Declarations Gender Mainstreaming Was Defined by the Economic and Social Council of UNO
A) Declarations Gender mainstreaming was defined by the Economic and Social Council of UNO as follows: Mainstreaming a gender perspective is the process of assessing the implications for women and men of any planned action, including legislation, policies or programmes, in any area and at all levels. It is a strategy for making the concerns and experiences of women as well as of men an integral part of the design, implementation, monitoring and evaluation of policies and programmes in all political, economic and societal spheres, so that women and men benefit equally, and inequality is not perpetuated. The ultimate goal of mainstreaming is to achieve gender equality. (United Nations Economic and Social Council's agreed conclusions 1997/2. )
Following those lines the WHO has sustained the approach to Gender in Health through a series of documents which appeared in the following years (See: a) Integrating gender perspectives into the work of WHO: World Health Organization, 2002. b) Strategic action plan for the health of women in Europe. Copenhagen, World Health Organization, 2001; c) resolution AFR/RC53/r4 on Women's health: a strategy for the African Region; and resolution CD46.R16 on PAHO gender equality policy; d) EB116/2005/REC/1, Summary record of the second meeting; e) Document WHO/FCH/GWH/07.1 .
At its 60th session in May 2007, the Health Assembly noted with appreciation the strategy and adopted resolution WHA60.25. The strategy was drawn up on the basis of broad consultation throughout the Organization, with representatives from ministries of health, and with external experts, from which it emerged that gender equality and equity should be integrated into WHO’s overall strategic and operational planning, in order to bring about systemic changes across all areas of work. A plan of action for implementing the strategy continues to evolve (Document WHO/FCH/GWH/07.1).
The Millennium Declaration of United Nations Organizations include the promotion of gender equality and the empowerment of women as effective ways to combat poverty, hunger and disease and to stimulate sustainable development (United Nations General Assembly resolution 55/2) The United Nations is strengthening gender mainstreaming through a system-wide strategy, with which the strategy is consistent. In order to ensure that women and men of all ages have equal access to opportunities for achieving their full health potential and health equity, the health sector needs to recognize that they differ in terms of both sex and gender. Because of social (gender) and biological (sex) differences, women and men face different health risks, experience different responses from health systems, and their health-seeking behaviour, and health outcomes differ.
In order to fully incorporate analysis of the role of gender and sex in health and determine appropriate action the WHO Secretariat has given itself the following principles (Strategy for integrating gender analysis and actions into the work of WHO May 2007) :
• addressing gender-based discrimination is a prerequisite for health equity
• leadership and ultimate responsibility for gender mainstreaming lie at the highest policy and technical levels of the WHO
• programmes are responsible for analysing the role of gender and sex in their areas of work and for developing appropriate gender-specific responses in all strategic objectives on a continuing basis
• equal participation of women and men in decision-making at all levels of the Organization is essential in order to take account of their diverse needs
• performance management should include monitoring and evaluation of gender mainstreaming.
WHO strategic directions are chosen as following:
· Building WHO capacity for gender analysis and planning. In order to help to ensure that analysis of the role of gender and sex in health and appropriate planning is integrated into WHO’s work at all levels, staff need to have a basic understanding of the subject matter.
· Bringing gender into the mainstream of WHO’s management. Incorporation of gender considerations – in the components of results-based management planning, budgeting, monitoring and evaluation – effectively influences the work of the Organization.
· Promoting use of sex-disaggregated data and gender analysis. In line with the commitment made in the Eleventh General Programme of Work (Document A59/25, paragraph 116), WHO will use sex-disaggregated data in planning and monitoring its programmes and provide support to Member States in improving the collection, analysis and use of quantitative data on health, disaggregated by sex, age and other relevant social stratifications.
· Establishing accountability. Accountability for the effective integration of gender perspectives into WHO programmes and operational plans will rest primarily with senior WHO staff.
· Role of the gender, women and health network. Implementation of the strategic directions will require advocacy, information, technical support and guidance to staff.
B) Short overview on the scenario
The cardiovascular disease (CVD) model
One of the critical problems relevant to gender approach is found in the main and largely impacting common (for men and women) diseases ( e.g. Cardiovascular Diseases (MI, Stroke)) the knowledge of the differences are fairly understood or known, and the treatment and prevention are suffering by the state of that understanding and knowledge.
Lack of knowledge is parallel to not always certified epidemiology information:
The Italian data (ISTAT 2006) on mortality of main diseases are certified just till 2002.
thousands / 2002 / 2003 / 2004CVD / men / 105.7 / 108.6 / 100.2
CVD / women / 131.4 / 138.8 / 123.2
Tumours / men / 93.4 / 94.4 / 94.5
Tumours / women / 69.6 / 68.6 / 70.3
Differences between genders on the single independent risk factors of CVD are well described. The reference values of many parameters (as Blood Pressure, Waist circumference, HDL,) are consequently indicated .
