Grassroots Activism at the Intersection of Gender and Health

Tiffany Nassiri-Ansari

Poster for In Conversation With Changemakers featuring the four speakers.

In Conversation With, the Lancet Commission on Gender and Global Health’s seminar series, returned with a seventh episode hosted by Secretariat Lead Emma Rhule on October 27th. Grassroots activism at the intersection of gender and health featured four partners from the Secretariat’s flagship public engagement programme, Changemakers, and highlighted the work of youth-led feminist organisations in Kenya and South Africa. Rhule, a senior researcher at UNU-IIGH, was joined by: 

This webinar was co-convened with UNU-IIGH. Rhule and speakers were joined by Commissioners and livestream audiences on Zoom and YouTube. A recording of the hour-long webinar is publicly available on the Commission’s YouTube channel. 

Setting the scene

Rhule began with a brief throwback to the early days of the Commission, which included countless conversations on its underlying principles and the need for an approach that is feminist, intersectional, decolonial, and political “to achieve transformative change at the intersection of gender and health”. She described an early awareness of the need to seek out voices beyond those of the Commissioners and interrogate notions of evidence and expertise.  

Under the leadership of Prof. Pascale Allotey, Co-Chair and then-director of UNU-IIGH, the Secretariat secured funding from the Ford Foundation to support engagement with youth-led feminist organisations working at the intersection of gender and health. In this sociopolitical climate which threatens not only potential progress but past victories, youth and community voices are key to upending a broken status quo and identifying more forward-looking ways of working. Seeking to take an explicitly decolonial and feminist approach, three guiding principles were developed to shape the Changemakers programme of engagement: look beyond the usual networks, create equal partnerships, and prioritise community outcomes over research outputs. 

Slide featuring the three principles of decolonial feminist engagement developed for this programme.

The four partners convened by the Secretariat are strong examples of youth voices making themselves heard at the communal, national, and international levels. Over the course of 2022, representatives from the Activist Education & Development Centre, the Rev. M.S Lugongolo Foundation, Young Women’s Leadership Institute, and Zamara Foundation as well as members of the Secretariat have had the opportunity to get to know each other, experience a series of workshops together, and envision what continued partnership beyond the life cycle of the Changemakers programme might look like. This webinar served as both a testament to the collaboration and conversation of the previous months and a prologue to the next phase of this partnership. 

On that note, Rhule swiftly introduced the speakers as well as a video package featuring the panel discussion, which was pre-recorded to facilitate equal and meaningful participation from all speakers in the face of unpredictable technical difficulties. 

Panel discussion: Exploring youth-led feminist activism

Lucy Kombe opened the panel by posing a question on behalf of Zamara Foundation, asking her peers: What is the role of women’s rights organisations in creating demand for action towards systemic change, especially in policy influencing? 

Jessica Booysen from Activist Education & Development Centre began by reaffirming the role women’s rights organisations play in continually promoting awareness and understanding of the importance of women’s rights in the face of countless gender-based issues. It is the role of these organisations, Booysen noted, to ensure that these issues are always on the agenda by participating in policy advocacy and legal reform to improve women’s health and rights. Mawande Lugongolo of the Rev. M.S Lugongolo Foundation echoed Booysen in highlighting the Foundation’s work on policy advocacy and change. He also noted that the Foundation generates demand for action by working with men and boys to unlearn some of the harmful things they have been taught and to instead work toward an equal society. 

Quote from Jessica Booysen: "Women's rights organisations must make sure [gender] issues are always on the agenda in every space, place, and platform".

Speaking on behalf of Young Women’s Leadership Institute, Melvine Obola spoke on the need for women’s rights organisations and young feminist-led movements to continually challenge patriarchy within societies and demand systemic change within communities. She reminded audiences that many of the rights enjoyed by women today were fought for by the women’s rights organisations that have come before, and that it is the role of contemporary activists to continue this fight by ensuring that knowledge is passed down and strengthening the capacities of young people to work toward policy advocacy and change. YWLI also believes that women’s rights organisations and movements have a role in co-creating spaces for feminist learning to amplify demand for change. 

The next question for the group came from Booysen, who asked: What are your organisations doing to ensure that young people in all their diversity are receiving the health information they need? 

Lugongolo detailed the foundation’s working relationship with schools in various districts, which allows them to engage with young people on health-related issues through informational pamphlets, in-person dialogues, and sporting activities. He highlighted the dialogues as an opportunity for young people to pose questions and debunk myths. Similar activities are also conducted with young people who have dropped out of school, using community libraries, halls, and parks as gathering places. Finally, Lugongolo spoke about the importance of forming partnerships with NGOs and departments of health so that young people are able to access not only information, but also services. 

Quote from Lucy Kombe: "We've been consistent and deliberate in ensuring that not only are we sharing factual information online but... that these messages are authentic and coming from an experienced point of view".

YWLI and Zamara spoke about the use of digital platforms to make information accessible and engaging. Obola noted that these platforms facilitate not just the sharing of information but the mobilisation of young people for change. YWLI also holds community conversations in different parts of the country to create safe spaces for women and girls in their diverse gender identities to share their lived experiences and “open new frontiers for adolescent girls and young women’s engagement in policy processes”. Both organisations shared their hopes of becoming an information hub for young feminists, and Kombe noted the care Zamara devotes to ensuring not only accuracy but also authenticity in the information it shares through meaningful engagement of and co-creation with affected populations. Beyond awareness raising and information sharing, Kombe shared that Zamara is also working towards ensuring access not just to information but also services for young women and girls, similar to the work being done by Lugongolo. 

Representing the foundation, Lugongolo posed a question to his peers regarding collaboration and alliance: What meaningful role do you think men-led organisations should be playing concerning gender and health issues, and are your organisations open to strategic planning in terms of addressing gender and health issues? 

Obola centered her answer around communication, noting that there is a role for men-led organisations in working with men and boys to catalyse conversations about gender equality and respecting women’s boundaries and bodies, recognising oppression and discrimination, and unlearning as well as challenging patriarchy and misogyny. Kombe touched on similar themes of learning about, acknowledging, and recognising the privileges bestowed upon men by the patriarchy, and being deliberate and proactive in showing solidarity with the movement for feminism and women’s rights. She noted that men have a role to play both as individuals and as part of a larger movement to bring about the societal equilibrium that feminism seeks to attain through gender equality. 

Quote from Melvine Obola: "Men-led organisations should be holding conversations with men about respecting women's bodies, boundaries, and rights".

Booysen emphasised the importance of working together to address issues which affect both women and men, such as gender-based violence. She highlighted information sharing, reduction of stigma, and encouragement of health-seeking behaviour as key areas in which men-led organisations could drive change through engaging adolescent boys and young men. 

Bringing the panel discussion to a close, Obola shared a forward-looking question from YWLI with her peers: What does the future of young feminist organising look like in your country? 

Kombe shared the future Zamara hopes to see in Kenya: one in which young feminist organising is outspoken, courageous, creative in pushing for transformative change and social justice, and intentional in ensuring diversity and representation. She identified some conditions which will be necessary to realise this vision, such as a focus on intergenerational feminism through mentorship and the need for more flexible and accessible funds and resources, and expressed optimism for a future in which young feminists will achieve the social justice they are working toward. 

Quote from Mawande Lugongolo: "I stand firm in concluding that feminism in South Africa has got a future and is making a huge impact".

