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EGALITATE DE ANSE I DE GEN


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EGALITATE DE ANSE I DE GEN


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SEPTEMBRIE 2015

STRUCTUR
I. INTRODUCERE

II. CLARIFICAREA CONCEPTELOR

EGALITATE N DREPTURI

EGALITATEA DE ANSE
Egalitatea de anse n legislaia european: origini i evoluie
Legislaie naional: ce este egalitatea de anse i unde se aplic?
Instituionalizarea egalitii de anse n Romnia
Planificarea aciunilor din domeniul egalitii de anse ntre femei i brbai

4
4
6
7
9

EGALITATE DE ANSE I EGALITATE DE GEN


Despre gen
Roluri de gen
Identitate de gen
Stereotipurile de gen
Ce sunt stereotipurile? Ce sunt stereotipurile de gen?

10
10
11
11
12
13

DISCRIMINARE
Formele discriminrii
Discriminare direct
Discriminare indirect
Discriminare multipl
Hruire. Hruire sexual
Victimizare
Dispoziia de a discrimina (ordinul de a discrimina)
Instituionalizarea nediscriminrii

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15
15
15
15
16
16
17
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III. EGALITATE DE ANSE I DE GEN PE PIAA MUNCII


Spee discriminare pe piaa muncii

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18

IV. N FINAL, CE FACEM? RECOMANDRI


nelegere
Integrare
Comunicare bazat pe stereotipuri ori pe deconstruirea stereotipurilor de gen?
Direcii de reflectat pentru jurnaliti

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21
21
22
24

Bibliografie

25

I. INTRODUCERE
Egalitatea de anse i de gen reprezint obiectivul oricrei societi democratice.
Obiectivele generale ale egalitii de anse i de gen constau n crearea unei societi cu aceleai
oportuniti, drepturi i obligaii pentru femei i brbai i n care diferenele dintre femei i brbai
s fie integrate altfel dect ca deficiene.
Suportul de curs Egalitate de anse i de gen i propune s abordeze problematica egalitii de
anse i de gen printr-o analiz teoretic i practic la nivel naional i european, adresndu-se mai
ales reprezentanilor autoritilor publice, reprezentanilor mass-media i ai celor din societatea civil
organizat.
La finalul parcurgerii suportului de curs Egalitate de anse i de gen, vei putea:
1. S definii concepte precum: gen, sex, roluri de gen, identitate de gen, stereotipuri de gen,
discriminare de gen, egalitate de anse i de gen.
2. S identificai cum se raporteaz autoritile publice la femei i la brbai.
3. S identificai stereotipurile de gen n discursuri publice i politice.
4. S analizai coninutul legislaiei i al activitii instituiilor care asigur implementarea politicilor
de egalitate de anse i combaterea discriminrii.
5. S analizai strategiile naionale i europene n domeniul egalitii de anse ntre femei i brbai.
6. S analizai politicile publice din perspectiva dimensiunii de gen.
7. S fii sensibili fa de discriminarea de gen.
8. S respingei inechitatea de gen i s fii orientai spre egalitate de anse i de gen n activitatea
pe care o desfurai.
9. S fii solidari cu alte grupuri excluse sau marginale aflate n situaii de discriminare.
10. S susinei n cunotin de cauz la nivel de ONG-uri, partide, pres proiectele de politici publice
care conduc la politici ale echitii de gen n relaiile de putere la nivel micro i macro-social.
11. S avei mai mult simpatie comprehensiv fa de victimele inechitii de gen.

II. CLARIFICAREA CONCEPTELOR

Ce vom afla din aceast seciune este cum definim egalitatea i care sunt unele forme pe care le
mbrac aceasta, respectiv: egalitate n drepturi, egalitate de anse, egalitate de gen. De asemenea, vom
nelege i cum s difereniem aceste noiuni i s nu le utilizm n relaie de sinonimie (egalitate n
drepturi i egalitate de anse). Totodat, n aceast parte v voi defini i explica alte noiuni importante
precum o nelegere substanial a egalitii de gen: gen, stereotipuri, discriminare. 1
Egalitatea este o noiune complex1. Din motive care in de nelegerea acesteia i de posibilitatea
de a o integra n activitate, fie c este cea de pres, la nivelul administraiei ori ntr-o organizaie
nonguvernamental, voi selecta i discuta dou abordri ale acesteia: egalitatea n drepturi i
cea de anse.

1 Pentru o abordare comprehensiv, vezi Baker, John; Lynch, Kathleen; Cantillon, Sarah; Walsh, Judy, 2004, Equality. From
Theory to Action (second edition), Palgrave Macmillan, New York.
3

EGALITATE N DREPTURI

Egalitatea n drepturi presupune c ne sunt asigurate aceleai drepturi tuturor. Acest concept este
asociat unei egaliti formale ntruct nu acoper i posibilitatea indivizilor de a-i exercita drepturile
ori capacitatea acestora de a i le realiza efectiv. Femeile au dreptul legal de a munci, dar n lipsa unor
politici de armonizare a vieii de familie cu cariera, n condiiile n care preponderent ele efectueaz
munca de ngrijire din familie, nu au posibilitatea efectiv de rmane ocupate pe piaa muncii. Lipsa
grdinielor poate constitui un obstacol pentru femei s ating un grad satisfctor de ocupare pe
piaa muncii.
Pentru a ajunge la egalitate n drepturi ntre femei i brbai, a fost parcurs un lung drum la nivelul
istoriei. Voi explica n cele ce urmeaz. S nu uitm c dreptul de a beneficia de educaie, de a putea
exercita o profesie, de a vota etc. sunt de dat relativ recent. n perioada interbelic, dac ne uitm
la Romnia, aflm c femeile nu au putut exercita profesia de avocat, chiar dac nu le era ngrdit
accesul la studii de specialitate. Accesul nengrdit la toate formele de pregtire i la toate tipurile de
cariere a fost o revendicare a ceea ce numim feminismul egalitii al crui scop a fost dobndirea
unui statut juridic egal al femeilor cu brbaii. i recunoaterea dreptului de a vota este de dat relativ
recent la scara istoriei. Abia n 1929 le-a fost recunoscut anumitor femei dreptul de a vota i de a
fi alese la nivel local2 dup ce organizaii de femei i organizaii feministe s-au mobilizat pentru a
revendica aceste drepturi3.
Un izvor esenial n prezent pentru egalitatea n drepturi ntre femei i brbai este Constituia
Romniei care a inclus egalitatea n drepturi n Titlul I, Principii generale, Titlul II, Drepturile, libertile i
ndatoririle fundamentale4.
- Art. 4, alin. 2 Unitatea poporului i egalitatea ntre ceteni: Romnia este patria comun i
indivizibil a tuturor cetenilor si, fr deosebire de ras, de naionalitate, de origine etnic,
de limb, de religie, de sex, de opinie, de apartenen politic, de avere sau de origine social.
- Art. 16. alin. (1) Egalitatea n drepturi: Cetenii sunt egali n faa legii i a autoritilor publice,
fr privilegii i fr discriminri.
Am introdus cele dou exemple de mai sus privind accesul la piaa muncii i drepturile politice
ntruct de foarte multe ori egalitatea n drepturi este confundat cu egalitatea de anse. Ultima are
semnificaii specifice i o raz de aciune mai ampl aa cum vom vedea n cele ce urmeaz.

EGALITATEA DE ANSE

Egalitatea de anse n legislaia european: origini i evoluie


Pentru a simplifica procesul de nelegere a acestei noiuni - egalitate de anse- i pentru a o integra
cu mai mult uurin n activitate, m voi referi n cele ce urmeaz la egalitatea de anse aa cum este
ea prevzut n legislaia naional. Ce aflm acum este c legislaia din Romnia conine prevederi
privind egalitatea de anse. Cadrele egalitii de anse ntre femei i brbai au fost asumate de ctre
Romnia n procesul amplu prin care a devenit stat membru al Comunitii Europene. Fac aceast
precizare deoarece statutul acesta presupune angajamente asumate de statele membre.
Egalitatea de anse ntre femei i brbai constituie un principiu important al Uniunii Europene prevzut
n legislaia primar i secundar, integrat n sistemul instituional. n demersul su de a face parte din
Uniunea European, Romnia a armonizat legislaia intern cu acquis-ul comunitar, ceea ce nseamn

2 Pentru mai multe detalii, vezi Mihilescu, tefania, 2002, Din istoria feminismului romanesc. Antologie de texte (1838- 1929),
Editura Polirom, Iai i Cosma, Ghizela, 2002, Femeile i politica n Romnia. Evoluia dreptului de vot n perioada interbelic,
Editura Presa Universitar Clujean, Cluj-Napoca.
3 Pentru o evoluie a mobilizrii pentru dreptul de vot, vezi Mihilescu, tefania, 2002, Din istoria feminismului romanesc.
Antologie de texte (1838- 1929), Editura Polirom, Iai.
4 http://www.cdep.ro/pls/dic/site.page?id=339&idl=1&par1=1
4

c noiunea de egalitate de anse a ptruns n spaiul romnesc odat cu nceperea procesului de


aderare la Uniunea Europeana (1996). ns, dac legislativ i instituional a intrat via Uniunea European,
n discursul public a fost integrat mai nti de organizaii neguvernamentale, mediul academic i apoi de
ali actori sociali (de pild, sindicate).
O scurt, dar necesar privire n istorie ne spune c rdcinile n prevederile europene n materie
merg nspre anul 1957, ctre articolul care definete misiunea Comunitii din Tratatul de la Roma: (...) s
promoveze n ntreaga Comunitate egalitatea de anse ntre femei i brbai ... (art. 2). Tot aici, articolul
141 menioneaz c noua organizare european trebuie s funcioneze n baza principiului egalitii
remuneraiei ntre brbai i femei pentru aceeai munc sau pentru munc de valoare egal (art.141).
Pe scurt, ce spune Tratatul de la Roma este c statele membre au obligaia de a promova egalitatea
remuneraiilor femeilor i brbailor pentru aceeai munc.
Pornind de la prevederile acestui Tratat, legislaia european s-a dezvoltat, iar n 1975 a fost adoptat
prima Directiv referitoare la egalitatea de anse ntre femei i brbai: Directiva Consiliului 75/117/
EEC din 10 februarie 1975 privind aplicarea principiului plii egale pentru femei i brbai. Treptat au
fost dezvoltate alte directive, dar legislaiei primare i se adaug documente de poziie, recomandri
i declaraii care acoper diverse teme precum: prevenirea i combaterea violenei asupra femeilor,
participarea femeilor la luarea deciziilor etc.
O alt etap important n istoricul egalitii de anse la nivel european o reprezint introducerea prin
Tratatul de la Amsterdam (1997) i Tratatul de la Nisa (2000), a articolului 13, care integreaz termenul
de discriminare. Acest articol a fost baza pentru elaborarea unei noi Directive Directiva privind
implementarea principiului tratamentului egal ntre femei i brbai n accesul i prestarea de bunuri i
servicii. Directiva face trecerea de la egalitatea de anse pe piaa muncii la accesul la bunuri i servicii
(servicii bancare i de asigurri, nchirierea de locuinte .a.).
Scurtul periplu istoric a fost necesar pentru a sublinia un decalaj de nelegere, percepie, asumare,
voin politic, elaborare i implementare de politici .a. n zona egalitii de anse ntre Romnia i
rile din Europa Central i de Est n general i cele care au o experien ndelungat de stat membru
n Uniunea European.

Directivele Uniunii Europene care acoper egalitatea de anse ntre femei i brbai
1. Directiva 75/117/EEC din 10 februarie 1975, privind armonizarea legislaiilor statelor membre
cu privire la aplicarea principiului plii egale pentru brbai i femei;
2. Directiva 76/207/EEC din 9 februarie 1976, privind aplicarea principiului egalitii de
tratament ntre femei i brbai referitor la accesul la angajare, pregtire profesional i
promovare, precum i la condiiile de munc;
3. Directiva 2002/73/EC din 23 septembrie 2002 care amendeaz Directiva 76/207/EEC privind
implementarea principiului egalitii de tratament ntre femei i brbai referitoare la accesul
la angajare, pregtire profesional i promovare, precum i la condiiile de munc;
4. Directiva 79/7/EEC din 19 decembrie 1978 pentru implementarea progresiv a principiului
egalitii de tratament ntre brbai i femei n materie de securitate social;
5. Directiva 86/378/EEC din 24 iulie 1986 privind implementarea principiului egalitii de
tratament pentru femei i brbai n schemele ocupaionale de securitate social;
6. Directiva 86/613/EEC din 11 decembrie 1986 referitoare la principiul tratamentului egal al
brbailor i femeilor angajai n activiti independente, inclusiv n agricultur i protecia
femeilor care desfoar activiti independente n perioada de sarcin i maternitate;
7. Directiva 92/85/EEC din 19 octombrie 1992 privind introducerea de msuri pentru ncurajarea
mbuntirii sntii i securitii n munc a lucrtoarelor gravide, a lucrtoarelor care au
nscut recent i a celor care alpteaz;
8. Directiva 96/34/EC din 3 iunie 1996 privind contractul cadru referitor la concediul parental,
susinut de UNICEF, CEEP i ETUC;
9. Directiva 97/80/EEC din 15 decembrie 1997 privind sarcina probei n cazurile de discriminare
bazate pe sex;
10. Directiva 97/81/EEC din 15 decembrie 1997 privind principiul nediscriminrii lucrtorilor cu
timp parial.
n prezent5, domeniul egalitii de anse ntre femei i brbai acoper un numr variat de teme6:
nediscriminarea de gen
- egalitatea de tratament ntre femei i brbai n afara pieei muncii,
- sarcina probei n cazuri de discriminare de gen (inversarea sarcinii probei n cazurile de
discriminare pe baz de gen (n aceste situaii, sarcina probei revine persoanei mpotriva
creia s-a formulat cererea de chemare n judecat, care trebuie s fac proba c nu a
svrit aciuni de discriminare pe baz de gen ).
accesul egal la munc i formare vocaional
- accesul la munc, formare vocaional i promovare,
- principiul plii egale,
- activitile liber profesioniste, inclusiv munca n agricultur,
- femeile i tiina.

5 Aici pot fi consultate documentele relevante n materie: http://www.mmuncii.ro/j33/index.php/ro/2014-domenii/


egalitate-de-sanse-intre-femei-si-barbati/1849-legislatia-in-domeniul-egalitatii-de-sanse-intre-femei-si-barbati
6 http://eur-lex.europa.eu/legal-content/RO/TXT/?uri=URISERV:c10940
6

protecie social
- reconcilierea vieii de familie cu cea profesional (se urmrete participarea echilibrat a
femeilor i a brbailor n ambele sfere ale vieii),
- concediul parental i concediul asociat problemelor familiale,
- protecia femeilor nsrcinate, a femeilor care au nscut recent i a femeilor care alpteaz,
- servicii de ngrijire a copilului (de tipul cree, grdinie),
- scheme de asisten social ocupaional,
- asisten social.
hruire sexual
- prevenirea hruirii sexuale la locul de munc,
- protecia demnitii femeilor i a brbailor la locul de munc,
egalitatea de anse ntre femei i brbai la nivel instituional
- integrarea dimensiunii de gen la nivelul tuturor politicilor Uniunii Europene (ceea ce se
cunoate sub numele de gender mainstreaming),
- participarea echilibrat a femeilor i a brbailor la procesul de luare a deciziilor,
- integrarea dimensiunii de gen la nivelul fondurilor structurale.
alte teme de interes
- prevenirea i combaterea violenei asupra femeilor,
- prevenirea i combaterea traficului cu femei,
- drepturile sexuale i reproductive.
n baza acestor prghii legislative, statele membre au dezvoltat legislaie naional, instituii, politici
publice care s urmreasc activ egalitatea de gen. Ce e de reinut este c c egalitatea anse i de
gen nu e un moft.
Legislaie naional: ce este egalitatea de anse i unde se aplic?
Legislaia naional a transpus prevederile fundamentale ale legislaiei comunitare, ns sincopele i
derapajele nu in de armonizare, ci de implementarea legislaiei.

Constituia Romniei a inclus egalitatea de anse n Titlul II, Drepturile, libertile i ndatoririle
fundamentale7.
- Art. 16. alin. (3) Funciile i demnitile publice, civile sau militare, pot fi ocupate, n condiiile
legii, de persoanele care au cetenia romn i domiciliul n ar. Statul romn garanteaz egalitatea de
anse ntre femei i brbai pentru ocuparea acestor funcii i demniti.
Legea care stabilete cadrul egalitii de anse ntre femei i brbai este Legea 202/2002 privind
egalitatea de anse i de tratament ntre femei i brbai. Potrivit legii 202 din 19 aprilie 2002 (republicat)
privind egalitatea de anse i de tratament ntre femei i brbai, prin egalitate de anse ntre femei i
brbai se nelege luarea n considerare a capacitilor, nevoilor si aspiraiilor diferite ale persoanelor
de sex masculin si, respectiv, feminin i tratamentul egal al acestora. (art. 1, al. 2).
Legea 202 din 19 aprilie 2002 (republicat) privind egalitatea de anse i de tratament ntre femei i
brbai ne spune c:
msurile pentru promovarea egalitii de anse i de tratament ntre femei i brbai i pentru
eliminarea tuturor formelor de discriminare bazate pe criteriul de sex se aplic n domeniul
muncii, educaiei, sntii, culturii i informrii, politicii, participrii la decizie, furnizrii
i accesului la bunuri i servicii, precum i n alte domenii reglementate prin legi speciale
(art. 2- sublinierea mi aparine).89
n pachetul de legi8 care acoper domeniul egalitii de anse ntre femei i brbai, regsim8:
1. HG 10 din 2013 privind organizarea i funcionarea Ministerului Muncii, Familiei, Proteciei
Sociale i Persoanelor Vrstnice.
2. Legea 25 din 2012 pentru prevenirea i combaterea violenei n familie.
3. HG 237 din 2010 Strategia naional pentru egalitatea de anse 2010-2012.
4. OUG 68 din 2010 privind unele msuri de reorganizare a Ministerul Muncii, Familiei i
Proteciei Sociale.
5. OUG111 din 2010 privind concediul i indemnizaia lunar pentru creterea copiilor.
6. Legea 62 din 2009 pentru aprobarea OUG 61 2008 bunuri i servicii.
7. OUG 61 din 2008 egalitatea privind accesul la bunuri i servicii.
8. OUG 67 din 2007 Egalitate tratament scheme profesionale securitate social.
9. HG 319 din 2006 Strategia Naional pentru egalitatea de anse 2006 - 2009.
10. Hotrrea 1.054 din 2005 - Regulament COJES.
11. Legea 217-2003 pentru prevenirea i combaterea violenei n familie.
12. Legea 53-2003 Codul muncii.
13. Legea 202-2002 republicat privind egalitatea de anse i tratament ntre femei i brbai.
14. Ordonana 137-2000 privind prevenirea i sancionarea discriminrii.
15. Legea 210-1999 privind concediul paternal.
Instituionalizarea egalitii de anse n Romnia
Este necesar prezena unor instituii responsabile care s urmreasc adoptarea i promovarea unor
politici, aplicarea lor, s propun msuri pentru corectare i sancionare. La nivel internaional, n anii 70
observm n statele democratice c se acord atenie sporit drepturilor femeilor i se consolideaz din
ce n ce mai puternic o perspectiv critic asupra obiceiurilor, practicilor, percepiilor. Este o perioad
7 http://www.cdep.ro/pls/dic/site.page?id=339&idl=1&par1=2
8 http://www.mmuncii.ro/j33/index.php/ro/2014-domenii/egalitate-de-sanse-intre-femei-si-barbati/1849-legislatia-indomeniul-egalitatii-de-sanse-intre-femei-si-barbati
9 Pentru o analiz extins a legislaiei care acoper domeniul egalitii de anse i de gen, vezi Analiz de diagnostic a
domeniului egalitii de anse i gen din Romnia: probleme, nevoi, soluii europene, coordonat de Georgiana Pascu i
Delia Ni, Centrul de Resurse Juridice http://www.crj.ro/wp-content/uploads/docs/analiza_de_diagnostic_domeniul_
egalitatii_romania.pdf
8

n care se produc redefiniri ale feminitii, ale diferenei dintre sex/gen care s includ liberul arbitru,
autonomia, critica stereotipurilor de gen asociate sferei publice i celei private i introducerea egalitii
de gen n politic i pe piaa muncii. Aceste interveniii redefiniri au loc trziu n Romnia, dup anii 90,
ceea ce arat un decalaj de percepie, nelegere, unul comportamental, de elaborare i implementare
a unor politici etc.
Exist cteva ntrebri importante privind instituionalizarea egalitii de anse, de pild:
1.) Dezvolt instituiile dedicate oportuniti de acces pentru cei care activeaz n zona egalitii de
anse?
2.) Influeneaz aceste instituii dedicate politicile n domeniu?
Constituirea acestor instituii scoate n eviden dou tipuri de influene: de factur extern
manifestat prin influena Uniunii Europene (n condiiile n care acest structur a reprezentat principalul
stimulent pentru schimbarea pachetului de legi n domeniul egalitii de anse), de factur intern care
se regsete n influena care vine dinspre micarea/gndirea feminist ctre aceste instituii.10
n Romnia, instituiile dedicate care s coordoneze politicile din zona egalitii au parcurs un
drum sinuos i au avut o existen mai curnd efemer dac lum n considerare: personalul angajat
i pregtirea acestuia n domeniu, gradul de independen al instituiei, resursele financiare i
transformrile succesive ale acestora. De exemplu, n anul 2000 n cadrul Ministerului Muncii funciona
Direcia de anse Egale care avea 4 angajai, inclusiv directoarea i nu avea buget propriu (Popescu,
2004, p.139). Cartea neagr a egalitii de anse ntre femei i brbai n Romnia (2006) a radiografiat nc
de la nceputurile instituionalizrii egalitii de anse neajunsurile din domeniu.
Istoria instituionalizrii egalitii de anse ntre femeii brbai trece prin structura numit Agenia
Naional pentru Egalitatea de anse ntre Femei i Brbai aflat n subordinea Ministerului Muncii care
a fost nfiinat printr-un Proiect Phare de nfrire instituional Romnia-Spania. Comisia European a
alocat 1,8 milioane de Euro pentru implementarea acestui proiect. ANES a fost nfiinat n luna martie
2005. n urma unei adrese trimis de Comisia pentru egalitatea de anse pentru femei i brbai din
Camera Deputailor - nr. 2604/12.05.2005- tim c ANES avea un personal alctuit din 10 persoane
i c n momentul nfiinrii bugetul alocat anului 2005 era nc executat de direciile de specialitate
din Ministerul Muncii, Solidaritii Sociale i Familiei.11 n anul 2006 a fost trimis o Scrisoare deschis:
Bil neagr pentru egalitatea de anse ntre femei i brbai n Romnia care a sintetizat verdictul a
peste 20 de organizaii neguvernamentale dat activitii Guvernului Romniei pentru interveniile sale
n domeniul anselor egale ntre femei i brbai. n anul 2010, n luna iulie, ANES a fost desfiinat prin
reorganizare administrativ. A fost un context delicat n condiiile n care statele europene erau afectate
de criza financiar-economic, iar Uniunea European sublinia c este nevoie de atenie sporit acordat
grupurilor vulnerabile i egalitii de gen. Rspunsul Romniei ns a fost scoaterea total a egalitii de
gen de pe agenda guvernrii, n condiiile unui angajament anterior oricum redus12.
n prezent, activitatea n domeniul egalitii de anse i tratament ntre femei i brbai este
coordonat de ctre Departamentul pentru Egalitate de anse ntre Femei i Brbai (DESFB)13 care este
condus de un secretar de stat14. Prin Ordonana Guvernului nr. 6/2015, DESFB a preluat i atribuiile
referitoare la prevenirea i combaterea violenei n familie care intrau anterior n activitatea Direciei
Protecia Copilului.
10 Pentru nceputurile instituionalizrii egalitii de anse, vezi Huminic, Adelina, 2002, Instituionalizarea politicii de
egalitate de anse n Grnberg, Laura (editoare), 2002, Gen i integrare, Smart Printing srl.
11 Informaii din arhiva personal.
12 i atunci organizaiile nonguvernamentale au trimis o Scrisoare de protest n data de 5 iulie 2010, adresat Premierului
Emil BOC, Ministrului Muncii, Familiei i Proteciei Sociale, Mihai Constantin eitan.
13 naintea Departamentului pentru Egalitate de anse ntre Femei i Brbai, activitatea era coordonat de Direcia
Ocupare i Egalitate de anse (DOES) din Ministerului Muncii, Familiei, Proteciei Sociale i Persoanelor Vrstnice.
14 Vezi HG 250/2014 privind organizarea i funcionarea Departamentului pentru Egalitate de anse ntre Femei i Brbai.
9

Potrivit Articolul 3 din HG 250/2014, DESFB exercit urmtoarele tipuri de funcii n domeniul egalitii
de anse ntre femei i brbai:
1.) de strategie, prin care se asigur fundamentarea, elaborarea i aplicarea strategiei i politicilor
Guvernului n domeniul egalitii de anse i de tratament ntre femei i brbai;
2.) de reglementare, n domeniul egalitii de anse ntre femei i brbai, inclusiv n ceea ce privete
armonizarea cu reglementrile Uniunii Europene n domeniu;
3.) de reprezentare a Guvernului Romniei, pe plan intern i extern n domeniul su de activitate;
4.) de autoritate n domeniul egalitii de anse ntre femei i brbai.15
De asemenea, trebuie specificat faptul c n cadrul Ministerului Muncii, Familiei, Proteciei Sociale
i Persoanelor Vrstnice i desfoar activitatea Comisia Naional n domeniul Egalitii de anse
ntre femei i brbai (CONES). Din CONES fac parte: reprezentani ai ministerelor, ai altor organe
de specialitate din administraia public central aflate n subordinea Guvernului, ai autoritilor
administrative autonome, ai organizaiilor sindicale i patronale reprezentative la nivel naional, precum
i reprezentani ai organizaiilor nonguvernamentale cu activitate recunoscut n domeniu.
ns, pe 9 septembrie 2015, Camerea Deputailor a adoptat proiectul de lege de modificare i
completare a Legii nr. 202/2002 privind egalitatea de anse i de tratament ntre femei i brbai
(republicat). Acest proiect prevede i renfiinarea Ageniei Naionale pentru Egalitate de anse
ntre Femei i Brbai (ANES)16. Ceea ce nseamn c structura instituional n domeniul egalitii
de anse va suferi o nou transformare.
Planificarea aciunilor din domeniul egalitii de anse ntre femei i brbai
Strategia naional n domeniul egalitii de anse ntre femei i brbai pentru perioada 2014-201717
asigur cadrul pentru planificarea aciunilor din domeniul egalitii de anse ntre femei i brbai.
Aceasta nu este prima Strategie elaborat n domeniu; este precedat de alte dou care au acoperit
perioadele: 2006-2009 i 2010-2012.
Ariile de intervenie pentru perioada 2014-2017 incluse n Strategie sunt:
- Educaia,
- Piaa muncii,
- Participarea echilibrat a femeilor i a brbailor la procesul de decizie,
- Abordarea integratoare de gen18,
- Violena de gen.
i la nivel european exist o Strategie n domeniul egalitii de gen care acoper intervalul 20102015. Sferele de aciune incluse sunt19:
- independena economic egal pentru femei i brbai,
- plat egal pentru munc de valoare egal,
- egalitate n procesul de luare a deciziilor,
15 http://www.dreptonline.ro/legislatie/hg_250_2014_departamentul_pentru_egalitate_sanse_intre_femei_barbati.php
16 http://www.mmuncii.ro/j33/index.php/ro/comunicare/comunicate-de-presa/4023-2015-09-09-ip-anes. Schimbrile
legislative pot fi urmrite n Raportul comun emis de Comisia pentru egalitate de anse pentru femei i brbai i Comisia
pentru munc i protecie social din Camera Deputailor http://www.cdep.ro/caseta/2015/06/19/pl13405_rp.pdf
17 Strategia naional n domeniul egalitii de anse ntre femei i brbai pentru perioada 2014-2017 poate fi consultat aici:
http://www.mmuncii.ro/j33/images/Documente/Transparenta/Dezbateri_publice/2014-01-24_Anexa_1_Strategia.pdf
18 Potrivit Consiliului Europei, abordarea integratoare a egalitii de gen poate fi neleas drept (re)organizarea,
mbuntirea, dezvoltarea i evaluarea proceselor politice, astfel nct perspectiva unei egaliti de gen s fie ncorporat
n toate politicile, la toate nivelurile i n toate etapele de ctre actorii implicai n mod normal n luarea deciziilor politicevezi Consiliul Europei, 1998, Gender mainstreaming: conceptual framework, methodology and presentation of good practices,
Strasbourg, p. 10.
19 Strategia poate fi consultat aici: http://ec.europa.eu/justice/gender-equality/
10

- demnitate, integritate i eliminarea violenei de gen,


- promovarea egalitii de gen n afara Uniunii Europene,
- intervenii orizontale: roluri de gen, rolul brbailor, legislaie i instrumente de guvernan.
Un aspect important al celor dou documente vizeaz rolul brbailor n susinerea egalitii de
gen. Strategia naional prevede i msuri adresate brbailor, de pild susinerea i ncurajarea
parteneriatului dintre femei i brbai n viaa privat i asumarea responsabilitilor de ngrijire a
copiilor i de ctre brbai20.
Problematizarea i a rolului brbailor n susinerea egalitii de gen ine de o eviden simpl:
noiunea de gen nu este un sinonim pentru cea de femei. n cele ce urmeaz voi clarifica aspectele
relevante acoperite de acest concept.

