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IGWG Members Take the Mic Series: Infertility Matters: Embracing the Gendered Spectrum of Stigma, Needs, and Experiences in Sub-Saharan Africa

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The “IGWG Members Take the Mic” blog series intends to highlight lessons learned and best practices from and innovative approaches to gender transformative programming and research from IGWG members’ work and advocacy efforts to advance gender equality outcomes in global health. This blog post—the first installment in this series—was developed in collaboration with the Agency for All project and authored by:

Courtney McLarnon (MEL Advisor), Center on Gender Equity and Health, University of California San Diego, USA, cmclarnon@health.ucsd.edu
Dinah Amongin (Lecturer), Makerere University, Uganda, damongin@musph.ac.ug
Lotus McDougal (Director of Gender Data and Methods), Center on Gender Equity and Health, University of California San Diego, USA, lmcdougal@health.ucsd.edu
Madeleine Short Fabic (Deputy Director, Health Division of the Bureau for Africa), United States Agency for International Development, USA, mshort@usaid.gov

The negative, gender-regressive consequences of infertility and related stigma are profound.

[He will be] insulting her, calling her names like ‘you dog’ or ‘you are very stupid.’ There is no need for him to keep her, and she has to leave.”1

[People] will not respect [a man who does not have a child]. They will call him by his first name.”2

Globally, one in six people has experienced some form of infertility[i] in their lifetime.3 Of all regions, sub-Saharan Africa bears the greatest burden of period infertility,4[ii] likely tied to higher rates of pregnancy-related complications and untreated sexually transmitted infections.5 Individuals and couples with infertility face immense stigma, as well as increased levels of stress, depressive episodes, loneliness, social isolation,6 marital dissolution, intimate partner violence,7 and economic distress.8

The stigma associated with infertility can negatively impact communities by affecting the environment in which people make decisions affecting their sexual and reproductive health.9 Stigma can create and reinforce contexts where individuals and couples take actions to avoid being perceived as infertile, contributing to health-related behaviors such as early marriage and childbearing, short birth spacing, and limited contraceptive use.10 Gendered stigma enforces norms and expectations influencing individuals’ lives, shaping their interactions, opportunities, and self-perceptions in gender-specific ways.

Despite these consequences, infertility-related experiences and stigma in sub-Saharan Africa are rarely studied or addressed, leading to a limited context-specific evidence base to inform policy and programming. This gap is contrary to broader sexual and reproductive health goals to support individuals in deciding whether, when, and with whom to have children. It also limits our understanding of how harmful gender norms and practices are influenced, perpetuated, or reinforced by infertility and related stigma. Without this understanding, infertility and infertility-related issues remain unaddressed, sexual and reproductive health suffers, and gender inequality persists. 

Agency for All Is Building the Evidence Base in Cameroon and Kenya

Agency for All is a five-year project funded by the U.S. Agency for International Development (USAID) that is working to generate evidence on the role of agency in social and behavior change programming to improve health and well-being. Recognizing the geographic burden of infertility in sub-Saharan Africa, and the profoundly gendered and normative consequences, Agency for All is conducting foundational research to understand the factors influencing infertility-related stigma in Cameroon and Kenya. This research is designed to inform interventions and provide new learnings that bring attention to and action on a long-neglected concern.

To inform this work, Agency for All conducted a literature review to explore myths and misperceptions, social consequences, and crosscutting factors associated with reproductive agency and infertility, as well as to identify promising, infertility-related social and behavior change and gender transformative programs11[iii] from across sub-Saharan Africa and globally. Infertility impacts people of all gender identities; however, the findings we synthesize are limited to cisgender and heterosexual women and men due to the focus of the existing literature. This blog shares insights from our review, highlighting key results and recommending next steps for gender transformative research, programming, advocacy, and policy on infertility.

Five Insights From a Literature Review in Sub-Saharan Africa

Infertility is a complex medical and public health issue that affects individuals, couples, families, and communities. It is influenced by environmental, social, and political systems, as well as basic access to services. The consequences of infertility and related stigma are profoundly gendered in their manifestations across sub-Saharan Africa. Women bear a disproportionate share of the burden,12 while men and individuals of other gender identities are often overlooked in research and programming. Here’s what we’ve learned so far:

  1. Infertility harms individuals and couples. Individuals with infertility often have compromised psychosocial well-being, including higher risk of stress, depressive symptoms,13 loneliness, sadness, social isolation, and suicidal thoughts and a lower quality of life.14 Couples experiencing infertility may face social and familial pressure to have extramarital affairs, become polygamous,15 or end their marriage, a phenomenon experienced by both women16 and men17 and sometimes openly endorsed18 by the broader community.
  2. Cultural beliefs about infertility impede reproductive agency. Socially constructed beliefs about the causes of infertility are common across different contexts in sub-Saharan Africa. Many of these beliefs, such as perceived promiscuity, inform norms that influence women’s behaviors and choices, including the use of modern contraceptives.19 Studies document widespread perceptions that infertility is a common side effect of using modern contraceptives,20 contributing to lower levels of use,21 particularly among young and newly married women who experience cultural pressures to demonstrate fertility. These misperceptions compromise women’s ability to set and achieve their own reproductive goals by limiting the choices they can make without risking social consequences.
  3. Infertility stigma reinforces inequitable gender norms. The practice of holding women responsible for infertility is well documented in research from sub-Saharan Africa.22 Infertility is often perceived as a female inadequacy; a woman who is unable to have children is seen as a failure in her role as a wife,23 whereas few studies in sub-Saharan Africa focus on men’s experiences of infertility. This blame can spur gender-based violence, in which women experience targeted physical or verbal abuse.24 It can also carry over into human rights violations; in some settings, fear of infertility has been used to promote female genital mutilation/cutting as a “cure.”25
  4. Infertility concerns contribute to child marriage and adolescent childbearing. Social norms and societal expectations pressure couples—especially women—to bear children upon marriage/union26 and further marginalize men from the discourse on fertility issues. High social value on childbearing in sub-Saharan Africa27 creates pressure to prove fertility at an early age in some countries, and early marriage and childbirth are recognized pathways to demonstrate fertility.28 Gendered stigma toward women is further compounded by son preference in some African countries, where not having a male child is considered equivalent to being infertile.29
  5. Policy-level attention to infertility issues is limited. The health policy landscape on infertility in sub-Saharan Africa is mixed, and evidence is sparse. There is little documentation of government programming that supports funding for and awareness of infertility.30 Sexual and reproductive health services in sub-Saharan Africa do not include biomedical infertility treatment services within public health financing or strategy. Assisted reproductive technologies, such as in vitro fertilization, are available in many countries, but are centralized in urban areas, are expensive, and are sometimes unregulated.31 Issues of affordability and access to treatment raise significant concerns related to intersectional factors of discrimination.

The Potential of Gender Transformative Interventions

There is growing evidence that interventions that support individuals and couples experiencing infertility can have profound impact on reducing stigma and building better outcomes.32 Such interventions include cognitive behavioral therapy, peer support groups, and mass media and social media approaches that build psychosocial and resilience assets and spread awareness. Increased investment in developing and testing innovative approaches to improving experiences around infertility should include education, counseling, and stigma-reduction activities that build on evidence from successful fertility awareness33 and norms-shifting programming.34

Gender transformative social and behavior change interventions that address the psychological and social determinants and consequences of infertility can bring significant value to individuals and couples in sub-Saharan Africa by challenging and transforming unequal gender norms, roles, and power dynamics that contribute to stigma, blame, and discrimination. For example, our literature review concluded that there is limited awareness of the challenges faced by men with infertility, perpetuating the perception that infertility is a women’s issue and compounding stigma. Interventions should be explicit about gender discrepancies in infertility experiences and incorporate notions of gender equity, agency, empowerment, and autonomy.

Interventions that aim to promote equitable fertility-related decision-making, shared responsibilities, improved communication between partners, and supportive environments for seeking care have growing potential. Examples of gender transformative approaches from initiatives in low- and middle-income countries include:

  • Infertility testing and services for men35 to reduce infertility-related gender discrimination.
  • Educational programs36 that provide accurate information on fertility, contraception, and reproductive health and rights for everyone in the community and initiatives that engage men in infertility discussions and encourage them to seek health and support services.
  • Individual and couple-based counseling services37 that address gendered attitudes, roles, and stigma toward people experiencing infertility.
  • While evidence is growing, structural efforts38 including policy and advocacy efforts to challenge harmful gender norms and stigma, hold great promise. Such efforts would likely have greater impact were they to adopt an intersectional lens in support of individuals, couples, and communities in all their diversity.

Where Do We Go From Here?

To date, infertility has not been a priority in global sexual and reproductive health research and programming. It has yet to be prioritized in programming in many parts of sub-Saharan Africa—from policy to research to implementation—where the social consequences of infertility are high and where stigma has a sweeping, negative impact. Results from our literature review highlight the importance of recognizing and addressing infertility as a common, highly stigmatizing, gendered, and long-neglected concern.

We encourage the broader global health community to sharpen the focus on reproductive empowerment by giving deserved attention to infertility and the ways in which infertility-related stigma manifests and inhibits reproductive and relational agency and individual well-being. We are not alone in our sentiment; in April 2023, the World Health Organization (WHO) released infertility prevalence estimates alongside policy and programmatic recommendations. Considering the results of our review and the emerging WHO recommendations, we recommend the following actions for governments, funders, researchers, program implementers, and others whose work touches on infertility:

  1. Invest in context-specific formative research to understand the unique gender-related drivers of infertility-related stigma and the broader social and economic impacts to inform responsive strategies, services, policies, and interventions. This research can highlight long-neglected intersectional issues around infertility, including stigma and treatment access, and how such issues influence other attitudes and behaviors, such as child and forced marriage, adolescent birth, contraceptive uptake, female genital mutilation/cutting, and intimate partner violence. Formative research can also identify potential strategies for early diagnosis and treatment and structural interventions to address policy, practice, and societal factors that underlie infertility stigma and discrimination. This research should include a focus on men’s experiences of infertility to contribute to destigmatizing infertility.
  2. Design and implement gender transformative interventions that aim for structural change at the policy and advocacy levels, increase community awareness, address stigma, and support individuals and couples to achieve their self-determined reproductive goals.
  3. Increase the availability and accessibility of infertility testing and treatment, especially for those who have been precluded from accessing such services due to cost and other barriers. Receiving a diagnosis, even without access to treatment, can alleviate suffering for individuals and couples. This suggests that education, consultation, and low-cost diagnostic examinations could be a first step to providing care—and a potential investment area for the research and development community.
  4. Prioritize funding for sexual and reproductive health policies and programs at the national and subnational levels to improve equity of access to and quality of comprehensive reproductive health care that encompasses the prevention, detection, and treatment of infertility for all.