Booysen noted that the future of young feminist organising in South Africa must be one in which young people are empowered to address their own challenges, as they “are the experts on their own experiences”. In the face of persistent challenges, she stressed the need for young people, especially women of colour and LGBTQI individuals, to be included, supported, and given an opportunity to lead. Lugongolo ended the conversation on a hopeful note, expressing his firm belief that the future of feminism is South Africa is looking bright thanks to the influence and growth of feminist-led organisations in the country. With more people starting to understand what feminism is, more women in leadership positions, and the establishment of a ministry for women, children, and people with disabilities, Lugongolo painted a picture of a movement going from strength to strength. 

Audience Q&A: Towards a more inclusive way of working

Rhule opened the Q&A session by welcoming the three panellists who were able to join the webinar live. 

Any reflections on the discussion? 

Obola agreed with the points made by her fellow panellists, in particular the role of men-led organisations in co-creating a space where men and women can work together in different roles to bring about gender equality. She also noted with dismay the increase of sexual violence, GBV, and cyber-bullying of young feminists during the pandemic, and reaffirmed the need to continually call out and challenge misogyny.  

Why do you think that feminism is important for men and the patriarchy is so harmful for all? 

Lugongolo addressed this question by speaking about inheritance, noting that “we have inherited a system that is now breaking us”. Societal expectations of men – that they should not express emotion or seek health care – cause harm to everyone, and men have to break the inheritance chain of bad beliefs and practices. The foundation contributes towards this by teaching young men and boys that it is high time to challenge the status quo and demand an equal society, one that is free of a system which has caused increasing rates of suicide among South African men who struggle to live up to the exacting standards of the patriarchy. 

What does it mean to work in a fully inclusive way, and what are some of the challenges? 

Drawing on Zamara’s experiences, Kombe reminded the audience that inclusivity is not just about having people at the table. Beyond meetings and convenings, Zamara is deliberate in ensuring that programmes, funding, and interventions engage different constituents from the inception stage. Interventions such as co-creating concepts, integrating inclusive language, and ensuring accessibility might seem small, but will have long-term impacts. Most importantly, however, Zamara works to create safe and accessible platforms for minoritised groups of young people to speak for themselves. While Kombe noted that the foundation is not always able to reach as many people as they would like due to constraints in terms of resources and funding, they have been able to make significant strides by partnering with other organisations which are similarly dedicated to inclusivity. 

What do you see as missing or needed in your ability to collaborate or work with academics and researchers? 

As an organisation which relies heavily on data for advocacy, Kombe shared Zamara’s struggle to access citizen-generated data which often cover key topics that government-provided data might overlook or not keep contemporary records on. Citizen-generated data can also offer richer insights as they capture community interventions and human stories which can be impactful for advocacy. Her recommendation is for research to adopt and include citizen-generated data, which are often well disaggregated in terms of age, sex, and context of data origin. 

Obola echoed the same support for the inclusion of grassroots voices in research and academic outputs, pointing out that researchers are often liable to overlook key interlinkages, challenges, and groups such as accessibility to mental health services, women and girls with disabilities, sexually minoritised individuals, and lack of adequate and flexible funding for community organisers. YWLI has tried to bridge this gap in research by working with communities and unregistered young feminist organisations, but a lack of resources and perpetual threats to the safety of young feminist organisers have constrained their ability to do so. 

Lugongolo identified similar challenges in his context, articulating the need for more community-informed research so that NGOs can design programmes which respond to the needs and gaps identified. He also highlighted the challenges of NGO-researcher partnerships in which both sides have to deliver on funder expectations such as milestones rather than focusing on creating quality work through consistent engagement. 

Final thoughts and moving forward: The importance of relationships

Screenshot of (clockwise) Melvine Obola, Mawande Lugongolo, Lucy Kombe, and Emma Rhule.

In wrapping up the session, Rhule added her own reflections on the Changemakers partnership to the list of recommendations voiced by Kombe, Obola, and Lugongolo for better collaboration between researchers and grassroots activists. She stressed the importance of building relationships in order to have difficult and nuanced conversations, and advised researchers to factor in time for relationship building right from the start, while developing research and funding proposals. She also suggested having partners involved from the early stages of inception, ensuring equitable distribution of funds, and making sure that all data collected is always co-owned, community-informed, and returned to communities in order for them to benefit from this knowledge. 

Rhule thanked the panellists for taking the time to join not just this webinar, but the engagement activities over a period of nine months, adding that the work of the Commission will be stronger for it. 

About the Author

Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.

Perspectives and Initiatives of Young People in All Their Diversity

Tiffany Nassiri-Ansari

Webinar poster

In Conversation With, the Lancet Commission on Gender and Global Health’s seminar series, returned with a sixth episode hosted by Commissioner Renu Khanna on October 6th. Perspectives and initiatives of young people in all their diversity featured two panel discussions which centered the voices of young people in identifying the challenges faced by their cohort and their visions for the future. Commissioner Khanna, founder of the Society for Health Alternatives (SAHAJ), was joined by two moderators and six speakers. 

Panel 1: 

Panel 2: 

This webinar was co-convened with the Asian-Pacific Resource and Research Centre for Women (ARROW) and Society for Health Alternatives (SAHAJ). Commissioner Khanna and speakers were joined by fellow Commissioners and livestream audiences on Zoom and YouTube. A recording of the ninety-minute webinar is publicly available on the Commission’s YouTube channel. 

Setting the scene

Commissioner Khanna introduced the webinar as a discussion devoted to the concerns and issues of adolescents and young people, with a focus on identifying promising practices and potential solutions to guide future action.  

This panel is just two years shy of the thirtieth anniversary of 1994’s International Conference on Population and Development in Cairo, which placed adolescent sexual and reproductive health and rights (ASRHR) on the global agenda. In the twenty-eight years since, several advancements have been made at the policy and programme levels for specific groups and issues. Countries have developed policies and programmes for adolescents and young people such as adolescent-friendly health services, and the diversity of this group is increasingly recognised as youth-led organisations continue to emerge and demand a seat at the table. However, many gaps remain. Khanna identified taboos around menstruation, fear-mongering about adolescent sexuality, and persistent gender norms as just some of the many challenges impeding continued progress on ASRHR. In addition to these social barriers, legal barriers such as the continued requirement for parental or spousal consent, debates around the ages of consent and marriage, and criminalisation of consensual sexual activity among underage individuals prevent adolescents and young people from accessing ASRHR. 

Health systems barriers exacerbate matters as well. Where ASRHR services exist, they are not always adolescent-friendly; provider attitudes and biases continue to contribute to disempowering environments. Many contexts and communities also continue to grapple with a lack of key ASRHR services, such as comprehensive sexuality education (CSE). As we move towards the 2030 goalpost set by the SDGs, Khanna questioned how we might build on lessons learned to confront these challenges. She expressed hope that today’s discussion would address a number of questions on designing policies and programmes that respond to the needs of young people in all their diversity, enhancing political commitment to generate more investment in ASRHR, and creating space for the meaningful participation of different groups of young people as well as the transformation of gender norms. 

Having set the scene, Khanna swiftly introduced the two panels before handing over to the moderators. She billed the first panel as a platform for young people to share their challenges and concerns, and the second as a sharing session on promising practices and potential solutions which can be scaled up and lead to improvements in ASRHR. 

