Gender-related barriers

Gender inequality impacts people’s vulnerability to HIV, TB and malaria. This section highlights key considerations for developing laws, policies, and interventions that address the gender-related barriers to combatting the three diseases.

Gender and HIV

Heightened risks among adolescent girls and young women

Adolescent girls and young women (AGYW) are disproportionately affected by HIV and other sexual and reproductive health risks. Laws, policies and practices that perpetuate gender inequality, harmful gender norms and gender-based violence create barriers to access to sexual and reproductive health & rights. Moreover, gender inequality limits access to education, resources and services for AGYW, preventing AGYW from being able to make decisions about, control and access health care services.

Sexual and reproductive health and rights are essential to the well-being of each individual and to support the fulfilment of national responses to health risks, such as HIV. However, the GCHL 2018 Risks, Rights and Health Supplement recognizes that, in global efforts to reach SDG targets, adolescent girls and young women (AGYW) are being left further behind. This leaves them at risk of poor sexual and reproductive health. For instance:

  • The Guttmacher Lancet Commission report Accelerate progress—sexual and reproductive health and rights for all found that “[c]ompared with young men, young women are more likely to acquire HIV, and the age of infection is 5-7 years earlier often coinciding with sexual debut. Other STIs, including HPV, are also commonly acquired in the early reproductive years—i.e., younger than 25 years.”
  • The UNAIDS Global AIDS Update 2020 reports that in sub-Saharan Africa, adolescent girls and young women (aged 15–24 years) accounted for 24% – almost one in four – HIV infections in 2019 despite being just 10% of the population. Women and girls of all ages represented 59% of new infections among adults (aged 15 and older) in the region.

Definitions: Adolescents and Young People

WHO defines adolescents as people between 10 and 19 years of age. The United Nations considers “youth” as those people between 15–24 years and “young people” as people between 10–24 years.

Here, we focus on adolescent girls aged 15 to 19 years and young adult women aged 20 to 24 years, in line with UNAIDS guidance. However, specific programmes should also include actions for adolescent girls aged 10 to 14 years and young adult women aged 25 to 29 years.

Adolescent girls and young women may also belong to one or more key populations or engage in activities associated with these key populations. Punitive laws, discrimination and violence combined with the vulnerability of youth, power imbalances in relationships and possible alienation from families and friends mean that young key populations face increased marginalization, hindering their ability to access HIV-related and other health services

Factors that heighten the risk of HIV and sexual and reproductive health risks amongst AGYW include biological factors, as well as legal, social, economic and cultural factors relating to gender inequality, harmful gender norms, gender-based violence and other human rights barriers experienced by AGYW. For instance:

  • The Guttmacher–Lancet Commission 2018 Report: Accelerate progress found that despite worldwide efforts to end child marriage, the practice remains common in developing regions, particularly in South Asia and sub-Saharan Africa. Child marriage increased sexual and reproductive health risks for adolescent girls for various reasons, including that “they are often socially isolated, tend to begin childbearing early, are vulnerable to STIs, including HIV, and are often unable to negotiate safer sex with their husbands, who are typically much older”. Research found that girls who marry before 18 years are at greater risk of intimate partner violence and forced sexual intercourse than those who marry at adulthood. The report also found that adolescents who give birth at 15 years or younger have increased risks of pregnancy-related complications and death.
  • The report also found evidence that adolescents’ self-stigma and fear of health care workers was a barrier to access to sexual and reproductive health care services: “only a few of sexually active adolescent women who have an STI or who have symptoms seek care in a health facility. Many adolescents do not know where to seek STI services, and those who do might feel ashamed or afraid to get treatment from health-care providers.”

Laws and norms that limit women’s and girls’ autonomy

A wide range of laws, customs and practices – for instance laws and norms allowing young girls to be married below the age of 18 years, laws that fail to criminalize the rape of a wife by her husband, laws and practices that prohibit women from owning or inheriting property or to having autonomous decision-making power within their relationships, and laws, policies and practices limiting adolescent girls’ independent and confidential access to sexual and reproductive health services – perpetuate gender inequality. These laws, policies and practices limit the ability of women and young girls to control their lives, including their ability to protect themselves from HIV and other sexual and reproductive health risks.