Our literature review was the first step to inform upcoming formative research, which we hope will fill some of these gaps. We encourage others to help fill the void so we can improve understanding and awareness; address urgent treatment gaps; and promote gender norms, policies, and behaviors that reduce and ultimately end infertility-related stigma and discrimination and improve sexual and reproductive health.

The Agency for All team invites readers to read the full review here.

This publication is made possible by the generous support of USAID under cooperative agreement 7200AA22CA00023. This post was produced and prepared independently by the authors. The contents of this post are the authors’ sole responsibility and do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Endnotes

[i] Infertility is defined by the World Health Organization as a disease of the male or female reproductive system characterized by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. Lifetime infertility refers to the occurrence of this failure to achieve a pregnancy over the course of an individual’s lifetime. Period infertility refers to the occurrence of this failure to achieve a pregnancy over the course of a given time interval—in this case, 12 months.

[ii] Sub-Saharan Africa bears the highest burden of period infertility, but not lifetime infertility, a data paradox most likely explained by the dearth of studies measuring lifetime infertility in the region.

[iii] Transformative policies and programs seek to transform gender relations to promote equality and achieve program objectives. This approach attempts to promote gender equality by 1) fostering critical examination of inequalities and gender roles, norms, and dynamics; 2) recognizing and strengthening positive norms that support equality and an enabling environment; 3) promoting the relative position of women, girls, and marginalized groups; and 4) transforming the underlying social structures, policies, and broadly held social norms that perpetuate gender inequalities.