EGALITATE DE ANSE I EGALITATE DE GEN21

Am vzut deja c la nivel european preferina terminologic merge nspre noiunea de


egalitate de gen. Aceasta este alegerea fcut i de muli actori din sectorul organizaiilor
nonguvernamentale active n domeniu, din mediul academic. La nivel naional, cel mai adesea
n plan legislativ, egalitatea a fost transpus sub forma de egalitate de anse ori, n documente
strategice22, cele dou formule alterneaz.
Imprecizie, neclaritate, inconsisten terminologic23
Doresc s atrag atenia asupra unui aspect, respectiv asupra impreciziei terminologice asociate
domeniului. Exist egalitate de anse ntre femei i brbai, egalitate de gen, oportuniti egale,
egalitate de anse ntre sexe etc.
Chiar documente oficiale alterneaz utilizarea noiunilor de egalitate de anse ntre femei i brbai
cu egalitatea de gen.
ns, pentru c nu mereu drumul mai scurt este i cel mai adecvat, ca s nelegem substanial
egalitatea de anse i egalitatea de gen este bine s ne familiarizm cu o serie de noiuni: gen,
roluri i identitate de gen, stereotipuri de gen.23
Despre gen
O prim observaie cu care voi ncepe acest seciune este urmtoarea: noiunea de gen nu
este un sinonim pentru cea de femei. Distincia sex-gen joac un rol fundamental n societile
actuale (practici cotidiene, politici publice etc.) deoarece exist diferene ntre femei i brbai care nu
au o origine biologic. Prin urmare, genul i sexul nu sunt echivalente (West, Zimmerman, 1987).
O definiie operaional complex ofer Judith Lorber n lucrarea sa Paradoxes of Gender (1994) n
care autoarea (des citat n literatura de profil) definete genul astfel: o instituie care stabilete modele
de comportament pentru indivizi, ordoneaz procesele sociale ale vieii de zi cu zi, care a infuzat
principalele organizri din societate, cum sunt economia, ideologia, familia i politica (...). (Lorber, 1994,
p.1) Lorber susine c genul i are rdcinile n dezvoltarea culturii umane, nu n biologie ori procreaie
20 http://www.mmuncii.ro/j33/images/Documente/Transparenta/Dezbateri_publice/2014-01-24_Anexa_1_Strategia.pdf,
p.19.
21 Pentru o abordare mai complex a domeniului egalitii de anse i de gen, unde am inclus i dou studii de caz
dedicate armonizrii vieii de familie cu profesia i violenei de gen, vezi Blu, Oana, 2014, Egalitate de anse i de gen
(suport de curs), seciunea II Sex, gen, prejudecat. Stereotipuri i discriminare, publicat n cadrul proiectului Media FEMcoala Naional de Jurnalism, editat de Blockbuster Media.
22 De pild: Strategia naional n domeniul egalitii de anse ntre femei i brbai pentru perioada 2014-2017.
23 Observaia aceasta a mai fost fcut i n 2006, ntr-o publicaie care radiografiaz egalitatea de anse ntre femei i
brbai din Romnia: Cartea neagr a egalitii de anse ntre femei i brbai n Romnia, coordonat de Laura Grnberg.
11

i c asemenea oricrei instituii sociale, genul variaz cronologic, cultural, geografic i afecteaz major
viaa indivizilor i interaciunea social. (Lorber, 1994, p.1) De pild, n urm cu ceva vreme, femeile
leinau pentru c acest act era o manifestare a feminitii, a delicateii lor, desigur c le i adaug
faptul c femeile purtau pe atunci un obiect vestimentar numit corset care le strngea talia pentru a
corespunde tiparelor de frumusee care cereau un mijloc subire i c din punct de vedere medical,
plmnii primeau cantiti reduse de oxigen.
Tot Lorber afirm c genul s-a schimbat n trecut, se va schimba n viitor, dar c fr o regndire
deliberat a sa, nu se va modifica obligatoriu n direcia unei mai mari egaliti ntre femei i brbai.
(Lorber, 1994, p.6) Judith Lorber introduce n lucrarea sa un indicator care, n opinia mea, este un fel
de busol n baza creia se poate aprecia gradul mai mare sau mai mic de egalitate specific unui spaiu
anume, astfel:
meta-regula ntr-o ordine social care s se bazeze pe egalitate este ca nici un individ dintrun grup i nici un grup din societate s nu monopolizeze resursele economice, educaionale,
culturale i poziiile de putere (Lorber, 1994, p. 294).
Dac observm un fel de monopol al femeilor n efectuarea muncilor domestice, n creterea i
ngrijirea copiilor, un altfel de monopol al brbailor n viaa politic, ne putem pune ntrebri privind
nivelul de egalitate din Romnia (dar i din alte state deoarece peste tot n lume brbaii sunt mai
numeroi cnd vine vorba despre participarea i reprezentarea politic).
Revenind cu abordrile teoretice pe trm romnesc, Laura Grnberg n (R)Evoluii n sociologia
feminist (2002) afirm c genul este un termen folosit pentru a evidenia aspectele politice, spirituale,
materiale i cultural specifice, contemporane i istorice, sistemice i individuale, expereniale i
conceptuale a ceea ce nseamn s trieti ntr-o lume care ne-a creat, nu doar ca fiine umane, ci
ntotdeauna ca femei sau brbai (Grnberg, 2002, p. 32).
Genul se dobndete i se nsuete n acelai timp timp (West, Zimmerman, 1987). Putem defini
genul drept produsul anumitor schimbri sociale i individuale - survenite prin experienele cotidiene
trite, prin interaciunea dintre femei i brbai sau dintre persoane de acelai sex (Blu 2013, 34-35;
Blu, Radu, 2015, p.167).
Prin urmare, din analiza genului ajungem s nelegem de ce considerm c un anumit gen
este mai potrivit pentru efectuarea muncilor din viaa privat, iar altul pentru cele din viaa
public (sau pentru anumite slujbe, de pild cele din sntate ori educaie) ori politic, inclusiv
mai priceput n legtur cu activitile de conducere a unei firme ori instituii ori stat.
Roluri de gen
Rolurile de gen reprezint atitudinile i comportamentele dominante pe care societatea le asociaz
cu fiecare sex, prin intermediul crora femeile i brbaii nva norme privitoare la masculinitate i
feminitate. (Grnberg, 2002 apud Miroiu, Dragomir, 2002, p. 313)
A da natere unui copil este un rol de sex (fiindc naterea este o experien exclusiv femeiasc), pe
cnd a-l ngriji este un rol de gen atribuit de cele mai multe ori femeilor, dar care poate fi efectuat de ctre
brbai fiindc ngrijirea se nva. n acest caz, n baza sexului biologic se atribuie un comportament ori
un rol de gen.
Laura Grnberg explic faptul c rolurile de gen se schimb n timp, variaz ntr-o comunitate ori ntre
comuniti ca rezultat al schimbrilor istorice, sociale, economice, politice i culturale, iar ideologia
i micrile feministe au influenat considerabil regimul de gen n care se construiesc aceste roluri
(Grnberg, 2002 apud Miroiu, Dragomir, 2002, p. 313)
Identitate de gen
Aceasta se dobndete n urma interiorizrii psihologice a trsturilor feminine/ masculine, prin
interaciunea dintre individ i societate i este mai curnd o experien subiectiv i nu este dependent
de sex. (Frumuani, 2002 apud Dragomir, Miroiu, 2002, p. 192)
12

De reinut
Diferenele de sex: sunt biologice, sunt nnscute.
Exemple:
Femeile dau natere copiilor.
Femeile alpteaz copiii.
Diferenele de gen: sunt predominant diferene dobndite prin educaie, prin socializare.
Exemple:
Femeile ngrijesc dependenii din familie (copii, vrstnici, persoane cu dizabiliti).
Roluri de gen: sunt atitudinile i comportamentele pe care le asociem cu femeile i cu brbaii.
Exemple
Ne ateptm ca femeile s aib grij de gospodrie, s fac mncare i s spele vasele.
Ne ateptm ca brbaii s dein funcii de conducere n viaa public i politic.
Rolurile de gen sunt reiterate n spaiul public, de pild, n preajma srbtorilor, cnd mass-media
difuzeaz materiale n care politicienele gtesc. Imaginile acestea arat, n opinia mea, poate nevoia
unei confirmri din partea politicienelor c dei activitatea lor se deruleaz ntr-un spaiu perceput ca
masculin, ele ndeplinesc i roluri tradiional asociate femeilor.
Stereotipurile de gen24
n timp ce cutam mai multe informaii despre o carte de memorii publicat de Hillary Clinton, am
gsit ntmpltor un comentariu pe www.adevarul.ro la finalul unui articol despre un turneu de lansare
a volumului su n Statele Unite. Nu este important n acest context identitatea utilizatorului (anonim,
de altfel), ci coninutul observaiilor sale n condiiile n care utilizatorul (ea sau el) reitereaz stereotipuri
de gen i de vrst privind rolul adecvat al femeilor.
nu neleg ce au n cap aceste senioare (merkel, clinton, etc.) de lupt att de aprig s ajung
n poziia de lider? nu neleg de ce sunt convinse ele c tiu exact ce ne trebuie? m trec fiorii
cnd aud cte o bbutz din asta care se crede super delteapt i vrea s-mi decid ea soarta...
nu avem nimic n comun...nu gndim la fel...nu simim la fel...consider, fr s fiu nedrept i ru
c locul lor este lng nepoi...25 (comentariul nu a fost corectat din punct de vedere gramatical).
Mi-au reinut atenia intersecia dintre gen i vrst, dar mai ales asocierile dintre numele a dou
politiciene extrem de cunoscute (Hillary Clinton i Angela Merkel) i rolul potrivit lor, adic cel de
bunic. Cele dou politiciene sunt senioare, bbutze, ar trebui s aib grij de nepoi, interesul lor nu
ar trebui s mearg nspre leadership (nu neleg ce au n cap aceste senioare (merkel, clinton, etc.) de
lupt att de aprig s ajung n poziia de lider?).
Stereotipurile asociate femeilor nu sunt o invenie a acestei perioade, le regsim i n timpuri mai
vechi, dar corelate, de aceast dat, cu emanciparea femeilor, cu accesul la cetenia politic. Titu
Maiorescu, ntr-o conferin despre Darvinismul n progresul intelectual, inut n 1882 la Ateneu,
sublinia riscurile de a permite unor fiine cu o capacitate cranian cu 10% mai mic s conduc treburile
publice i politice.

24 Pentru o abordare teoretic actual nsoit de exemple unde gsii informaii i despre categorii de sterotipuri, vezi
Blu, Oana; Radu, Raluca-Nicoleta, 2015, Evitarea stereotipurilor n Radu, Raluca-Nicoleta, Deontologia comunicrii
publice, Editura Polirom, Iai.
25 http://adevarul.ro/international/statele-unite/noua-carte-lansata-hillary-clinton-rampa-lansare-campanieiprezidentialele-20161-1_5397325e0d133766a875e715/index.html, data accesrii: octombrie 2014.
13

Dac n treact vom deschide aici chestiunea emanciprii femeii, noi observm att numai,
c ideea, cu toat frumuseea ei teoretic, n starea de azi a lucrurilor, este precipitat i cam
nerealizabil. Cum am putea n adevr s ncredinm soarta popoarelor pe mna unor fiine a
cror capacitate cranian e cu 10 la sut mai mic? Abia ajung astzi creierii cei mai dezvoltai
pentru a putea conduce o naiune pe calea progresului i a prosperitii materiale.26
Sofia Ndejde, o feminist socialist a acelor vremuri, a scris articolul Rspuns d-lui Titu Maiorescu
n chestia creierului la femei, publicat n ziarul Contemporanul, din care extrag un pasaj : Chestiunea
creierului e nc o urm de prejudiiile vechi. Nu e mult de cnd se credea c femeia n-are suflet (Ndejde,
1881-1882 apud Mihilescu, 2002, p. 95).
Dac pim ntr-o zon contemporan diferit de articolele de pres, observm c n prezent, n
publicitate, stereotipurile de gen sunt rspndite. n Femeile spun NU publicitii ofensatoare (2013) i
Catalogul reclamelor ofensatoare (2012) artam c:
reclamele nfieaz un ideal de feminitate mai degrab static, impregnat cu stereotipuri de
gen, arhaic i c reclamele ne vnd tipuri de reprezentri cu care, este posibil, ca multe femei s
nu se identifice nici pe departe, astfel n privina muncilor de ngrijire, ni se spune c femeile
i le asum unilateral cu voie bun, apoi mai aflm c femeile sunt mai puin inteligente, n
schimb sunt extrem de frumoase, capricioase, ahtiate dup gospodrie fie c este vorba despre
prepararea unor mncruri ori despre curenie, sunt mai mult trup dect minte, iar abilitile
lor tehnice las de dorit. (Blu, 2012, p. 13-14)
Dac trecem de exemplele aleatorii selectate de mine anterior, observm c literatura tiinific
dedic pagini considerabile i cercetri noiunilor de stereotip, prejudecat, discriminare i stigmatizare
i atrage atenia asupra dificultilor de a schimba percepiile i credinele. Pentru nceput ns, este
important s nelegem semnificaia i importana stereotipurilor pentru a le putea observa i deconstrui
n interaciunea cotidian, n discursurile publice i politice, n elaborarea politicilor publice.
Ce sunt stereotipurile? Ce sunt stereotipurile de gen?
n capitolul Evitarea stereotipurilor (2015) scriam c o definiie operaional spune c stereotipurile
sunt un ansamblu de convingeri mprtite vizavi de caracteristicile personale, de trsturile de
personalitate, dar i comportament, specifice unui grup de persoane (Yzerbyt, Schadron 1997, 98;
Blu, Radu, 2015, p. 163).
Walter Lippmann, n Public Opinion (1922), a introdus noiunea de stereotipuri n accepiunea
sociopsihologic, nelese drept imagini n mintea noastr, aadar constructe mentale n baza crora
interpretm realitatea nconjurtoare pentru c, potrivit opiniei sale, noi nu vedem nainte de a defini,
ci definim nainte de a vedea. (Yzerbyt, Schadron, 1997, p. 99; Nastas, 2004, p. 263-264) Termenul exista
din 1798, era mai degrab prezent n rndul tipografilor i nsemna turnarea plumbului ntr-o form
destinat formrii clieului tipografic (Yzerbyt, Schadron, 1997, p. 99) Prin preluarea acestei noiuni,
Lippmann atrgea astfel atenia asupra concepiilor noastre rigide n raport cu grupurile sociale.
Potrivit lui Adrian Neculau, stereotipurile pot fi considerate reprezentri sociale deturnate,
ncremenite, rigidizate (Neculau, 1998, p. 65; Blu, Radu, 2015, p. 163). Trebuie precizat c acestea
se formeaz ntr-un anumit context sociocultural i c sunt induse de modelul cultural-ideologic, de
structurile mentale mprtite de membrii unei colectiviti. (Neculau, 1998, p. 65; Blu, Radu, 2015,
p. 163).

26 Titu Maiorescu, conferina despre Darvinismul n progresul intelectual, de la Ateneu publicat n Romnia Liber din 5
mai 1882 vezi i Ndejde, Sofia, 1881/1882, Rspuns d-lui Maiorescu n chestia creierului la femei n Mihilescu, tefania,
2002, Din istoria feminismului romnesc, Editura Polirom, Iai, p. 88-95
14

Stereotipurile pot porni de la date reale despre diferenele dintre grupuri, dar ele in cont numai de
cele mai distinctive trsturi (Blu, Radu, 2015, p. 163). Se consider c stereotipurile care pornesc de
la trsturi individuale destul de stabile precum rasa, religia ori genul sunt failibile. n consecin:
acesta este primul motiv pentru care profesionitilor n comunicare public li se recomand
evitarea stereotipurilor: Sunt generaliti care nu au legtur cu prezentarea adevrului. Prin
utilizarea stereotipurilor, imaginea oferit este simplificat i nu exist, de cele mai multe ori,
posibiliti de corectare, deoarece multe grupuri minoritare nu au acces n media (Blu, Radu,
2015, p. 163).
Stereotipurile de gen sunt credine i opinii n legtur cu caracteristicile femeilor i ale brbailor.
Acestea fac parte dintr-un sistem mai amplu de credine despre gen care are efecte asupra percepiilor
despre femei i brbai (Dragomir, 2002, apud Miroiu, Dragomir, 2002, p. 341).
n literatura de specialitate gsim o exemplificare util a stereotipurilor asociate femeilor i brbailor
pe care o voi reda n cele ce urmeaz ntruct ne ajut s nelegem ce sunt stereotipurile i s le
identificm. Este o structur util indiferent dac lucrm n mass-media, administraia public, organizaii
nonguvernamentale, sistemul de educaie etc. (Kite, 2001 apud Miroiu, Dragomir, 2002, p. 342-343):

Asociate
femeilor

Trsturi

Roluri

Devotate celorlali
Contiente de
sentimentele celorlali
Emoionale

Pregtesc masa

Caracteristici
fizice
Frumoase

Fac cumprturile

Drgue

Expresive

Spal
Sunt receptive la
mod

Cochete

Creative

Splendite

Imaginative

Graioase

Intuitive

Mici

Perceptive

Sexi
Au vocea
blnd

Au gust
Au abiliti verbale
foarte bune

Caracteristici
fizice

Abiliti cognitive

Atletici

Analitici

Masivi

Exaci

Cu umeri largi

Buni la abstracii

Robuti

Buni la cifre

Musculari

Buni la rezolvatul
problemelor

Sritoare
Blnde
nelegtoare

Sunt o surs de
ajutor moral
Au grij de copii

Calde

Fac menajul

Trsturi

Roluri

Bune

Iau repede decizii

i asum
responsabilitile
financiare
Sunt capul familiei

Competitivi

Ctig bani

Activi

Asociate
brbailor

Se simt superiori
Independeni
Nu renun uor

Sunt responsabili de
reparaiile casei
Au iniiativa n
relaiile sexuale
Se uit la sport la
televizor

Artistice

Puternici fizic

Au ncredere n ei

Duri

Rezist bine la stres

nali
15

Abiliti cognitive

Abiliti
matematice

Nu trebuie s uitm c rolurile de gen tradiionale i stereotipurile reprezint surse ale


discriminrii de gen.

DISCRIMINARE

Ordonana nr. 137 din 31 august 2000 (republicat) privind prevenirea i sancionarea tuturor
formelor de discriminare este legea de baz care reglementeaz prevenirea i combaterea discriminrii
n Romnia i funcionarea Consiliului Naional pentru Combaterea Discriminrii (CNCD).
Potrivit articolului 2 din ordonana nr. 137 din 31 august 2000 (republicat) privind prevenirea i
sancionarea tuturor formelor de discriminare27, discriminarea este:
orice deosebire, excludere, restricie sau preferin, pe baz de ras, naionalitate, etnie, limb,
religie, categorie social, convingeri, sex, orientare sexual, vrst, handicap, boal cronic
necontagioas, infectare HIV, apartenena la o categorie defavorizat, precum i orice alt criteriu
care are ca scop sau efect restrngerea, nlturarea recunoaterii, folosinei sau exercitrii,
n condiii de egalitate, a drepturilor omului i a libertilor fundamentale sau a drepturilor
recunoscute de lege, n domeniul politic, economic, social i cultural sau n orice alte domenii
ale vieii publice.
Sintetic, a discrimina nseamn a diferenia sau a trata diferit dou persoane sau situaii, atunci cnd
nu exist o distincie relevant sau de a trata ntr-o manier identic dou sau mai multe persoane sau
situaii care sunt n fapt diferite28. Din aceast abordare, deducem c identificm:
1.) discriminarea de jure sau formal: care se refer la a diferenia sau a trata diferit dou persoane sau
situaii atunci cnd nu exist nicio distincie relevant29;
2.) discriminarea de facto sau substanial: care privete tratarea ntr-o manier identic a dou sau
mai multe persoane sau situaii care sunt n fapt diferite.30 Aceast ultim form atrage atenia c
tratarea diferit a unor probleme ce in de inegalitate nu este numai permis, ci chiar cerut.31
Formele discriminrii
Legea 202/2002 privind egalitatea de anse i de tratament ntre femei i brbai i Ordonana 137/
din 31 august 2000 (republicat) privind prevenirea i sancionarea tuturor formelor de discriminare
definesc o serie de termeni cheie pentru domeniul nostru de interes.
Discriminare direct
Legea 202/2002 privind egalitatea de anse i de tratament ntre femei i brbai stipuleaz c prin
discriminare direct se nelege situaia n care o persoan este tratat mai puin favorabil, pe criterii
de sex, dect este, a fost sau ar fi tratat o alt persoan ntr-o situaie comparabil. (art. 4 din Legea
202/2002 privind egalitatea de anse i de tratament ntre femei i brbai).
Discriminare indirect
Se petrece atunci cnd o prevedere, un criteriu ori o practic aparent neutre dezavantajeaz anumite
persoane, cu excepia cazului n care aceast dispozitie, acest criteriu sau aceast practic este justificat
obiectiv de un scop legitim, iar mijloacele de atingere a acestui scop sunt corespunztoare i necesare
(art. 4 din Legea 202/2002 privind egalitatea de anse i de tratament ntre femei i brbai).
27 http://www.cncd.org.ro/legislatie/
28 Csaba, Asztalos, 2012, Dreptul la egalitate i nediscriminare n administrarea justiiei - Manual de pregtire n domeniul
nediscriminrii adresat magistrailor i practicienilor dreptului, p. 6, http://www.cncd.org.ro/cauta/
29 Csaba, Asztalos, 2012, Dreptul la egalitate i nediscriminare n administrarea justiiei - Manual de pregtire n domeniul
nediscriminrii adresat magistrailor i practicienilor dreptului, p. 6, http://www.cncd.org.ro/cauta/
30 Csaba, Asztalos, 2012, Dreptul la egalitate i nediscriminare n administrarea justiiei - Manual de pregtire n domeniul
nediscriminrii adresat magistrailor i practicienilor dreptului, p. 6, http://www.cncd.org.ro/cauta/
31 Csaba, Asztalos, 2012, Dreptul la egalitate i nediscriminare n administrarea justiiei - Manual de pregtire n domeniul
nediscriminrii adresat magistrailor i practicienilor dreptului, p. 6, http://www.cncd.org.ro/cauta/
16

Discriminare multipl
Se produce atunci cnd o persoan sau un grup de persoane sunt tratate difereniat, ntr-o situaie
egal, pe baza a dou sau a mai multor criterii de discriminare, cumulativ. Articolul 2, alin. 6 din Ordonana
137/din 31 august 2000 (republicat) privind prevenirea i sancionarea tuturor formelor de discriminare
prevede c orice deosebire, excludere, restricie sau preferin bazat pe dou sau mai multe criterii
prevzute la alin. (1) constituie circumstan agravant la stabilirea rspunderii contravenionale dac
una sau mai multe dintre componentele acesteia nu intr sub incidenta legii penale.32
Hruire. Hruire sexual
Este orice comportament care duce la crearea unui cadru intimidant, ostil, degradant ori ofensiv, pe
criteriu de ras, naionalitate, etnie, limb, religie, categorie social, convingeri, gen, orientare sexual,
apartenen la o categorie defavorizat, vrst, handicap, statut de refugiat ori azilant sau orice alt criteriu
(art. 2, alin. 6 din Ordonana 137/din 31 august 2000 (republicat) privind prevenirea i sancionarea
tuturor formelor de discriminare).
Legea 202/2002 privind egalitatea de anse i de tratament ntre femei i brbai definete hruirea
sexual drept situaia n care se manifest un comportament nedorit cu conotaie sexual, exprimat
fizic, verbal sau nonverbal, avnd ca obiect sau ca efect lezarea demnittii unei persoane i, n special,
crearea unui mediu de intimidare, ostil, degradant, umilitor sau jignitor (art. 4).
Fenomenul de hruire sexual ncalc principiile fundamentale ale egalitii de anse i ale respectului
pentru demnitate la locul de munc. Hruirea sexual const n comportamente de ameninare,
constrngere, umilire, intimidare, realizate de ctre o persoan mpotriva alteia. Aceste comportamente
sunt de natur sexual i se pot manifesta prin acte verbale, non-verbale sau fizice.
Hruirea poate avea loc pe vertical de la efi ctre angajat() i pe orizontal ntre colegi.
Hruirea se poate produce nu numai n cadrul organizaiei (la locul de munc), ci i n afara acesteia
(la ntlniri n interes de serviciu, conferine, deplasri ori dup terminarea programului de lucru etc.).33
Formele hruirii:
- fizice atingeri, blocarea trecerii, agresiune fizic etc.,
- verbale comentarii despre viaa privat, propuneri i avansuri sexuale, expresii sau glume cu
conotaii sexuale,
- nonverbale studierea ostentativ a corpului unei persoane,
- scrise sau grafice fotografii cu tent sexual, scrisori, mesaje trimise pe telefon etc.,
- psiho-emoionale ameninri, constrngeri, abuz de autoritate prin condiionarea obinerii
unor beneficii n plan profesional de acceptarea comportamentelor de hruire, obligarea angajailor s
poarte mbrcminte sumar la locul de munc.34
Victimizare
Este orice tratament advers, venit ca reacie la o plngere sau aciune n instan sau la instituiile
competente, cu privire la nclcarea principiului tratamentului egal i al nediscriminrii (art. 2, alin. 7 din
Ordonana 137/din 31 august 2000 (republicat) privind prevenirea i sancionarea tuturor formelor de
discriminare).
32 De exemplu, discriminarea multipl la recrutare i angajarese produce cnd una dintre cerinele impuse candidailor
este s nu fie femei i s nu depeasc o anumit vrst sau s nu aib o anumit etnie.
33 Vezi Aninoanu, Livia; Mari, Daniela; Sorescu, Irina, 2007, Ghid practic pentru manageri, manageri de resurse umane
i reprezentani ai sindicatelor- Cum gestionm cazurile de hruire sexual, Centrul Parteneriat pentru Egalitate, http://
www.hartuiresexuala.ro/docs/brosura_hartuire_sexuala.pdf
34 Vezi i Aninoanu, Livia; Mari, Daniela; Sorescu, Irina, 2007, Ghid practic pentru manageri, manageri de resurse umane i
reprezentani ai sindicatelor- Cum gestionm cazurile de hruire sexual, Centrul Parteneriat pentru Egalitate,
http://www.hartuiresexuala.ro/docs/brosura_hartuire_sexuala.pdf
17

Dispoziia de a discrimina (ordinul de a discrimina)


Este considerat a fi tot o form de discriminare i reprezint un ordin primit de o persoan sau un
grup de persoane de la o alt persoan sau grup de persoane pentru a discrimina. 35
Legea 202/2002 privind egalitatea de anse i de tratament ntre femei i brbai definete
discriminarea bazat pe criteriul de sex drept discriminarea direct i discriminarea indirect, hruirea
i hruirea sexual a unei persoane de ctre o alt persoan la locul de munc sau n alt loc n care
aceasta i desfasoar activitatea, precum i orice tratament mai puin favorabil cauzat de respingerea
unor astfel de comportamente de ctre persoana respectiva ori de supunerea sa la acestea. (art. 2)
Legea 202/2002 privind egalitatea de anse i de tratament ntre femei i brbai i O.G.
137/2000 privind prevenirea i sancionarea tuturor formelor de discriminare trebuie respectate
de orice persoan fizic sau juridic, indiferent dac au un caracter public ori privat.
Instituionalizarea nediscriminrii
Instituia care gestioneaz prevenirea, combaterea i sancionarea discriminrii este Consiliul Naional
pentru Combaterea Discriminrii36. CNCD este responsabil cu aplicarea i controlul O.G. nr. 137/2000
privind prevenirea i sancionarea tuturor formelor de discriminare, cu armonizarea actelor legislative
care intr n conflict cu principiul nediscrimnrii (art. 18, al 1). De asemenea, CNCD are printre atribuii
i n domeniul elaborrii i aplicrii politicilor publice n domeniul nediscriminrii, iar n acest demers,
CNCD colaboreaz cu organizaii neguvernamentale, sindicate, instituii publice etc. (art. 18, al 2).
Potrivit O.G. 137/2000 privind prevenirea i sancionarea tuturor formelor de discriminare CNCD
acioneaz pentru:
a) prevenirea faptelor de discriminare;
b) medierea faptelor de discriminare;
c) investigarea, constatarea i sancionarea faptelor de discriminare;
d) monitorizarea cazurilor de discriminare;
e) acordarea de asisten de specialitate victimelor discriminrii. (art. 19)
Dup ce ne-am familiarizat cu o serie de noiuni importante pentru domeniul egalitii de anse i de
gen, putem particulariza mai departe analiza n raport cu piaa muncii, de pild.