The GCHL 2018 Risks, Rights and Health Supplement examined select legal, human rights and gender-related barriers to sexual and reproductive health for AGYW. It reported that criminalization, stigma, discrimination, violence and other legal and human rights barriers undermined women’s and girl’s ability to control their own bodies, choose their partners or to receive high-quality sexual and reproductive health care. For instance, it found that globally, laws and policies in more than 70 jurisdictions allow health-care providers to refuse to provide health services to girls and young women based on claims of “conscience,” preventing AGYW from accessing critical services such as contraception or abortion.

Increased vulnerability to HIV infection has also been linked to intimate partner violence, which is more common among younger women and women who are economically dependent on their male partners. Violence or the fear of violence can make it very difficult for women to insist on safer sex and to use and benefit from HIV and sexual and reproductive health services. Women living with HIV who experienced intimate partner violence were significantly less likely to start or adhere to antiretroviral therapy, and they had worse clinical outcomes than other HIV-positive women. Read more: GCHL (2012) Risks, Rights and Health

Gender Equality, HIV and COVID-19

“Just as HIV has held up a mirror to inequalities and injustices, the COVID-19 pandemic has put a spotlight on the discrimination that women and girls battle against every day of their lives,” said Winnie Byanyima, Executive Director of UNAIDS. “Many of the drivers of inequality in the HIV epidemic are the same as those driving inequality and injustice in the COVID-19 pandemic—both epidemics can only be successfully fought by putting gender equality at the centre of the response.” Read more: Six Concrete Measures to Support Women and Girls in all their Diversity in the Context of the COVID-19 Pandemic

Recommendations for building enabling laws and policies

Enabling legal environments need to prioritise laws, policies and programmes that address the human rights and gender-related factors that cause heightened risk of HIV and other sexual and reproductive health risks amongst AGYW.

The GCHL Risks, Rights and Health Supplement recommends that governments must adopt and enforce laws that remove legal barriers to accessing the full range of sexual and reproductive health services and that protect and promote sexual and reproductive health and rights.

The Guttmacher-Lancet Commission report Accelerate progress—sexual and reproductive health and rights for all warns that a continuation of the status quo would mean that human rights violations, such as child marriage, female genital mutilation, intimate partner violence and sexual coercion and violence, will persist, along with major inequalities in health and access to health care. The report identifies high priority legal and policy reforms to support sexual and reproductive health and rights as outlawing child marriage, promoting gender equality and women’s autonomy, liberalizing abortion laws and prohibiting discrimination against people with diverse sexual orientations and gender identities and expression.

Case Study: Liberalizing abortion reduces women’s health risks

Law reform to broaden the grounds on which abortion is permitted is crucial to improving the sexual and reproductive health and rights of adolescent girls and young women. Abortion law reform paves the way to training providers in safe abortion care, ensuring access to safe methods and destigmatizing the practice.

In South Africa, where a liberal abortion law went into effect in 1997, the incidence of severe complications from unsafe abortions declined between two study periods, 1994 and 1999–2001, and the number of women who died due to abortion fell by 91%.

In Nepal, where a liberal abortion law was passed in 2004, the proportion of severe abortion complications dropped dramatically between 2001 and 2010.

In Mexico City, after first-trimester abortion became legal on demand in 2007, use of abortion methods recommended by the World Health Organization increased, shifting away from more invasive procedures. In the public sector in Mexico City, medication abortion as a proportion of legal abortion procedures rose from 25% in 2007 to 83% in 2014.

Source: Guttmacher–Lancet Commission (2018) Accelerate progress: sexual and reproductive health and rights for all

Case Study: Decriminalising consensual sex among teens in Peru

In Peru, more than 10,000 young people successfully challenged the constitutionality of the criminalization of consensual sex among teens,which had the effect of prohibiting preventive reproductive health services for adolescents. In 2012, the court ruled in their favour, referring to international human rights law and the country’s constitution (and the fact that many teens were already parents). It declared that young people aged 14–18 years had a right to personal autonomy and self- determination regarding their sexuality.