Panel discussion 1: Youth challenges

Moderator Fara Rom introduced the first panel with an acknowledgement of the diversity of young people’s needs, concerns, and challenges, and the frequent marginalisation and exclusion of crucial voices from decision-making. She dedicated this panel to the voices of young people working on the ground to address their issues and challenges, and invited the three panellists to enlighten audience members on the challenges faced by young people in their communities and countries. 

Jivitesh Gupta spoke first, sharing the challenges he has faced as a very young adolescent (VYA) in accessing civic spaces and healthcare services. VYAs are commonly defined as adolescents between the ages of ten and fourteen, and Gupta identified this cohort as a very underrepresented group globally in terms of meaningful participation in policy planning, implementation, monitoring, and evaluation. This lack of VYA representation can be attributed to lack of affordable and quality education, cultural barriers, prevalence of harmful practices such as child marriage and illegal adoption, lack of youth-friendly ASRHR information, barriers to services in academic institutions and healthcare facilities, and lack of access to legal aid. He stressed that myths, stereotypes, and ignorance of mentors, parents, guardians, and government at all levels cannot be used as an excuse for the underrepresentation of VYAs, who must be considered equal among all stakeholders for policies, programmes, and activities meant for them at the very least. 

Quote from Jivitesh Gupta: "We are minors as per law, but it does not mean we do not have a right to participate in stakeholder consultations".

Gupta reflected on his personal experiences of participation in stakeholder consultations to further urge improvements to engagement with VYAs, warning against tokenistic inclusion. He shared a recent experience in which he and his sister were invited to participate as younger and older adolescents, respectively, in multistakeholder consultations on a draft National Youth Policy, yet their suggestions were conspicuously absent from the final compilation of suggestions forwarded to the ministry. Nevertheless, he expressed optimism that his active representation of VYAs in fora such as this webinar will encourage more VYAs to step forward and volunteer for civic action.  

Sharing his hopes for the future of VYAs, Gupta reiterated that young people must be empowered to represent themselves. With proper resources and supportive guardians, “we can do justice to our role as responsible global citizens”. In particular, he called upon all stakeholders involved to provide CSE to VYAs as an early intervention to prevent self-harm and sexual abuse, improve health-seeking behaviour, and ease the transition into adulthood. He outlined ways in which government bodies, private actors, and civil society can create a supportive and empowering environment for VYAs to represent themselves in inter-generational dialogues and interactions with lawmakers, acting as agents of positive change for a better future. 

Pooja Katwa brought the lens of disability to this discussion on youth perspectives, speaking about the challenges she has experienced as a person living with vision impairment. She shared that discrimination began at birth, with society treating her differently and schools going so far as to reject her application at the mere age of six. Principals suggested that her parents enrol her in ‘special’ schools, but her parents persisted and were eventually successful in enrolling her in a ‘mainstream’ school; unfortunately, she continued to face discrimination and marginalisation from teachers and students alike throughout her schooling. Despite graduating with a master’s degree, Katwa faced similar challenges in seeking employment due to ableist stigmatisation of her disability.  

Katwa has experienced marginalisation in every corner of society, including the health system. While many Indian communities rely on anganwadis for basic healthcare, she shared that she has never been contacted or assisted by these community health workers. Her only exposure to ASRHR has been through SAHAJ, which provided her with information on menstruation, contraception, abortion, and more. She stressed that this important information must be made available to all, regardless of (dis)ability. 

Quote from Pooja Katwa: "When I talk about health, no one thinks about the health of the disabled".

Advocating for the rights of people with disabilities to live a normal life, Katwa called on the Indian government to reconsider its eligibility criteria for pension schemes, increase the budget allocation for education and employment for the disabled, and improve infrastructure to be more disabled-friendly. She recommended strict implementation of legal provisions to protect disabled people from abuse, improvement of health and counselling centres to accommodate people with disabilities, and sensitisation of healthcare providers as well as members of society at large to prevent further discrimination. 

Pema Wangmo Lama added her voice to the discussion as a Mugum representative of Nepal’s Indigenous youth, sharing the challenges faced by her peers in accessing ASRHR. Indigenous women and girls in particular struggle to access SRHR services due to the stigmatisation of their identities, and Indigenous youth wield a limited amount of power over their own SRHR due to multiple forms of social and political discrimination. This leaves an entire group of young people vulnerable to SRHR violations, with the rate of sexual violence experienced by Indigenous women and girls nearly threefold that of their non-Indigenous counterparts. 

Challenges to the collective rights of Indigenous people are numerous: derogatory views, forced evictions, internal displacement, and militarisation contribute to the overall poor educational and economic status of Indigenous people, with significant knock-on effects for their SRHR. Indigenous and rural youth face additional barriers due to inadequate provision of sexual and reproductive education, stigmatisation of sexual education as “too mature” for young people, and lack of country-level disaggregated data on the status of Indigenous youth’s access to ASRHR. With Indigenous identity still not officially recognised in most of the country, Lama noted that Indigenous youth are left behind in national research, studies, and statistics, causing further discrimination and biased policies which exacerbate the situation. 

Quote from Pema Wangmo Lama: "The active engagement of Indigenous youth and youth in all their diversity is crucial in the design of policies and programmes".

Lama invoked the theme of this year’s International Youth Day, “Intergenerational solidarity: creating a world for all ages”, to call for action that focuses on leveraging the potential of all generations. She also called on the state to recognise the historical discrimination, exclusion, cultural assimilation, and deprivation of rights which have led to the marginalisation of Indigenous people, and to provide accessible, adequate, and quality health care for Indigenous people with due acknowledgement of their collective rights and traditional health systems. Lama emphasised the need for CSE to “promote a safe and enabling environment for knowledge transfer,” and urged stakeholders to include Indigenous youth in the design and implementation of culturally appropriate community-based interventions and services. In closing, she noted that progressive change is a constant effort, and youth in all their diversity must be at the forefront of this movement to fight for due recognition of their experiences and narratives as well as meaningful participation in determining their future. 

Moderator Fara Rom thanked the speakers for sharing their experiences, challenges, and suggestions for a better future, and echoed all three panellists in calling for the meaningful engagement of young people in policy- and decision-making. Noting that inclusive solutions can only be developed when we listen to young people, she then handed over to fellow moderator Souvik Pyne for the second panel on promising practices. 

Panel discussion 2: Promising practices

Pyne began by thanking the first set of speakers for articulating the myriad challenges they face due to their unique identities, and noted that solutions often fail to acknowledge the diversity and heterogeneity of young people. He urged stakeholders to think of solutions and practices which are not one-size-fits-all, and invited the second set of speakers to share some promising initiatives taken by young people themselves as well as the multilateral agencies which support young people in their endeavours.  

Born and raised in Afghanistan, Ahmad Nisar has years of experience operating in a fragile and conflict-ridden setting. He highlighted that what some take for granted as basic rights can be a privilege or even distant dream for young people living in conflict zones. Nisar shared that his experiences of community engagement certainly align with statistics which suggest that mental health, alcohol and drug use, and child pregnancy are some of the main health problems faced by adolescents, recalling the challenges of a seventeen-year-old boy who became the sole breadwinner of his family when his father was killed in a missile attack and continues to experience PTSD as a result of this. This young man is just one of an estimated 54% of adolescents around the world with an unmet need for mental health services, a service gap exacerbated in conflict zones where the country allocates most of its budget for military use and external funding rarely reaches those who need it most. 