35 http://www.cncd.org.ro/new/formele_disciminarii/ i http://www.dreptonline.ro/legislatie/legea_egalitatii_sanse_femei.php
36 http://www.cncd.org.ro/profil/
18

III. EGALITATE DE ANSE I DE GEN PE PIAA MUNCII37

Legislaia romneasc n domeniul egalitii de anse ntre femei i brbai pe piaa muncii
reglementeaz38:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Accesul pe piaa muncii (recrutare i selecie).


Formarea i perfecionarea profesional.
Promovarea.
Sancionarea.
Concedierea.
Salarizarea.
Maternitatea/ Parentalitatea, creterea i ngrijirea copilului
Hruirea sexual.
Drepturile la asigurri sociale39.

Egalitatea de anse ntre femei i brbai pe piaa muncii nseamn c femeile i brbaii:
1. Pot s-i aleag i s exercite liber o profesie sau o activitate,
2. Pot s se angajeze n posturile sau locurile de munc vacante i la toate nivelurile ierarhiei
profesionale,
3. Beneficiaz de informare i consiliere profesional, de programe de iniiere, calificare, perfecionare,
specializare i recalificare profesional;
4. Pot s promoveze la orice nivel ierarhic i profesional.
Cui se aplic prevederile?
- lucrtorilor din sectorul public,
- lucrtorilor din sectorul privat,
- lucrtorilor independeni,
- lucrtorilor din agricultur,
- funcionarilor publici,
- personalului contractual.
V propun s nelegem egalitatea de anse ntre femei i brbai pe piaa muncii pornind de la cazuri
concrete de nclcare a prevederilor legale aa cum sunt acestea prezentate i explicate n Rapoartele
de activitate ale CNCD.
Spee discriminare pe piaa muncii
Potrivit Raportelor de activitate ale Consiliului Naional pentru Combaterea Discrimnrii, cazurile
reclamate n baza criteriului de gen se refer preponderent la concedierea anagajatelor n urma strii
de graviditate, a faptului c acestea au beneficiat de concediu de maternitate ori de cel de cretere i
ngrijire a copilului. Aa cum vom vedea din cazurile selectate, organizaiile sancionate sunt deopotriv
de stat ori angajatori privai.

37 Pentru o analiz mai ampl, vezi vezi Blu, Oana, 2014, Egalitate de anse i de gen (suport de curs), seciunea II Sex,
gen, prejudecat. Stereotipuri i discriminare, publicat n cadrul proiectului Media FEM- coala Naional de Jurnalism,
editat de Blockbuster Media.
38 Cum promovm egalitatea de anse la nivel local, Centrul Parteneriat pentru Egalitate, 2007, p.13.
39 Nu voi discuta aici despre acest drept deoarece prezentarea se axeaz pe intrarea i meninerea femeilor pe piaa
muncii.
19

Legislaia interzice i sancioneaz concedierea pe durata:


- n care femeia salariat este gravid, n msura n care angajatorul a luat la cunotin de acest
fapt anterior emiterii deciziei de concediere,
- concediului de maternitate,
- concediului pentru creterea copilului n vrst de pn la doi ani sau, n cazul copilului cu
dizabiliti, pn la mplinirea vrstei de 3 ani.
1.) Graviditatea ori maternitatea ca motiv de concediere. Graviditatea este o experien exclusiv
femeiasc, dar i n prezent exist angajatori care sancioneaz femeile pentru o stare natural40.
Petenta, salariat a C.N. Pota Romn n funcia de economist, n cadrul Serviciului Contabilitate,
susine c n luna mai 2012 a ntiinat angajatorul cu privire la starea sa de graviditate. n luna
iunie 2012, ca urmare a unor msuri de reorganizare, angajatorul a anunat scoaterea la concurs
a posturilor din cadrul Serviciului Contabilitate, comunicnd totodat c avea posibilitatea de a
participa la concurs. La interviul organizat au fost declarate respinse doar salariatele care erau n
stare de graviditate sau se aflau n concediu de cretere copil. n urma interviului, petenta susine c
a fost emis decizia de concediere. Aplicarea acestei msuri nelegale de concediere a supus petenta
unui stres ce i-a provocat suferin fizic, existnd riscul de a pierde sarcina. Partea reclamat,
C. N. Pota Romn depune la dosar un punct de vedere prin care susine faptul c petenta dei
a fost respins la interviu, nu a fost concediat aa cum susine n petiie. Acest fapt este rezultat
din adresa ITM, unde se menioneaz c petenta figureaz cu contract de munc activ de la data
angajrii, aspect neprobat de prile reclamate. Prin hotrrea nr.61/06.02.2013, Colegiul director
constat existena unei fapte de discriminare, respectiv constat nclcarea dispoziiilor art.2 alin.5
coroborate cu dispoziiile art.6 lit. a din O.G. nr.137/2000, republicat. Fa de aceste aspecte, avnd
n vedere dispoziiile art. 26 din O.G. nr.137/2000, republicat, Colegiul director dispune sancionarea
contravenional a reclamatului (Compania Naional Pota Romn S.A. Direcia Regional de Pot
N.E., prin Director) cu o amend contravenional n cuantum de 2.000 lei.
Sursa: Raportul de activitate - 2013 al Consiliului Naional pentru Combaterea Discriminrii, p. 28.
2.) Concediul de maternitate
S.C. Raiffeisen Bank S.A. - Sucursal trateaz difereniat petenta dup ntoarcerea acesteia din
concediul de maternitate prin desfacerea contractului individual de munc. Petenta menioneaz
c i s-au pus la dispoziie posturile vacante, la care a aplicat prin e-mail, dar nu a fost chemat la
interviu i nici nu i s-a rspuns. (..)
Raiffeisen Bank SA arat c nu a luat decizia ncetrii raporturilor de munc cu salariata n
considerarea situaiei salariatei (maternitate urmat de concediu de ngrijire copil), ci exclusiv pe
baza criteriilor profesionale, performana i vechimea n cadrul organizaiei. (...)
Colegiul director constat c petenta a fost anunat cu privire la desfiinarea postului su la
ntoarcerea din concediul de cretere a copilului. Colegiul director apreciaz c prin acest tratament
difereniat, anume desfacerea contractului de munc, neoferirea unui post similar cu cel deinut
anterior i nechemarea la interviu pentru ocuparea altui post, petentei i-a fost ngrdit dreptul la
munc i la o remuneraie echitabil. Prin hotrrea nr.169/03.04.2013 Colegiul director a dispus
constatarea existenei unui tratament difereniat, discriminatoriu potrivit art. 2 alin. 1 i art. 6 lit.
a) i g) din O.G. nr. 137/2000 privind prevenirea i sancionarea tuturor formelor de discriminare,
40 M refer la faptul c din punct de vedere biologic femeile sunt cele care pot s poarte o sarcin.
20

republicat i sancionarea S.C. Raiffeisen Bank S.A. cu amend contravenional n valoare de 4.000
lei, pentru faptele prevzute de art. 6 lit. a) din O.G. 137/2000, republicat, conform art. 26 alin. 1
din O.G. 137/2000 privind prevenirea i sancionarea tuturor formelor de discriminare, republicat
i sancionarea S.C. Raiffeisen Bank S.A. cu amend contravenional n valoare de 2000 lei, pentru
faptele prevzute de art. 6 lit. g) din O.G. 137/2000, republicat, conform art. 26 alin. 1 din O.G.
137/2000 privind prevenirea i sancionarea tuturor formelor de discriminare, republicat.
Sursa: Raportul de activitate - 2013 al Consiliului Naional pentru Combaterea Discriminrii, p. 28.

3.) Concediul de cretere i ngrijire a copilului


B.R., n calitate de administrator judiciar Euro Insol SPRL, s-a plns unei jurnaliste TV cu privire la
situaia unei categorii de angajate din cadrul S.C Hidroelectrica S.A, aflate n concediu de cretere i
ngrijire copil ori de luzie. Petenta F.S.H, n calitate de reprezentant a persoanelor ce fac obiectul
petiiei, sesizeaz faptul c reclamata arat intenia de a le concedia odat cu demararea procedurilor de
insolven i reorganizare a societii, artnd totodat i un dispre fa de acestea, leznd demnitatea
uman i crend o atmosfer de intimidare, ostil, degradant i ofensatoare; Hidroelectrica este o
societate de producie, nu de luze, denumindu-le ftuci care au fcut copii pe band rulant i
nu au mai dat de muli ani pe la Hidroelectrica, plimb aerul prin curtea instituiei, pentru c sunt
neveste i amante de mecheri; eu ce s fac? S dau afar inginerii care sunt n producie sau s le dau
pe fetele astea care nu au mai dat de 4-6 ani pe la Hidroelectrica i care sunt, oricum personal TESA.
Colegiul director, prin hotrrea nr. 562/18.09.2013, a constatat c aspectele sesizate n petiie sunt
discriminatorii potrivit art. 2 alin 1 i art. 15 din O.G nr.137/2000, republicat i a dispus sancionarea
prii reclamate pentru declaraia fcut potrivit art. 15 i art. 26 alin 1), din O.G nr.137/2000,
republicat, cu amend contravenional n cuantum de 10.000 lei.
Sursa: Raportul de activitate - 2013 al Consiliului Naional pentru Combaterea Discriminrii, p. 28.

4.) Angajare acces pe piaa muncii


n data de 3.04.2009, Centrul de Dezvoltare Curricular i Studii de Gen: FILIA a trimis o petiie ctre
CNCD n care a reclamat un proces de recrutare discriminatorie n baza criteriului de gen de ctre
Inspectoratul General al Poliiei Romne.
Inspectoratul General al Poliiei Romne, instituie a statului aflat n subordinea Ministerul
Administratiei Internelor, a comunicat n data de 31 martie 2009 c n perioada 1 10 aprilie a.c., i
deschide porile i i invit pe toi cei care sunt interesai i i doresc s devin poliiti s se nscrie
pentru a participa la concursul pentru cele 1200 de posturi de ageni de poliie pentru structurile de
ordine i siguran public (citat din comunicatul Poliiei Romne). Acelai comunicat conine ns
pe lng numrul de posturi i o segregare numeric a acestora n funcie de sex, de exemplu,
n cadrul Direciei Generale de Poliie a Municipiului Bucureti din cele 450 de locuri, 420 sunt
alocate brbailor, iar 30 femeilor. Mai mult, aa cum reiese din comunicat, exist uniti teritoriale
n care locurile sunt exclusiv pentru brbai, de exemplu Inspectoratul de Poliie al Judeului Alba,
Inspectoratul de Poliie al Judeului Braov, Inspectoratul de Poliie al Judeului Brila etc.
Sursa: Fragmentul face parte din petiia trimis de Centrul FILIA n data de 3.04.2009 ctre CNCD.
21

Cu titlu de exemplificare, redau n continuare un fragment din comunicat care arat diferene ntre
femei i brbai n selectare care nu au legtur cu competenele profesionale:
Unitile teritoriale de poliie organizatoare sunt urmtoarele:
Unitate

Total posturi

Brbai

Femei

Direcia General de Poliie a Municipiului Bucureti

450

420

30

Inspectoratul de Poliie al Judeului Alba

20

20

Inspectoratul de Poliie al Judeului Bacu

70

67

Inspectoratul de Poliie al Judeului Bistria-Nsud

20

17

Inspectoratul de Poliie al Judeului Botoani

50

47

Inspectoratul de Poliie al Judeului Braov

10

10

Inspectoratul de Poliie al Judeului Brila

10

10

Inspectoratul de Poliie al Judeului Buzu

10

10

Sursa: Comunicat, Inspectoratul General al Poliiei Romne din 31 martie 2009.

IV. N FINAL, CE FACEM? RECOMANDRI


nelegere
Indiferent dac suntem parte din administraia local ori central, c lucrm ntr-o organizaie
nonguvernamental ori c suntem oameni din pres, primul demers pe care e recomandat s l facem
este s nelegem. Ce presupune acesta este s nelegem semnificaia noiunilor de: egalitate de anse i
de gen, discriminare, ce sunt rolurile de gen i ce se afl n spatele lor, ce sunt stereotipurile de gen i cum
funcioneaz ele, care le sunt consecinele. nelegerea este primul pas ctre activitatea profesional
aezat contient pe drumul susinerii egalitii de anse i de gen.
Integrare
Un alt pas important dup ce am parcurs etapa nelegerii este s integrm n activitatea nostr o
perspectiv de gen pentru ca femeile i brbaii s se bucure de anse egale. Exist Ghiduri elaborate de
instituii europene, de organizaii nonguvernamentale care ne ajut s integrm o perspectiv de gen
n activitatea profesional41.

41 Vezi, de pild: Consiliul Europei, 1998, Gender mainstreaming: conceptual framework, methodology and presentation of
good practices, Strasbourg.
22

Comunicare bazat pe stereotipuri ori pe deconstruirea stereotipurilor de gen?


Dintr-o monitorizare42 recent de pres din perioada iulie 2014 aprilie 201543, realizat n cadrul
proiectului FA - Femei active pe piaa muncii, Beneficiar Fundaia MULTIMEDIA- pentru democraie
local aflm urmtoarele: interesul fa de problematica de gen este destul de sczut, media prefer s
ilustreze femeile ntr-un context negativ, presa local are o abordare mai pozitiv n raport cu egalitatea
de gen, presa opereaz cu stereotipuri de gen.
Interesul presei fa de problematica de gen (statutul femeii n societate) este destul de sczut
doar 499 de articole din 1.574 selectate au corespuns criteriilor analizei de context. n condiiile n
care presa este unul dintre cei mai importani formatori ai opiniilor i percepiilor publice, abordarea
limitat a unor teme care s vizeze statutul femeii n societate explic, cel puin n parte, atitudinile,
valorile i comportamentele dominante social (stereotipuri, prejudeci, discriminare etc.).
Media prefer s ilustreze femeile ntr-un context negativ dei cele mai multe uniti de analiz
(810 din 1.574) prezint femeia ntr-un context neutru, raportul context pozitiv (211) context negativ
(553) este, indubitabil, n favoarea ultimei categorii. n acest caz, presa nu face dect s reflecte realiti
i situaii sociale defavorabile femeilor (este posibil ca portretizarea femeilor n contexte negative s
fie expresia unui stereotip care nu este contientizat i combtut ca atare la nivelul media).
Discriminarea i stereotipurile n spaiul mediatic o constant a spaiului mediatic este aceea
a reprezentrii femeilor ca obiecte sexuale ori n ipostaze tradiionale (specifice unei societi
patriarhale); exist tendina legitimrii violenei domestice, precum i o viziune extrem de restrictiv
n raport cu drepturile sexuale i reproductive; un alt stereotip reprodus de media este reprezentat de
inegalitatea salarial dintre femei i brbai, pentru aceeai munc prestat; este justificat adulterul
masculin, iar femeia este reificat; se sugereaz c femeia trebuie s aib o doz de masculinitate
pentru a reui44 (n politic).
Sursa: Raport de monitorizare pres, iunie 2015, realizat n cadrul proiectului FA - Femei active pe
piaa muncii, Beneficiar Fundaia MULTIMEDIA- pentru democraie local, p. 1.
https://proiectfapm.files.wordpress.com/2015/07/femei-active-raport-monitorizare-presa-final.pdf
4243

Reiau o informaie inclus anterior n text: rolurile de gen tradiionale i stereotipurile sunt surse
ale discriminrii de gen.
Un rol important n comunicarea tradiional a stereotipurilor de gen ori n deconstruirea lor l au jurnalitii.
Premisele de la care pornesc n aceast seciune sunt acelea c mass-media au un rol important
n construirea social a realitii, n informarea i semnalarea unor probleme. Diferite organizaii
internaionale, instituii au conceput o serie de recomandri generale care ne sunt de folos n activitate. 44
42 Monitorizarea a inclus publicaii centrale i locale/regionale (Regiunea Centru, Regiunea Nord-Vest, Regiunea Sud
Muntenia, Regiunea Bucureti-Ilfov), unitatea de analiz fiind articolul/ editorialul. Publicaiile au fost selectate n baza
tirajului raportat ctre Biroul Romn de Audit al Tirajelor (BRAT)2. Astfel, publicaiile selectate n vederea monitorizrii au
fost: Unirea, Mesagerul de Sibiu, Tribuna, Ziarul Apulum, Informaia zilei, Actualitatea de Clrai, Prahova i cotidienele
Evenimentul Zilei i Adevrul (generaliste, cu acoperire naional). Vezi - Raport de monitorizare pres, iunie 2015,
realizat n cadrul proiectului FA - Femei active pe piaa muncii, beneficiar Fundaia MULTIMEDIA- pentru democraie
local, https://proiectfapm.files.wordpress.com/2015/07/femei-active-raport-monitorizare-presa-final.pdf p. 4.
43 Raport de monitorizare pres, iunie 2015, realizat n cadrul proiectului FA - Femei active pe piaa muncii, beneficiar
Fundaia MULTIMEDIA- pentru democraie local, https://proiectfapm.files.wordpress.com/2015/07/femei-activeraport-monitorizare-presa-final.pdf
44 Pentru o analiz a stereotipurilor de gen din politic, vezi Blu, Oana, 2015, Gen, politic i mass-media: reprezentri
stereotipizate. Cum tragem linia? n Revista Sfera Politicii nr. 1 (183), martie-aprilie 2015, p. 105-119.
http://www.sferapoliticii.ro/sfera/183/pdf/183.10.Baluta.pdf
23


La nivelul organizaiei
- Participarea la programe de formare n domeniul egalitii de anse i de gen pornind de la
principiul: nimeni nu s-a nscut gata nvat.
- Adoptarea unor coduri de bune practici pentru relatarea despre grupuri vulnerabile.
- Verificarea informaiilor vehiculate n spaiul public i punerea lor n relaie cu date statistice fiindc
de multe ori realitatea bate filmul.
- Colaborarea cu organizaii nonguvernamentale active n domeniu ntruct acestea desfoar
aciuni de contientizare privind efectele negative ale stereotipurilor.
- Stabilirea unei legturi cu audiena feminin, cu cititoarele. Femeile consum materiale de pres
fie c este vorba despre produse din media tradiionale ori noile media, de ce s fie prezentate, aadar,
n ipostaze care abund de stereotipuri? n plus, e posibil ca ele s aib un cuvnt de spus atunci cnd
se decide distribuia bugetului n familie. Accesul la un material de pres poate s i coste, prin urmare
contientizarea stereotipurilor poate fi o abordare bun din punct de vedere economic45.

La nivelul coninutului
- Strategia de contact: interaciune direct cu persoane (femei i brbai) din grupul cruia i sunt
asociate stereotipuri.
- Elaborarea de materiale de pres care s nu uite de rolul social al jurnalitilor.
- Consultarea Ghidurilor de bune practici care vin n sprijinul jurnalitilor. De exemplu, Exist
Ghiduri46 pentru jurnaliti care scriu despre violena de gen/violena asupra femeilor, iar acestea fac o
serie de recomandri jurnalitilor:
1. Agresiunile asupra femeilor sunt un atentat la adresa drepturilor omului, reprezint o nclcare a
drepturilor femeilor. Agresiunile sunt o infraciune, o problem social i ne privesc pe toi i toate, nu
sunt o chestiune privat, domestic sau o ntmplare nefericit.
2. S nu confunde curiozitatea morbid cu interesul social. Info-spectacolul nu este formatul adecvat
pentru acest tip de violen.47
3. Violena asupra femeilor nu este o ntmplare sau o tire convenional i nici urgent. Urgent
este s se rezolve problema, de aceea e nevoie ca ceea ce s-a ntmplat s fie cercetat atent, s fie
contextualizat informaia care se nscrie n categoria violen asupra femeilor. Tema nu trebuie inclus
la categoria ntmplri sau cronic neagr.
4. S ofere informaii utile, s se consulte cu persoane care cunosc fenomenul. Un caz de agresiune ce a
condus la deces poate fi o tire, dar la fel pot fi i aciunile judiciare sau poliieneti, sanciunile, victimele
care au reuit s-i refac viaa i indic o cale de scpare. i opiniile experilor ajut la localizarea
adecvat a problemei.48

45 http://www.ifj.org/fileadmin/images/Gender/Gender_documents/Gender_Equality_Best_Practices_Handbook_-_
English_version.pdf, p. 26.
46 Vezi de pild Ghidul RTVE (Corporacin de Radio y Televisin Espaola) privind reprezentarea violenei mpotriva femeilor
n programele de tiri, http://manualdeestilo.rtve.es/cuestiones-sensibles/5-5-tratamiento-de-la-violencia-contra-lasmujeres/, Telling the Full Story: An Online Guide for Journalists Covering Domestic Violence. TheOnline Guide, 2012, http://
www.dvonlineguide.org/en/
47 n cazul comunicrii unei agresiuni sexuale precum cea de viol, recomand parcurgerea poziiei Active Watch cu privire
la campania publicaiei Adevrul Dreptate pentru fataviolatnVaslui http://blog.activewatch.ro/freeex/comunicareaunui-viol-este-ireversibila/
48 Pentru o altfel de abordare a fenomenului violenei asupra femeilor n presa din Romnia, vezi Blu, Oana, 2015,
Representing and consuming women. Paradoxes in media covering violence against women n Journal of Media
Research, vol.8, issue 2, (22), 2015. http://www.ceeol.com/aspx/issuedetails.aspx?issueid=4e7763e6-9468-4554-8cf26dd1ae5a0422&articleId=9e7983dd-5191-427a-a7f2-f3f294d18382
24

Direcii de reflectat pentru jurnaliti


- nelegi cu responsabilitate impactul pe care materialul tu de pres l are asupra publicului tu?
De pild, nelegi diferena dintre un material de pres care abordeaz violena asupra femeilor n
termeni de amor cu nbdi i altul care o prezint ca nclcare a drepturilor femeilor? Ori dintre un
material n care accesul femeilor n politic este prezentat n paradigma amantlcurilor i un altul care
se raporteaz critic la recrutarea candidailor de ctre partidele politice?
- Eti contient() de puterea pe care o au cuvintele emoionale?
- Eti contient() de prejudecile tale atunci cnd alegi persoane pe care le intervievezi? Se ntmpl
ca n categoria experilor s selectezi mai degrab brbai, de exemplu, pentru c vocea autoritii pare
c este una masculin?
- Cine sunt cei/cele care vorbesc despre femei? Cine sunt experii n materie?
- Cnd lucrezi la un material cu subiecte din tiin, cine sunt experii?
- Ct de mult mergi n profunzimea subiectului? Alegi s intervievezi persoane deja cunoscute ori
ncerci s sapi i dup cei care nu apar pe ecranul televizorului, dar poate au o activitate susinut n
domeniu? De multe ori, cele/cei care lucreaz n domeniul egalitii de anse i de gen nu apar sistematic
la televizor. Munca lor este substanial, dar nu mereu vizibil publicului larg. Dac vei cuta aceste
persoane, aduci opinii avizate n materialul tu.
- Te-ai gndit c prin materialele tale poi deconstrui stereotipurile despre femei? C, de pild, poi
pune sub semnul ntrebrii o mulime de idei false despre femei care afecteaz egalitatea de anse i
de gen? De exemplu, cel potrivit cruia femeile nu sunt pricepute la conducerea treburilor publice ori
politice? tii femei care conduc o companie? tii femei care conduc un stat? Cte femei care sunt decane,
rectore, preedinte de organizaii nonguvernamentale cunoti? Dac nu le tii, nu nseamn c ele nu
exist, ci c nu le-ai descoperit pn acum prin munca ta. Dac nu le-ai identificat, nici nu nseamn c
munca lor nu este relevant, ci c nu te-ai uitat i acolo.
- Te-ai gndit c prin materialele tale poi deconstrui stereotipurile despre brbai? tii c poi
deconstrui modul n care este privit public relaia dintre brbai i copii? C mai degrab n cazul
brbailor se vehiculeaz ideea de nepricepere i lips de responsabilitate fa de propriul copil? C
se uit ori se omite voit faptul c ngrijirea se nva i c femeile nu s-au nscut cu un cip n minte
care s le spun cnd e nevoie s schimbe pampers-ul copilului, deci nu exist niciun cip care s le
lipseasc brbailor? tii dac n alte state se promoveaz public i politic o alt reprezentare a asumrii
parentalitii de ctre brbai? Rspunsul este da, i-l spun eu, ns nu i voi scrie care sunt aceste state
fiindc m atept s caui singur().
- Ct de mult influeneaz experienele i cunotinele tale alegerea subiectelor i a ncadrrii lor?
De exemplu, dac n trafic, ai intrat n coliziune cu o main condus de o femeie, n materialele tale vei
porni de la premisa c femeile nu tiu/pot s conduc un autoturism?
- Cnd abordezi subiecte care prezint fapte de discriminare de gen, ct de mult eti obiectiv() i
raional() i mergi ctre date statistice, ct de mult i aduci aminte de standardele jurnalistice?
- Crezi c prezini realitatea n diversitatea ei? Adic te uii n jur i vezi c femeile sunt diferite ca
vrst, mediu de reziden, etnie, orientare sexual, educaie etc.? tii c aceste diferene pot s le
poziioneze specific n societate i c se pot confrunta cu anumite experiene de discriminare tocmai
pentru c aparin unei etnii ori au o anumit vrst? tii c i brbaii sunt diferii i c aceast diversitate
i aeaz i pe ei n contexte particulare n societate?
Un gnd aparent simplu ctre final: ce facem noi las nite urme. Depinde i de noi (indivizi
ori organizaii) dac vrem s acionm pe un drum al egalitii ori al inegalitii, pe unul al
nondiscriminrii ori pe altul presrat cu discriminare.

25

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27

4. h
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Legislaie
1. L egea 202 din 19 aprilie 2002 (republicat) privind egalitatea de anse i de tratament ntre femei
i brbai.
2. Ordonana 137 din 31 august 2000 (republicat) privind prevenirea i sancionarea tuturor
formelor de discriminare.

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Reader
I.

Blu, Oana, 2015, Egalitate de anse i de gen- suport de curs elaborat n cadrul
proiectului FA - Femei active pe piaa muncii, Beneficiar Fundaia MULTIMEDIApentru democraie local, paginile 4-18.

https://proiectfapm.files.wordpress.com/2015/09/suport-curs-competente-civice-a4corectat.pdf
ntrebri
1. Cum definii noiunea de gen?
2. Cum definii noiunile de roluri de gen i stereotipuri de gen. Oferii cte dou
exemple (total 4).
3. Ce nseamn egalitate de anse? Unde se aplic egalitatea de anse?
4. Care este legea cadru care acoper egalitatea de anse n Romnia?
5. Care este diferena dintre egalitate de anse i egalitate n drepturi. Exemplificai.
6. Ce nseamn discriminarea de gen?
7. Care este legea cadru care acoper prevenirea i combaterea discriminrii n
Romnia?

Data and Information on Womens Health


in the European Union

Faculty of Medicine Carl Gustav Carus


Research Association Public Health Saxony and Saxony-Anhalt
Technische Universitt Dresden,
Dresden, Germany

The information contained in this publication does not necessarily reflect the opinion or the
position of the European Commission.
Neither the European Commission nor any person acting on its behalf is responsible for any use
that might be made of the following information.

Europe Direct is a service to help you find answers


to your questions about the European Union
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numbers or these calls may be billed.