Prevalence of risk factors are different in men and women in the population. The risk factors taken in consideration (Lancet 2004;364: 937-52) are ApoB/ApoAI ratio, Blood Pressure, overweight/obesity, smoking, diabetes bad nutrition, sedentarity, stress, social unsatisfaction. Recently air pollution has been added. They are accounting more than 92% of the global CVD risk. Less is given to genetic risk. The correlation of those risk factors with CVD were shown marginally stronger in women than in men. These results suggest that the existence of 1 additional risk factor may increase the risk of cardiovascular disease more steeply in women than in men (Gend Med. 2006;3:196–205).
Differences are described in the outcomes of Myocardial Infarction in Hospitals
Hospital out come report in Italy 2003
DRG / Number of admissions / Days staymen not complicated MI alive discharged / 28.169 / 7.59
women not complicated MI alive discharged / 13.763 / 8.82
men complicated MI alive discharged / 13.617 / 9.54
women complicated MI alive discharged / 10.154 / 10.78
women MI deceased / 3.551 / 6.02
women MI deceased / 3.831 / 5.84
CVD Mortality in US Women Is Not Declining (AHA Heart Disease and Stroke Statistics–2005 Update. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497). Women tend to delay seeking treatment longer than men Þ 18’ longer vs. men; time to treatment was 12’ longer (GUSTO I; Weaver WD. JAMA 1996). More than 20% of young women with multiple risk factors delayed coming to the hospital by 12 h. or more after onset of symptoms (Barron HV. Circulation 1998). Women may experience further delay in the hospital before receiving thrombolytic therapy Þ (mean 112’ vs 89’; p<0.01); they waited 7’ longer before having their first ECG (mean 26’ vs 19; p<0.01)(Goldberg RJ. Am Heart J 1998)
Much research in past 20 years on diagnosis and treatment of CHD excluded or underrepresented women. Only 20% of studies including women published sex-specific findings.Tests and therapies used to treat CHD in women based on studies conducted primarily in men (Stanford-UCSF Evidence-based Practice Centre. Profile, November 2002. Agency for Healthcare Quality and Research, Rockville, MD. http://www.ahrq.gov/clinic/epc/ucsfepc.htm)
Cardiovascular diseases in men are prevalent till the age of 65 years, after that age CVDs prevail in women. Women die for CVD more than men because of the age and because of anatomical, functional and prevalence of risk factors and concomitant mobility. Beyond those differences the attention is even more focussed on treatment disparity . There is a sort of gender bias in the medical approach (NEJM 1991; 325: 274-27. Arch intern Med 1998; 158: 981-988. NEJM 2007; 356: 898-1009 . Circulation 2007; 115: 833-39)
Anatomical and endothelial functional differences in vessels are described (Am Heart J 2000;139: 649-653) aging and diabetes are increasing differences (Hypertension 2004; 44: 67-71) Aging, hormonal fluctuation, oxidative stress, metabolic syndrome are getting differentely between genders inadequate the repairing activities (Circulation 2004; 109:722-725). An early menopause, gestational diabetes (as described in NEJM 2008;358:2061-3), preeclampsia, eclampsia , birth underweight, and other conditions in the young age, refer to higher risk of CVD in the advanced ages (J Am Coll Cardiol 2006; 47: 30S-35S).
Stroke is a condition of CVDs were the differences of gender are known. How much of this knowledge is utilized in the management of Stroke in the Stroke Units, or in the risk assessement and prevention in the genders (Lancet 2008;371:1612-23).