References

  1. Bornstein, M., J. D. Gipson, G. Failing, V. Banda, and A. Norris. 2020. “Individual and Community-Level Impact of Infertility-Related Stigma in Malawi.” Social Science & Medicine 251: 112910. https://doi.org/10.1016/j.socscimed.2020.112910. ↩︎
  2. Bornstein, Gipson, Failing, Banda, and Norris, “Individual and Community-Level Impact of Infertility-Related Stigma in Malawi,” 112910. ↩︎
  3. World Health Organization. 2023. Infertility Prevalence Estimates, 1990–2021. Geneva: World Health Organization. https://www.who.int/publications/i/item/978920068315.  ↩︎
  4. World Health Organization, Infertility Prevalence Estimates, 1990–2021. ↩︎
  5. World Health Organization, Infertility Prevalence Estimates, 1990–2021.  ↩︎
  6. Cui, W. 2010. “Mother or Nothing: The Agony of Infertility.” Bulletin of the World Health Organization 88(12): 881-2. https://doi.org/10.2471/BLT.10.011210. ↩︎
  7. Hess, R.F., R. Ross, and J.L. Gililland. 2018. “Infertility, Psychological Distress, and Coping Strategies Among Women in Mali, West Africa: A Mixed-Methods Study.” African Journal of Reproductive Health / La Revue Africaine de La Santé Reproductive 22(1): 60–72. https://www.jstor.org/stable/26493901. ↩︎
  8. Anaman-Torgbor, J.A., J.W.A. Jonathan, L. Asare, B. Osarfo, R. Attivor, et al. 2021. “Experiences of Women Undergoing Assisted Reproductive Technology in Ghana: A Qualitative Analysis of Their Experiences.” PLOS One 16(8): e0255957. https://doi.org/10.1371/journal.pone.0255957. ↩︎
  9. Bornstein, Gipson, Failing, Banda, and Norris, “Individual and Community-Level Impact of Infertility-Related Stigma in Malawi,” 112910. ↩︎
  10. Bornstein, Gipson, Failing, Banda, and Norris, “Individual and Community-Level Impact of Infertility-Related Stigma in Malawi,” 112910. ↩︎
  11. Interagency Gender Working Group (IGWG). 2017. The Gender Integration Continuum Training Session User’s Guide. ↩︎
  12. Fledderjohann, J.J. 2012. “‘Zero is Not Good for Me’: Implications of Infertility in Ghana.” Human Reproduction 27(5): 1383–90. https://doi.org/10.1093/humrep/des035. ↩︎
  13. Groene, E.A., C. Mutabuzi, D. Chinunje, E.M. Shango, S. Kulasingam, et al. 2021. “Comparing Infertility-Related Stress in High Fertility and Low Fertility Countries.” Sexual & Reproductive Healthcare (29): 100653. https://doi.org/10.1016/j.srhc.2021.100653. ↩︎
  14. Olusola, P.A., O.D. Olaogun, and T. Aduloju. 2018. “Quality of Life in Women of Reproductive Age: A Comparative Study of Infertile and Fertile Women in a Nigerian Tertiary Centre.” Journal of Obstetrics and Gynaecology 38(2): 247-251. https://doi.org/10.1080/01443615.2017.1347916. ↩︎
  15. Cui, “Mother or Nothing: The Agony of Infertility,” 881-2. ↩︎
  16. Ofosu-Budu, D. and V. Hanninen. 2020. “Living as an Infertile Woman: The Case of Southern and Northern Ghana.” Reproductive Health 17(69). https://doi.org/10.1186/s12978-020-00920-z. ↩︎
  17. Dierickx, S., K.O. Oruko, E. Clarke, S. Ceesay, A. Pacey, et al. 2021. “Men and Infertility in the Gambia: Limited Biomedical Knowledge and Awareness Discourage Male Involvement and Exacerbate Gender-Based Impacts of Infertility.” PLOS One 16(11): e0260084. https://doi.org/10.1371/journal.pone.0260084. ↩︎
  18. Bornstein, M., S. Huber-Krum, M. Kaloga, and A. Norris. 2021. “Messages Around Contraceptive Use and Implications in Rural Malawi.” Culture, Health & Sexuality 23(8): 1126-41.  https://doi.org/10.1080/13691058.2020.1764625. ↩︎
  19. Bornstein, Gipson, Failing, Banda, and Norris, “Individual and Community-Level Impact of Infertility-Related Stigma in Malawi,” 112910. ↩︎
  20. Bell, S.O., C. Karp, C. Moreau, and A. Gemmill. 2023. “If I Use Family Planning, I May Have Trouble Getting Pregnant Next Time I Want to”: A Multicountry Survey-Based Exploration of Perceived Contraceptive-Induced Fertility Impairment and Its Relationship to Contraceptive Behaviors.” Contraception: X (5): 100093, https://doi.org/10.1016/j.conx.2023.100093. ↩︎
  21. Sedlander, E., J.B. Bingenheimer, S. Lahiri, M. Thiongo, P. Gichangi, et al. 2021. “Does the Belief That Contraceptive Use Causes Infertility Actually Affect Use? Findings from a Social Network Study in Kenya.” Studies in Family Planning 52: 343-59. https://doi.org/10.1111/sifp.12157. ↩︎
  22. Dimka, R.A. and S.L. Dein. 2013. “The Work of a Woman Is to Give Birth to Children: Cultural Constructions of Infertility in Nigeria.” African Journal of Reproductive Health / La Revue Africaine de La Santé Reproductive 17(2): 102–17. https://www.jstor.org/stable/23485925. ↩︎
  23. Fledderjohann, “‘Zero is Not Good for Me’: Implications of Infertility in Ghana,” 1383–90. ↩︎
  24. Dhont, N., J. Van de Wijgert, G. Coene, A. Gasarabwe, and M. Temmerman. 2011. “‘Mama and Papa Nothing’: Living With Infertility Among an Urban Population in Kigali, Rwanda.” Human Reproduction (26)3: 623–9. https://doi.org/10.1093/humrep/deq373. ↩︎
  25. Tabong, P.T.N. and P.B. Adongo. 2013. “Understanding the Social Meaning of Infertility and Childbearing: A Qualitative Study of the Perception of Childbearing and Childlessness in Northern Ghana.” PLOS One 8(1): e54429. https://doi.org/10.1371/journal.pone.0054429. ↩︎
  26. Bornstein, Gipson, Failing, Banda, and Norris, “Individual and Community-Level Impact of Infertility-Related Stigma in Malawi,” 112910. ↩︎
  27. Cui, “Mother or Nothing: The Agony of Infertility,” 881-2. ↩︎
  28. Bornstein, M., J. D. Gipson, G. Failing, V. Banda, and A. Norris. 2020. “Individual and Community-Level Impact of Infertility-Related Stigma in Malawi.” Social Science & Medicine 251: 112910. https://doi.org/10.1016/j.socscimed.2020.112910. ↩︎
  29. Beyeza-Kashesy, J., S. Neema, A.M. Ekstrom, F. Kaharuza, F. Mirembe, et al. 2010. “‘Not a Boy, Not a Child’: A Qualitative Study on Young People’s Views on Childbearing in Uganda.” African Journal of Reproductive Health (14)1: 71-81. https://www.ajrh.info/index.php/ajrh/article/view/475. ↩︎
  30. Beyeza-Kashesy, Neema, Ekstrom, Kaharuza, Mirembe, et al., “‘Not a Boy, Not a Child’: A Qualitative Study on Young People’s Views on Childbearing in Uganda,” 71-81. ↩︎
  31. Anaman-Torgbor, Jonathan, Asare, Osarfo, Attivor, et al, “Experiences of Women Undergoing Assisted Reproductive Technology in Ghana: A Qualitative Analysis of Their Experiences,” e0255957. ↩︎
  32. Gerrits, T., H. Kroes, S. Russell, and F. van Rooij. 2023. “Breaking the Silence Around Infertility: A Scoping Review of Interventions Addressing Infertility-Related Gendered Stigmatisation in Low- and Middle-Income Countries.” Sexual and Reproductive Health Matters 31(1): 2134629. https://doi.org/10.1080/26410397.2022.2134629. ↩︎
  33. Institute for Reproductive Health (IRH). 2023. “FACT Project’s WALAN Group Learning and Counseling Model.” https://www.irh.org/walan-group-learning-counseling/. ↩︎
  34. High Impact Practices in Family Planning (HIP). 2022. Social Norms: Promoting Community Support for Family Planning. Washington, DC: USAID. https://www.fphighimpactpractices.org/briefs/social-norms/. ↩︎
  35. Inhorn, M.C. and P. Patrizio. 2015. “Infertility Around the Globe: New Thinking on Gender, Reproductive Technologies and Global Movements in the 21st Century.” Human Reproduction Update 21(4): 411-26. https://doi.org/10.1093/humupd/dmv016. ↩︎
  36. Naab, F., R. Brown, and E.C. Ward. 2021; “Culturally Adapted Depression Intervention to Manage Depression Among Women With Infertility in Ghana.” Journal of Health Psychology 26(7): 949-61. https://doi.org/10.1177/1359105319857175. ↩︎
  37. Ehsan, Z., M. Yazdkhasti, M. Rahimzadeh, M. Ataee, and S. Esmaelzadeh-Saeieh. 2019. “Effects of Group Counseling on Stress and Gender-Role Attitudes in Infertile Women: A Clinical Trial.” Journal of Reproduction & Infertility 20(3): 169–77. https://pubmed.ncbi.nlm.nih.gov/31423420/. ↩︎
  38. Gerrits, Kroes, Russel, van Rooji, “Breaking the Silence Around Infertility: A Scoping Review of Interventions Addressing Infertility-Related Gendered Stigmatisation in Low- and Middle-Income Countries.”, 2134629. ↩︎