Cataloguing data can be found at the end of this publication.


ISBN-978-92-79-13659-7
European Communities, 2009
Reproduction is authorised provided the source is acknowledged.

Authors
Kerstin Thmmler
Faculty of Medicine Carl Gustav Carus
Research Association Public Health Saxony and Saxony-Anhalt
Technische Universitt Dresden,
Dresden, Germany
Amadea Britton
Faculty of Medicine Carl Gustav Carus
Research Association Public Health Saxony and Saxony-Anhalt
Technische Universitt Dresden,
Dresden, Germany
Wilhelm Kirch
Faculty of Medicine Carl Gustav Carus
Research Association Public Health Saxony and Saxony-Anhalt
Technische Universitt Dresden,
Dresden, Germany
List of Contributors
Wilhelm Kirch
Faculty of Medicine Carl Gustav Carus
Research Association Public Health Saxony and Saxony-Anhalt
Technische Universitt Dresden,
Dresden, Germany
Robert Bauer

Austrian Road Safety Board (kfV)
A-1100 Vienna
Austria
Kerstin Thmmler
Faculty of Medicine Carl Gustav Carus
Research Association Public Health Saxony and Saxony-Anhalt
Technische Universitt Dresden,
Dresden, Germany
Claudia Schindler
Faculty of Medicine Carl Gustav Carus
Research Association Public Health Saxony and Saxony-Anhalt
Technische Universitt Dresden,
Dresden, Germany
Amadea Britton
Faculty of Medicine Carl Gustav Carus
Research Association Public Health Saxony and Saxony-Anhalt
Technische Universitt Dresden,
Dresden, Germany

Ines Kube
Faculty of Medicine Carl Gustav Carus
Research Association Public Health Saxony and Saxony-Anhalt
Technische Universitt Dresden,
Dresden, Germany
Grit Neumann
Faculty of Medicine Carl Gustav Carus
Research Association Public Health Saxony and Saxony-Anhalt
Technische Universitt Dresden,
Dresden, Germany

Acknowledgements:
The following literature update on womens health in the European Union was reviewed for DG SANCO
and the European Commission by Dr. med. Natalie M. Schmitt, a Johns Hopkins Bloomberg School
of Public Health MPH graduate and expert in the field of Womens and Reproductive Health. The
authors would also like to thank Anna Klamar and Sabrina Gaitzsch for their invaluable assistance
in the preparation of this report.

European Commission

Data and Information on Womens


Health in the European Union

Foreword

Dear Reader,
This report Data and Information on Womens Health in the European Union provides a
short overview concerning womens health.
This report provides an overview of the main topics, as a necessary first step for further
work. Of course, much more could be done in all the areas covered for example in the mental
health area on violence against women, or in the lifestyle areas on smoking and alcohol.
Nevertheless, this report provides an overview of issues related to womens health across
the EU Member States also including EEA countries. It highlights gaps and special topics
where research and more information are needed.
Some of the principal findings of this report are the following:
-the main causes of death in women in the EU and EEA are cardiovascular disease (CVD) and
cancer,
- Women are particularly affected by mental health problems such as depression, dementia
and Alzheimers
-there is a great need for further research into how certain diseases affect women in particular.
The womens health report is the first step to look into gender health aspects under different angles. The next gender report will be the First European Mens health report which is
currently being prepared.
Let me express my hopes that this report will already provide a useful overview and help to
identify areas where more action is need.



Andrzej Ry
Director - Public Health and Risk Assessment

Contents

Summary

11

Introduction

17

Demographic and socio-economic Trends

21

Population Structure

22

Social Trends Marital status of women across the lifespan

24

Life Expectancy

24

Healthy Life Years

25

Population Change

26

Education and Employment

29

Health Issues

33

Cardiovascular Diseases

34

Coronary heart disease (CHD)

34

Cerebrovascular disease (stroke)

34

Cancer

35

Breast Cancer

35

Cervical Cancer

36

Lung cancer

37

Colorectal Cancer (Colon and rectal cancer)

38

Infectious diseases

38

HIV/AIDS

38

Influenza

39

Syphilis (Treponema pallidum)

40

Chlamydia

40

Gonorrhoea

40

Vaccination coverage

41

Sexual and Reproductive health

42

Fertility

42

Pregnancy outcome

42

Maternal mortality

43

Abortion

43

Sexual and intimate partner violence

44

Endometriosis

45

Diabetes mellitus

46

Mental health

47

Dementia and Alzheimers disease

47

Depression

48

Musculoskeletal Disorders

49

Rheumatoid arthritis

49

Osteoporosis and osteoporotic fracture

50

Lifestyle

53

Smoking

54

Alcohol consumption

55

Overweight, Obesity and Eating Disorders

57

Physical Activity (PA)

58

Drug and substance abuse

59

Accidents and Injuries of Women in the EU

60

Health care

65

Access to health care

66

Quality of Health care

69

Responsiveness of healthcare to specific needs of women

70

HPV vaccination

70

Health promotion of physical activity (PA) among working women

71

Conclusion

74

Recommendations

76

Glossary

80

References

81

List of abbreviations

87

10

Summary

11

This report presents an overview of the state of womens health in the European Union. The report
focuses on women aged 15 years and older in the 27 EU-Member States, as well as the EEA
countries Norway, Iceland, and Liechtenstein, and occasionally Switzerland.
The report is divided into six chapters. The first chapter introduces the report and its goals and
methodologies. Chapter 2 deals with changing demographic and socio-economic trends that are
pertinent to womens health. Chapter 3 provides an overview of the main issues in womens health
and describes different trends, risk factors, and health determinants. Supplementing this information,
Chapter 4 concentrates on the main lifestyle-related determinants of diseases that affect women,
such as tobacco and alcohol use. Chapter 5 provides an overview of womens access to health
care, the quality of health care provided for women, and the responsiveness of different health
care systems to womens needs. Finally, Chapter 6 concludes the report with a summary of key
information presented in the report and recommendations for policy makers and stakeholders for the
promotion of womens health across the European Community.

Demographic and socio-economic trends


Overall, there are marginally more men than women in Europe, with the proportion of women
increasing in older age categories. In 2005, there were approximately 15% more women than men
among those aged 65-69 and almost two times more women than men aged over 80, leading to a
total of 43% more women than men aged 65 and over (EUROSTAT 2008a, 2008b).
In all European countries, life expectancy is greater for women than for men, with the largest gap
between the sexes in Lithuania (11.7 years) and the smallest in Iceland (3.4) (based on 2006 data).
Eurostat predictions indicate that in 2010 average life expectancy for women will range from 76.5 to
84.5 years and in 2050 it will have increased to 82 to 89.1 years (EUROSTAT 2008a).
On average European women reach higher levels of education than men. However, women are
also more likely to receive lower wages: in 2006 women in the EU-27 earned on average 15% less
per hour than men. Women also spend more of their time doing unpaid work than men (women
average 278 minutes a day of unpaid domestic work, while men spend less than half of that time
(EUROSTAT 2008b).

Health issues
Breast cancer is the most common form of incident cancer and the dominant cause of cancer-related
death among women aged 0-74 across the European Union. Female mortality due to lung cancer
is significantly lower than that of breast cancer, and is also lower in women than men, but has been
steadily rising (Bosetti et al 2008, Boyle Lewin 2008).
Across the EU/EEA countries, men are more affected by HIV than women, with an infection ratio of
2:1. In women the predominant routes of transmission are heterosexual contact and injection drug
use (ECDC 2008a).
In terms of other sexually transmitted infectious diseases, a number of European countries showed
a recent increase in new chlamydia infections. This is particularly relevant to women as chlamydia
is more often diagnosed in women than in men (ESSTI 2008).
The total fertility rate among the countries of the EU is very low, having declined from 2.6 in early
1960 to 1.4 in 1995-2005. Meanwhile, the mean age of women bearing children increased at

12

least two years in the period 1995-2006, meaning women are giving birth later and having fewer
children. Southern European countries have the highest percentages of low birth weight babies
(Spain, Portugal, Greece), whereas Northern countries have the lowest percentages. Abortions in
adolescents and young women less than 20 years of age remain high, having increased during the
period 1995-2005 (EUROSTAT 2008a).
Diabetes is a growing problem and it is estimated that between 2007 and 2025 Germany, Italy, and
France will have the greatest increases in women aged 20-79 years with diabetes mellitus (DM)
(IDF 2006). For women the average death rate due to DM was 12.8 and among individual countries
the highest rates were observed in Cyprus (35.5), Portugal (25.3), Austria (23.4), and Malta (19.2)
(EUROSTAT 2009).
The prevalence of dementia and Alzheimers disease (AD) is higher among elderly women than
among elderly men. Significant gender differences are found in the incidences of AD after the age
of 85 years.
Depression is more common in women than in men (lifetime prevalence: 9.4%; 12-month prevalence:
2.8%) (European Commission 2008b). Studies reveal prevalence of suicide attempts is two times
higher in women than in men (DG for Health and Consumers 2008).

Lifestyle
Smoking prevalence is lower in women than in men, however, this gap has been closing in recent
years due to decreasing numbers of men smoking and increasing numbers of women smoking in
certain countries. In addition, smoking-associated deaths among women are still on the rise in some
Eastern European countries. Young girls are more likely to smoke than boys, particularly in Northern
and Western European countries. (WHO 2009b)
Across the EU overall drug use is more common in men than in women, but the use of tranquilisers
and sedative substances is more common in school-aged girls than boys in most EU-Member States
(EMCDDA 2006).
The prevalence of overweight and obesity is rapidly increasing in many European countries for both
sexes. The highest percentages of women with obesity were found in Austria, the UK, and Germany
(IOTF 2009).
Data on specific eating disorders, such as bulimia nervosa, are rare. However, the generally accepted
prevalence rate of bulimia nervosa is about 1% among young women (Hoek 2006).

13

Health care
Reliable and comparable data on access to health care across the EU-27 Member States is limited.
The most comprehensive available data comes from the 2007 Eurobarometer Survey Health and
Long-Term Care in the European Union, which is a public opinion survey and sufficient only to
suggest potential trends. Based on those women interviewed for the survey, the majority of European
women report having easy access to health care. Approximately 88% of women felt that it was easy
to access a family doctor or general practitioner. However, the survey suggests that access to
health services varies widely within and across Europe (DG Employment, Social Affairs and Equal
Opportunities 2007).
Current data on health care utilization in Europe tends to make no distinction between sexes.
Gendered data on healthcare expenditures is lacking and data on health care costs and health
insurance coverage for women is weak.
Comparable data on screening volume and health promotion programme participation is limited. As
of 2007, in a review of the EU-27, breast cancer screening was available at the population level in
eleven countries (IARC 2008a).

Conclusions and Recommendations


There is persistent evidence that sex and gender differences are not only relevant for reproductive
health issues, but also for the prevalence of diseases, risk factors, and health care among women. It is
essential to acknowledge that differences in health between women and men are due to interactions
between environmental, behavioural, and biological factors. It is important to keep in mind that this
report is not intended to cover all facets of the health status of women in the EU. The subject areas
addressed are limited by their relevance to womens health, the availability of reliable and topical
data for all or most EU-27 Member States and the EEA, and the availability of data in a sex-specific
format, which is not the case for many fields. In light of this, the main recommendation of this report
is to implement standardised gendered data collection and to improve data quality in areas where
current data is either non-existent or non-sex-specific, including access to health care, health care
expenditures and costs, specific eating disorders, pain and migraine, alcohol use, smoking habits,
and abuse and misuse of legal medications.

14

Life on the planet is born of woman

Adrienne Rich

15

16

Introduction

17

Womens health encompasses more than pregnancy and reproductive health. In many parts of the
world a womans reproductive years comprise less than half of her life. Weismans definition (1998)
of womens health addresses the complexity of the field, highlighting that
- health is a product of cultural, social, and psychological factors, as well as biology;
- it is important to consider and emphasize a lifespan and multiple role perspective;
- the individual and society have to promote health and prevent disease in order to fulfil the concept
of health beyond the absence of disease.
Based on this understanding of womens health, the exclusive focus adopted by this report on
women and their corresponding health issues and needs is necessary to adequately address the
topic. There are diseases which are unique, more prevalent, or more serious in women and for some
diseases risk factors and interventions are different for women and men. Changes in diseases over
time and across the lifespan also differ between women and men. Furthermore, womens health
is significantly associated with differences in gender equality in social, educational, cultural, and
economic status (Schmitt 2008). In light of these sex-dependent factors, there is much to be gained
by approaching womens health as its own important field.
This report presents an overview of the state of womens health in the European Union and addresses
both the differences between men and women and the differences among women living in different
Member States. It examines the main patterns of mortality and morbidity and the health risk factors at
different stages of womens lives and reports on the current situation and recent trends in European
womens health. It also provides information about the influence of demographic trends and socioeconomic factors on womens health.
The report is divided into five chapters: demographic and socio-economic trends; womens health
issues; lifestyle; health care; and conclusion and recommendations for future research in the field
of EU womens health.
Each chapter is subdivided into separate sections addressing specific issues in womens health
which are oriented around the health indicators developed by the European Community Health
Indicators project (ECHI) (Kilpelinen et al. 2008).

18

The focus is on women aged 15 years and older in the 27 EU-Member States, as well as Norway,
Iceland, and Liechtenstein, as shown in Table 1.
The main sources used in the preparation of the report include:
- the Statistical Office of the European Communities (EUROSTAT 2009),
- the Organisation for Economic Co-Operation and Development (OECD),
- the World Health Organization (WHO) databases: European Health For All Database (HFA),
European mortality database (MDB), Alcohol control database, Tobacco control database,
- various reports and publications from organisations working on specific womens health
issues,
- literature searches in academic publications available through the PubMed database.
Table 1: Member States of the EU

Member States of the EU (EU27)


Austria

Luxembourg

Belgium

Malta

Bulgaria

Netherlands

Cyprus

Poland

Czech Republic

Portugal

Denmark

Romania

Estonia

Slovakia

Finland

Slovenia

France

Spain

Germany

Sweden

Greece

United Kingdom

Hungary
Ireland

Additional Countries

Italy

Norway

Latvia

Iceland

Lithuania

Liechtenstein

19

20

Demographic and
Socio-economic
Trends

21

Between 1960 and 2007 the population in the current EU-27 countries expanded from 403 million
people to around 495 million people (EUROSTAT 2008a). Factors that influence population change,
such as life expectancy, fertility and mortality rates, and net migration are currently undergoing
significant change, as are other socio-demographic behaviours such as marriage rates. In addition,
the socio-economic status of women is changing. More women are employed and reaching higher
levels of educational attainment, which has resulted in greater female autonomy. There are still
significant gender gaps in fields of employment and education and in time spent doing unpaid work
(such as household chores, childcare, and care of elderly and sick family members). These trends
are significant for womens health.

Population Structure
Size
In 2006 the population of the combined EU-27 Member States was 494,049,094 including
252,956,162 women (EUROSTAT 2009). Germany had the largest absolute female population
(42,055,887), followed by France (32,489,038), the UK (30,914,956), and Italy (30,318,835)
(EUROSTAT 2009).

Sex Ratio
There are marginally more women than men in Europe (104.9 women for every 100 men in the EU27 in 2007), but the sex ratio varies by age group, as shown in figure 1. Among live births in 2005
in EU-25 countries, 51.3% were boys, while 48.7% were girls (EUROSTAT 2008b). Men outnumber
women until the age of 45, after which the proportion of women relative to men increases in each
successive age category. In 2005, there were approximately 15% more women than men among
those aged 65-69 and almost two times more women than men aged over 80, leading to a total of
43% more women than men aged 65 and over (EUROSTAT 2008a; EUROSTAT 2008b).

Fig. 1: Women per 100 men in the combined EU-27 population in 2007. (EUROSTAT 2009)

Age Categories
Decreasing fertility and increasing life expectancy have led to overall population ageing. In 1990,
19% of the EU-25 population was under 15 and 14% was 65 or overby 2005 those numbers had

22

changed to 16% and 17% respectively (EUROSTAT 2008b). By 2007, 16.9% of the total population
in the combined EU-27 Member States was over 65 years old ranging from 10.9% in Ireland to
19.9% in Italy (EUROSTAT 2009).
Eurostat predicts a continued demographic shift towards greater percentages of the European
population in older age categories. This shift is expected to have significant consequences, including
impacting the school-age population, family structures, labour force participation, health care, social
protection and social security issues, government finances, and economic competitiveness. As
women already comprise larger percentages of the age categories expected to increase in size,
elderly women are an increasingly important demographic group (EUROSTAT 2008a).

Fig. 2: Percentages of EU-27 women and men in different age categories in 2006. (EUROSTAT 2009)

23

Social Trends Marital status of women across the lifespan


The age at which women first marry has increased in the EU in recent years, a result of more time
spent in education and increased priority being placed on the establishment of a professional career
before marriage. Average age at first marriage is similar across Europe and overall, women still
marry slightly younger than men (EU average in 2003 was 29.8 for men, 27.4 for women). However,
the age difference is small across most of the EU. The largest gap in age at first marriage, based
on data from 2003, occurs in Greece (3.8 years) (EUROSTAT 2008b). There has also been a trend
toward an overall reduction in the number of marriages and an increase in the number of divorces
in Europe (EUROSTAT 2008a).

Life Expectancy
Life expectancy is the average number of years that an individual is expected to live if mortality
patterns remain unchanged for the duration of his or her lifespan (WHO 2008). Life expectancy
at birth is greater today than it was in 1995 for women from all parts of Europe, a result of better
living conditions and health care and greater awareness of health issues (EUROSTAT 2008a).
The greatest increases since 1995 have been observed in Estonia (4.3 years) and other Eastern
European countries, as well as in Ireland (3.8 years) (EUROSTAT 2009).
For female children born in 2006, life expectancy ranges from 76.2 years in Romania to 84.4 years
in France and Spain. Life expectancy at birth is relatively low for Bulgarian women and high for
women from Sweden, Liechtenstein, and Finland.
For women aged 65 in 2005, life expectancy was highest in France (22.6 additional years of life) and
lowest in Bulgaria (16.3 additional years) (EUROSTAT 2009).
In all European countries, life expectancy for women is greater than that for men. The greatest gap
between the sexes, based on 2006 data, occurs in Lithuania (11.7 years) and the smallest gap is in
Iceland (3.4), as shown in figure 3. However, the gap between life expectancies has been closing
in recent decades, potentially due to increased similarities in lifestyles between the sexes (e.g.
increased smoking among women), and this trend is likely to continue, with the greatest gains for
males in the newest EU-Member States (EUROSTAT 2008a). Eurostat predictions indicate that in
2010 life expectancy will range from 65.8 years (in Latvia) to 79.1 years (in Sweden) for men and
from 76.5 years (in Romania) to 84.5 years (in Spain) for women; in 2050 it is projected to range
from 74.3 years (in Latvia) to 83.6 years (in Italy) for men and 82 years (in Romania) to 89.1 years
(in Spain) for women (EUROSTAT 2008a).

24

Fig. 3: Average life expectancy in years of women and men in the EU-27 in 2006. (EUROSTAT 2009)

Healthy Life Years


With more women living longer lives the quality of the additional years becomes a central question.
Healthy life years (HLYs), also referred to as disability-free life expectancy, is the number of remaining
years of life that a person of a specific age is expected to live without any moderate or severe health
problems or acquired disabilities (EUROSTAT 2008a). The indicator is meant to complement life
expectancy data and provides information on the quality of years lived rather than the quantity.
HLYs also provide information on the structural and financial burdens the health care system faces
as women age.
Overall, across Europe, women are expected to live a slightly smaller proportion of their years in
good health than men (75.4% versus 80.7%) (EUROSTAT 2009). In the EU-25 in 2006, men were
on average expected to have 61.6 HLYs, while women were expected to have 62.1 HLYs, as shown
in figure 4 (EUROSTAT 2009). Combined with their longer average life expectancy, this means
women experience more years of disability than men.
For women in the EU in 2006, HLYs expected at birth ranged from 52.1 in Latvia to 69.2 in Malta,
with women in Slovakia, Finland, and Estonia expected to have fewer than 55 HLYs and women in
Denmark, Greece, Ireland, Iceland, Italy, Sweden, and the UK expected to have more than 65 HLYs
(EUROSTAT 2009).
Among women 65 and over in 2006, women from Denmark had the largest number of expected
HLYs remaining (14.1) while Slovakian women had the smallest (3.8) (EUROSTAT 2009).

25

Fig. 4: Average number of expected healthy life years for women born in 2006 and women
aged 65 by European country in 2006. (EUROSTAT 2009)

Population Change
Birth rate
There were 5,281,625 live births in the EU-27 in 2007. In Europe the greatest number of live births
occurred in France (819,605), the UK (772,245), and Germany (684,862) and the smallest number
occurred in Liechtenstein (351), Malta (3,871), and Iceland (4,560), as shown in figure 5 (EUROSTAT
2009). In 2005 the birth rate or live births per 1,000 population was 10.4 in the EU-27, ranging
from 8.31 in Germany to 14.78 in Ireland (WHO 2009h).

Fig. 5: Total number of live births by European country in 2007. (EUROSTAT 2009)

26

Mortality
Standardised death rate (SDR) per 100,000 is significantly higher in European men than in women.
In 2006, the SDR in the EU-27 was 503.6 for women and 827.4 for men (data unavailable for
Belgium, Denmark, Iceland, and the UK). SDR was also higher among men than women in all
individual countries for which data was available, ranging from 391.7 in Spain to 808.5 in Bulgaria.
The discrepancy between male and female SDR is greatest in Lithuania, where an average of 835.9
more men than women die per 100,000 individuals. SDR is also higher among Eastern European
countries and newer EU-Member States (EUROSTAT 2009).
Mortality rate varies in the different age categories. For infants 0 to 1 year old, mortality is higher
among males. In 2004, female infant mortality was 3.9 (per 1,000 live births) while male infant
mortality was 4.8 (EUROSTAT 2008b). Mortality for girls aged 1-4 was around 20/100,000 and for
girls aged 5-14 it was around 11/100,000 (based on 2005 data).
Mortality increases after age 15 for both sexes, but female mortality increases less quickly than
male mortality. Mortality among women aged 15 to 19 was 22/100,000, while male mortality was
54/100,000 (2005 data). In the early 20s, male mortality is almost triple female mortality.
After that, crude female mortality (based on 100,000 female inhabitants in the EU-27) was 46 for
women 30-34, 117.6 for women 40-44, 317.8 for women 50-54, 685.5 for women 60-64, 1,890.9 for
women 70-74, and 16,235.1 for women above 85 years (EUROSTAT 2008b; EUROSTAT 2009).

Fig. 6: Standardised death rate (SDR) among women by European country in 2006. (EUROSTAT 2009)

Leading causes of death differ across the lifespan. Based on data from 2001 to 2003, for the age
group 0 to 19, the leading causes of death among women were conditions originating in the perinatal
period and external causes (injury and poisoning); for women aged 20 to 44 they were cancers and
external causes (injury and poisoning); for women aged 45-64, malignant neoplasms (cancer) and
diseases of the circulatory system; and among those women 65 and over, diseases of the circulatory
system (Niederlander 2006).

27

Overall, of 100,000 women of all ages in the EU-27 in 2005, 213.7 died of diseases of the circulatory
system, 135.5 of malignant neoplasms, 35.5 from diseases of the respiratory system, 22.3 from
external causes (injury and poisoning), 15.4 from diseases of the nervous system and sensory
organs, 12.8 from diabetes, 8.2 from chronic liver disease, 4.8 from suicide and intentional selfharm, 1.0 from alcohol abuse, 0.7 from homicide or assault, 0.5 from AIDS, and 0.2 from drug
dependence (please see figure 7) (EUROSTAT 2009).

Fig. 7: Causes of death among women in the EU-27 in 2006. (EUROSTAT 2009)

Migration
Based on 2005 data, net migration is positive for almost all states in the EU (excluding the Netherlands,
Poland, Lithuania, Romania, and Latvia) and overall immigration into the EU has been increasing.
Between 2001 and 2005, 1.15 to 2.03 million immigrants entered EU-27 countries each year and
immigration is now the main driver of demographic growth in the majority of EU countries. Women
immigrants are therefore a growing subpopulation. In 2004, 324,574 female immigrants entered
Germany, 310,240 entered Spain, and 257,477 entered the UK (EUROSTAT 2008a, 2009; data
unavailable for some countries).

28

Education and Employment


On average, European women reach higher levels of educational attainment than European men.
Of men and women aged 18-24, a much larger proportion of men leave school with at most a lower
secondary education and are not in further education or training (17.2% of men versus 13.2% of
women in the EU-27 in 2007) (EUROSTAT 2009). Slightly more women than men in the EU-27
complete upper secondary education (EUROSTAT 2008a) and in all European countries except
Liechtenstein, more women than men graduated from tertiary education programs in 2005 (please
see figure 8). In 2006, 55.1% of students enrolled in tertiary education in the EU-27 were women
(EUROSTAT 2009).
However, the proportion of women in tertiary education programs varies significantly across
disciplines. Among 2005 tertiary education graduates, women accounted for only 37.2% of students
studying science, mathematics, and computing and only 24.4% of students studying engineering,
manufacturing, and construction (EUROSTAT 2009).

Fig. 8: Women per 100 men graduating from tertiary education by European country in 2005. (EUROSTAT 2009)

More women than men also participate in lifelong education and training 10.4% of female participants
aged 25 to 64 in the 2006 EU Labour Force Survey had received some form of education or training
in the four weeks preceding the survey, while only 8.8% of men had (EUROSTAT 2008b).

29

Employment Trends
Female employment increased by 9.8% between 2000 and 2007 (in that time male employment
grew by 4.3%) reaching 58.3% among women aged 15 to 64 in the EU-27 (male employment was
72.5%). The highest rates of female employment were found in Iceland (80.8%), Norway (74.0%),
Denmark (73.2%), Sweden (71.8%), and the Netherlands (69.6%). The lowest rates were recorded
in Greece (47.9%), Italy (46.6%), and Malta (36.9%) (European Commission 2008a).
Considering different age categories, employment was highest among women 25-54 (71% of
this age group was employed), followed by women aged 55-64 (36%), and women aged 15-24
(34.2%) (European Commission 2008a). However, it is projected that population ageing will lead to
a change in the European workforce. In the last few decades Europe has had a large proportion of
the population in the working age category (15 to 64), but as these individuals age the proportion of
older individuals in the EU will grow and the proportion of individuals of working age supporting them
will shrink (EUROSTAT 2008a).
Parenthood appears to have a significant affect on employment among women: in 2006 women
aged 20-49 with children under 12 in EU-27 Member States had a 62.4% employment rate while
women without children had a 76% employment rate. Men with children did not experience the drop
in employment and were in fact more likely to be employed than men without children: 91.4% of men
20-49 with children under 12 were employed, while only 80.8% without children were (European
Commission 2008d).
Women are employed part time much more frequently than men in all European countries. In 2007,
31.2% of all employed women in the EU were working part-time, whereas only 7.7% of employed
men were part-time workers. Based on 2007 data, part-time work is predominant in the Netherlands,
where 75% of employed women work part-time. Percentages of employed women engaging in parttime work in 2007 also exceeded 40% in Sweden, Austria, Belgium, the UK, and Germany. However,
part-time employment is also relatively low in Bulgaria (only 2.1% of employed women worked parttime in 2007), Slovakia, Hungary, the Czech Republic, and Latvia (European Commission 2008a).
Women are more likely than men to work on a fixed-term contract (15.2% of women vs. 13.95% of
men work on fixed-term contracts) and are less often self-employed (12.2% vs. 19.1%) (European
Commission 2008a). Women are also more likely to receive lower wages: in 2006 women in the EU27 earned on average 15% less per hour than men (European Commission 2008d).
Women are concentrated in relatively few work sectors in Europein 2005 61% of women in the
EU-25 worked in health care and social work, retailing, education, public administration, business
activities, and hotels and restaurants (EUROSTAT 2008b). In total, 81.8% of employed women in
2007 worked in the services sector while only 58.4% of men did (European Commission 2008a).

Unemployment
The unemployment rate among women aged 15 and over is higher than that of men in the EU-27
(7.8% compared to 6.6% in 2007) and is particularly problematic in Spain (10.9%) and Slovakia
(12.7%); long-term unemployment is also more common among women in the vast majority of
Member States (3.3% of the female labour force in 2007 as opposed to 2.8% of the male labour
force) and is high in Greece (7%) and Slovakia (9.3%) (European Commission 2008a). In addition,
women aged 18-59 are far more likely than men to live in households in which no one is employed
(EUROSTAT 2008b).