Source: Guttmacher–Lancet Commission (2018) Accelerate progress: sexual and reproductive health and rights for all

Gender and TB

Gender-related risk factors for TB

Gender is an important determinant of risk and vulnerability to TB. The Global Fund Technical Brief: Tuberculosis, Gender and Human Rights identifies various gender-related risks and barriers to access to TB services, including:

  • The negative impact of notions of masculinity on men’s health seeking behaviour, leading to delays in diagnosis and lower rates of treatment access and completion amongst men.
  • Employment conditions (e.g. in the mining sector) impacting upon men.
  • The deprioritization of women’s health needs in families, due to gender norms, child-care and family responsibilities or limited autonomy for health decision-making, leading to delays in diagnosis and lower rates of treatment access and completion amongst women.
  • Higher rates of stigma against women with TB, leading to avoidance of health care by affected women.

Example: Gender-related TB risks

Current global data from the World Health Organization show that men account for almost twice as many TB cases as women. They are also less likely to be diagnosed and reported, and account for the majority of deaths among HIV-negative people.

However, women may have less access to TB prevention and treatment services and may be discouraged or unable to seek appropriate health care services.

Source: Global Fund Technical Brief: Tuberculosis, Gender and Human Rights

Gender-responsive approaches to TB

A gender-responsive approach to TB requires integrating gender equality norms and principles in the design, implementation, monitoring and evaluation of TB programmes, as well as implementing various programmes to empower key and vulnerable populations to address their particular needs and ensure their participation in health decision-making.

The Political Declaration of the UN General Assembly High Level Meeting on the Fight Against TB commits Member States to recognising the various sociocultural barriers to TB prevention, diagnosis and treatment services, especially for those who are most vulnerable, ending TB-related stigma and discrimination and developing health service approaches that protect gender equality, amongst other things.

Tool to assess gender in TB responses

The Stop TB Partnership Communities Rights and Gender Assessment is a tool to support countries to review their legal and policy frameworks for the TB response, understand TB-related stigma and discrimination, the way in which gender impacts on vulnerability to TB infection and access to services and to develop recommendations to overcome human rights, gender and key population related barriers, to improve the TB response.

See Tools to identify Human Rights Barriers for more information on tools to support rights-based responses to HIV, TB and malaria.

Gender and Malaria

Gender-based risk factors for malaria

Gender-based constraints on access to malaria services have been identified as key factors in vulnerability to malaria. For instance:

  • Women and girls may face malaria risks linked to gender norms where they are required to undertake tasks pre-dawn or in the early evening (e.g. preparing food, fetching water or working in fields) that expose them to mosquitoes. Similarly, men may be exposed due to migrant work, or work in forests, fields, mines or other high-exposure locations.
  • Adolescent girls may have limited access to health services due to laws requiring parental consent for access to health care in a number of countries.
  • Limited access to health information – e.g. due to low literacy – may impact on women more than men, limiting their acess to information on malaria prevention and treatment.
  • In some circumstances, gender norms may dictate who receives long-lasting insecticidal nets; women may not have the autonomy to seek or receive nets, or purchase additional nets when needed.

Example: Heightened malaria risk among pregnant adolescents

Pregnant women are at greater risk of developing severe malaria in most endemic areas. Pregnant adolescents face higher risk of severe malaria than women over the age of 19 years and may also face greater barriers to antenatal and reproductive health care than older women. Read more: The Global Fund Malaria, Gender and Human Rights Technical Brief

Addressing gender-related barriers to malaria prevention and treatment

Health responses to malaria should be informed by a thorough analysis and understanding of all gender-related barriers to access to malaria prevention and treatment services and should seek to implement programmes to address these barriers.

Malaria Matchbox Toolkit

The Global Fund and RBM Partnership Malaria Matchbox Toolkit is a tool to support countries in identifying and analysing gender-related barriers to health care for malaria and developing appropriate programmatic responses.

Programmatic recommendations – Global Fund Working Group on Malaria

The Global Fund Working Group on Malaria sets out programmatic responses to malaria, human rights and gender equality. In 2016, a group of experts convened by the Global Fund for the first time defined concrete programmes and approaches to reducing human rights and gender-related barriers to malaria services, as outlined in the Malaria, Gender and Human Rights Technical Brief (updated in 2019). It notes that human rights and gender assessments of malaria-related risks and vulnerabilities should be undertaken, meaningful participation of affected populations should be ensured and access to malaria services for refugees and others affected by emergencies improved.