Identifying a need for community members to provide psychological support, Nisar established Changemaker, an initiative that pushes the narrative around mental health and merges its interconnected links with other SDGs. The initiative provides young people with the support they need through WhatsApp or phone calls, operating as an anonymous, accessible, and free service. While it is currently limited in capacity, Nisar shared his hopes that expansion or duplication of such efforts might help decrease the overall prevalence of mental illness among young people. He also shared ideas for a decentralised and computerised system that would encourage and enable displaced healthcare workers to return and provide care in post-conflict situations. Another challenge Nisar has noted is the prevalence of underage alcohol and drug abuse due to a variety of enabling factors, and he suggested that schools and communities utilise motivational interventions which position the young person as a partner in their own recovery process. Changemaker adopts a similar approach, centering young people in health interventions and encouraging them to question their own health behaviours and choices. 

Quote from Ahmad Nisar: "All adolescents possess strong potential to envision and shape the future they want, given that they are provided with the opportunities to reach their full potential".

In closing, Nisar reiterated the key message of this webinar by calling for young people to be given a seat at the table. He noted that panels like this have a proven impact on improving health outcomes for adolescents by showing faith in the power of young people, the first and foundational step towards ending the widespread challenges faced by today’s youth. 

Best Chitsanupong Nithiwana joined the conversation to share some of the successes and solutions she has found as a young woman advocating for queer rights in Thailand, often praised for its inclusivity and diversity. However, she learned first-hand that this reputation does not necessarily match up to reality in 2018, when she was not allowed to wear clothes matching her gender identity to her graduation ceremony. Nithiwana successfully pushed her university to change its regulations after creating an online petition which garnered 2000 signatures and the support of multiple human rights and LGBTQ rights organisations, citing the Gender Equality Act as grounds for her request.  

This experience, among other challenges, inspired Nithiwana to establish Young Pride Club, which empowers LGBTQ youth to advocate for gender equality in Thailand. Through youth leadership workshops which bring together queer youth leaders from four region, Young Pride Club has empowered fifty youth leaders since 2020 to become community leaders, scholarship recipients, and changemakers at the local and international levels. The organisation also generates impact through collaboration, working with partners and LGBTQ youth to organise the first Youth Pride in Bangkok in 2020. 

Quote from Best Chitsanupong Nithiwana: "We want LGBT youth to have effective, meaningful participation in decision-making, policy-making, and political processes".

Drawing from her experiences and successes, Best highlighted the need to monitor and hold governments and organisations accountable by collecting information on and evaluating their work. She called for reform of existing laws to protect and fulfil rights, supportive and effective implementation of laws related to gender and student rights, and meaningful participation and representation of LGBTQ youth. 

Finally, Dr. Venkatraman Chandra-Mouli joined the panel as a long-time WHO public health professional to highlight how multilateral organisations can support the leadership of local youth in innovating and implementing their own solutions. He drew on a case study from Jamaica to illustrate one example that WHO has been involved in, which is a long-running project to help girls who drop out of school due to unintended pregnancy return to formal education. 

Slide from WHO/HRP, detailing a case study in Jamaica.

Forty years ago, a local NGO in Kingston identified the challenges facing teenage mothers such as the lack of re-entry opportunities into secondary schools, lack of continuous education opportunities, and high second birth rate. This Jamaican-designed, Jamaican-led initiative created an intervention package which has enabled adolescent mothers to return to schools and move on with their lives, receiving external support but maintaining local leadership throughout the past four decades. Today, this program has been scaled up throughout the Caribbean and is being introduced to South Africa, proof of the change that is possible when young people are involved in the identification of their challenges and solutions. 

On that note, moderator Souvik Pyne thanked the panellists for their interventions and highlighted the importance of multistakeholder, multisectoral approaches that centre the lived experiences of young people to identify not only their needs but potential solutions as well. In closing, he called for continued learning and growth among all stakeholders before handing back to Commissioner Renu Khanna for the Q&A session. 

Audience Q&A: Supporting gender-sensitive and gender-responsive interventions 

Khanna thanked both sets of speakers for an uplifting discussion, and posed two audience questions to the panel.  

Are there any learnings on best practices to make teachers and school administrative staff more gender-sensitive and gender-responsive?  

Dr. Chandra-Mouli shared an example of a program in South Africa, where a women – typically a qualified teacher with teaching responsibilities – is appointed the Guardian Teacher. Having a go-to person for any students experiencing bullying or student harassment is immensely helpful for young people in terms of identifying someone with a mandate to help them. 

From a more preventive aspect, he highlighted an initiative from Rutgers International which takes a whole-of-school approach to make schools a safe space by working not just with children but also teachers, principals, and staff to model healthy gender norms to prevent violence in schools. 

Many times, bullying, failure, jealousy, love affairs, and sexual harassment lead youth to self-harm, suicidal ideas, and suicide. Are there any learnings from this? How can these be prevented and dealt with? 

Gupta noted the need for a mindset change in addressing these challenges, as young people are discouraged from seeking help due to stereotypes which brand those who require psychological support as “mentally disturbed”.  

Dr. Chandra-Mouli echoed this need to support young people in seeking help, suggesting that youth are given clear steps to seek support be it through the provision of a safe space, a hotline, or a person who is qualified to give advice on the situation. All of these interventions require constant communication with young people to ensure they know how to reach out for help. 

Finally, Lama emphasised the importance of constant communication between young people themselves as well as with their families to identify challenges and promote mindfulness. The latter practice especially was highlighted as a way to discourage young people from promoting bullying and to instead create safe spaces for sharing within peer groups and families. She also suggested offering counselling sessions for support and integrating morals and ethics into school syllabi to prevent harmful behaviours. 

Final thoughts and moving forward: Hope for the future

Lamenting that the discussion was heating up just as time had run out, Khanna once again thanked the speakers for an informative conversation. Her key takeaway was the need to create an enabling environment for young people “wherein they can find in themselves the ability and the potential to contribute their ideas and thoughts”. 

Co-chair Pascale Allotey expressed her appreciation to all panellists as well, sharing that the webinar had left her feeling hopeful for the future. In closing, Allotey noted that those in positions of privilege and leadership have a lot of work to do, and must start by explicitly and regularly stepping aside to create spaces for and amplify the voices of youth, “recognising that nothing we do matters if it doesn’t work for them – it’s not our future, it’s theirs”. 

About the Author

Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.

Masculinities and Health: Relational and Intersectional Perspectives

Tiffany Nassiri-Ansari

Poster for webinar hosted by Gary Barker.

In Conversation With, the Lancet Commission on Gender and Global Health’s seminar series, returned with a fifth episode on July 27th. In Masculinities and health: Relational and intersectional perspectives, Commissioner Gary Barker emphasised the need for relational and intersectional perspectives to move the masculinities and health discourse beyond its current impasse. Barker, President and CEO of Equimundo: Center for Masculinities and Social Justice (formerly Promundo-US), was joined by three colleagues: 

This webinar was co-convened with UNU-IIGH and the Gender & Health Hub. Commissioner Barker and speakers were joined by fellow Commissioners and livestream audiences on Twitter, YouTube, and Zoom. A recording of the hour-long webinar is publicly available on the Commission’s YouTube channel. 

Setting the scene

Barker opened by situating this discussion as one that considers “the broad social determinants that drive health outcomes for women, men, and non-binary individuals” through the lens of masculinities and strives to move beyond the scarcity lens that frequently pits men’s health against women’s health without due consideration for the ways in which both intersect and impact upon each other. 