30

Fig. 9: Percentage of women aged 15 to 64 unemployed by European country in 2007. (EUROSTAT 2009)

Unpaid work
Women spend more of their time doing unpaid work than men, including household chores,
childcare, care of elderly and sick family members, and voluntary work. Comparing data collected
in 14 countries through national time use surveys conducted in the period 1999 to 2004, women
aged 25 to 44 spent almost triple the time men did on childcare per day (60 vs. 22 minutes). Women
15-24 also spent 60 minutes more per day preparing food, washing dishes, and cleaning the house
and women 25-44 spent an average of 162 minutes more per day these tasks. The difference is
particularly pronounced in Italy (over five hours of unpaid work per day for women; 1 hour 13 minutes
for men) (EUROSTAT 2008b). Women are also the majority of all carers (60% to 80%) (Grammenos
2005). Therefore, despite lesser time spent in paid employment, women spend more hours working
than men, if paid and unpaid work are combined (EUROSTAT 2008b).
Womens increased employment and the higher educational levels attained are important factors in
their increasing autonomy and lead to greater equality between men and women in society.

31

32

Health Issues

33

Cardiovascular Diseases
Diseases of the heart and circulatory system (called cardiovascular diseases or CVD) are a main
cause of mortality as well as disability and morbidity among women in Europe. CVD is caused by
disorders of the heart and blood vessels and includes coronary heart disease (heart attacks) and
cerebrovascular disease (stroke) (WHO 2009c).
Each year CVD causes over 2 million deaths in EU-Member States and approximately half of all
deaths in the EU (42% total: 45% of deaths in women and 38% of deaths in men) (European heart
network 2009).

Coronary heart disease (CHD)


Coronary heart disease is the single most common cause of death in Europe, resulting in 741,000
million deaths in EU-Member States each year. Over one in seven women (15%) and over one in
six men (16%) die from the disease (European heart network 2009).
In the period 1995-2004, a decrease in deaths due to CHD (SDR per 100,000 adults aged 0 to 64
years) was observed in both men and women in EU-Member States (from 60 to 40 among men and
from 15 to 9 among women) (European heart network 2009).
In 2004, mortality rate from CHD (deaths per 100,000) among women was greater in Central and
Eastern Europe than in Northern, Southern, and Western Europe, and was particularly high in
Lithuania (27/100,000), Romania, Hungary (28/100,000), and Latvia (34/100,000).

Cerebrovascular disease (stroke)


Another major disease of the circulatory system is cerebrovascular disease (stroke). Stroke is
defined by the WHO as the interruption of the blood supply to the brain, usually because a blood
vessel bursts or because of blockage by a clot. This cuts off the supply of oxygen and nutrients to
the brain, causing damage to the brain tissue (WHO 2009c).
Stroke is the second most common cause of death in Europe and is responsible for 508,000 deaths
in the European Union each year. Over one in eight women (12%) and one in ten men (9%) die from
this disease.
Death rates from stroke among both sexes are higher in Central and Eastern Europe than in Northern
and Western Europe (European heart network 2009).
Mortality from stroke for women under 65 (SDR per 100,000) decreased from 11.75 to 7.38 in the
27-EU Member States between 1995 and 2005.
In 2005, among women less than 65 years of age, the highest death rates were observed in Eastern
European countries as illustrated in table 2 (WHO 2009a).
Table 2: Standardised death rates (SDR) from stroke, women aged 0-64 years in Eastern European countries in 2005.
(WHO 2009a)

Eastern European
countries
Estonia
Lithuania
Latvia
Romania

Standardised death rates (0-64), women,


stroke per 100,000 in 2005
16.09/100,000
16.31/100,000
25.17/100,000
31.25/100,000

34

Because death rate increases with age, stroke mortality is highest among elderly women. In 2005
the death rate from stroke for women over 65 varied from highs of 1,276.55/100,000 in Latvia and
874.43/100,000 in Lithuania to lows of 218.44/100,000 in France and 297/100,000 in Iceland (WHO
2009a).
There are a number of known risk factors for cardiovascular diseases in women. Some of these factors,
including ageing, genetic disposition, and hormonal change, are unmodifiable, but factors such as
obesity, hypertension, tobacco use, physical inactivity, and increased levels of blood cholesterol
may be influenced through lifestyle changes (Rich-Edwards 1995; European heart network 2009).
Hypertension is one of the most important risk factors for CVD.

Cancer
Cancer remains an important public health problem in Europe. In 2004 in the EU-25 Member States
there were over 2 million estimated incidence cases of cancer (2,060,400 incident cancer cases
among individuals aged 0-74) and over one million cancer deaths (1,161,300 cases). The most
common incident forms of cancer among women were
- breast cancer (275,100 cases; 29% of all incidence cases among women),
- colorectal cancer (129,000 cases; 13.7%),
- cancer of the uterus (81,500 cases; 8.6%), and
- lung cancer (62,000 cases; 6.5%) (Boyle, Ferly 2005).
-
Breast cancer was the major cause of cancer-related death among women aged 0-74 in the 25-EU
Member-States (n=88,400 deaths, 17.4%), followed by colorectal cancer (n=67,000, 13.2%), and
then lung cancer (n=55,900 deaths, 11%) (Boyle, Ferly 2005).
However, a recent downward trend in mortality rates in almost all forms of cancer has been observed
in both sexes in the EU-27 Member States. From 1982 to 1992 the total cancer mortality in men was
stable; it then declined by 13% from 1992 (185.5/100,000) to 2002 (162.3/100,000).
In women, the death rate declined by 2% from 1982 to 1992 and by 8% from 1992 to 2002 (to
95.8/100,000) (Bosetti et al. 2008).

Breast Cancer
The incidence of breast cancer is still rising in most EU-Member States, although this may be
a result of increased detection through screening programmes. Figure 10 details breast cancer
incidence in 2005 among the EU-27 (plus Norway and Iceland; data unavailable for Liechtenstein)
(WHO 2009h).
Mortality from breast cancer has shown a declining trend in the EU-27 in the last few years: SDR
(per 100,000) in middle-aged women (35-64 years) decreased from 40.58/100,000 to 33.84/100,000
(-17%) in the period 1982-2002 (Bosetti et al. 2008).
Survival rates have improved because of early detection and more effective therapies. In the period
1988-1999, in 16 European countries (Austria, the Czech Republic, Denmark, Finland, France,
Germany, Iceland, Italy, the Netherlands, Norway, Poland, UK, Slovenia, Spain, and Sweden) the
five-year relative survival in women with breast cancer increased from 74% to 83%. Survival was
heterogeneous between countries, ranging from 73% in Poland to 85% in Sweden in the period
1997 -1999.

35

The countries with the poorest initial survival rates show the greatest improvements in survival, being
in general lower in Eastern Europe (Poland, Czech Republic) and higher in the northern region of
Europe, especially in Sweden, Finland, and Iceland (Verdeccia et al. 2007; Verdeccia et al. 2009).

Fig. 10: Female breast cancer incidence and mortality per 100,000 in 2005. (WHO 2009h)

The risk of breast cancer depends on the number of reproductive years throughout womens
lifespan. It decreases by about 15% for each year of delay in age at menarche and increases by
3% for each year of delay in age at menopause. Artificial menopause exerts a similar or somewhat
stronger protective effect than natural menopause (Colditz et al. 2006; Boyle, Lewin 2008). Further
risk factors include genetic disposition, lifestyle factors (such as obesity, physical inactivity, and
smoking) and environmental factors, a late first birth, and Hormone Replacement Therapy (HRT)
(Boyle, Lewin 2008).

Cervical Cancer
Cervical cancer is caused by a persistent infection with one or more of 15 oncogenic types of the
human papilloma virus (HPV) (Boyle, Lewin 2008).
During 1995-2005 a number of EU-27 Member States showed a slight decline in the incidence (per
100,000) of cervical cancer. However, incidence rates continued to increase in Eastern European
countries such as Estonia, Lithuania, Latvia, Bulgaria, and Romania.
In 2004, the highest incidence rates were found in
- Lithuania (31.1/100,000),
- Romania (29.9/100,000), and
- Bulgaria (26.98/100,000).
While the lowest incidence rates were found in Malta, Cyprus, and Finland (1.98/100,000 to
6.07/100,000) (WHO 2009h).
As cervical cancer typical develops slowly, cervical cancer screening has been proven to be effective
in reducing incidence rates (see also cahapter health care HPV vaccination and Cervical cancer
screening).

36

Mortality (SDR all ages) from cervical cancer in Europe decreased from 4.38 per 100,000 to 3.45
per 100,000 between 1995 and 2005, the most recent interval for which data was available. The
exceptions were Bulgaria, Latvia and Romania, because in these countries mortality rates rose
slightly over this period. The lowest SDR (all ages) were observed in
- Iceland (0.79/100,000),
- Malta (0.97/100,000),
- Greece (1.22/100,000),
- Luxembourg (1.33/100,000), and
- Finland (1.4/100,000) (WHO 2009h).
Epidemiological studies identify a wide range of risk factors for developing cervical cancer, for
example tobacco smoking, low socio-economic status, infection with Chlamydia trachomatis, long
term use of oral contraceptives, multiple sexual partners, multiparity, and micronutrient deficiency in
fruits and vegetables (Boyle, Lewin 2008).

Lung cancer
Lung cancer remains one of the most important forms of cancer for the population of the European
Union.
During the period 1995-2005 the greatest increases in female cancer incidence (per 100,000) of the
trachea, bronchus, and lung were observed in:
- Hungary: increasing from 24.86/100,000 to 67.12/100,000 (+42.26)
- Slovenia: from 17.42/100,000 to 29.68/100,000 (+12.26)
- Norway: from 26.83/100,000 to 38.64/100,000 (+12.02)
- the Netherlands: from 24.51/100,000 to 41.35/100,000 (+16.84) (WHO 2009h).
Although the average mortality rate of lung cancer is much lower in women than men, the female
death rate has been steadily rising in the EU, with a measurable increase in the last few years (WHO
2008; Bosetti et al. 2008).
The pattern of lung cancer mortality in women is quite different from that observed in men. In the
period 1982-2002 lung cancer mortality (SDR in men and women aged 35-64 years) was higher in
men than in women, but male mortality declined from 77.18/100,000 to 56.49/100,000. Conversely,
while women had an overall lower mortality rate than men, the rate increased throughout the period
from 12.82/100,000 to 18.59/100,000 (Bosetti et al. 2008).
In 2005, the highest female death rates (per 100,000 aged 0-64 years) were found in the Netherlands
(16.55/100,000), Iceland (17.29/100,000), and Denmark (19.47/100,000). In these countries men
and women had similar average death rates. Sweden also showed higher-than-average death rates
in both women and men. Latvia, Finland, Estonia, Lithuania, Slovakia, Malta, Spain, Romania, and
Greece had low death rates in women (WHO 2009h).
The current geographical patterns of lung cancer incidence are the result of smoking habits 20-30
years ago rather than those of today. The higher lung cancer mortality among women in countries
such as Iceland, the Netherlands, Poland, Norway, Sweden, and the United Kingdom reflect the
earlier uptake of smoking in a larger proportion of women in these countries (Boyle, Lewin 2008).
However, today smoking among women is more prevalent in Southern than in Northern European
countries, and as a result the incidence pattern will change in the near future.

37

Lung cancer survival is particularly low. The mean five-year survival in Europe (based on data
from Austria, Czech Republic, Denmark, Finland, France, Germany, Iceland, Italy, the Netherlands,
Norway, Poland, the UK, Slovenia, Spain, Sweden, and Switzerland) increased from 11% in the
period 1988-1990 to 13% in 1997-1999. The greatest improvements in survival among European
women were estimated to have occurred in Sweden, Poland, and Italy (Verdeccia et al. 2009).

Colorectal Cancer (Colon and rectal cancer)


The average European five-year relative survival for colon-cancer (based on data from Austria,
the Czech Republic, Denmark, Finland, France, Germany, Iceland, Italy, the Netherlands, Norway,
Poland, the UK, Slovenia, Spain, Sweden, and Switzerland) increased from 48% to 54% in both
sexes in the period 1988-1999 (Verdeccia et al. 2009). Country-specific survival rates for colon
cancer diagnosed between 1997 and 1999 vary greatly, from 38% in Poland to 60% in France.
During this period colon cancer survival was highest among Italian women (61%). (Verdeccia

et al.
2009)
Survival rates for rectal cancer in both sexes are similar to those for colon cancer. Similar recent
improvements in survival rates for men and women were also observed, increasing from 45% in
1988-1990 to 55% in 1997-1999. The increase was greatest in countries with poorer initial relative
survival (Poland, the Czech Republic, Slovenia, and Denmark).
The highest relative survival among women with rectal cancer occurred in Central and Northern
European countries (Switzerland, France, Norway, and Sweden) (Verdeccia et al. 2009).

Infectious diseases
HIV/AIDS
Infection with Human Immunodeficiency Virus (HIV) and the development of Acquired
Immunodeficiency Syndrome (AIDS) is a major health issue in the EU/EFTA population.
Between 2000 and 2007, newly diagnosed cases of HIV infections increased from 44 per million
(14,483 cases) to 58 per million (19,435 cases) in 28 EU/EFTA countries.
In 2007, the EU/ EFTA (excluding Italy and Austria) reported 26,279 newly diagnosed cases of HIV
infection (64.1/million), with the highest rates recorded in Estonia (472/million, 633 cases total),
Portugal (217/million, 2,302 cases total), and Latvia (149/million, 338 cases total). Romania (7/
million, 158 cases total) and Slovakia (7/million, 39 cases total) reported the lowest infection rates.
Generally, men are more affected by HIV than women in EU/EFTA countries. In 2006, 67% of newly
diagnosed cases of HIV (n=17,289) were in men and 33% were in women
(n=8,484), leading to infection rates of 7.2 and 3.4 per 100,000 respectively (male to female ratio
2:1) (ECDC 2008a).
The majority of newly diagnosed HIV infections in women were reported among women 20-39
years.
Among women the predominant routes of transmission are heterosexual contact and injection drug
use. Between 2003 and 2005 newly diagnosed HIV infections among female injection drug users
declined from 623 to 496. However, newly diagnosed cases as a result of heterosexual contact
increased from 6,231 to 7,377.
In 2007, mother-to-child transmission resulted in 270 cases of HIV infections (please see figure 11)
(ECDC 2008b).

38

Despite the increase in newly diagnosed cases of HIV, between 2000 and 2007 the number of AIDS
cases in EU/EFTA Member States continued to decline, dropping from 20.8/million to 9.3 /million,
with the highest rates in Estonia (42.4/million), Portugal (30.2/million), and Latvia (23.7/million)
(ECDC 2008b).

Fig. 11: Newly diagnosed HIV infections (notification year 2007) contracted through mother-to-child transmission in the
EU/EFTA, by country. (ECDC 2008b)

Influenza
Seasonal influenza is caused by a virus that mainly attacks the upper respiratory tract the nose,
throat, and bronchi and rarely, the lungs Seasonal influenza poses a considerable public health
threat. In 2004, SDR due to influenza per 100,000 EU-27 women was 0.2 (WHO 2009a). However,
SDR can be dramatically higher among certain risk groups.
Risk groups include elderly people, residents of institutions of elderly people and the disabled, very
young children, and people of any age with certain chronic health conditions (such as chronic heart
or lung disease, metabolic or renal disease, or immuno-deficiencies).
SDR was highest among those women 75 years and older, reaching a peak of 12.77 per 100,000
EU-27 women in 2004 (WHO 2009a).
During the winter of 2006-2007 influenza activity was primarily associated with virus A (H3) (18,278
cases), while in winter 2005-2006 virus B was the predominant cause of illness (11,303 cases).
Activity spread in a south to north pattern across Europe (EISS 2008).

39

Syphilis (Treponema pallidum)


Syphilis surveillance data for 2007 is available for 21 European countries (data unavailable for
Poland, Romania, Bulgaria, Hungary, Liechtenstein, and Lithuania).
Differing trends were observed across European regions. Western EU-Member States reported a
decrease in incidence after 1996, followed by a trend reversal and an increase of cases related to
outbreaks among the MSM population (men who have sex with men) of a number of cities in the
early 2000s. In Central EU-Member States the rate of syphilis incidence has been relatively stable
over the last few years. Reported syphilis cases have declined in Eastern European countries since
the late-nineties decreasing in Estonia by 93% (from 1,050 cases to 76 cases) and in Latvia by
88% (from 2,597 cases to 301 cases) between 1998 and 2007.
According to 2007 data, in eight of eighteen European countries, over 80% of diagnosed syphilis
cases occurred in men (Denmark, France, Germany, Norway, the Netherlands, Slovenia, Sweden,
and the UK). However, some Central and Eastern European countries reported a higher proportion
of cases among women, especially compared to Western Member States. In 2007, syphilis cases
were more common among women than men in Estonia (51 female cases), Latvia (53 female cases),
and Slovakia (119 female cases) (ESSTI 2008).
Syphilis transmission is particularly high among homosexual populations in these countries.
Among women, the largest proportion of cases occurs in individuals 20-34 years of age, while the
largest proportion of cases among men occurs between the ages of 25 and 44 (ESSTI 2008).

Chlamydia
The main relevance of chlamydia infection in Europe comes from its relationship with infertility and
adverse pregnancy outcomes.
During the period 1998-2007, most European countries showed an increase in new chlamydia
cases, particularly France with cases increasing by 144%, Slovenia (183%), and Sweden (210%)
(data unavailable for Germany, Austria, Greece, Italy, Poland, Spain, Slovakia, Lithuania, Romania,
Bulgaria, Hungary, and Liechtenstein). Exceptions include Estonia and Latvia where the number
of new chlamydia infections decreased by 37% (from 3,916 cases to 2,480 cases) and 48% (from
1,367 cases to 711 cases) during this period (ESSTI 2008).
The cause of this increase is not clear. Potential explanations include a genuine rise in incidence,
an increase and change in diagnostic testing, and/or the introduction of screening in various
countries.
Chlamydia is more often diagnosed in women than in men. In 2007, 55% of all reported chlamydia
cases were in women, with the largest proportion of female cases in Estonia (83%), Denmark (63%),
and France (67%).
For both sexes chlamydia affects mainly younger age groups (individuals 15-24 years of age).
Approximately 77% of all cases in women in 2007 (based on data from 11 European countries)
occurred in women under 25 years, compared with 58% among men under 25. (ESSTI 2008).

Gonorrhoea
Between 1998 and 2007, increases in gonorrhoea cases were observed in a number of European
countries, including France (298% increase from 224 cases to 891 cases) and Sweden (87% increase
from 343 cases to 642 cases) (data were unavailable for Germany, Poland, Lithuania, Romania,
Bulgaria, Hungary, and Liechtenstein). In 2007, the largest number of new cases occurred in the
Czech Republic (1,149 cases), the Netherlands (n=1,827), and the UK (18,710 cases). Reported
cases also declined in a number of countries in 1998-2007, falling by 49% in Latvia (1,237 cases to
669 cases), 89% in Estonia (1,574 cases to 174 cases), and 88% in Cyprus (42 cases to 5 cases).

40

Gonorrhoea occurs less often in women than in men. About 71% of all known gonorrhoea cases in
2007 occurred in men, reaching a high of 98% in Greece.
Gonorrhoea affects sexually active people and over half of reported gonorrhoea infections are
reported in individuals older than 25 years (ESSTI 2008).

Vaccination coverage
Vaccination plays a central role in infectious disease morbidity and mortality. Diseases for which
vaccinations are widely available include measles, mumps, rubella, chickenpox, diphtheria, tetanus,
pertussis, polio, influenza, and Streptococcus pneumoniae in the elderly.
Sex-and-age-specific data on basic vaccination coverage is currently minimal. However, as most
vaccination occurs during infancy and childhood, rates of vaccination among European children
provide relevant information.
Using combined data from 2005 and 2007, 90% or more of all European children are vaccinated
against diphtheria, tetanus, pertussis, and poliomyelitis, with the exception of Austria, Denmark, and
Malta where rates were below 90% (and Romania and Greece, for which data was unavailable).
Hungary had the most extensive vaccine coverage for these diseases, reaching 99.9% of children
in 2007. Slovakia had 99.3% coverage and Luxembourg provided 99.1% coverage in 2007. With
less than 90% of children covered, Austria (84.5%), Denmark (75%), and Malta (74% for diphtheria,
tetanus, and pertussis; 76% for polio) were at the lower end of vaccination coverage in 2007 (WHO
2009h).
Vaccination for measles, mumps, and rubella (MMR vaccine), commonly given together, has
generally high coverage, but has experienced a reduction in uptake in recent years. As a result of
scepticism and public concern about vaccine safety, isolated subpopulations, and the success of
earlier vaccination campaigns decreasing the perceived health risk of the diseases, vaccination
remains far below EU target levels. In 2007, vaccination was below 90% in Austria (77%), Malta
(79%), the UK (86.2%), Italy (87%, data from 2006), Cyprus (87%), Ireland (87%), and Denmark
(89%).
The low vaccination rate is pronounced in Western Europe and vaccination is greater among nations
that entered the EU after 2004 (97.59%) than for EU members before May 2004 (91.49%). For
some countries, MMR vaccination is in fact decreasing despite the much broader trend of increased
vaccination: in the UK, MMR vaccination decreased from 99% in 2000 to 86.2% in 2007 and in
Denmark from 100% in 2000 to 89% in 2007 (WHO 2009h).
Vaccinations against the remaining diseases (chickenpox, influenza, and Streptococcus pneumoniae)
is varied. As of 2008, Germany was the only European country with a routine childhood chickenpox
immunisation programme and the vaccine is officially recommended in only a few other countries
(Belgium, Finland, Italy, Spain, and the UK) (Sengupta 2008).
Of the 30 EU and EEA states, 29 provide information on influenza policies and 22 supply estimates
of vaccination coverage among the elderly (persons aged 65 years and over). Thirteen of these 22
countries exceeded the 2005 target of the World Health Assembly (target of 50% vaccination uptake
in the elderly by 2005-2006), however, only two countries (the Netherlands and the UK) reached or
passed the 2010 target (75% uptake in the elderly by 201011) (ECDC 2008a).
Data on Streptococcus pneumoniae vaccination is highly limited.

41

Sexual and Reproductive health


Fertility
Fertility rate is defined as the number of children that would be born to a woman over her lifetime if
age-specific fertility remained constant over her reproductive lifespan. The total fertility rate across
the countries of the
European Union is very low. The rate declined from 2.6 in early 1960 to circa 1.4
in the period 1995-2005 (EUROSTAT 2008a).
The rates are higher in countries which adopt family-friendly policies such as implementation of
easily accessible and affordable childcare and/or flexible working time patterns (Northern European
countries and France) (EUROSTAT 2008a).
During recent years there has been a distinct trend in the deferral of birth to older ages, particularly
visible in the Czech Republic, Baltic countries, Hungary, and Slovenia. The mean age for child
bearing increased at least two years in the period 1995-2006. In 2006, the average age of women
bearing children increased to over 30 years in Spain, Italy, the Netherlands, Sweden, and Denmark
and ranged from 29 to 30 years in an additional 10 EU-countries (EUROSTAT 2008a).
Data on European reproductive health indicators related to infertility (such as woman trying to get
pregnant for one or more years, deliveries associated with artificial reproductive technology, etc.) is
currently insufficient (Gissler et al. 2008).
Data concerning contraceptive use of any method among currently married women aged 15-49 (%)
are inadequate in EU-Member States. The prevalence of contraceptive use in both sexes, aged 1549, is relatively low in Romania (60%) (Gissler et al. 2008).

Pregnancy outcome
From 1995-2005 live births per 1,000 populations in the EU declined from 10.77 to 10.40, with the
highest rates in Iceland (14.47/1,000), Ireland (14.78/1,000), France (12/1,000) and the lowest rate
in Germany (8.3/1,000). In Bulgaria and Romania a respective 14% and 13% of all live births were to
mothers under age 20, in contrast to lower rates of births to women under 20 in Northern European
countries (WHO 2009h).
Low birth weight (under 2,500g) is an indicator for maternal care. Low birth weight babies are at
higher risk of poor perinatal outcome, as well as a higher risk of physical and cognitive impairments.
Babies with a birth weight less than 1,500g, defined as very low birth weight, are at the greatest risk.
The causes of low birth weight include preterm birth or intrauterine growth restriction (IUGR).
In 25 EU-Member States which provided data on the indicator birth weight, the percentages of live
births with a birth weight under 2,500g ranged from 4.2% to 8.5% of all births in 2004. These data
also showed that Southern European countries (Greece, Hungary, Portugal, Malta, and Spain) had
the highest percentages of babies born with low birth weight (ranging from 8.5 to 7.5) and that
Northern countries had the lowest percentages (Finland 4.2, Sweden 4.2, Luxembourg 4.4 and
Norway 4.8).
The percentage of live births of children under 1,500g ranged from 0.7 in Lithuania to 1.4 in Hungary
(EURO-PERISTAT 2008).

42

Maternal mortality
The causes of maternal death can be separated into directly attributed to pregnancy complications (for
example thrombo-embolism, hypertension, infection/sepsis, obstetrical complication, haemorrhage)
and indirectly attributed, which include cardiac or maternal conditions that are aggravated by
pregnancy.
Maternal mortality in the EU has declined greatly in the last decade. Absolute maternal deaths (per
1,000,000 live births) declined in European countries from 9.32 in 1997 to 6.05 in 2006.
In 2006, maternal mortality (per 100,000 live births) was highest in Slovenia (15.83), Romania
(15.49), the Czech Republic (13.23), and Latvia (13.45). Malta, Iceland, Ireland, Lithuania, and
Luxembourg did not report any maternal deaths (WHO 2009h).
Between 1995 and 2005 Caesarean sections per 1,000 live births in EU-Member States rose from
16,462 to 24,451, as shown in figure 12. In 2005, C-sections per 1,000 live births were highest in
Hungary (274), Italy (382), and Malta (302) (WHO 2009h).

Fig. 12: Caesarean section per 1,000 live births 2005). (WHO 2009h)

Abortion
The legal requirements for abortion vary between European countries, because the abortion laws
are a reflection of religious belief, culture, and economic status. For example, in Malta abortion
is illegal, while in Poland and Ireland abortion is only allowed if pregnancy physically or mentally
threatens the womans life. In a study of six European countries considering legality, availability of
facilities, and health insurance coverage, it was shown that abortion services are easily accessible
in the Netherlands, France, and Slovenia, while abortion services were less accessible in Great
Britain and Hungary and limited in some Eastern European countries (Pinter et al. 2005).
Across the EU-countries in 2005, the highest abortion rates (abortions per 1,000 live births) were
observed in Hungary, Latvia, Bulgaria, and Estonia (ranging from 499 670/1,000 live births); the
Netherlands, Germany, and Finland report substantially fewer abortions.
In addition, average rates of abortion in countries in Eastern and Central Europe are higher than
in Western Europe. However, from 1995 to 2005, in these countries (the Czech Republic, Estonia,

43

Lithuania, Latvia, Bulgaria, Hungary, Slovenia and Romania) a significant decline in abortions per
1,000 live births was observed (WHO 2009).
Abortions in adolescents and young women less than 20 years of age remain high, having increased
during the period 1995-2005. The reasons for this general trend across industrialized countries
are broader than factors limited to any one country: increased importance of education, increased
motivation of young people to achieve higher levels of education and training, and greater centrality
of goals other than motherhood and family formation for young women (Singh, Darroch 2000).