The 2023 IGWG Plenary: Breaking Barriers: Addressing Gender Inequities Facing Global Health Workers

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View event overview, slides, and graphics here.

 

Véase el gráfico en español más abajo. 

Voir le graphique français ci-dessous.

Why:

  • Learn about the gender inequity barriers health workers are facing in the workplace, including sexual harassment, discrimination, pay gaps, and inadequate workplace policies.
  • Understand opportunities for addressing gender barriers to promote a more equitable and inclusive workplace for health workers.
  • Explore promising practices and lessons learned from innovative program interventions addressing gender barriers in workplaces throughout the health system.

The Interagency Gender Working Group (IGWG) invites you to its 2023 Annual Plenary on Thursday, August 31 from 8:00-10:00 a.m. EDT, which will explore how gender transformative programs can better address workplace inequities affecting health workers, and improve health and gender outcomes.

Gender inequities affect health workers in many ways. Gender inequities are common in health care system practices related to recruitment, retention, promotion pathways, leadership roles, earnings, and even access to full-time employment. Women represent about 70% of the health workforce but earn on average 28% less than men. Gender discrimination also affects health system leadership, governance, and occupational segregation. Women remain least represented in decision-making roles, including as physicians, administrators, and managers. Sexual and gender-based harassment, objectification, mistreatment, and violence are commonly reported by health workers around the world. Additionally, few policies and practices recognize and support the informal care that health workers, predominantly women, are expected to provide at home.

Despite evidence that gender discrimination and inequities in the health workplace are systemic, programmatic attention and funding to address these inequities are limited. However, evidence from other sectors indicates that addressing these inequities could lead to a more sustainable health system that can better address gender inequalities as a social determinant of health, and, ultimately, improve health outcomes for all.

The 2023 Plenary will highlight research that examines gender inequities faced by health workers and showcase promising practices and lessons learned from innovative programs working to address gender barriers in the health system workplace. The 2023 IGWG Plenary aims to better equip IGWG members to examine gender inequity in their own organizations and to promote more equitable and inclusive workplaces—both within and outside the health system.

The virtual event will begin with a panel discussion led by experts and representatives of dynamic gender transformative programs addressing gender inequity in the health workforce.

Panelists will include:

  • Dr. Amina Aminu Dorayi, Country Director, Pathfinder Nigeria
  • Seblewongel Fekadu, Gender Advisor, Jhpiego Ethiopia
  • Dr. Michelle McIsaac, Economist / Lead Gender Equity and Human Rights, Health Workforce Department, World Health Organization
  • Catherine Menganyi, Chapter Lead, Women in Global Health Kenya
  • Dr. Shabnum Sarfraz (moderator), Deputy Executive Director, Women in Global Health

Following the panel discussion, participants will join breakout rooms and share their personal experiences addressing health workplace inequities, including challenges encountered in their work and advocacy efforts.

We look forward to seeing you there!

Questions or feedback? Please contact the IGWG team at igwg@prb.org.

 

June Gender Knowledge Exchange Event: Examining Intersectional Approaches in Gender Transformative Programming

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Why:

  • Explore insights into the what, why, and how of applying an intersectional lens to gender transformative health programming and how these intersectional approaches can influence gender and health outcomes.
  • Explore strategies and approaches to applying an intersectional lens to gender transformative health programming, research, and advocacy efforts
  • Hear directly from advocates from diverse backgrounds and settings on their experiences applying intersectional approaches in their work to advance gender equality.

Despite increasing calls from programmers, researchers, and community advocates for gender transformative programs to systematically incorporate intersectionality as a core principle, program implementers and gender advocates still grapple with how best to integrate intersectional considerations in their efforts to advance gender equality for all individuals.

The Interagency Gender Working Group (IGWG) hosted a gender knowledge exchange event on June 20 from 8:00–10:00 a.m. EDT to explore approaches to understanding intersectionality in gender transformative programming in global health.

Although gender is widely understood in public health settings as a fluid concept that incorporates behaviors, expressions, roles, responsibilities, identities, relations, norms, and institutional practices, many program interventions miss the mark in addressing the vast array of lived experiences across the diversity of people affected by gender bias, discrimination, and violence. Coined by Kimberlé Crenshaw, the term intersectionality illustrates the effects of overlapping systems of discrimination, such as those based on gender, race, class, sexuality, and other identities. Program implementers, researchers, and advocates can improve their understanding of historical structural inequalities and power dynamics across a range of issues that intersect with gender—and improve health and gender outcomes—by applying a wider intersectional lens to gender transformative programs and health interventions.