Gary Barker: "We often fail to look as well at how men's health - their premature death and chronic health needs - affect the lives of women and girls, and vice versa".

Critiquing the lack of relational approaches to men’s health, Barker noted that “it’s often women who pick up the pieces when sons or male partners or other men in the household either face chronic health conditions or premature death”. This lack of a “bigger picture” understanding also extends to the limited and superficial ways in which intersectionality has been applied to masculinities and health, with some analyses paying nominal attention to poverty as a key element but little else. Overall, this creates a “frozen picture of risk, vulnerability, and harm” that does not sufficiently interrogate the structural, systemic, and social forces at play, and fails to acknowledge the resilience and care shown, for example, by individual men or groups of men who act as activists and allies for their own health, and that of their households and communities. 

With those limitations in mind, Barker invited his colleagues to a panel discussion that specifically sought to address the broader structural, systemic, and contextual factors that shape men’s health. 

Panel discussion: Intersectional approaches, systemic reforms, and narrative shifts 

The three panellists drew from their rich and varied experiences within the broad area of masculinities and health to speak on the importance of intersectionality in the US context, the possibility of systemic change as illustrated by the Brazilian men’s health programme, and the value of narrative-based interventions that resonate with men and boys as applied by Movember in the UK. 

Derek Griffith: "We tend to prioritise masculinities and gender over other social determinants of health that may have equal, or potentially even more, implications for and drive the poor health of men".

Drawing on his work with men of colour in both the US  context and other countries, Griffith highlighted how race, ethnicity, and sexual orientation can intersect with gender to shape health needs and outcomes through economic and political factors. This tied into a larger finding about men’s individual perspectives on health issues, and the fact that the deficit lens often associated with masculinities in health is not consistent with the ways that  many men think about their health. Instead, he found that men “tend to think about their age… and what it means to be an adult, in addition to what it means to be a man or presenting as male or living their lives as men” in relation to their health. 

This mindset highlights the distinction between manhood and masculinities, and leads to a more relational approach for men in thinking about the impact they have on their families and communities. Griffith noted that men with this mindset tend to focus on their ability to positively affect others in their lives more than on their own physical and mental health. He also drew on Kimberlé Crenshaw’s work on intersectionality to comment on the need to “disrupt the tendency to see gender and race as separate” at three levels: the structural, the political, and the representational. These considerations inform the strength-based approach Griffith applies to his work on masculinities and health, which looks at policies and practices through the life course to identify, understand, and build on existing strengths and positivity in this area. Finally, he acknowledged that many countries and actors are “starting to recognise the importance of men’s health… frankly because men’s health tends to be a drain on the economies and health resources of a lot of our countries”. 

Brazil was an example of this integration of and focus on men’s health within national health systems, launching its men’s health programme in 2009. Unfortunately, Nascimento noted that the programme has not been fully implemented in the thirteen years since, as Brazil is a geographically large and economically disparate country. However, he remains involved in ongoing efforts to improve and implement the programme, with a particular focus on fatherhood and care in his work. His work with colleagues has identified fatherhood “as a good entry point to bring men to the health services”, and the implementation of Brazil’s childbirth companion law and engagement of men throughout their partners’ pregnancies has greatly improved men’s access to rapid tests, SRHR services, and immunisation among others. 

Marcos Nascimento: "We still need to sensitise health professionals about men and masculinities in health".

Returning to his initial point about the socioeconomic diversity among Brazil’s 5570 municipalities, which are responsible for implementing primary healthcare, Nascimento noted that more work is required to implement the national program at a local level, especially in terms of training healthcare providers to work with men. In this aspect, community health workers often set an example by making the effort to engage men beyond health settings. However, those working in both health services and research are gravely challenged at the moment by Brazil’s political climate, which Nascimento described as living “in an anti-gender offensive”. It is in this “conservative moment” that the need for and value of intersectionality becomes most apparent, as social movements and civil society organisations are tasked with an increasing amount of responsibility and ability to push forward agendas surrounding health programmes for LGBTQ+, Black, and other marginalised populations. 

Representing one such organisation, Sternberg described Movember as a “positive disrupter” that has shaped change by leading creative and thoughtful discussions on men’s health. Initially established as a fundraising campaign some fifteen years ago in Australia, today Movember “has an array of programmatic activity [worldwide]… and is increasingly thinking about how to move into… health systems more broadly”. This growth has been enabled by Movember’s ability to “engage men in ways that feel fun” as part of a “human-centred design approach to centring men’s health”. A large component of this engagement hinges on Movember’s discovery that most men do not resonate with many of the contemporary framings around masculinities and health, and the consequent pivot to “trying to contextualise these things and… make them feel like they are part of life”. 

Sarah Sternberg: "Rather than trying to fit a square peg in a round hole, we're much better off finding concepts that do resonate with men".

Echoing Nascimento’s comment that fatherhood is a tried-and-tested entry point for men into healthcare systems, Sternberg shared that Movember has also identified sports as “a really fruitful entry point” to both work with and challenge masculine norms regarding mental health and resilience. This is one of many examples of how Movember has experimented with framing and setting to challenge the broader sociocultural determinants of health for men, such as gender norms. Ultimately, Sternberg identified the key to this work being Movember’s ability to “situate ourselves in the lived realities of our audiences”, linking her remarks to the discussion’s larger theme about the importance of context-appropriate interventions. 

Audience Q&A: Addressing marginalisation, mitigating risk factors, and preserving autonomy 

Moderated by Barker, the brief Q&A session was able to address four questions from the audience on marginalised groups, risk factors, and strategies to engage men without side-lining women. 

What recommendations would you offer around changing societal and cultural expectations around men of colour who are gay, pan, or trans in terms of their health needs? How to get the health system to respond, and what are the cultural shifts that need to happen? 

Griffith began by establishing that the challenges described above are not with the populations themselves, but with systems and societies that fail to accept them. “We need to put our energy into changing the system, not changing the men we’re talking about,” he added, and suggested that trustworthiness and efficiency are two key areas for improvement. Nascimento agreed that systemic change is crucial, but also suggested that it could be beneficial to bring together key non-health players such as those working in education and social development to better assess and understand the health needs of populations. 

What are the necessary approaches and strategies for external causes of death such as accidents, suicide, and violence? Are there any nuances beyond the numbers for men versus women? 

In the Brazilian context, Nascimento stated that such external causes “provoke death in the male population much more than any disease or other factors”. While social class is crucial to analyses of external causes, he also stressed the need to approach this from a perspective that interrogates the relationship between masculinities and violence as the default conflict-management strategy for men. 

Speaking on a more structural level, Griffith added that infrastructure can also be a significant contributing factor to these external causes of death. He stressed that while gender is an important part of the conversation on violence, failed economic opportunities and the resultant quality of life are also key factors to keep in mind. In terms of suicide as an external cause of death, Griffith suggested that a better understanding of gendered symptoms of depression is needed. 

Cancer follows heart disease as the second leading cause of death among men in the US among other countries. What do we need to do to address this? 

Drawing on Movember’s work, Sternberg stated that while early care is the key to preventing death and mitigating the impacts of cancer, masculine norms typically prevent men from admitting vulnerability and seeking help. The rise of telehealth, driven by COVID-19 restrictions, further exacerbated this by adding an element of distance between men and healthcare providers. 