Sexual and intimate partner violence


Sexual and intimate partner violence result from a complex interplay of individual, relationship,
social, cultural, and environmental factors and may take physical, sexual, or emotional forms. Up
to 1 in 4 women have reported sexual assaults during their lifetime and between 6-10% of women
suffer domestic violence in a given year. Reported violence is most often performed by a husband
or intimate partner (Council of Europe 2002; Womens aids 2009).
Data on sexual violence against women collected by the justice system underestimates the size of
the problem, as only 5-25% of women report rape to the police. Reasons for underreporting may
include shame, stigma, and fear of social exclusion or repeat victimisation (WHO 2006).
Measuring the incidence of sexual violence among victims is also very difficult because perceptions
of what is unacceptable sexual behaviour and readiness to report incidents to an interviewer may
differ across countries.
Some estimates of the rates and prevalence of sexual violence against women in various countries
are reported in table 3 (EUGLOREH 2007).
Table 3: Informations on sexual violence in various countries. (EUGLOREHHE 2007)

Countries
Francea
Irelanda (2002 study)
Latviab (1998 study)
Lithuania

Hungaryb (1999 data)

Sexual violence
- 25,000 raped per year
- 20.4% of women have reported a sexual
assault as adults
- 6.4% reported rape as adults
- 5.2% women reported being sexually
assaulted in last five years
- 26.5% of women reported sexual abuse by
a stranger after 16 years
- 18.2% of women reported sexual abuse by
a unknown man after 16 years
- 2.2% of women over 16 years reported
being raped
- 9.4% reported almost being raped

United Kingdom (Wales &


England)b (2000 data)

- 7.4% raped by their partner


- 4.9% of women have reported rape or
sexual assault on at least one occasion
since the age of 16 years

European Womens Lobby, 2001

London Metropolitan University, 2003

44

The health consequences of sexual violence may result directly from a violent act or may stem
from long term effects, and can range from injuries to death in extreme cases. Violence against
women is associated with sexually transmitted infections (e.g. HIV/AIDS), different physical health
problems such as back and abdominal pain, gastrointestinal disorder, and irritable bowel syndrome,
gynaecological complaint, and severe psychological problems such as depression or post-traumatic
stress disorder, which can lead to suicide. Unwanted pregnancy, which often leads to induced
abortion, occurs in as many as one in six rapes among women aged 12-45 years (WHO Europe
2006).
Greater systematic documentation and dissemination of information on sexual and intimate partner
violence is necessary. To accomplish this goal, the health sector must collaborate with the police,
justice, and welfare systems (EUGLOREH 2007).

Endometriosis
Endometriosis, a disease occurring only in women, is defined as the presence of endometrial-like
tissue, i.e. glands and stroma, outside the uterus. The most-affected sites are the pelvic organs and
peritoneum. The disease varies from a few, small lesions on otherwise normal pelvic organs, to solid
infiltrating masses and ovarian endometriotic cysts (endometriomas). Symptoms are subfertility,
dysmenorrhoea, dyspareunia, chronic pelvic pain or perimenstrual symptoms (frequently bowel or
bladder), abnormal bleeding, and chronic fatigue. Many women with endometriosis are asymptomatic.
Depending of the severity of endometrioses, it can cause infertility and subfertility.
In the reproductive years the prevalence is circa 10 % in women (Vigano et al. 2004). The most widely
used classification is that of the American Society for Reproductive Medicine (ASRM). The severity
of endometriosis is described as minimal (Stage 1), mild (Stage 2), moderate (Stage 3), or severe
(Stage 4). This definition was developed to assist in determining the prognosis and management of
patients with endometriosis undergoing surgery for subfertility.
The study group (Parazzini et al. 2005) have analysed a risk of recurrence of endometriosis after
the first line treatment (two-year recurrence rate was 5.7% among cases stage 1-2 and 14% among
stage 3-4).
If a woman suffers from endometriosis she more frequently develops autoimmune diseases e. g.
rheumatoid arthritis or systemic lupus erythematosus (SLE).
Risk factors for the development of endometriosis are age, obesity, and greater exposure to
menstruation (e.g. short cycles, menorrhagia, and low parity). Smoking, exercise, and oral
contraceptive use may be protective (Koninckx 1994). Genetic predisposition is likely, as endometriosis
occurs 6-9 times more often in 1st degree relatives, suggesting endometriosis is a complex genetic
trait like diabetes or asthma.

45

Diabetes mellitus
Diabetes is a chronic non-communicable disease which occurs when the pancreas does not produce
enough insulin, or when the body cannot effectively use the insulin it produces. This leads to an
increased concentration of glucose in the blood (hyperglycaemia).
Type 1 diabetes (previously known as insulin-dependent or childhood-onset diabetes) is characterised
by a lack of insulin production. Type 2 diabetes (formerly called non-insulin-dependent or adult-onset
diabetes) is caused by the bodys ineffective use of insulin. It often results from excess body weight
and physical inactivity. There is also gestational diabetes or hyperglycaemia that is first recognized
during pregnancy and can either persist thereafter or not (WHO 2009f).
Diabetes mellitus is a growing burden in Europe.
An estimate by the International Diabetes Federation (IDF) suggests that the number of people with
diabetes in EU-countries will rise from 25 million to 29 million between 2007 and 2025. During this
period (2007-2025) Germany (from 3,815,9 to 4,19.2), Italy (from (1882,8 to 2,122.9), and France
(1,92.6 to 2,369.0) will have the highest estimated increases in number of diabetes mellitus cases
in women (aged 20-79 years) (IDF 2006).
The prevalence of diseases is similar among men and women, but is slightly higher among men
over 60 and older women.
Diabetes mellitus is associated with increased mortality and morbidity from cardiovascular disease
(Almadal et al. 2004).
In 2005, deaths due to diabetes mellitus among men and women in EU-27 Member States was
estimated to be 14.3 per 100,000 inhabitants (SDR). In women the average death rate was 12.8 with
the highest single-country rates found in Cyprus (35.5), Portugal (25.3), Austria (23.4), and Malta
(19.2) (EUROSTAT 2009).
The number of people of both sexes suffering from diabetes mellitus is rising due to increased
ageing of the population, prevalence of obesity, and physical inactivity (Wild et al. 2004; Carlsson
et al. 2007).
The major risk factor for diabetes Type 2 is obesity, particularly when the excess weight was due to
abdominal fat. Further risk factors are high blood pressure and high cholesterol, age, and genetic
disposition.
Women with previous gestational diabetes mellitus (GDM) show an increased risk of developing
diabetes mellitus Type 2 in later years. Therefore these women form a population in which direct
efforts at diabetes prevention may be effective (IDF 2008).
Pregnancy in woman with diabetes mellitus Type 1 is associated with an increased risk of preterm
delivery, Caesarean section, stillbirth, neonatal mortality, and congenital malformations (Evers et al.
2004; Lapolla et al. 2008).

46

Mental health
Currently mental health problems constitute one of Europes major public health challenges. Over one
in four European adults are affected by mental health problems every year (DG SANCO 2006b).
Mental disorders comprise a broad range of problems, with different symptoms. However, they are
generally characterized by some combination of abnormal thoughts, emotions, behaviours, and
relationships with others (WHO Definition of Mental disorders 2009g). Statistics on mental disorders
as a group conceal the considerable differences that exist between men and women in the prevalence
of specific types of mental disorders at different stages of the life cycle. In later life women are more
likely than men to suffer from poor mental health (Patel 2005). In particular, dementia, Alzheimers
disease (AD), and depression are common mental disorders among the elderly.

Dementia and Alzheimers disease


The term dementia is used to describe a pattern of symptoms of brain disorder which involve
the progressive damage and death of brain cells. The result is a loss of cognitive and intellectual
functions (such as thinking, concentrating, remembering, and reasoning) of sufficient severity to
interfere with a persons daily functioning.
Dementia is not actually a disease but rather a syndrome, which may be caused by an almost infinite
number of cerebral and extra-cerebral diseases. However, neuro-degenerative diseases and small
vessel cerebro-vascular diseases account for most cases of dementia; Alzheimers disease (AD) is
the most common form (Kipelinen et al. 2008; Kurz 2009).
The majority of available studies on the prevalence and incidence of dementia do not differentiate
between the various forms and stages of the disease. The EURODEM group (Hofmann et al. 1991)
and Ferri et al. (2005) have attempted to define the prevalence rates of dementia in different age
categories. Using these prevalence rates and demographic information on the EU-27 as reported
in EUROSTAT the prevalence rate of dementia is between 1.13% and 1.25 % (n=5,526,488n=6,120,842) among the total population of the EU-27 Member States.
Dementia is more common in people over 65 years. It affects about one person in 20 over 65, one
in five over 80, and one in three over 90 years. Generally, prevalence is higher among old women
than among old men (EUGLOREH 2009).
In EURODEM studies, significant gender differences were found in the incidences of AD after 85
years of age. In particular, they concluded that there was a higher risk of AD in older women than
men: at 90 years of age the rate of AD among women was 81.7 versus 24.0 in men (Andersen et
al. 1999).
Studies suggest an association between female sex and increased risk of development of AD
(Gorelick 2004; Lobo et al. 2000). Hypertension and hypercholesterolemia predict a higher risk of
developing AD in later life for both sexes (Nahid et al. 2007).
Numerous studies have also examined individual risk factors for dementia, but only a few studies
show gender differences in dementia risk factors. According to the review by Nahid et al. (2007),
age is the strongest predictor for dementia in both sexes, but the prevalence of dementia is higher
among older women than among their male counterparts. Diabetes mellitus in women, more than
in men, is associated with substantial risk factors of cognitive impairments. Women who suffered
from diabetes for more than 15 years had a 57%-114% greater risk of major cognitive decline than
women without diabetes. Midlife obesity seems to be a slightly greater risk factor for dementia in
women than in men (7.1% vs. 6.7%).

47

Lindsay et al. (2002) found that regular physical activity protected against cognitive impairment and
AD in women more so than in men.

Depression
Mood disorders, particularly depression, are quite common among the European Member States.
Depression is characterized by sadness, loss of interest or pleasure, feelings of guilt or low selfworth, disturbed sleep or appetite, low energy and poor concentration. These problems can become
chronic or recurrent, substantially impairing an individuals ability to cope with daily life. At its most
severe, depression can lead to suicide. Most cases of depression can be treated with medication
and psychotherapy (WHO 2009e).
In the European study of the Epidemiology of Mental Disorders (ESEMed-project) relevant
epidemiological data of adults over 18 years were collected in Belgium, France, Germany, Italy, the
Netherlands, and Spain. In these countries a lifetime prevalence of any mood disorder of 14.0% and
a 12-month prevalence of 4.2% were reported. Mood disorders were more common in women in
both lifetime (18.2%) and 12-month time-frames (5.6%) than in men (9.5% and 2.8% respectively)
(EUGLOREH 2007).
Among mood disorders, major depression was the most common. For example, in Spain a lifetime
prevalence of 13.4% and a 12-month prevalence of 4.1% were found. Depression disorders were
more common among women (lifetime prevalence: 17.1%; 12-month prevalence: 5.3%) than men
(lifetime prevalence: 9.4%; 12- month prevalence: 2.8%) (European Commission 2008b).
The Share Study (Castro-Costa et al. 2007) described the national variation in prevalence of
depressive symptoms in persons aged over 50 years across ten European countries and found
the highest prevalence rates of depressive symptoms in France, Spain, and Italy. In all involved
countries the affective symptoms (depressed mood, tearfulness, fatigue, and suicidality) generally
had a higher prevalence among women.
Suffering from a mental disorder is a key risk factor for suicidal behaviour.
Results from the ESEMed study showed a two-fold higher prevalence rate of suicide attempts in
women compared to men (DG for Health & Consumers 2008).
The mortality rates for suicide and intentional self-harm among the 27 EU-Member States (and
Switzerland, Norway, and Iceland) are higher among men than among women. Figure 13 shows that
the mortality rates (SDR) amongst women are highest in Lithuania, Hungary, Slovenia, Belgium, and
Finland.

48

Fig. 13: Mortality rate due to suicide and self inflicted accidents (per 100,000) in women in 2004. (EUGLOREH 2009)

Musculoskeletal Disorders
Musculoskeletal disorders are characterised by pain and/or disability. They include osteoporosis
(and osteoporotic fractures) as well as (rheumatoid) arthritis. Musculoskeletal disorders significantly
affect quality of life and daily activities.
Dysfunction and other problems of the musculoskeletal system are common and their impact is
pervasive. In a 2007 Eurobarometer Survey, about a third (32%) of all respondents said that in the
week preceding their interview they experienced muscle, joint, neck, or back pain, which affected
their daily activities (DG SANCO 2007b).
Musculoskeletal disorders are often chronic diseases and are one of the most common causes of
disability in older adults. Osteoporosis and rheumatoid arthritis are particularly prevalent among the
elderly. The disease burden, measured in disability-adjusted life years (DALYS), is one of the seven
highest in Europe and is expected to increase as the result of an aging population (WHO 2006).
Women are at a higher risk than men of developing osteoarthritis, rheumatoid arthritis, and
osteoporosis and fragility fractures. Generally, fractures of the forearm (80%), humerus (75%), hip
(70%), and spine (58%) are found frequently in women (Johnell, Kanis 2006).

Rheumatoid arthritis
Rheumatoid arthritis (RA), a systemic auto-immune disease that affects predominantly synovial
joints, is the most common chronic form of polyarthritis and is also known as the most common form
of inflammatory arthritis. RA usually begins in the small joints (hands, feet), spreading later to the
larger joints. The inflamed joint lining or synovia extends and then erodes the articular cartilage and
bone, causing joint deformity and progressive physical disability (EUGLOREH 2007).
Generally, the prevalence and incidence are two times higher in women than in men and increase
with age until about the age of 70 after which they begin to decrease. In both sexes the prevalence
of RA is characterised by a south (lowest) to north (highest) gradient in Europe. For example, RA
prevalence is estimated at 1% in Finland, at 0.86% in France, and at 0.51% in Italy (EUGLOREH
2007).

49

There are complex interactions between the female sex hormones and RA. Therefore, RA is
rare during pregnancy, whereas the disease is more common in nulliparous women. The use of
oral contraceptives pill, or another factor associated with its use, appears to protect against the
development of severe RA. Smoking and obesity are also risk factors for RA (Symmons et al.
2000).
Studies have shown that life expectancy may be reduced in people with RA (Symmons et al. 2000).
A study in the United Kingdom reported a 10-year reduction in median survival for men with RA
compared to the general population and an 11-year reduction for women with RA (Minaur et al.
2004).

Osteoporosis and osteoporotic fracture


Osteoporosis is a systemic skeletal disease, characterised by low bone mass, micro-architectural
deterioration in bone tissue, and increased bone fragility (EUGLOREH 2007).
According to the WHO, a woman is osteoporotic when her bone mineral density (BMD) is 2.5 standard
deviations or more below the normal mean of a young woman (EUGLOREH 2007).
Fracture data is an indirect measure of osteoporosis incidence. In 2000, 3.79 million Europeans
suffered from osteoporosis fractures, of which 0.89 million were hip fractures. The estimated number
of hip fractures each year in women is dramatically higher (611,000 cases) than it is in men (179,000
cases) (IOF 2009b).
The prevalence of age-related osteoporotic (osteoporosis occurring in individuals over age 50) is
higher in women than in men because of increased bone loss and related to menopause. The
result is an increase in the incidence of fractures, particularly of hip fractures. The figures 14 and 15
related to a Report on Osteoporosis in the European Community in 1998.

Age-specific incidence figures for hip fracture in


EU-Member states per 10,000 population in women
500,000
450,000
400,000
50-54

Incidence per 10,000

350,000

55-59

300,000

60-64

250,000

65-69

200,000

70-74
75-79

150,000

80-84

100,000

85+

50,000
0,000
Austria

Finland

Greece

Luxembourg

Spain

Fig. 14: Age-specific incidence for hip fracture in EU-Member States (per 10,000 populations) in women. (European
Commission 2008b)

50

Age-specific incidence figures for hip fracture in


EU-Member states per 10,000 population in me
500,000
450,000
400,000
50-54

Incidence per 10,000

350,000

55-59

300,000

60-64

250,000

65-69

200,000

70-74
75-79

150,000

80-84

100,000

85+

50,000
0,000
Austria

Finland

Greece

Luxembourg

Spain

Fig.15: Age-specific incidence for hip fracture in EU-Member States (per 10,000 populations) in men. (European
Commission 2008b)

An increased incidence of distal forearm fracture was also found among women aged >70 years in
Western countries between the end of the twentieth-century and the first decade of the twenty-first
(EUGLOREH 2007).
Most fractures are the result of a fall; only a minority of fractures are caused by serious accidents
(Piirtola et al. 2007). Preventable risk factors of osteoporosis include physical inactivity, low peak
bone mass in early adulthood, previous fractures, smoking, low body weight, and low exposure to
sunlight. For example, studies have shown that walking positively influences the BMD in the hip and
spine in postmenopausal women. Other effective activities for increasing BMD are weight-bearing
exercises, aerobics, and weight-resistance exercises (Johnell, Herzmann 2006). Studies have also
concluded that diabetes and poor self-rated health are risk factors for osteoporotic fractures in
women (Homeberg et al. 2006).

51

52

Lifestyle

53

An understanding of health determinants and their interactions is important as they greatly affect the
structure, condition, and sustainability of a populations health.
This chapter describes a number of the main lifestyle determinants of diseases that affect women,
including risk factors such as smoking, alcohol use, obesity, inadequate physical activity (PA),
accidents and injuries, and drug and substance abuse (EUROSTAT 2009).

Smoking
Smoking is the leading cause of preventable disease and death in Europe (EUGLOREH 2007). The
prevalence of female daily smokers in the period 1996-2003 ranged from 6.8% in Portugal to 32.2%
in Austria (EUROSTAT 2009). Although recent complete data is unavailable, partially complete
data for the period 2002-2005 suggests that the prevalence among women has increased in some
European countries. Combining both daily and occasional smokers, the prevalence reached 46.5%
in Austria and was above 20% in the majority of European countries for which data was available
(WHO 2009b).
Overall, the smoking prevalence is lower among women than among men. However, this gap has
been closing in recent years due to decreasing numbers of male smokers and increasing numbers
of female smokers in some countries (EUGLOREH 2007). Smoking-associated female deaths are
also still on the rise in some Eastern European countries (European Communities 2003). In the
years 2002-2005, the smoking prevalence was higher among women than men in Sweden (19%
vs. 14%) and rates were almost identical in Ireland (23.6% vs. 24.2%), please see figure 16 (WHO
2009b).
In addition, young girls are more likely to smoke than boys, particularly in Northern and Western
European countries. In the 2002-2005 period more girls than boys smoked in Italy, Sweden, Finland,
the Czech Republic, France, Spain, Denmark, Ireland, the UK, Norway, Belgium, the Netherlands,
Hungary, Germany, Austria, Greece, Portugal, and Slovenia (data from national sources and
therefore with varying relevant age-range , but in general referring to youth approximately 15 years
of age) (WHO 2009b).
Smoking is also more common in lower socio-economic groups (EUGLOREH 2007).

Fig. 16: Percentages of adult women and adolescent women smoking by European country in the years 2002-2005.
(WHO 2009b)

54

Smoking is associated with an extensive array of diseases and adverse health effects, including
stroke, chronic bronchitis, cancers (of the lung, pharynx, larynx, and cervix among others),
atherosclerotic peripheral disease, low birth weight babies, and lower fertility (EUGLOREH 2007;
European Communities 2003). Second-hand smoke is associated with acute respiratory illness
in early childhood (SIDS Sudden Infant Death Syndrome), irreversibly reduced lung function in
children and adults, increased symptoms and decreased lung function in asthmatics, lung cancer,
and ischaemic heart disease (European Communities 2003).
Cancers, cardiovascular diseases, and respiratory diseases are the most common causes of
smoking-related mortality, causing 43%, 28%, and 18% respectively of smoking-related deaths
(EUGLOREH 2007). In total, about 90% of lung cancers and 25% of heart disease deaths are
associated with smoking (European Communities 2003).
According to the Eurobarometer Special Survey Attitudes of Europeans Towards Tobacco, the
majority of Europeans are in favor of smoking bans in restaurants, bars and pubs, indoor public
spaces (metros, airports, shops), and offices (DG SANCO 2007a). The most contested of these
bans is the ban in bars and pubs, which women support more strongly than men - 65% vs. 59% of
women in the EU-25 (DG SANCO 2007a). These results should, however, be taken with caution, as
the Eurobarometer survey is only a broad overview of public opinion.

Alcohol consumption
Per capita alcohol consumption is higher in Europe than in any other region in the world and is a
significant lifestyle-related health determinant (Anderson, Baumberg 2006). In general, men drink
more and more frequently than women, but comparable data on average alcohol consumption among
European women is limited. The Eurobarometer Special Survey on Attitudes Towards Alcohol, which
provides a snapshot of womens drinking habits, suggests that in the EU-25 more men than women
drank alcohol in the last 12 months (84% vs. 68%); more men than woman who drank in the last
12 months had also had a drink in the last 30 days (92% vs. 82%); and men drank more on each
occasion, with 41% of women claiming never to have had 5 or more drinks on 1 occasion, while only
22% of men said they had never had that much at one time (DG SANCO 2006a).
More men than women are also dependent on alcohol, with an estimated 5% of European men and
1% of women being dependent in any one year (Anderson, Baumberg 2006).
A significant number of women (25 to 50%) drink alcohol during pregnancy (Anderson, Baumberg
2006).
Total SDR in the EU-27 in 2007 for men and women from selected alcohol-related causes was
64.06 per 100,000 (WHO 2009). Using combined data from the period 2005-2007, SDR for women
due to alcohol abuse was lowest in Bulgaria, Greece, and Malta (0/100,000) and highest in Estonia
(5.6/100,000). Most European countries fell somewhere between 0 and 2 alcohol abuse-related
deaths per 100,000 women. SDR from alcohol abuse was much higher among men, reaching a
peak of 27.5/100,000 in Estonia (data was unavailable for Belgium, Cyprus, Denmark, and Slovakia)
(EUROSTAT 2009).

55

Fig. 17: Standardised death rate (SDR) due to alcohol abuse per 100,000 women by European country in 2005-2007.
(EUROSTAT 2009)

Harmful alcohol consumption has been associated with a wide range of diseases and conditions
including injuries, occupational diseases, mental and behavioural disorders, gastrointestinal
conditions, cancers, cardiovascular diseases, immunological disorders, lung disease, and skeletal
and muscular diseases.
There are also risks specific to women. Harmful consumption may result in prenatal harm in pregnant
women (increased risk of premature birth and low birth weight), may affect fertility, results in a higher
risk of diabetes than with men, and is associated with victimization of women, such as domestic
abuse, sexual assault, and rape (Edwards et al. 1994). Studies also suggest that although women
are not more likely to report social problems for a given level of alcohol consumption, they are
more likely to be at risk of physical harm at lower levels of consumption than men (Edwards et al.
1994). The relative risks for women of some of these conditions based on different levels of alcohol
consumption are listed in Table 4.
Table 4: Relative risks in women for selected conditions caused by drinking.
(Rehm et al. 2004)

Cirrhosis of the liver


Oesophageal varices
Diabetes mellitus
Mouth and oropharynx cancers
Oesophageal cancer
Laryngeal cancer
Liver cancer
Breast cancer
Coronary heart disease
Ischaemic stroke
Ischaemic stroke
Haemorrhagic stroke
Spontaneous abortion
Low birth weight
Prematurity
Intrauterine growth retardation

Relative risk for alcohol consumption, g/day


0-19
20-39
40+
1.3
9.5
13.0
1.3
9.5
9.5
0.9
0.9
1.1
1.5
2.0
5.4
1.8
2.4
4.4
1.6
3.9
4.9
1.5
3.0
3.6
1.1
1.4
1.6
0.8
0.8
1.1
0.5
0.6
1.1
0.5
0.6
1.1
0.6
0.7
8.0
1.2
1.8
1.8
1.0
1.4
1.4
0.9
1.4
1.4
1.0
1.7
1.7

56

Alcohol may also negatively affect relationships, family, friendships, employment, and finances
(Institute of Alcohol Studies 2008).
Predisposing factors for the development of heavy drinking or alcohol problems include having
a family background of heavy drinking, a history of sexual abuse, low self-esteem, traumatic life
events, and eating disorders (Anderson, Baumberg 2006). Health effects of alcohol depend on how
much and how quickly alcohol is consumed, length of time drinking, body size and weight, age,
general health, genetic disposition, and nutritional status (WHO 2005).

Overweight, Obesity and Eating Disorders


Overweight and obesity
Overweight and obesity are defined as abnormal or excessive fat accumulation that poses a risk to
health. A standardised measure of obesity is the body mass index (BMI). A person with a BMI of 25
or more is considered overweight and a person with a BMI of 30 or more is defined as obese.
The prevalence of overweight and obesity is rapidly increasing in many European countries for
both sexes. As illustrated in figure 18, the highest percentages of women with obesity are found in
Austria, the UK, and Germany. The figure also shows that there are a great number of EU-countries
in which the prevalence of overweight among women is greater than 30% (IOTF 2009).

Fig. 18: Estimated prevalence of overweight and obesity in women by country for latest available year. (IOTF 2009)

Since 1980, the prevalence of obesity has increased three-fold, even in countries with traditionally
low obesity rates. Among women and men in Ireland and the UK, the prevalence of overweight has
risen by a rapid 0.8 percentage points a year (based on observational data) and self-reported annual
increases in obesity were highest in Denmark, Ireland, France, and Hungary. On the other hand,
Estonia and Lithuania self-reported adult obesity rates have fallen (WHO 2007).

57

Table 5: Trends in increase in prevalence of overweight

Country

Period

Denmark
Ireland
France
Hungary

19987-2001
1998-2002
1997-2003
2000-2004

Increase in prevalence
of overweight in women
(percent points, selfreported data)
1.2
1.1
0.8
0.6

Increase in prevalence
of overweight in men
(percent points, selfreported data)
0.9
1.1
0.8
0.6

The obesity epidemic is progressing at a particularly alarming rate among children and adolescents.
The International Obesity Taskforce (IFO) predicts that about 38% of school-age children in the
WHO European Region will be overweight by 2010 and that more than a quarter of these children
will be obese (Wang, Lobenstein 2006)
Overweight and obesity in women are associated with an increased risk of CVD, hypertension, and
diabetes type 2 (Schienkiwitz et al. 2006).
Other studies reveal that overweight and obesity are associated with breast and endometrial cancer in
postmenopausal women and musculoskeletal disorders (such as osteoarthritis and lower back pain)
(IARC 2008b). Studies emphasise the importance of a within-normal-range pre-pregnancy weight,
and show links between pre-pregnancy overweight and obesity and pregnancy complications, such
as higher risk for caesarean delivery, gestational diabetes, or increased risk of birth anomalies. In
addition, maternal obesity substantially increases a childs risk of being overweight (WHO 2007).

Eating disorder Bulimia nervosa


Eating disorders are a great risk to individual health and are gender-specific.
Bulimia is a specific eating disorder which is characterized by frequent bouts of binge eating,
followed by attempts to compensate the fattening effects of the binged food with various behaviour
(fasting, emesis), and an overall permanent preoccupation with food (Kirch 2008). There are few
representative epidemiological studies on this topic, particularly studies that differentiate between
men and women. However, the generally accepted prevalence rate of bulimia is about 1% among
young women. Only a minority (6%) of patients with bulimia enter the mental health care system
(Hoek 2006).

Physical Activity (PA)


The 2003 Special Eurobarometer Survey Physical Activity collected data on the prevalence of healthenhancing physical activity for both sexes across 15 EU-countries (Austria, Belgium, Denmark,
Finland, France, Germany, Great Britain, Greece, Ireland, Italy, Luxembourg, the Netherlands,
Portugal, Spain, and Sweden) using the International Physical Activity Questionnaire (IPAQ)
(Sjstrm et al. 2006). Among the participating countries only one third of the adult population (29%)
was sufficiently active for optimal health benefits. Among the individual countries rates of sufficient
activity ranged from 44% in the Netherlands to 23% in Sweden and according to the measure total
weekly activity, men were 1.6 times more likely than women to be sufficiently active and less likely
to be sedentary.
The results also showed that in Greece, Denmark, Germany, and the Netherlands there was a
higher prevalence of sufficient activity (31.4% - 40.2%) among women than in other participating
countries. In France (19.5%), Sweden (17.9%), and Spain (17.2%) few women were sufficiently
active (Sjstrm et al. 2006).

58

The quality and quantity of PA among men and women depends heavily upon context (work,
transportation, home, or leisure-time). According to the Eurobarometer survey, about a third of
women (32.1%), compared to 16% of men, reported a lot of physical activity in and around the
home. For leisure-time, men reported a lot (18.1%) or some (38.6%) leisure-time physical activity,
while women reported a lot or some physical activity only 11.8% and 34.7% of the time. Meanwhile,
for physical activity at work, men reported they had engaged in a lot or some physical activity during
the last 7 days more often than women (DG SANCO 2003).
Physical inactivity is an independent risk factor for breast cancer, osteoporosis, cardiovascular
diseases, and Type 2 diabetes mellitus. Physical inactivity is also associated with obesity (EUGLOREH
2007).
A Danish prospective cohort study identified predictors of physical inactivity in initially active people
for women these were found to be heavy smoking, poor self-rated-health, and lack of the belief
that their effort had an effect on health (Zimmermann et al. 2008).