This gender knowledge exchange provided IGWG members with the opportunity to hear lessons learned from gender champions and experts on intersectionality in a small-group setting. The event began with a panel discussion led by a group of experts, advocates, and researchers focused on strategies for and approaches to intersectionality in gender transformative health programs and research aiming to advance gender equality outcomes. Attendees then joined breakout rooms to ask questions and share their insights.

Panelists included:

  • Njeri Kimotho (she/her), Global Gender and Social Inclusion, Intersectional Feminist, Gender Equality & Social Justice Lead, Solidaridad Network, Kenya
  • Doose Didi Mchihi (she/her), Founder/Chief Psychotherapist, The WellBeing Center, Nigeria
  • Dr. Lata Narayanaswamy (she/her), Associate Professor, University of Leeds, United Kingdom (moderator)

Event Recording

Key Takeaways

What is intersectionality—and what is it not?

  • Intersectionality is a lens and approach to understanding how humans experience the world in the systems and environments around them. Gender champions should apply both gender and intersectional analytical lenses, recognizing that individuals have multiple identities and may identify in different ways depending on the environment and experience different inclusions, exclusions, and barriers. No person experiences one single struggle.
  • Intersectionality is about more than identity; it is not a checklist of identities. By integrating an intersectional lens, program implementers can better understand how their implementation efforts are producing privileges, marginalization, and other effects.
  • Intersectional approaches should meet people at their points of need. Intersectionality means recognizing individuals’ economic barriers, health care accessibility, and other issues, and designing programs that incorporate these holistic issues. For example, consider a woman living with a disability in Nigeria who might be responsible for raising children without a partner—using an intersectional lens and recognizing how her multiple identities influence her lived experience, what needs might she have that program implementers should consider in program design?

What are opportunities for intersectionality in gender transformative programming, and why is intersectionality important?

  • When applying an intersectional lens, program designers and implementers should aim to understand the unique challenges and identities of the groups they are working to reach. For example, intersex women face many issues, such as violence and discrimination. We must recognize these issues to adequately design programs to address them. The LGBTQ+ community experiences structural barriers influenced by their sexual orientation. Implementers should aim to break down these structural barriers to achieve comprehensive outcomes in program design. Project design should be oriented around voices that are not typically heard. Intersectionality means reaching groups that are not often reached by mainstream programs.               
  • Program implementers must change how gender analyses are conducted. Intersectionality provides a new lens to ask different questions, taking a research or problem-solving approach. Intersectionality encourages the consideration of greater nuance of insights about how people experience the world and interact with systems and policies. To do so, program implementers must check their own personal biases, starting with acknowledging gaps in their own knowledge. This process also requires program implementers to acknowledge their own intersectional identities.

What have you found challenging for program implementers when applying intersectionality in your work?

  • A gender analysis is often an assessment conducted by external experts. It has not always incorporated an explicit requirement to check personal implicit biases as part of the process. The step of assessing and addressing implicit biases as part of an intersectional lens has been a challenge in program implementation. Similarly, bias within program staff (for example, misogyny, homophobia, racism, and classism) needs to be addressed. Intersectionality challenges program implementers to question their understanding and experiences and to incorporate open-ended questions. 
  • One challenge program implementers face is resistance from policymakers and stakeholders. Doose Didi Mchihi discussed how she addressed such resistance while launching a life planning program in northern Nigeria for adolescents and youth surrounding sexual and reproductive health and scaling up the availability of contraceptives. Program implementers understood that the program was being implemented in a region where religion has a strong influence. The program saw high rates of forced child marriage. Existing power dynamics made it difficult for married adolescent girls to participate in the program. Because some husbands and fathers were not allowing girls to attend program activities, implementers realized they had to include men, boys, and religious leaders in the program. Doose described that the team had to stop and re-strategize during the implementation. They asked other civil society organizations that were already established in the area to help and invited input from relevant stakeholders within those communities who were able to share strategies that would be culturally accepted. After incorporating stakeholder input, implementers developed programs that were culturally responsive, and thus achieved desired outcomes.
  • The expected outcomes of intersectional approaches are often not reflected in the levels of funding allocated for these approaches. Many gender equality and social inclusion (GESI) teams integrate gender into very large programs with no budget lines. Transformative intersectional work requires adequate funding.
  • Programs should seek partnerships with movements, such as feminist and women’s rights movements, LGBTQ+ movements, and movements by racial and ethnic minority groups. Large-scale change is impossible without movement efforts.

How do you apply an intersectional lens in program design and intervention in gender transformative health programming and advocacy? Do you have any examples of what worked well or lessons learned? How do you manage risk in programs?

  • It is important to invite people from the communities that programs are targeting to speak about the issues affecting them, as well as to be involved in program design and implementation. In Nigeria, the LGBTQ+ community has been able to design capacity-building training for people within the community. Speaking on her work with the LGBTQ+ community, Doose shared an approach that she has seen work at the grassroots level is to start from the health and human rights angle, then discussing topics, such as sexuality, that may be considered sensitive. Recognizing that within the LGBTQ+ communities in Nigeria, there are people who are sex workers, people who use drugs, and people with other marginalized identities, questions program implementers working in these contexts should consider when designing programs include: Do you feel comfortable doing this? Do you feel safe? Are there any risks?

