs, notably from reduced self-esteem and depression among women, and frustration among men due to unrealistic expectations.

Studies repeatedly show that educating girls and women raises every index of development. Denying education to women has slowed social and economic development. An estimated two thirds of the 300 million children without access to education are girls, and two thirds of the some 880 million illiterate adults are women.

Economic returns on investment in women's education, on the other hand, exceed those for men. Differences in fertility levels between regions are strongly related to differences in levels of health and women's education. A recent study attributed one third of the increase in male and female life expectancy between 1960 and 1990 to gains in the educational attainment of women.

Demographic trends

Family planning and reproductive health programmes in general improve women's health. They tend to result in lower total fertility and slower population growth. The ageing of populations will also have social and economic consequences; old age poses different challenges for women and men. Gender factors strongly influence these trends and demand fresh attention from policy makers.

Economic benefits from declining fertility include a one-time "demographic bonus" as the workforce increases relative to the dependent population. Improving education for girls and meeting their special health needs will help make the most of the demographic bonus.

Box 3: Beyond 6 Billion

Measuring gender bias

Several composite measures are used to assess gender bias. Variation is considerable, and for many countries, the indicators differ on what areas need most attention; but all agree to a large extent on the relative standing of countries and localities.

Working to End Gender Inequality (Chapter 6)

Equality is a human right

The equality of women and men has been accepted as a fundamental principle of human rights since the adoption of the United Nations Charter in 1945. Several international treaty agreements, such as the Convention on the Elimination of All Forms of Discrimination against Women, oblige signatory states to take action against discriminatory practices.

As expressions of the world's conscience, the consensus decisions of international conferences are powerful instruments for promoting the right to equality. The 1994 ICPD and the Fourth World Conference on Women in 1995 and their respective five-year reviews agreed on specific goals towards achieving it.

Box 4: ICPD+5 Review and Gender

Action Taken, Action Needed (Chapter 7)

Governments must take the fundamental decisions to move ahead on gender equality. Legal changes are a matter for sovereign decision; also, in many developing countries civil society is relatively small and powerless. Governments are also major employers, and their rules and practices have a powerful influence on social change. Governments are the major suppliers of services such as health and education, and public policy in these areas will determine the pace of change.

Parliamentarians are the interface between people and governments, though non-governmental organizations are playing a growing part in defining and promoting gender equality and equity. Parliamentarians are often the channel through which responses to policy, and news of changing needs and practices, reach governments.

Social change cannot be brought about merely through legislation; it must be encouraged by leadership and example. It can also be encouraged by international action to put into effect the agreements reached in legally binding instruments such as the Convention on the Elimination of All Forms of Discrimination against Women and the morally binding consensus of international discussions such as the ICPD. Major initiatives such as the global campaign for girls' education have been launched to re-energize the discussion and mobilize the promised support.

Donor countries are called upon to support these priorities, and have agreed to do so. But donors in the 1990s have not met even half of the agreed resource targets in the area of population and reproductive health; international assistance for education and women's empowerment is also woefully inadequate. The shortage of funding to help countries advance gender equality harms the interests of women and men, their countries and the global future.

Box 5: "Beijing+5" Review Reaffirms Commitment to 1995 Platform for Action

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