Drug and substance abuse


Drug abuse is generally more common among men than women in European countries. This
includes the use of cannabis, ecstasy, and cocaine. However, the sex differences have recently
been decreasing lately. (EMCDDA 2006).
The number of lifetime experiences of cannabis use among students (aged 15-16 years) is higher
in men than in women, but these ratios are low and show little variation between EU-countries (1.0
in Ireland, Finland, and Norway to 1.8 in Portugal). Among adults (15-64 years old) the number of
lifetime experiences of cannabis use is higher and varies more between EU-countries. The adult
male to female ratio of use ranged from 1.3 in Finland to 4.0 in Estonia.
The overall prevalence of ecstasy use is lower in both sexes than the prevalence of cannabis use,
but the rate varies between countries and population subgroups. In over half of EU-countries, the
lifetime experience of ecstasy use in 15-to-16-year-old female students is roughly the same as in
male students. Among adults (15-64 years) lifetime experiences are lower in women than men
(ratios ranged from 1.0 in Estonia to 6.0 in Poland).
The prevalence rate of cocaine use is lower among adults and school students than the prevalence
of cannabis and ecstasy use. Men using cocaine outnumber women by a factor of 2 or more in most
countries. The reported lifetime prevalence for women of cocaine use ranged from 0.1% in Lithuania
to 7.1% in the United Kingdom.
Tranquilisers and sedatives are legal over the counter medicines that do not require a doctors
prescription. A transquiliser or sedative is a substance that induces sedation by reducing irritability
or excitement. Among school students (aged 15-16 years), use was clearly higher in women than
in men in most EU-Member States. Comparable data on abuse of legal drugs are not available for
adults.
Men outnumber women among drug treatment clients and also tend to be older. Available data from
2004 shows that among drug users asking for treatment for the first time, men outnumbered women
by a ratio of 4 to1 and among clients new to treatment; women were on average two years younger
than men.

59

Accidents and Injuries of Women in the EU


With more than 80,000 fatalities each year (about 250,000 in both sexes), accidents and injuries
represent the fifth (fourth) major cause of death of women in the European Union. Only cardiovascular
diseases, cancer, diseases of the respiratory system and diseases of the digestive system claim more
lives (KfV 2007). The recent injury death rate for women in the EU is 21.6 per 100,000 inhabitants
(Table 4), with a range from 11.5 in Greece (low also in Malta and Spain) to 60.6 in Lithuania (high
also in Latvia and Estonia). Two thirds (67%) of womens injury deaths in the EU are attributable
to unintentional injuries (accidents: 14.4 deaths per 100,000 inhabitants). For all EU-27, EEA, and
candidate countries the range is from 9 (Portugal, Greece) to over 40 deaths per 100,000 inhabitants
(Lithuania and Latvia). These differences combined with strong evidence that prevention works
indicate there is potential for reducing injury mortality.
Injury death rates are consistently lower for women than for men at all ages, for all major causes and
for all EU-27, EEA, and candidate countries. However, it is interesting to note that on the average of
the EU-27 the risk of women of dying from a fatal injury is only about one third (35%) of that of men,
but that this share is lowest (22% to 24%) in countries with a high overall injury mortality (Lithuania,
Latvia, Estonia) and highest (45% to 51%) in countries with low to medium overall injury rates like
the Netherlands, Switzerland or Norway (Figure 19).
As indicated in Table 6 transport accidents (19%) and falls (19%) are the leading causes of
unintentional injury deaths among women. Falls are also the leading cause of hospital admissions
of nonfatal injuries, in particular in the elderly (65+) and in particular for women: 29% of hospital
discharges of women in the age group over 65+ are diagnosed with hip fracture (849 per 100,000)
as opposed to only 17% for men (401 per 100,000). Extrapolated to the population of the EU-27,
these rates amount to 340,000 women over 65 years admitted for hip fractures each year, and 1.2
million hospital admissions for injuries in general, mostly due to falls. Fall prevention can therefore
be considered the most relevant approach to women specific injury prevention, with a number of
resources made already available to this avail at EU level (ProFaNE 2009; EUNESE 2009).

60

200
180
160

Standardized Death Rate for


all causes of injuries, all
ages per 100000

140
120
100
80
60
40
20

02

Li
th
ua
ni
02
a
7
La
01
tv
ia
4
Es
01 ton
i
a
5
F
02 inla
n
0
Hu d
ng
04
ar
3
y
Sl
ov
en
01
ia
0
Cr
oa
01
01
tia
2
6
Cz
Fr
ec
an
h
c
Re e
02
9
Lu pub
lic
xe
m
bo
03
ur
4
g
No
03 rwa
y
5
Po
03
la
8
nd
Ro
m
01
an
3
De ia
nm
02
ar
k
1
Ic
e
04
la
n
5
Sw d
04
6
Sw ede
n
itz
er
la
00
nd
4
Au
04
st
ria
2
Sl
ov
ak
ia
05
01 5 E
U
1
03
C
3
Ne ypr
u
th
s
er
01
la
nd
8
s
G
er
m
05
an
02
2
y
2
Un
Ire
ite
l
a
d
nd
Ki
ng
do
02 m
4
I
04 taly
4
Sp
03 ain
0
M
01
al
ta
9
G
re
ec
e

Women

Men

Fig. 19: Injury death rates for women and men in selected European countries, age standardised death rates per
100,000 inhabitants. (EUROSTAT 2005-2007)

Table 6: Major causes of fatal injuries in the EU by sex, age standardized death rates per 100,000 inhabitants. (Eurostat
2005-2007)

External cause of injury and


poisoning

Female

Male

Accidents (V01-X59)
Transport accidents (V00-V91)
Accidental falls (W00-W19)
Accidental poisoning (W00-W19)
Suicide (X60-X84)
Homicide (X85-Y09)
All external causes (ICD10 V01Y89)

14.4
4.2
4.2
1
4.7
0.6
21.6

67%
19%
19%
5%
22%
3%
100%

38.2
14.9
7.2
3.2
16.9
1.4
60.9

63%
24%
12%
5%
28%
2%
100%

Female/
Male
(%)
38%
28%
58%
31%
28%
43%
35%

Another gender specific approach to injury prevention is practiced in sports medicine. Although the
existence of a major sex divide in sports injuries is still controversially discussed, a well documented
example for a lesion that women are more likely to sustain than men are knee injuries, namely
tears of the anterior cruciate ligament that are closely related to all sports and recreational activities
(
Ahmad et al. 2006
).
The challenge for physicians and researchers there is to determine why women are more susceptible
to these sports injuries than men and how the injuries can be effectively prevented.

61

Table 7: Hospital treated knee injuries by sex and type of sports (top ten) (n=404,000; All injury data from Austria,
Cyprus, Germany, Latvia, Malta, the Netherlands, Sweden, Slovenia (ProFaNE 2009)
EU Injury Database 2006 and 2007

Type of sport
Soccer Outdoor
Skiing Alpine/downhill
Gymnastics
Hockey Field
Trail or general horseback riding
Basketball
Volleyball
Jogging/running
Handball Team
Tennis

Observed Knee
Injuries
1472
222
180
146
123
115
111
98
96
88

% Female
10%
55%
54%
56%
83%
34%
46%
39%
61%
38%

In order to provide the appropriate data for guiding and evaluating these specific injury prevention
approaches adequate injury data is also needed: characteristics that make women more or less
vulnerable to injuries (e.g. preventable risk factors)
as well as detailed information about activity, type of sports, place of occurrence, mechanism,
involved products, and a narrative description of the injury scenario (Kisser et al. 2009). In the
EU, the Injury Database (IDB) is generating such information in a number of Member States and
is meant to expand to the entire EU-region (IDB 2009). The EU IDB shows the percentages of all
occurring knee injuries sustained by women in sports with frequent knee injuries.
Although we know that injury death rates in the EU are lower for women than for men at all ages,
and injury hospitalisation rates are higher for women than for men beyond the age of 65, we still
have a long way to go in exploring the impact of injuries on womens lives. In particular unintentional
injuries create an enormous burden on the lives of women. Moving forward in reducing the burden
of accidents requires intensifying the ongoing work in the EU that already provides a strong context
and framework for research and dissemination.
As an empirical basis for this work also a dedicated prevention oriented data system for injury
surveillance like the EU IDB has to be in place that supports the exploration of the impact of injuries
on womens lives with the required information accidents and injuries.

62

You dont get to choose how youre


going to die. Or when. You can only
decide how youre going to live now.
Joan Baez

63

64

Healthcare

65

This chapter examines womens access to health care, the quality of the health care women receive,
and the responsiveness of different health care systems to womens needs. In order to compare
diverse health care systems and to address the complexity of the issue, a set of objective indicators
is required. Topics for this chapter are based on indicators recommended by The European
Community Health Indicators (ECHI) Monitoring Project (Kilpelinen et al. 2008). The majority of the
indicators are not gender-specific and there is very limited gendered data on health care available.
For this reason, only those indicators with specific relevance to women or with gender-specific data
available are presented here. For assessing accessibility, this includes equity of access and general
practitioner utilization and for quality of health care, breast cancer screening and cervical cancer
screening. Patient satisfaction is also addressed, as acknowledging patient views is an increasingly
important part of health care quality assessment.
To examine responsiveness, which the ECHI list does not directly address, two brief examples
highlighting the role of responsiveness in current European womens health issues are included
acceptability of HPV vaccination and health promotion of PA among working women.

Access to health care


Reliable and comparable data on access to health care across the EU-27 Member States is limited.
The most comprehensive available data comes from the 2007 Eurobarometer Survey Health and
Long-Term Care in the European Union. However, it is essential to recognize that the data from this
survey are only sufficient to suggest potential trends, as it is a broad public opinion survey with limited
sample size. Based on those women interviewed for the survey, the majority of European women
report having easy access to health care. Approximately 88% of women felt that it was easy to access
a family doctor or general practitioner, 76% felt that it was easy to reach a hospital, and 62% felt that
it was easy to access medical or surgical specialists. However, the survey suggests that access to
health services varies widely within and across Europe. Approximately 8% of interviewed women
reported they had gone without necessary hospital care in the past 12 months because a hospital
was not available or easily accessible; 10% had gone without medical or surgical specialists; 14%
without dental care; and 16% without family doctors or general practitioners although they needed
to (DG Employment, Social Affairs and Equal Opportunities 2007).
Data on unmet medical needs, as seen in figure 20, also suggests that for the most part women
have access to health care, however, there is some discrepancy among income quintiles, with the
poorest women much more likely to report unmet medical needs (EUROSTAT 2009).

66

Fig. 20: Percentage of women with unmet needs for medical examination by income quintile and European country in
2006. (EUROSTAT 2009)

The current data on health care utilization in Europe tends to make no distinction between
sexes, however, there is some limited sex-specific data. In 2005 the number of inpatient hospital
discharges per 100,000 female inhabitants was higher than the number of discharges per 100,000
male inhabitants in 19 out of 21 European countries for which data was available. Discharges were
highest in Austria, with 28,663.7 per 100,000 women and lowest in Cyprus with 6,251.5 per 100,000
women (EUROSTAT 2009).
The average percentage of women consulting a medical doctor in the last 12 months, according
to data collected in 19 European countries between 1999 and 2003, was around 81%. In Hungary,
Germany, the Czech Republic, and Belgium, more than 90% of women had been to a doctor during
that time-span and in all other countries for which data was available, except Romania, a minimum
of 70% of women had consulted a doctor (EUROSTAT 2009).
Available facilities and specialists vary extensively between countries. In 2005 the number of practicing
medical professionals with a specialty in obstetrics and gynaecology per 100,000 inhabitants ranged
from 2.2 in Ireland to 23.1 in the Czech Republic (data was unavailable for Cyprus, Finland, Hungary,
Iceland, Lithuania, Malta, Spain, and Poland) (EUROSTAT 2009).

67

Fig. 21: Number of physicians with a specialty in gynaecology and obstetrics per 100,000 inhabitants in 2005. (EUROSTAT
2009)

In addition to the physical accessibility and availability of health care, costs of health care play a
central role. Despite this, gendered data on health care expenditures is lacking and data on health
care costs and health insurance coverage for women is weak. Most gender-specific data on costs
come from public opinion surveys, such as the previously mentioned Eurobarometer Special Survey
Health and Long-Term Care in the European Union.
Using this survey again cautiously as a general guide, the majority of European women consider
hospitals affordable (54%) or report that they are free of charge (21%). Only 3% of women surveyed
had gone without hospitals or general practitioners/family doctors in the last 12 months because of
cost issues. However, 22% of the surveyed women judged hospital services to be unaffordable.
The availability of dental care proves to be a particular challenge across Europe the majority
of European women (53%) thought dental care was unaffordable and 13% reported having gone
without dental care due to cost issues (DG Employment, Social Affairs and Equal Opportunities
2007).
Specific at-risk groups of women face additional obstacles. Migrant women, residents of rural areas,
and elderly or functionally limited women may experience cultural, social, and physical barriers
reaching and utilizing healthcare services (European Commission 2008c).

68

Quality of Health care


Health care quality is determined by numerous factors such as access, effectiveness, efficiency,
safety, equity, appropriateness, and timeliness, to name only a few (Legido-Quigley et al. 2008).
As it is outside the scope of this report to analyze the overall non-gender specific quality of care
in all EU-Member States, the ECHI criteria breast cancer screening and cervical cancer screening
are used as indicators for their particular relevance to womens health. It should be noted that
comparable data on breast and cervical cancer screening volume is limited. It is difficult to compare
national screening programmes because of different logistical set-ups (targeted age range, regional
or nationwide implementation, recommended screening interval) and because the absence of an
active screening programme does not mean that screening is not occurring research suggests a
significant proportion of total screening is done on an opportunistic basis (outside of an established
programme) (IARC 2002). However, examined here is the best available data on screening.
Breast cancer screening by mammography has been shown to reduce breast cancer mortality
among women aged 50-69, when implemented at population level, i.e. individuals are identified as a
pre-selected target population and invited (via letter or phone call) to receive screening for a specific
disease or condition (IARC 2002). Most European countries recommend breast cancer screening at
a 1-3 year interval for women of this age group (IARC 2002).
As of 2007, in a review of the EU-27, breast cancer screening was implemented at the population
level in eleven countries (Belgium, Cyprus, Estonia, Finland, France, Hungary, Luxembourg, the
Netherlands, Spain, Sweden, and the UK). On top of this, screening programmes at the population
level were currently being introduced in seven countries (the Czech Republic, Denmark, Germany,
Ireland, Italy, Poland, and Portugal) and three countries were planning or piloting a nationwide
screening programme (Malta, Romania, and Slovenia). Four countries had non-population based
screening programmes (Greece, Latvia, Lithuania, Slovakia), one country offered nationwide
subnational population-based screening (Austria), and one country had no active or planned
screening programme (Bulgaria) (IARC 2008a).
Cervical cancer screening, which has been recommended by the EU since 1987, is associated
with up to 60% reductions in mortality when implemented in organized population-based screening
programmes (WHO 2009d). Cervical cancer screening, most commonly a cytological (Pap smear)
test, is recommended by almost all European countries for women between 25 and 64 years of age,
at intervals of 1, 3, or 5 years (IARC 2005).
As of 2007, in a review of the 27 EU Member States, seven countries had active nationwide
population-based screening programmes (Denmark, Finland, Hungary, the Netherlands, Slovenia,
Sweden, and the UK), five were rolling-out, planning, or piloting nationwide population-based
programmes (Estonia, Ireland, Italy, Poland, and Romania), twelve had non-population based
programmes (Austria, Belgium, Bulgaria, the Czech Republic, France, Germany, Greece, Latvia,
Lithuania, Luxembourg, Slovakia, and Spain), and two had no programmes or planned programmes
(Cyprus and Malta) (IARC 2008a).
In total, of the 59 million EU women for which the European Commission recommends breast cancer
screening (aged 50-69) (The Council of the European Union 2003), 91% were targeted for screening
in 2007 through some type of programme (IARC 2008a). Of the 109 million EU women aged 30-60,
the EC recommended screening age range for cervical cancer (The Council of the European Union
2003), 51% were targeted for population-based screening programmes and 47% were targeted by
non-population based programmes in 2007 (IARC 2008a).

69

It is essential to recognize that while this data gives an idea of the aspired screening coverage in
the EU and of individual-country action on making screening available to womenmore data on
womens utilization of these services is necessary. The availability of data on participation rates of
women in cervical and breast cancer screening programmes is of utmost importance to womens
health.
Examining patient satisfaction as a measure of quality, European women believe that they are for
the most part receiving good quality care: seven out of ten women judge the quality of hospitals in
their country good (DG Employment, Social Affairs and Equal Opportunities 2007). Based on the
Second European Quality of Life Survey, most women in the EU-27 are satisfied with their own
health, although there is some discrepancy between those women in the lowest and highest income
quartiles. Women in the middle income quartile ranked satisfaction with their health at 7.2 out of 10,
while women in the lowest quartile ranked their satisfaction at 6.8 and women in the highest quartile
ranked their satisfaction at 7.8 (Anderson et al. 2009).

Responsiveness of health care to specific needs of women


Part of quality health care for women is responsiveness to womens needs. Responsiveness is not a
direct measurement of the quality of health outcomes, but rather refers to the non-health features of
the health care system and whether a populations expectations for care provision are met, including
respect for personal dignity, confidentiality, autonomy to participate in choices about ones own
health, and freedom in the selection of facilities and care providers (WHO 2000). Responsiveness is
especially relevant for women already facing barriers for utilization of the health care system.
Very little data directly measuring European-wide responsiveness exists, thus the acceptability to
women of female-specific programmes, namely HPV vaccination programmes and physical activity
promoting programmes, are used as illustrations of the state of responsiveness to womens needs
in this section.

HPV vaccination

Cervical cancer is caused by persistent infection with one or more of 15 types of oncogenic HPVs
(Boyle, Lewin 2008).The first of two currently commercially available vaccines to protect against
a subset of these viruses (HPVs 16 and 18, estimated to cause 73% of cervical cancer cases in
Europe) was made available in 2006 (King et al. 2008; Clifford et al. 2006). As of February 2009,
introduction of the HPV vaccine into national immunization schedules had been approved in Austria,
Germany, France, Italy, Belgium, Greece, Luxembourg, Portugal, Spain, Sweden, and the UK (King
et al. 2008; Tegnell et al 2009).
The acceptability of the vaccination among women is fundamental to its implementation. Crucial
questions include: do women trust the vaccine as effective and safe; do they want or expect the
HPV vaccine to be part of a required national immunization schedule; do they expect vaccination
costs to be covered by national health insurance programmes; will they allow preadolescents and
adolescent children to be vaccinated for a disease linked to sexual activity (male children may also
be potential candidates for vaccination as men may benefit from HPV vaccination for protection
against genital warts or be virus carriers later infecting women).

70

Considering the relatively recent introduction of the vaccine and the ongoing process of developing
national guidelines, clear-cut answers to these questions are not available, making the collection
and analysis of current data necessary. In November 2008 the Ministry of Public Health in Romania
also began a campaign aimed at immunizing 110,000 girls in 4th grade, however, in an example of
the importance of assessing current vaccine acceptability, parents were not informed until the day
of the immunization and many refused to allow vaccination (WHO 2009i).

Health promotion of physical activity (PA) among working women


Most adults spend half of their waking hours at the workplace. An adequate level of physical activity
may be needed to maintain or promote work ability, particularly among aging female workers.
Therefore, in order to prevent consequences such as early retirement preventive promotion of
health and work ability is needed. This section outlines worksite interventions that aim to promote
moderate PA among working women and their acceptability to women.
The outcomes measured in worksite health promotion programmes are variable (for example
proportion of workers engaging in regular exercise, aerobic capacity and body fat level, or level
of stress). However, most studies of such programmes present positive findings and significant
changes in womens health.
PA interventions can be divided into two groups those based on counselling and education
sessions and those offering facilities, space, or time for the workers to engage in PA. The outcomes
of these studies show that offering fitness facilities or classes may not be more successful than
offering educational sessions.
A low employee participation rate is one of the main problems in health promotion activities, suggesting
acceptability has not been well addressed. Data on which baseline characteristics of the target
population are associated with participation rates are limited. Still, it is known that older women, less
educated women, and women with lower socioeconomic status are less likely to engage in PA than
other women.
Women with lower incomes or those working in blue-collar occupations in small to medium-sized
worksites (for example women in manufacturing) have less access to health promotion programmes,
as such worksites often lack comprehensive health programmes and resources. Women working at
these types of worksites tend to have elevated health risks due to a high prevalence of unhealthy
behaviour and higher stress because of high demands and low control.
Time constraints stemming from womens multiple roles and responsibilities in work, family, and
private life may also cause participation problems (Janer, Kogevinas 2008).

71

72

Conclusion and
recommendations

73

Conclusion
This report was prepared to provide an overview of issues related to womens health across the
EU-27 Member States and the EEA (Norway, Iceland, and Liechtenstein). It considers a variety of
morbidity and mortality related risk factors, as well as issues of health determination and health
promotion. Detailed description of the state of womens health at the national and European levels
would require consideration of the interaction of potential health promoting and health risk factors.
However, current data related to womens health are scattered, inconsistent, and in some cases even
unavailable. This report is an attempt to identify information gaps and topic areas that need focus
and attention and thus pave the way for European policy-making in relation to womens health.
Therefore, this report is not a complete overview of womens health in the EU today, in the sense
that all facets of womens health are discussed. Subjects were included based on their relevance to
womens health and the availability of sufficient, reliable, and topical data for all or most of the EU27 Member States as well as Norway, Iceland, and Liechtenstein. In addition, gender specific data
had to be available.
For this report a wide range of statistical databases from EU-countries and international sources
were used. All efforts were made to use the most up-to-date data available. If for a certain variable
data was unavailable for only one or two countries, data from the most recent available year has
been substituted (including in tables and graphs). Where this was done, it has been clearly indicated
in the text. Data was particularly unavailable for Liechtenstein.
However, although available data was occasionally a limiting factor and much data was not broken
down by gender, it is nonetheless possible to provide a picture of a number of different dimensions
of womens health in Europe.

Demographic and Socio-Economic Trends


In the European population there are more women than men. Women generally live longer than
men in all parts of Europe, but women also experience more years of disability than men. With the
increasing population of old women the risk of chronic diseases such as diabetes and mental health
problems is increased. To ensure womens health it is necessary to make explicit how womens
physical, psychosocial, and social health should be addressed at every stage of their lifespan.
Health care must be more sensitive to womens specific needs, particularly the specific needs of
older women, as they are a growing demographic.
Women are more likely to receive lower wages than men, even though on average women have a
higher level of education. In addition, women are employed part time much more frequently than
men in all European countries, partially because part time work may enable women to balance their
double role as employee and caretaker. Women carry out a greater proportion of unpaid work (e.g.
household and caring work) compared to men. Adding paid and unpaid work women work more
hours per week than men. The double workload (family and work duties) puts women at greater risk
of mental health problems. More research is necessary to examine this work life balance.

74

Health Issues
The main causes of death for women in the EU and EEA are still CVD and cancer. In spite of the
improvements seen in mortality rates for most forms of cancer, further research is required to reduce
these rates through primary and secondary prevention.
HIV infection remains of major public health problem in Europe and reported cases of HIV infection
continue to increase. However, the available data are incomplete because of limitations in reporting
systems, which urgently need to be addressed in the near future.
Mental health disorders are a common public health problem in the European community. In particular,
dementia and AD are of major concern to women due to their longer life expectancy. In this report
data from the EURODEM group was used because we were unable to locate any comprehensive,
current, gendered data on the prevalence and incidence of dementia which differentiated between the
different forms and stages of the condition. Thus analysis of gender-related differences in dementia
and AD and relevant health determinants should be a research priority. Women suffer more often
from mental health problems than men such as depressive disorders. A possible influencing factor
may be their multiple roles in society (mother, employee, wife, etc).
Health surveys pertaining to musculoskeletal disorders such as osteoporosis are also limited. There
were no data routinely collected available.
There are a number of additional issues related to womens health for which statistics were extremely
scarce. For example, current local epidemiological data of endometriosis in European women are
rare and EU-wide studies were not available within the scope of the literature reviews performed for
this report. Data on migraine in European women and its effect on womens work and health status
are also rare.

Health care
Analyzing the quality of health care across an area as large and varied (in terms of health care
systems, demographic composition, and cultural behaviours) as the EU/EEA is a difficult task. Both
adequate indicators and sufficient data are necessary. Currently, there is a significant gap in available
data on health care-related issues from utilization of health care facilities to participation in health
care programmes and health promotion activities to awareness of womens specific desires from
and satisfaction with the health care system. Where data is available, it tends to be regional, from
a relatively limited sample, and not gender specific. Improvements in gendered data collection on
health care-related issues are an essential step in identifying relevant issues for women and for
analysing the efficacy of current measures. However, based on the little data is available, most EU
women generally have easy access to good quality health care.

75

Lifestyle
Data on lifestyle determinants shows that there is still cause for concern and much room for
improvement in lifestyle-related diseases. The prevalence of female smokers in some European
countries is on the rise, as are smoking-associated female deaths. There are also limitations in
official reporting systems, such as those for drug and substance abuses and alcohol use among
European women. For example, the available epidemiological data do not always include a gender
breakdown, and when data do exist, figures relating to women are sometimes low and difficult to
interpret.
Overweight and obesity are a serious public health problem in European women. As women are
more often responsible for the preparation of meals, they are an important target group in the fight
against the obesity epidemic in Europe, not only in the female population. Available annual data
includes self-reported and measured data, but is important to recognize that self-reported data
tends to underestimate the actual weight in overweight and obese people. Making comparisons
among countries is difficult due to different methods of data collection, years of collection, and age
ranges included, as well as the lack of measured and valid BMI data for a number of EU-countries.
There is also a particular need for more information on eating disorders among EU women: a number
of studies focusing on eating disorders in European women suggest that they are increasingly a major
health problem, however, data related to specific eating disorders, particularly Bulimia nervosa, are
limited.

Recommendations
The fundamental aim of this report was to present and summarize available data on important issues
in the field of womens health. However, the larger intended impact was to bring to light both current
and emerging important womens health issues, identifying areas where more communal, medical,
financial, and political effort is needed, and to foster discussion among stakeholders. Based on the
analysis of available data as presented in this report, the authors recommend that womens health
shall be recognised as a public health subject area of considerable importance in research and
policy making.

76

77

78

Glossary and
references

79

Glossary
Kirch: Encyclopedia of Public Health, Springer New York, 2008
Determinants of Health: Determinants of health are health indicators that represent factors
which either directly cause illness and disease, or are risk factors that affect the health status of
populations and individuals. Determinants of health include the social environment (such as political,
policy, socio-economic factors), the physical environment (living and working conditions), personrelated dimensions (such as genetic endowment and health behaviour), and access to health care
services.
Incidence: Incidence refers to the number of people newly affected by a certain condition in a
specific period of time. It can be given as a number or as a ratio, having as denominator the total
number of people who can possibly be affected by the mentioned condition.
Indicator:
An indicator is a measurement that reflects the status of a system. Indicators reveal
the direction of a system (a community, the economy, or the environment); if it is going forward or
backward, increasing or decreasing, improving or deteriorating, or staying the same.
Fertility Rate: Fertility rates are measured in terms of the number of live births per women-year of
exposure for a given period, usually one year.
Morbidity Rate The morbidity rate is the proportion of individuals who become ill with particular
disease within a susceptible population during a specific time period, e.g. given year. It is usually
expressed as number of people afflicted per 1,000, 10,000, or 100,000 people. It can also refer to a
percentage of people who have complications after a procedure or treatment.
Mortality Rate: Mortality rate is a measure of number of deaths in a given population. Mortality rate
is typically expressed in number of death per 1,000 individuals per year.
A standardised death rate is a crude death rate that has been adjusted for differences in age
composition between the region under study and a standard population. Standardisation allows for
comparisons when the population structures differ and is key in assessing the potential influence of
environmental or cultural factors on death rates in a region
Prevalence: Prevalence refers to the total number of people affected by a certain condition at a
given point in time. It can be given as a total number, or as a percentage of the total population or
as a ratio.
Reproductive Health: Reproductive health refers to the complete physical, mental and social wellbeing in all matters concerning the reproductive system, its functions and processes.