Griffith suggested that rather than looking at cancer and heart disease as two distinct causes of illness and death, perhaps more insight can be gained by analysing the two together to understand “what it is over the life course that puts [men aged 45 and older] at risk for both”. 

Are there any strategies for engaging men in prenatal care that pay equal attention to supporting women’s decision-making over their own sexual and reproductive health and bodily autonomy? 

Wrapping up the Q&A session, Barker stressed that the key to this challenge is not pitting men’s needs over the needs of women and other individuals, and that health services for men cannot come at the expense of women. Referring to his work for the Brazilian men’s health programme, Nascimento added that while Brazil still has a long way to go in addressing this, next steps must be guided by an understanding of gender equality which brings together and values all perspectives involved. 

Final thoughts and moving forward: A relational and intersectional approach 

Clockwise from upper left: Gary Barker, Sarah Sternberg, Derek Griffith, and Marcos Nascimento.

In conclusion, Barker summed up the panellists’ remarks to call for a more nuanced application of intersectionality to masculinities and health, underscored the need for more consideration of gendered norms and lived experiences, and remarked on the challenging nature of this work particularly in the context of rising political backlash against merely speaking about gender in some contexts. 

Finally, he urged those working on masculinities and health to adopt “this relational, intersectional life-cycle approach” as the way forward, and thanked the panellists for their contributions to crucial work that will inform the Commission’s approach to this topic. 

 

About the Author

Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.

Gender Activism, Politics, and Intersectionality in the Era of COVID-19

Tiffany Nassiri-Ansari

In Conversation With, the Lancet Commission on Gender and Global Health’s seminar series, returned with a fourth episode on June 22nd. In Gender activism, politics, and intersectionality in the era of COVID-19, Commissioner Fran Baum examined the intersectional inequities exacerbated by the pandemic and invited colleagues to share their insights from studying the structural violence experienced by many throughout the pandemic. Baum, Professor of Health Equity and NHMRC Investigator Fellow at University of Adelaide’s Stretton Institute, was joined by three colleagues: 

  • Connie Musolino, Research Fellow at Stretton Health Equity, Stretton Institute, University of Adelaide 
  • Jennie Popay, Distinguished Professor of Sociology and Public Health, Division of Health Research, Lancaster University
  • Priyanka Samy, Anti-caste activist, National Federation of Dalit Women (NFDW) 

This webinar was co-convened with UNU-IIGH and the Gender & Health Hub. Commissioner Baum and speakers were joined by fellow Commissioners and livestream audiences on Zoom and Twitter. A recording of the hour-long webinar is publicly available on the Commission’s YouTube channel. 

Setting the scene

Baum began the session with an overview of the many inequities that predated the pandemic but were undeniably worsened by COVID-19, with compounding factors such as gender, class, caste, race, disability, and sexuality. She identified structural violence as the overarching theme of pandemic response, evident in the “massive vaccine inequity” seen around the world. At the time of her comments, for instance, only 13% of Nigeria’s population had received a single dose of any vaccine, compared to the vaccination rates of high-income countries which tend to hover between 80-90%>. Even within those countries however, she noted that “the picture would be very different” if these rates were broken down to focus on people with disabilities, people of different sexualities, and other marginalised populations. 

Beyond vaccines, the pandemic has generated gendered impacts that have disproportionately affected women and girls. Baum touched on women’s involvement in front line occupations, increased risks of experiencing violence during lockdown, additional burden of navigating care and work duties at home, and findings which suggest that women have been more affected by pandemic-related job losses and employment insecurity. Trans and gender diverse individuals have also faced gendered impacts in their experiences of the pandemic, with “the normal structural systemic inequities… [becoming] more pronounced”. 

To shed light on these experiences of the pandemic, Baum swiftly moved into the panel discussion, which focused on better understanding some of the challenges that emerged during the pandemic through an intersectional lens. 

Panel discussion: The exacerbation of existing inequities 

Between the three of them, the panellists brought to the discussion insights from an examination of COVID-19 experiences in 17 case study countries, experiences of community engagement with Dalit and Adivasi women, and compelling arguments for the importance of narrative. 

Musolino began with a focus on gender divisions in the care economy which emerged as a consistent theme across the 17 case study countries she recently analysed with colleagues at Stretton Health Equity. With women making up approximately 70% of the global health and social care workforce, the burden of care during the pandemic fell primarily on women shouldering paid and unpaid care responsibilities. The intersection of gender with class, caste, race, and more exacerbated the impacts of this burden for many, such as women of colour in the United States who were disproportionately represented in jobs which were deemed essential and necessitated continued work outside of the home even during the worst waves of COVID-19. Women employed in low-paid and precarious roles as caregivers for the elderly faced “some of the most deadly outbreaks”, but the informal nature of their employment often “meant that workers did not have access to paid sick leave and other entitlements, further increasing the risk of illness and spread”. 

Utilising a political economy perspective, Musolino argued that “the COVID-19 pandemic is intrinsically linked to local and global economic and political histories”, with the legacies of colonisation, slavery, and patriarchy evident in the continued exploitation of care worker in countries “which often rely on and exploit groups in poorer neighbouring countries” as evidenced by the example of Peru’s treatment of Venezuelan migrants informally contracted to be maids and carers. Migrant and undocumented workers, both in the care economy and outside of it, often have little to no access to social security or rights, are more vulnerable to exploitation and abuse, and face harsher public health measures than the majority of other workers as seen in the case of long-term residential aged care workers in Singapore. However, in the latter example, Musolino also highlighted how swift measures were put in place by the Singaporean government to support care workers once the virus began to spread in aged care facilities. 

Civil society activism tends to play a role in such stories of good practices, with Musolino crediting civil society not just for playing a role in political decision-making but also engaging in public discourse to raise awareness, fact-check misinformation, combat fear and stigma, and amplify the voices of marginalised groups by “pushing back against the politicisation of such identities during the pandemic”. However, different actors within the wider umbrella of civil society also feature prominently in cases of bad practices, such as anti-vaccination movements which have “lobbied governments and industry bodies to influence such things as withdrawal of mask mandates”. 

Ultimately however, Musolino emphasised the importance of civil society activism as a force for good, highlighting the role South African and Indian civil society groups played in ensuring access to vaccinations and “engaging in broader issues around politics and power… to highlight intersections of oppression during COVID-19”. 

Samy drew on her experience working with the National Federation of Dalit Women to speak on the role of civil society in the Indian context, and emphasised the influence of India’s caste system – “the longest surviving social hierarchy” – in individual experiences of the pandemic. She identified Dalit and Adivasi (tribal) women as “being at the lowest rung of the caste and gender hierarchies”, thus bearing the brunt of the exacerbated inequalities brought forth by COVID-19. The country-wide lockdown announced by the government in the early days of the pandemic had immediate effects on these marginalised groups, with Samy estimating that 90% of the internal migrants who lost their livelihoods and shelter overnight as a result of the lockdown belonged to Dalit and Adivasi communities. With no assurance of food or transport from the government, Samy recalled how “thousands of families – women, children, babies – walked back [to their villages] with several people dying of starvation en route”.  

The impact of the pandemic on Indian women was immediate and devastating – while 73 million women were found to be living in conditions of extreme poverty in 2019, by 2020 it was estimated that the number had swelled to 110 million. In a call-back to Musolino’s earlier comments about women occupying low-paid and precarious roles, Samy commented that most workers in the unorganised and informal sector belong to Dalit and Adivasi communities and were disproportionately affected by the economic impacts of lockdown. With the pandemic threatening gainful employment and exacerbating unpaid care burdens, marginalised women, women with disabilities, and trans women found their labour market participation substantially affected. 