What other factors should program implementers and designers and researchers consider for incorporating intersectional approaches in their work?

  • Program implementers should invite communities to plan programs and strategies from the beginning of programming, as well as find ways to question their assumptions about what is important.
  • Programs should incorporate a learning agenda. Learning does not necessarily mean collecting data points; it also means listening to communities. During assessments, midterm, or evaluations, program implementers can incorporate qualitative data collection and analysis, as well as leadership by community members. In such assessments, implementers should question whose knowledge is being produced. It is important to move beyond the individual approach to see how programs have a ripple effect on communities at large.

How have you balanced the integration of various intersectional issues?

  • Njeri Kimotho shared how she approaches intersectional social relations assessment as research. Adopting a research angle, she starts with a problem analysis and then identifies who is most affected by that problem: men or women? Boys or girls? Age brackets? Different religious groups? It’s important to be very specific in identifying who the program will target. Starting with the problem provides an opportunity to have a more in-depth discussion with the correct people and determine who the problem is truly affecting. Implementers should remember that some people may want to be part of a project while not actually being impacted adversely by the problem at hand.
  • Implementers should consider conducting needs assessments, as well as incorporating a focus group discussion with the range of people the program is targeting to identify the problems that need to be addressed immediately. Needs assessments allow implementers to identify priority areas and then channel resources toward solving relevant problems.

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Infographic: How to Effectively Partner With Community Leaders in Gender Transformative Programming

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The 2022 Interagency Gender Working Group (IGWG) Plenary, “Promising Practices in Community-Led Gender Transformative Programming,” on May 26, 2022 explored promising practices in community-led gender transformative global health programming, particularly in the contexts of family planning, reproductive health, and gender-based violence prevention.

Many gender transformative programs engage communities, but they vary widely in approach, which can range from working with formal leaders to hosting group education sessions for community volunteers to mobilizing whole communities through peer outreach. Definitions of community mobilization and leadership also vary, as does the intensity of involvement by community members, and the power dynamics between communities and collaborators. Key components of successful community engagement for social and behavior change include communication that is empowering, horizontal (versus top down), and elevates the voices of traditionally excluded and marginalized community members.

This infographic highlights and synthesizes some of the key takeaways from the 2022 IGWG Plenary, suggesting promising practices for identifying community leaders and improving partnerships with community leaders and social movements in gender transformative programming. This resource intends to be a tool for program designers and implementers who wish to foster more community leadership and improve collaborations with community leaders within existing and future programs. The infographic also offers insights for program designers and implementers to strengthen programs that have already integrated elements of community mobilization and leadership.

Click on the image below to view the infographic.

September Gender Knowledge Exchange Event: Exploring Evaluation and Learning Methods in Community-Led Gender Transformative Programming

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Background: The 2022 Interagency Gender Working Group (IGWG) Plenary explored the elements and impacts of community-led, gender transformative programming, a topic that resonated with our members and attendees. The event, which convened more than 200 attendees representing 46 countries, highlighted promising practices and lessons learned for how to ensure meaningful community leadership in gender transformative global health programming.

The discussions that arose during the plenary highlighted the importance of gender champions cultivating effective and equitable learning and evaluation partnerships with community leaders and groups—both formal and informal—to help address common challenges such as limited resources, competing agendas, and ingrained power differences.

Event Recording:

The opinions expressed in this video are those of the presenters and do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States government.

Event Materials:

View slides from the event here.

Event Overview: Building on the momentum of the 2022 Plenary, the IGWG hosted a gender knowledge exchange event on September 7 from 9:00-11:00 a.m. EDT, exploring in more depth one of the plenary’s many thematic areas of interest: participatory and inclusive evaluation and learning methods in community-led, gender transformative programming, particularly family planning, reproductive health, and gender-based violence prevention.

Despite the wide acceptance of the importance of community leadership in theory and practice, many implementation challenges remain, particularly in strengthening programming’s participatory learning and evaluation components. Recent published literature reveals questions about the relationship between degree of participation and impact, how impact should be defined, and the role of wider social forces on the evaluation process for health programs. Additionally, practical process and content questions remain about how to get started implementing participatory learning and evaluation in programs, what steps are necessary to form these processes, how decisions are made, and what outcomes should be monitored.

This gender knowledge exchange provided members with the opportunity for deeper and more informal exchange as participants heard lessons learned from gender champions and experts on these topics in a small-group setting. It began with a panel discussion led by a group of experts, community leaders, and researchers focusing on strategies for and approaches to participatory and inclusive evaluation and learning methods and exploring promising practices for measuring community leadership in gender transformative programming. Following the panel discussion, attendees had the opportunity to participate in a Q&A session with speakers. Panelists included:

  • Nancy Glass, Professor and Independence Foundation Chair, Johns Hopkins University School of Nursing
  • Tamil Kendall, Director, Partnership for Women’s Health Research Canada
  • Renu Khanna, Co-Founder and Mentor, Society for Health Alternatives (SAHAJ)
  • Rachel Litoroh, Monitoring, Evaluation, Accountability, and Learning Manager, Comitato Internazionale per lo Sviluppo dei Popoli/International Committee for the Development of Peoples (CISP)

Key Takeaways:

How can program implementers engage with community leaders to improve monitoring and learning activities and influence the effectiveness and relevance of gender transformative programs?