Diabetes and genders
Even when women were included in clinical trials, investigators typically made no attempt to assess the impact of sex differences on the reported results. Existing studies, however, reveal several differences between men and women with diabetes. The prevalence of DM is growing fastest for older minority women. Women with diabetes, regardless of menopausal status, have a 4- to 6-fold increase in the risk of developing coronary artery disease (CAD), whereas men with diabetes have a 2- to 3-fold increase in risk. Women with diabetes have a poorer prognosis after myocardial infarction and a higher risk of death overall from cardiovascular disease than do men with diabetes. Women with type 2 DM experience more symptoms of hyperglycemia than do their male counterparts. Obesity, an important contributor to type 2 DM, is more prevalent in women. Women with diabetes have an increased risk of hypertension compared with men with diabetes. Women have a more severe type of dyslipidemia than do men (low levels of high-density lipoprotein cholesterol, small particle size of low-density lipoprotein cholesterol, and high levels of triglycerides), and these risk factors for CAD have a stronger influence in women. ( Gender Med 2006 3:131-58)
Gender and pharmacology
The influence of gender on the effects of aspirin in preventing myocardial infarction
Gender accounts for a substantial proportion of the variability in the efficacy of aspirin in reducing MI rates across these trials, and supports the notion that women might be less responsive to aspirin than men (BMC Medicine 2007, 5:29). It is shown that 75 mg/die aspirin produce conclusive benefit in secondary prevention and in treatment in MI, Stroke and vascular disorders Men and women have apparently equal benefits in using aspirin in the secondary prevention after CVD events; women do not have equal benefit as men by using aspirin in the primary prevention of CAD. ( Women Health Initiatives results (communicated by Julie. Buring - Europrevent Congress. Paris May 2nd 2008)
Smoking and Gender
Although the rate of smoking is, for the most part, higher among males, the results of this study showed that the disease is associated with smoking is higher among females. Because this risk is higher for females at both high and low levels of smoking, there may be some underlying effects that place females at a higher risk regardless of how much they oke Point Estimates in Low Level or High Level of Groups Smoking has given (respectively) different results: Both sexes 2.98 and 1.97; Males 1.42 and 1.95; Females 1.77 and 2.75; Overall 1.70 and 2.09 .The disease outcomes included in the analyses were similar for both sexes, thus the difference in risk may not be due solely to any difference in the outcomes in each group. Rather, there are other factors involved, such as a gender difference in the relationship of smoking to specific disease exacerbation. (Am J Prev Med. 2006;30:405–412. and Gend Med. 2006;3:279–291)
Molecular Biology and Genders
Have been described differences in the length of telomeres (repeated sequence TTAGGG at the ends of chromosomes) of women and men cells nucleus. The telomeres are gradually eroded as life goes on, and several studies have shown that men have shorter telomeres than women do (Med Hypotheses. 2004;62:151–154). Many cells are dying when the telomeres join to a critical length. This one is considered a marker of biological life.
“...the replicative history of male cells might be longer than that of female cells, resulting in the exhaustion of the regeneration potential and the early onset of age-associated disease predominantly in large-bodied males” (BMJ. 2000;321:1609–1612).
Osteoporosis and gender
Projections about increasing numbers of cases of osteoporosis in the future are well-founded, since the population in general is aging and age itself is a risk factor. It is estimated that the current number of osteoporosis cases in the U.S. alone is at 10 million, with another 34 million individuals at risk of fracture due to low bone mass. Osteoporosis incidence increases with age, affecting: n 37% of women between the ages of 50 and 59; n 50% between the ages of 60 and 69; n 75% between ages 70 and 79; n and 87% of women older than 80 years of age (Improving and Measuring Osteoporosis Management National Pharmaceutical Council, by The Joint Commission 2008). Men are not immune from the disease, as 5% of men on Medicare in 2001 had an osteoporosis diagnosis(Am J Manag Care. 2006;12(Suppl 7):S181-S190).Estimates are that the number of persons older than age 50 with osteoporosis will increase to 12 million by 2010 and to nearly 14 million by 2020 (Am J Med. 2006;119(4)(Suppl 1):S3-S11). One out of two women and one out of eight men will be affected by osteoporosis in their Lifetime.There are several identified risk factors for the development of low bone mass. Chief among these is age itself. A recent study among 616 women, aged 60-94, found that for each year of increasing age, the fracture risk increases by 3% (Bull World Health Organ. 2003;81(11):827-830) Among women, the gradual loss of estrogen at menopause contributes significantly to this decline in bone integrity and is a principal factor in what Riggs and Melton proposed in 1983 as Type I involutional osteoporosis (N Engl J Med. 1986;314(26):1676-1686) .The reduction in circulating estrogen triggers osteoclast activation and bone resorption, resulting in rapid bone loss at a rate of 1% to 5% yearly; this phase lasts from four to eight years (Am J Manag Care. 2001;7(special SP5-16)).The second phase, a more gradual bone loss, occurs 10 to 20 years after menopause and affects men as well as women. This Type II osteoporosis is marked by a rise in parathyroid hormone (PTH) levels, increase in bone turnover, and a decline in osteoblastic activity causing reduced bone formation (Am J Manag Care. 2001;7(special SP5-16)). In spite of the a.m. detailed description many questions are still open to understand the differences between gender and consequently the necessary different medical approach in treatment and prevention of the osteoporosis. Defective sight balance loss, microcirculation disorders in the diabetes feet can play a important role in the fractures of falling women with osteoporosis (::::::::::::::J. Two gene variants of key biological proteins (one close to osteoprotegerin, the other close to the LDL-receptor related protein) found in men, increase the risk of osteoporosis and osteoporotic fracture. The combined effects of these risk alleles on fractures is similar to that of most well-replicated environmental risk factors, and they are present in more than one in five white people (Lancet 2008;371:1505-12)