Beyond the economic impacts, Samy identified a “shadow pandemic” in which guidelines to social distance coincided with “the highest ever” incidence rate of violence and sexual harassments against marginalised women, who were “further distanced, discriminated, and distressed with no access to essential services and rights whatsoever”. Many girls and women were also forced to drop out of school due to lack of access to online learning platforms and economic burdens; the National Federation of Dalit Women partnered with these young women and girls to strengthen collective agency and leadership skills during the pandemic, providing opportunities for them to advocate for pandemic relief such as dry rations and free shelter. These young women and girls swiftly started engaging with the heads of village councils, advocating with local authorities, and building social capital in communities where people “who were earlier dismissive of our very being now respect and look up to us as leaders”. In the context of increasing depoliticisation and government crackdowns on civil society, Samy’s final message was a reminder that “inequality is political and therefore our efforts to overcome inequity and inequality also have to be political”, as demonstrated by the young women and girls who were able to organise and challenge political forces to advocate for change. 

The intersection between lived experiences and policy change is one Popay also explores through the COVID-19 Other Front Line Global Alliance, an online platform which highlights the stories of “groups bearing the brunt of social injustice… and [brings] the storytellers into conversations about the impact of the pandemic”. The platform was established based on the observation that insufficient attention was being given to “lived experience narratives that are not generated through research” in conversations surrounding COVID-19. Inspired by Maya Angelou, Popay stressed that “all our stories help us to understand the nature of social problems and begin to think about appropriate solutions”, with stories featured on The Other Front Line supporting the narratives shared by the other two panellists, particularly on the “intensification of [women’s] roles as carers” as well as unsafe living and working conditions. Other stories, however, showed “what equity might look like” and detailed “deepening social relationships in families and communities”; while Popay acknowledged that positive stories do not negate any of the negative experiences shared to the platform, she pointed out the value in understanding that these different perspectives can coexist, showcasing strength and resistance in different ways. 

While these stories hold potential for informing recovery plans, Popay noted that narratives are primarily used by civil society and rarely given value by policymakers and academics alike, who tend to view them as “simply anecdotal”. In closing, Popay acknowledged challenges such as digital inequalities and language barriers which might limit the stories shared on The Other Front Line and other such platforms, but called for a democratisation of these spaces to enable the identification of common interests “in as many ways as we can” so that storytellers do not merely experience social injustice, but are given a way to become part of the solution as well. 

Audience Q&A: Models of collective care 

A range of audience questions were acknowledged, touching on gendered environmental risks, men’s COVID-19 health risks, and collective practice of care. Due to time constraints, the panel was only able to address the latter in detail. 

Can collective practice of care and activisms demonstrate change by challenging the dominance of neoliberal concepts of self-care and individual responsibility? 

Drawing on her years of experience and learnings from The Other Front Line, Popay agreed that such practices hold promise but cautioned against the risk of “narratives of community care and powerful reciprocity” leading to a shift in responsibility from the public sector to communities. Models of community-driven collective care are insufficiently resourced, and Popay warned that “the risk is that the next iteration of the welfare state post-pandemic in countries that did have good welfare provision will be this DIY model”. Moving forward, she emphasised the need for sufficient financial and material support from the public sector to continue resourcing these community-delivered models. 

Final thoughts and moving forward 

In closing, Baum thanked the panel for raising these important issues about intersection, not just for public debate but also for Commissioners to keep in mind as they work to produce a final report that is sensitive and inclusive for all. 

About the Author

Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.

Gender Violence in Health Institutions as a Global Health Issue

Tiffany Nassiri-Ansari

Poster for "Gender violence in health institutions as a global health issue", hosted by Commissioner Simone Diniz with guest speakers Ana Flavia d'Oliveira and Daphne Rattner.

In Conversation With, the Lancet Commission on Gender and Global Health’s seminar series, returned with a third episode on May 25th. In Gender violence in health institutions as a global health issue, Commissioner Simone Diniz revisited a topic she first explored twenty years ago in 2002’s “Violence against women in health-care institutions: An emerging problem”. Diniz, Professor of the Department of Health and Life Cycles as well as Deputy Director of School of Public Health at the University of São Paulo, was joined by two colleagues:

This webinar was co-convened with UNU-IIGH and the Gender & Health Hub. Commissioner Diniz and speakers were joined by facilitator and Commission Co-Chair Prof. Sarah Hawkes, fellow Commissioners, and livestream audiences on Zoom, Twitter, and YouTube. A recording of the hour-long webinar is publicly available on the Commission’s YouTube channel.

Setting the scene

Diniz began by noting that this webinar happened to fall on the twentieth anniversary of the abovementioned article, which was published by The Lancet in May 2002. Since then, there has been a notable increase in initiatives, responses, and particularly new terms surrounding the issue, such as the simultaneous existence of “too little too late” and “too much too soon” care often found in low- and middle-income countries.

Slide on "Essentialism, public health, and the correctional approach industry".

“This is a very intersectional form of violence,” Diniz commented on institutional gender violence, which operates upon the idea that women’s bodies are inherently defective and in need of routine correction. Experiences of obstetric violence are differentiated and exacerbated by a “hierarchy of motherhood” shaped by race, class, age, (dis)ability, gender, health history, marital status, and more.

She situated this issue within the broader movement for cognitive and epistemic justice, and highlighted activism and knowledge production within Latin America and the Caribbean since the 1990s as a key component of change. Chief among these actions has been the movement to humanise childbirth, which builds on two frameworks: human rights in health and evidence-based healthcare. Progress has been limited, however, by the idea that alliances and humanised care are “a luxury in poor settings”.

It is within this context that Latin American and global grassroots movements have been operating for decades, creating new terms, indicators, and evidence bases to identify and confront the challenge of obstetric violence. New initiatives to classify forms of violence and work across countries to conduct comparative studies are especially promising, and Diniz highlighted global progress on this front through the abundance of obstetric policies being formulated in Africa and Asia alongside Latin America.

Ultimately, the hope is to communicate the view that “women are understood not as victims of their own violent bodies, but submitted to gendered institutional violence in maternity care”, and promote respectful care through gender equity. Moving towards suggestions and solutions, Diniz identified midwives as a central figure in this fight, and stressed the need to invest power, money, and resources in women as they “fight for the rights of women, children, and communities”.

She transitioned into the panel discussion by raising a number of questions for consideration by both speakers and viewers alike, touching on the role of social movements in both the global South and the global North, the potential of educational institutions and governments to either help or hinder change, and the possibility for a ‘reverse-learning’ opportunity in which the South takes the lead on contextualising this issue within the lenses of intersectionality, coloniality, racism, and more.

Panel discussion: Naming and confronting obstetric violence

Moving into the panel discussion, Diniz introduced her colleagues and guest speakers as not just academics, but long-time activists. She invited both speakers to reflect on how knowledge itself has changed in the three decades since they first started working on this issue, how research and teaching can better harness the production of knowledge, and how international and collaborative activism can change reality.