  • Program implementers should consult regularly with community members to hear their concerns and feedback and build trust, understanding that the primary role of implementers in these meetings should be to keep a pulse on what is happening in the community and listen to constituents. For example, the SAHAJ program implemented periodic federation meetings where community leaders of each group came together to share issues, lessons learned, and challenges. This feedback was then incorporated into program interventions.
  • In meetings with community leaders, implementers should be open to hearing alternative solutions to challenges and not go into meetings with decisions already made.

How can the role or insights of community leaders in monitoring or evaluation contribute to and affect gender transformative programming’s attention toethical dilemmas and efforts to do no harm?

  • Recruiting peers to lead evaluation interviews may help interviewees feel more comfortable about discussing sensitive or taboo topics. To document SRH violations that women living with HIV were experiencing, the ICW (International Community of Women Living With HIV)-Latina/Balance program recruited peers to document evidence and trained all peer researchers in confidentiality protocol and informed consent.
  • Program implementers should ensure community leaders have decision-making power over program evaluation goals and what data and information are documented. For example, community leaders can co-create questionnaires, helping to decide the language and framing of the questions. Implementers should ensure evaluation tools are communicated in a way that community leaders can understand (in other words, with less jargon), and support community leaders in feeling a sense of ownership over the program data, encouraging them to use the data in their work. Additionally, collaborating with community leaders to develop messaging around program data can foster a sense of joint ownership, which may support leaders’ use of the data in their work and advocacy efforts.
  • Community leaders can help program staff navigate discussions on sensitive topics with community members. For example, before discussing issues related to sexual and reproductive health and rights (SRHR) with youth in India—topics that are considered very sensitive and require consent to be discussed with young people—the SAHAJ program created community advisory groups of adults or supporters, progressive parents, teachers, and community leaders to guide the discussions and the ensure they were culturally appropriate and acceptable.
  • Implementers should support the inclusion of marginalized and excluded groups in evaluation and learning processes, recognizing that in some contexts, deep-seeded and intergenerational structures (for example, caste systems) are more difficult to penetrate.

How can community leaders play a role in the evaluations of gender transformative programs?

  • Before developing the program evaluation, implementers should meet with community leaders to discuss expectations for outcomes, what success looks like, and outcome indicators. Similarly, community leaders should be included in discussions for external evaluations. External evaluators should build in spaces to engage with community leaders and provide them with the opportunity to reflect on their work and why it has or has not worked, as well as to encourage leaders to share their stories.
  • Recognizing that community leaders have an important stake in the program evaluation process, implementers should engage leaders (including government officials) early to ensure programs are context-specific and achieve support for program results. For example, after receiving feedback from community leaders and authorities about the exclusion of female genital mutilation in their programming, the Community Care Programme (CCP) incorporated this topic into its interventions and evaluation.
  • Community leaders should help decide how evaluation findings are communicated back to the community, including how the results are shared and with whom. Their participation is especially important for findings on sensitive issues, which may face serious backlash from the community. Involving community and peer leaders can help program implementers frame their findings in a way that provides transparency and avoids setting back the work of gender transformative social norms or creating further risk to impacted groups.
  • Recognizing possible tensions that may arise between supporting organizations and the ability of community leaders to be frank and critical, program implementers should work to build the trust of community leaders to engage in evaluation and learning method processes effectively. Implementers should recognize that criticism from community leaders may be an indicator that they are starting to trust program processes.

What are some practices and methods that programs can apply and use to measure changes in community leadership?

  • To assess changes in growth in community leadership at individual and organizational levels, implementers can build questions into evaluations related to changes in community leaders (and their organizations’) capacity to lead during regular check-ins and progress meetings, as well as capture these changes through formal interviews and participant observations. The ICW/Balance program asked participants about how their views and personal priorities and practices related to SRH, and their organization’s priorities and collective action efforts with other organizations, changed throughout the process and documented these changes. In one example of growth, program participants—women living with HIV—acted as subject matter experts and used program-generated evidence to influence policy and care guidelines at the national level.
  • Stories shared during discussions with community leaders can be a rich way of learning about various forms of leadership, how capacities have changed and evolved, and how subject knowledge of issues has grown. Stories can also provide insight into the experiences of community leaders and marginalized groups, as well as the intersectional experiences of program participants.
  • In addition to using formal tools, program implementers can monitor the behavior of community leaders who are successfully and effectively facilitating discussions on sensitive topics. The CCP monitored how community leaders led discussions on sensitive topics, which helped indicate leaders who were likely to continue these discussions after the end of the program and identified those who could mentor other leaders. The CCP also mapped out reference groups, recognizing that leaders who are most vocal and well-known may not be the only the ones driving change.

IGWG Gender Integration Continuum Graphic Now Available in French, Portuguese, and Spanish

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The Interagency Gender Working Group (IGWG) Gender Integration Continuum is a necessary tool to identify whether an intervention encourages gender equity to improve development outcomes, such as in reproductive health. The Gender Integration Continuum graphic is available in English, French, Portuguese, and Spanish.

Access the English version here.

Access the French version here.

Access the Portuguese version here.

Access the Spanish version here.