Naming violence as violence

d’Oliveira began by noting that reflection is an important theme in healthcare, and this webinar allowed her to return to a topic she first started working on a long time ago. In 2002, when she and Diniz first published their paper with colleague Lilia Blima Schraiber, obstetric and institutional violence were just starting to be named around the world. At the University of São Paulo, colleagues felt that “it was not right that we had the space to write at such a prestigious journal as The Lancet and had chosen to expose such a bad image of Brazil”. Negative reactions to this work continued, with d’Oliveira and her fellow researchers dubbed “the violent women” for working on a WHO multi-country study on domestic violence.

Quote by Ana Flavia: "Violence is not easy to recognise, and its perpetuation is based also in this trivialisation and naturalisation".

This pushback and silencing would continue for more than a decade, as d’Oliveira and colleagues later discovered when they created the Don’t Stay Silent movement in 2014 to denounce sexual violence and abuse perpetuated by colleagues and professors within the university. Speaking out was crucial, d’Oliveira stated, as “naming violence as violence is a way to challenge its presence, its trivialisation, its naturalisation, but it may also be very threatening for those who want the issue to remain invisible”. The movement continued to speak out despite instructions not to, insisting that “a violent institution is no shelter and cannot support women experiencing domestic or sexual violence, and this is a precondition to support survivors – for the service not to be violent itself”.

Moving on to speak about the different forms of violence, d’Oliveira also touched on different experiences of violence and levels of vulnerability for different women, emphasising that “we are not just one woman. We are women in our diversity, and violence affects us all but in different ways”. She identified the medical system as a key player in the reproduction of gender, class, and race inequalities alongside perpetuating institutional violence, and called for changes in health systems, knowledge, and practice to centre women and recognise them as subjects rather than objects.

Ultimately, d’Oliveira noted that by 2002, researchers already had more than ten years of evidence that violence could occur within the health system. Twenty years later, “it is difficult to believe and it is very upsetting that in the very place of care where people are suffering and need treatment and cure, violence [remains] present”. She called for change in how health and medicine are taught and practiced, challenged the Brazilian government’s attempts to prohibit the term “obstetric violence”, and advocated for collaborative and cognitive justice to transform care “into a more pleasant, healthy, and meaningful experience for all involved”.

Motors of change

Picking up on d’Oliveira’s call for change, Rattner identified “two big motors of change” in her reflections on the past two decades of activism and progress in the movement for humanised care: international organisations and grassroots movements. She noted that the World Health Organization first started writing about appropriate technologies for birth and women’s right to proper prenatal care in 1985, and yet this remains an issue to this very day.

Quote from Daphne Rattner: "Every women has the right to proper prenatal care, and has a central role in all aspects of this care".

However, more actors have since joined the call for change, such as the International MotherBaby Childbirth Organization, the International Federation of Gynecology and Obstetrics, and the White Ribbon Alliance. Working together as a movement, these international organisations emphasise that “woman-centred care, childbirth care, pregnancy care, and postnatal care should become a positive experience for women”, and play a key role in bringing knowledge and guidelines to this space.

Their work unfolds in parallel with the activism of grassroots organisations such as the Brazilian Network for the Humanization of Childbirth (ReHuNa), which Rattner has been involved with since its establishment in 1993. ReHuNa organised the first International Conference on the Humanization of Childbirth in 2000, and has been working ever since to “give visibility to this violence” through policy influencing, advocacy, international convenings, diffusion of information, and more. The three speakers and other colleagues published a paper based on this work in 2018, titled “Disrespect and abuse in childbirth in Brazil: Social activism, public policies and providers’ training”.

Rattner ended with an assessment of the current situation in Brazil and contemporary challenges. In 2011, the Stork Network proposed the establishment to 250 new birth centres to change the childbirth care paradigm in Brazil; as of today, only 50 of those centres have been created, making it “very difficult to change the environment of childbirth care”. ReHuNa has identified an additional 50 birth centres not included in the network’s list, and is calling for “more training, more schools of midwifery,” and more investment in prenatal care.

However, the situation is complicated by government pushback as mentioned by d’Oliveira. Rattner pointed out that medical councils are also “one of the centres of resistance”, with some going so far as to issue resolutions against humanised care and women’s bodily autonomy. The COVID-19 pandemic has further exacerbated this situation by reversing the clock on maternal mortality, with Brazil now reporting numbers comparable to those from the 1990s, due in part to the government’s failure to produce timely guidelines for vaccinating pregnant women. Ending her grim assessment of the current situation, Rattner branded these failures to prevent avoidable deaths as “a kind of institutional violence”.

Audience Q&A: Defining and classifying forms of violence

Hawkes returned to thank the speakers for sharing a “rich set of ideas, experiences, and solutions” before segueing into the audience Q&A session, which covered two questions on definitions and classification.

“You mentioned the different terms relating to obstetric violence – how do you think that the use of different terms and the multitude of terms affects the reporting and understanding of the issue?”

Diniz reflected on both the advantages and disadvantages of working with multiple terms. She stated that the multiplicity of terms allows for many approaches and different perspectives, and that this captures the richness and diversity of the issue and allows for the customisation of the problem to local cultures and languages.

“There is an advantage in the openness,” she said, but at the same time there is a disadvantage as “we need something that’s relatively comparable for us to create indicators that could be used in different settings”. Common indicators for comparative analyses are crucial, and Diniz pondered on the ways in which the Commission might play a role in “trying to figure out what would be the commonalities for international, global collaborative research and action”.

Slide on obstetric violence as a frontier object with many terms.

“To what extent can we classify the omission of services as obstetric violence? Is it obstetric violence when countries remove the right to legal and safe abortions?”

This question on classification elicited a small debate among speakers. Diniz felt strongly that the denial of abortion services is in fact a form of obstetric violence, and Rattner added that there are different levels of violence to be considered, from the individual to the systemic. At the societal level, she opined that the “absence of laws to guarantee women’s rights can be called some form of violence too”. Crucially, Rattner reminded everyone that “things at the social level can seep into the interpersonal level, as they interact and intersect”.

However, d’Oliveira raised a question about definitional limits, and asked whether there is a line between gender-based violence and gender inequalities and discrimination. She pointed to the existence of terms such as reproductive justice and reproductive coercion which might be more relevant to the issue of abortion rights and laws, and recommended that the term ‘obstetric violence’ be reserved for instances of humiliation and abuse. d’Oliveira highlighted a WHO multi-country study on intimate partner violence as a relevant example in terms of how ‘violence’ was defined as a fixed set of actions, and suggested that “we need a set of acts that we call violence, and a set of unfair distributions of healthcare that we call gender-based inequalities”. In summary, she acknowledged that the lack of safe abortion is a cause of maternal mortality around the world, but urged audiences to think strategically and consider: “How much do we gain or lose by putting everything under the umbrella of obstetric violence?”

Final thoughts and moving forward: From the individual to the structural

Clockwise: Daphne Rattner, Ana Flavia d'Oliveira, Simone Diniz, and Sarah Hawkes.

Due to time constraints, a number of audience questions were unfortunately left unaddressed. Hawkes identified key themes from these questions, which touched on individual experiences of violence, systemic and structural determinants, and the complex overlaps between obstetric violence and reproductive justice.

She linked these themes to a topic that the Commission as a whole is grappling with: “Situating inequalities not just as an individual experience, but also as something that is embedded within the systems and structures that we all operate within”. In closing, Hawkes stressed that in order for progress to take place, systems and structures will have to change just as much as individuals and practices.

 

About the Author

Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.