80

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86

List of abbreviations
AD

Alzheimer Disease

AIDS

Acquired Immunodeficiency Syndrome

BMD

Bone Mineral Density

BMI

Body Mass Index

CVD

Cardiovascular Disease

CHD

Coronary Heart Disease

DALYs

Disability-adjusted life years

DM

Diabetes Mellitus

ECHI

European Community Health Indicators

EEA

European Economic Association EUROPEAN

EFTA

The European Free Trade Association

EURODEM European Community Concerted Action on the



Epidemiology and Prevention of Dementia Group
ESEMed

European Study of the Epidemiology of Mental Disorders

GDM

Gestational Diabetes Mellitus

HIV

Human Immunodeficiency Virus

HLYs

Healthy Life Years

HPV

Human papilloma virus

IDB

Injury Database

IDF

International Diabetes Federation

IFO

International Obesity Taskforce

MMR

Measles, Mumps, and Rubella

Number

PA

Physical Activity

SDR

Standardised Death Rate

RA

Rheumatoid Arthritis

87

88

89

90

91

ND-80-09-924-EN-C

II.

Data and Information on Womens Health in the European Union, 2009,


Directorate General for Health &Consumers.

1. Explicai rolul noiunilor de sex i gen n analiza sntii femeilor. Oferii dou
exemple.
2. Care sunt aspectele particulare pe care le comport sntatea reproducerii pentru
femei ?
3. Care sunt aspectele particulare pe care le comport sntatea mintal pentru femei ?

POSITION PAPER
Brussels, June 2010

European Womens Lobby Position Paper:

Womens Health in the European Union


Introduction
Women have the right to the enjoyment of the highest attainable standard of physical and
mental health. The enjoyment of this right is vital to their life and well-being and their ability to
participate in all areas of public and private life.
Beijing Platform for Action, Women and health, 1995
Health and wellbeing, both physical and mental, are crucial conditions for the full development of every
human being. Health is more than a biological issue, representing according to the World Health Organisation,
a state of complete physical, mental and social well-being and not merely the absence of disease or
infirmity.1 Both the biological concept of sex and the social construct of gender matter in health at all levels
and impact differently on women and mens health, access to health and health-care.2 Unequal access to
resources coupled with other social factors produce unequal health risks and access to health information,
care, and services for women and men. In addition to this, biological differences imply that women have
particular health concerns and needs, especially related to their sexual and reproductive health.
Public policies in the health sector theoretically sometimes acknowledge that gender is a significant health
determinant across the life cycle.3 However, womens health needs are not fully and consistently integrated
into European and national health policies.4 The lack of a consistent and integrated approach to womens
rights and gender issues within health policy needs to be urgently addressed, including in a context of a
financial and social crisis marked by cuts in public spending in services that are crucial for the attainment of a
high level of human health protection for all, as guaranteed by the European Union (EU) Treaties.5 To be
effective, all aspects of health policies, currently to a large extent gender-blind in practice, must include a
women-specific approach and make full use of gender mainstreaming as a tool.
The present paper presents first the analysis of the European Womens Lobby (EWL) regarding these issues
and then recommendations for national and European decision-makers in order for public policies in the
health sector to fully address womens health needs.
1. The gender dimension of womens health
Biology plays a crucial role in health status. Differences related to reproductive functions have long been
recognised as of primary importance, while womens health needs must not be reduced to these functions, as
1

Preamble to the Constitution of the WHO, adopted 1946.


Sen, G. & P. stlin, Unequal, Unfair, Ineffective and Inefficient. Gender Inequity in Health, 2007.
3
Council of the European Union, Conclusions on Women and Health, 2005; Conclusions on Health and Migration in the EU, 2007;
Conclusions on Roma Inclusion, 2008; Resolution on the health and well-being of young people, 2008.
4
See Section 4 below.
5
Art. 168 TFEU (ex Art. 152 TEC).
1
2

POSITION PAPER
is currently the case in many EU Member States.6 Biological differences between women and men also
include, for example, the better infant survival rates of females, sex-specific diseases, distinctions in symptoms
of diseases, or womens longer life expectancy. Some of these biological differences seem to advantage
women over men. However, they are mostly cancelled out by the gender inequalities embodied in the social
disadvantages women face in comparison to men, such as lesser access to resources (including unequal pay
and unequal pensions), heavier workload as women combine a greater share of paid and unpaid work, male
violence against women, services and treatments which are not adapted to womens need, and sex-based or
multiple discrimination. Gender stereotypes also affect all areas of health care.
Biological sex must not be used as an isolated factor to analyse and tackle health issues. Beyond sex, the social
construct of gender influences the extent to which women are able to have control over the circumstances
affecting their health and quality of life. Existing research indicates gender inequalities in health status, healthrelated behaviour, access to health and treatment.7 Policy makers and medical research must question and
investigate the causes of these inequalities and offer effective answers.
For example, biomedical research continues to be based on the unstated assumption that women and men
are physiologically similar in all respects apart from their reproductive systems, and it ignores other biological,
social and gender differences which have a considerable impact on health.8 It is the case for pain: women have
pain more often, more intense pain and pain killers are less effective with women than with men.9 Another
relevant example is the identification of differences in symptoms and application of targeted treatment of
coronary heart diseases for women and men. Only recent research on womens heart conditions and
symptoms has proved that women suffer from cardiovascular heart diseases (CHD) in much higher numbers
than men, but these diseases come later in life, manifest themselves through different symptoms as compared
with men, and should be treated differently in terms of medication allocation.10 In many cases, preventive and
curative strategies are applied to women while they have been tested only on men and might therefore have
little or even counterproductive effect.
Some research centres acknowledge the fact that men and women are not biologically equal and take a
broader perspective on the biological aspects of a womans life, i.e. childhood, adolescence, childbearing age,
pregnancy, and menopause. Nevertheless, the fact remains that, there are still major gaps in expertise and
general knowledge about the differences between disease processes in women and men, and a blatant lack of
sufficient gender-sensitive studies, analyses, investigations and sex-disaggregated data that can provide an
answer to these differences.

6 Crepaldi, Ch. Et al., Access to Healtcare and Long-Term Care: Equal for women and men, 2009, p. 61.
7
World Health Organisation, Women and Health. Todays Evidence, Tomorrows Agenda, 2009; Thummler, K. et al., Data and
Information on Womens Health in the European Union, 2010; European Institute of Women's Health, Womens Health in Europe.
Facts and Figures Across the European Union, 2006.
6 Crepaldi, Ch. Et al., Access to Healtcare and Long-Term Care: Equal for women and men, 2009, p. 61.
7
World Health Organisation, Women and Health. Todays Evidence, Tomorrows Agenda, 2009; Thummler, K. et al., Data and
Information on Womens Health in the European Union, 2010; European Institute of Women's Health, Womens Health in Europe.
Facts and Figures Across the European Union, 2006.
8
Lin, V. & al., Gender-sensitive indicators: Uses and relevance, International Journal of Public Health, vol.52, 2007, pp. 527-534.
9
Conseil National des Femmes francophones de Belgique, Les femmesngliges par la mdecine?, 2009.
10
Schenck-Gustafsson, K., Centre of Gender Medicine, public presentation sponsored by 1.6 Million Club for Womens Health, Brussels,
26 January 2010; See also Red Alert on Womens Hearts. Women and Cardiovascular Research in Europe, 2009.
2

POSITION PAPER
2. Womens health risks and needs
The sex and gender dimensions of health entail that women face a number of specific health risks over their
lifetimes. In addition to this, age, ethnicity, disability, sexual orientation or identity, resources, education,
social and marital status, position in the labour market, place of residence, the level of gender equality in
society and other attributes influence womens health needs and access to health. Taking into consideration
womens diversity and incorporating it in the health policies addressed to women would strengthen the
efficiency of these policies.
2.1 Womens specific health concerns
a. Cancer of the breast, cervix or uterus
Cancer represents one of the biggest health threats in Europe today, fatal in 2006 for 140 women out of every
hundred thousand.11 Women suffer predominantly from different forms of cancer than their male
counterparts, most notably breast, uterus and cervical cancers. Breast cancer affects almost exclusively
women and remains the main causes of cancer mortality among women in the EU, with 25.14 victims per
hundred thousand women under 65 years of age.12 Cervical cancer affects women exclusively and is
potentially lethal, especially for women living in new EU Member States.13
Screening procedures are considered to be one of the most efficient cancer prevention measures.14 Breast and
cervical cancer can be treated in their early stages if access to effective screening is ensured to all women and
is coupled with scientifically validated treatments. All EU Member States have provisions for breast and
cervical cancer screening, but conditions of access and quality of treatment differ from country to country.
Only ten EU Member States have set the very much-needed target screening 100% of the female population
for breast cancer and only 8 countries have such a target for cervical cancer screening.15
Two vaccines have recently been made available to prevent two types of Human Papilloma Viruses (HPV) that
are said to cause 70% of cervical cancers.16 In order to be effective, the vaccine must be given prior to the
beginning of sexual life.17 It is available in 13 EU Member States, targeting girls between 9 and 13 years of age,
and in most cases is free of charge and available on demand. In several other Member States, like Cyprus, the
Czech Republic, Estonia and Malta, plans to make the vaccine available to the public have been discussed but

11

EUROSTAT, Key Figures on Europe, 2009, Figure 2.8: Causes of death, EU-27 by 2006, p. 58.
Mladovsky, P. et al., Health in European Union, 2007, p. 27. There is a need for more research to prove the impact of environment,
specifically endocrine disruptors, on the increased incidence of breast cancer among women in Europe.
13
World Health Organisation, Regional Office in Europe, Atlas of health in Europe, 2008, p. 49.
14
Spadea, T. et al., Inequalities in female cancer screening rates, in EUROTHINE, Tackling Health Inequalities in Europe: An Integrated
Approach, 2007, pp. 500-521.
15
Spadea, T. et al., Inequalities in female cancer screening rates, in EUROTHINE: Tackling Health Inequalities in Europe: An Integrated
Approach, 2007, pp. 500-521.
16
HPVs are a group of over 100 related viruses among which 9 are considered high-risk HPV that might lead to cervical or anal cancer.
The vaccination is only for HPV 16 and 18, which according to statistics represent 70% of the HPV found in cervical cancer (to take with
caution
as
it
might
be
pharmaceutical
companies
who
provide
these
figures).
Source:
http://www.who.int/immunization/topics/hpv/en/
17
European Cervical Cancer Association, Guidelines for Cancer Prevention, HPV Vaccination Across Europe, 2010.
3
12

POSITION PAPER
as yet either not adopted or not implemented.18 Availability of the HPV vaccination, however, should not lead
to a decrease in cervical cancer screening, which remains the main tool for cervical cancer prevention given
the absence of full coverage of the vaccination.
Other forms of cancer that affect both women and men have gendered dimensions. Lung cancer, for example,
was for a long time considered a male disease and measures to prevention and treatment measures were
developed accordingly. Existing data shows that lung cancer continues to be more predominant among men in
Europe as compared to women,19 but womens mortality rates have increased rapidly over the last decades.20
Indeed, while mens rates are decreasing, womens continue increasing almost everywhere, except in the UK
and, to some extent, in Ireland and Denmark.21 According to a French study, while the lung cancer rate for
men of 40 years of age has halved over the last ten years, the rate for women has multiplied by four over 15
years.22 For women, lung cancer has only recently been recognized as a health problem and treated as such.
European comparative data has highlighted a geographical pattern of lung cancer incidence linked with
smoking habits over the last two to three decades. Thus, the highest rates of lung cancer are among women in
Denmark, Hungary and the United Kingdom, while the lowest are in Spain, Malta and Portugal.23 On the other
hand, today smoking is more prevalent among women in Southern European countries compared to those
from further North.24 Accordingly, prevention and treatment approaches need to change and adapt to these
gendered and geographical patterns.
b. Reproductive health and care, maternal mortality, infertility and Artificial Reproductive
Technologies (ART)
Womens reproductive health and care and maternal mortality
Each year more than five million women give birth in the EU. Another two million women have failed
pregnancies spontaneous and induced abortions as well as ectopic pregnancies.25 Because of different
factors ranging from longer studies, growing involvement in paid employment, difficulties in conciliating
private and work life, costs, etc, women in Europe are increasingly having children later in life, which creates
different types of health risks and needs.26

18

Ibid.
Mladovsky, P. et al., Health in European Union, 2007, Fig. 3.6 Standardised lung cancer incidence rates per 100 000, in selected
European countries, 2000, p. 33. World Health Organization, Atlas of health in Europe, 2008, Deaths from lung cancer, 25 64 years, p.
47.
20
Unfortunately, mortality for lung cancer among women is increasing almost everywhere, except in the UK and, to some extent, in
Ireland and Denmark. The leading contribution to lung cancer are the number of cigarettes smoked per day, the degree of inhalation
and the initial age at which individuals start smoking. In Mladovsky, P. et al., Health in European Union, 2007, p.34.
21
Ibid.
22
LInstitut de veille sanitaire, Bulletin pidmiologique No. 19-20 (BEH), Special Issue World No Tabacco Day, 31 May 2010,
http://www.invs.sante.fr/beh/
23
Thummler, K. et al., Data and Information on Womens Health in the European Union, 2010, p. 37.
24
Boyle, P. and Fery, F., Cancer incidence and mortality in Europe 2004, in Annals of Oncology No. 16, pp. 481- 488. Elmadfa I (ed.) :
European Nutrition and Health Report 2009, Forum Nutrision Basel, Karger, vol. 62, pp. 180-184.
25
An ectopic pregnancy happens when the pregnancy implant is located outside of the uterine cavity. It is treated as an emergency
and if not properly dealt with can be a cause of death.
26
World Health Organisation, Regional Office in Europe, Atlas of health in Europe, 2008, p. 16.
4
19

POSITION PAPER
Health-care for pregnant women must begin as soon as possible in the first trimester of pregnancy in order to
make it possible to identify specific conditions that may require surveillance, recognise social problems for
which women may need help from social or mental health services, and inform women about pregnancyrelated issues. Focus on the expectant mothers health and the provision of extra attention to women at risk
of preeclampsia, diabetes, and high blood pressure can significantly lower mother and child mortality and
morbidity. 27 Pre-conceptual examination of both partners needs to be promoted, as there are several health
risks that can be avoided: genetic diseases that lead to haemophilia, infections (HIV-AIDS, Hepatitis C, Syphilis,
Tuberculosis, diabetes and the prevention of Spina Bifida. )
Data from a number of EU Member States28 shows that more than 90% of women undertake a medical checkup during their first trimester of pregnancy, which means that still one in ten women in Europe doesnt access
care in the first months of pregnancy.29 In addition, access to antenatal care and even childbirth services is
sometimes problematic. Women living in rural areas, for example, often need to travel long distances in order
to give birth, which may put their lives in danger.
In most EU countries, childbirth services are provided for free, even if a woman is not insured.30 Nevertheless,
in many EU Member States, women are not given a free choice between different ways of giving birth. There
is an overmedication of birth documented by caesarean section rates of over 30% that can lead to different
types of obstetrical complications and health problems. The psychological trauma and negative experiences of
childbirth must be paid more attention, as they are part of the quality of maternity care.
Maternal mortality is considered a major marker of health system performance.31 The maternal mortality ratio
in Europe is low compared to other regions, due both to a very low fertility level (1.5 children per woman) 32
and to high levels of care. Data from the latest global report on maternal mortality (April 2010) shows that 13
EU Member States are among the 20 countries in the world where the maternal mortality ratio is the lowest,
around 7/100 000 live births.33 Still, even one maternal death can be considered a warning signal of some
dysfunction in the provision of care, and five new EU Member States have maternal mortality ratios higher
than 18/100 000.34

27

Preeclampsia, Pregnancy Induced Hypertension and toxaemia are closely related conditions. Helpp syndrome and eclampsia are the
manifestations of the same syndrome. Globally preeclampsia and other hypertensive disorders of the pregnancy are a leading cause of
maternal and infant illness and death.
28
Czech Republic, Germany, France, Italy, Portugal, Slovenia, Finland and Sweden.
29
Table 5.1 Percentage of pregnant women by timing of first antenatal visit, in European Perinatal Health Report, 2008, p. 73
30
EURO-PERISTAT Project, European Perinatal Health Report, 2008, p. 94.
31
Maternal mortality ratio is the number of maternal deaths per 100 000 live births.
32
See http://epp.eurostat.ec.europa.eu/portal/page/portal/population/data/main_tables
33
The Lancet, Maternal mortality for 181 countries, 1990-2008: a systematic analysis of progress towards Millennium Development
Goal 5 April 2010.
34
Ibid. Latvia (18), Slovenia (19), Estonia (22), Romania (26), Bulgaria (28) and Cyprus (41).
5

POSITION PAPER
Womens infertility and access to Assisted Reproductive Technologies (ART)35
The majority of EU Member States have deemed infertility a medical condition, but there are significant
differences between the Member States in regulating the access and provision of ART services to treat
infertility in both women and men or in other cases. In most cases, all or some portion of infertility treatments
are funded through national health policies. For example, in Portugal and Spain, ART procedures are fully
reimbursed if provided in a public clinic or hospital. Germany and Austria reimburse 70% of the cost of
treatment.36 Lack of public funding restricts access in e.g. Ireland, Romania, and UK; in Portugal and Italy, for
example, national legislation prohibits certain ART treatments. In such cases, women or couples take
advantage of European freedom of movement provisions to travel to other countries in order to receive
treatment. For instance, half of the women receiving fertility treatment in Spain come from other EU Member
States.37
Women also widely face restrictions when accessing ART treatment on the basis of age, sexual orientation and
marital status. Belgium and France are the only two European countries to provide access to ART to women
over the age of 40.38 The majority of EU Member States exclude single and/or lesbian women from access to
such services. Slovakia is such an example where assisted reproduction intervention is conditioned by intimate
physical relationship between a man and a woman. Where treatment is legally possible for single women or
those in same-sex relationships, e.g. in Belgium, it is provided only subject to certain conditions.
HIV-AIDS
In 2008, 850 000 adults and children were expected to live with HIV-AIDS in Western and Central Europe, a
third of whom are women. While the dominant way of transmission of HIV-AIDS is sex between men,
heterosexual intercourse amounts to 29% of new HIV diagnosis in Western Europe and 51% in Central Europe.
The rate of mother-to-child HIV transmission for Europe as a whole approaches zero, but has not totally been
eradicated in all countries.39 Due to a combination of biological factors and gender inequalities women and
girls are particularly vulnerable to HIV infections: They are twice more likely to acquire HIV from unprotected
heterosexual intercourse with a partner than men. Additionally, economic and social dependence sometimes
increases the vulnerability of women who might not have the power to refuse sex or to negotiate the use of
condoms.40

35

Assisted Reproductive Technologies cover: in vitro fertilization (IVF), intra cytroplasmic sperm injection (ICSI), frozen embryo
replacement (FER), egg donation (ED), pre-implantation genetic diagnosis/screening (PGD/PGS) and in vitro maturation (IVM). See
Sorensen, C., ART in the European Union, Euro Observer, 2006, Vol. 8, No. 4.
36
Table 1: Funding and reimbursement status of ART in EU-15, Euro Observer, 2006, Vol. 8, No. 4, p. 7.
37
Euro Observer, 2006, Vol. 8, No. 4.
38
Due to declining fertility and greater risk of miscarriage with increased age, the costs of IVF per successful pregnancy are more than
three to five times higher for women age 40 years or older, compared to those 30 years and younger. Data available at Table 1:
Funding and reimbursement status of ART in EU-15, Euro Observer, 2006, Vol. 8, No. 4, p. 7.
39
UNAIDS/WHO: AIDS epidemic update 2009, Geneva, p. 65-67, 82.
http://data.unaids.org/pub/Report/2009/jc1700_epi_update_2009_en.pdf
40
http://www.unaids.org/en/PolicyAndPractice/KeyPopulations/WomenGirls/default.asp
6

POSITION PAPER
Sexually Transmitted Diseases (STDs)
The risk of infection by a sexually transmitted disease or HIV-AIDS is significantly higher for women than for
men. But women mostly depend on the goodwill of their partner in relation to prevention.41 Womens
organizations involved in the Beijing and Cairo Conferences have highlighted the need to develop new
methods of prevention like new models of female condoms or virucides to give women the power to protect
themselves; however, the financial resources to develop new female condoms have not been awarded, or
even planned.
Womens sexual and reproductive rights
Sexual and reproductive rights include open access to legal and safe abortion, reliable, safe, and affordable
contraception, coupled with sexual education and information in relation to sexual and reproductive health,
free choice and consent. It is vital that all women living in the European Union Member States must enjoy
freely these rights and have full access to the related health services.
Some EU Member States perform well in terms of guaranteeing women these rights. Denmark, Sweden,
Finland, and the Netherlands have the lowest abortion rates in Europe and in the world. Women living in
these countries gained the right to free abortion in the 1970s or 1980s, and are provided with access to
information and to all methods of contraception.
On the other hand, these rights are severely limited and/or conditioned in several EU Member States. In Malta
and Ireland, abortion is a criminal offence. Poland and Cyprus have very restrictive laws on abortion. The
legislation in Hungary, Latvia, Lithuania, Luxembourg and Slovakia is also highly restrictive as it imposes a
complicated procedure of authorisation. Furthermore, in these countries, the price for such a medical
intervention is extremely high and mostly not covered by health insurance. Access to contraceptive methods is
equally limited by price. The lack of access to sexual and reproductive rights leads to dangerous and costly
illegal abortions, as well as inequalities between women.
Even in countries where abortion is legal, access is often restricted by lengthy procedures, costs and
geographical disparities in the availability of such services. The increasing number of medical professionals
who refuse to perform abortions, especially in Spain, Italy, Poland and Hungary, represents another threat to
the health and rights of women. In many Member States, women under 18 years of age are requested to have
the consent of a parent or legal guardian.42 Not all countries provide counselling pre- and after abortion as
well as information about contraception and its availability.43 Restrictions and budgetary cuts made by
national governments in the area of public health also make access to services and health more onerous.
Finally, the rising influence of anti-choice and religious movements plays a very important role in the
limitation of sexual and reproductive health services and in breaching the right to self-determination for
41

WHO, UNAIDS, The Female Condom. A guide for planning and programming, Geneva, 2001.
IPPF European Network, Abortion Legislation in Europe, 2009.
43
The latest data of using contraception show that in only 6 EU Member States more than 70% of women between 15 and 49 use
modern contraception; in 8 EU Member States like Poland, Lithuania, Romania, Bulgaria, less than 40% of women use modern
contraception. Save the Children, The Complete Mothers Index 2010, in Women on the Front Lines of Health Care. State of the
Worlds Mothers 2010.
7
42

POSITION PAPER
women. In this respect, the restrictive Protocols and Unilateral Declarations annexed to Accession Treaties to
the European Union for Ireland, Malta and Poland need to be denounced.
c. Eating disorders
Women report eating disorders more often than men.44 Womens self-perception of health is generally worse
than that of men.45 More particularly, women, especially those under 30, have a more negative selfperception of body image as compared to young men.46 The eating disorders associated with this reported low
sense of self-worth are rooted in pressure emanating from pervasive stereotyping of womens bodies in media
and advertising.47 The long-term physical and mental health effects of eating disorders such as anorexia and
bulimia have been well documented, as has the gender-dimension of their causes.48 Nevertheless, a gendersensitive approach needs to be mainstreamed within the health discourse and in information addressed to the
general public.
d. Osteoporosis, musculoskeletal problems and central nervous system illnesses
Illnesses such as osteoporosis,49 musculoskeletal problems and central nervous system illnesses like Alzheimer
and/or dementia50 are linked to hormonal changes women experience at the time of menopause.51 While it is
therefore known that women are affected by these illnesses with higher frequency than men, the gender
dimension of research on such topics has been weak and there is a general lack of programmes that address
the specific needs of women, inform them about prevention methods, offer training to medical staff, etc.52
One of the most consistent findings in the social epidemiology of mental health is the gender gap in
depression. Because of a variety of factors including mainly different gender roles and gender inequalities,
depression is approximately twice as prevalent among women as it is among men. However, the absence of
comparable data hampers cross-national comparisons of the prevalence of depression in general populations.
A study examining the situation indicates that women report higher levels of depression than men do in all
countries, but there is significant cross-national variation in this gender gap. Gender differences in depression
are largest in some of the Eastern and Southern European countries and smallest in Ireland, Slovakia and some
Nordic countries. Socioeconomic as well as family-related factors moderate the relationship between gender
44

Elmadfa, I. et al., Health and Lifestyle Indicators in the European Union, in Elmadfa I (ed.): European Nutrition and Health Report
2009, Forum Nutrision Basel, Karger, vol. 62, pp. 157-171.
45
European Commission, Special Eurobarometer No. 283, Health and long-term care in the European Union, 2007.
46
World Health Organisation, Regional Office in Europe, A Snapshot of the Health of Young People in Europe, 2009, p. 56 and Figure
3.3.4
47
Orbach, S., Bodies, 2009, Profile Books LTD, London, UK.
48
Orbach, S., Fat is a Feminist Issue, 1978, Arrow, UK.
49
Data from International Osteoporosis Foundation, facts and Statistics about osteoporosis and its impact:
http://www.iofbonehealth.org/facts-and-statistics.html The same data offer information on the estimated number of women and men
suffering from osteoporosis in several EU Member States (BE, DK, FIN, FR, GER, GR, SP, SE, UK) and the availability and the costs of
treatment for this disease.
50
Alzheimer Europe, Dementia in Europe. Yearbook 2008, p. 133.
51
World Health Organisation, Gender and Health, Gender, Health and Ageing, 2003.
52
Two publications are cited as evidence for this conclusion: Freedman KB, Kaplan FS, Bilker WB, et al. (2000) Treatment of
osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am 82-A:1063 et Siris ES, Miller PD, Barrett-Connor E, et al.
(2001) Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the
National Osteoporosis Risk Assessment. JAMA 286:2815 sur http://www.iofbonehealth.org/facts-and-statistics.html
8

POSITION PAPER
and depression. Lower risk of depression is associated in both genders with marriage and cohabiting with a
partner as well as with having a generally good socioeconomic position. In a majority of countries,
socioeconomic factors have the strongest association with depression in both men and women53.
e. Womens consumption of alcohol and drugs
The consumption of alcohol and drugs increases drastically among women and girls, which poses serious
threats to their physical and psychological health. Research and statistics in Sweden as well as in Europe shows
growing alcohol-related health problems among women. The traditional treatment of abusive problems has
had mens needs and symptoms as norm and starting point. Women, thereby, are seen as a subgroup and
programmes for prevention, access to help etc are done based on mens experiences. This has to change in
order to make sure women get adequate treatment and care.
2.2 Structural determinants of womens health risks
a. Male violence against women
Male violence against women and its impacts on womens health constitute a fundamental barrier to the
achievement of gender equality and womens full enjoyment of their human rights. Male violence against
women is violence directed against a woman because she is a woman or that affects women
disproportionately. It includes acts that inflict physical, mental or sexual harm or suffering, threats of such
acts, coercion and other deprivations of liberty.54 Male violence can happen to anyone. It is a structural
phenomena not primarily related to social status, education, poverty or any other issue.
According to the Council of Europe, one-fifth to a quarter of women are subjected to male violence, which can
take many forms.55 Fore example, more than one in ten women in Europe is a victim of sexual violence
involving the use of force.56 In the UK, two women die each week at the hands of a partner or an ex-partner.
80,000 women experience rape or attempted rape.57 In France, one woman is killed every three days by her
partner.58 Between 40 and 50% of women in the EU report experiencing sexual harassment at work.59 Out of
an estimated 250,000 people trafficked in Europe each year, 79% are trafficked for sexual exploitation and

53

Gender differences in depression in 23 European countries. Cross-national variation in the gender gap in depression, Van de Velde S,
Bracke P, Levecque K., Soc Sci Med. 2010 Jul;71(2):305-13. Epub 2010 Apr 24.
54

CEDAW Committee, General Recommendation No. 19. Male violence against women includes, though is not limited to: sexual
assault; rape; sexual harassment; physical violence; verbal violence; mental and psychological violence; male domestic violence (in
intimate partnership and/or in the family); stalking; forced marriage; female genital mutilation; crimes committed in the name of
honour including murder, stoning, acid attacks and forced suicide; violations of womens sexual and reproductive health and rights
including forced sterilization; pornography and sexist advertising; violence in institutional settings like hospitals and care institutions,
prisons or reception centres for asylum seekers; prostitution; trafficking in women; and male violence against women in conflict.
55
Council of Europe, Combating violence against women stocktaking study on the measures and actions taken in Council of Europe
member states, 2006.
56
Council of Europe, 2008.
57
Phillips, T., Chair Equality and Human Rights Commission in UK, intervention on 26 November 2007.
58
Mission galit des Femmes et des Hommes, 2009.
59
United Nations Factsheet, 2006.
9

POSITION PAPER
more than 80% of these victims are female.60 Currently, it is estimated that 500,000 women and girls living in
the European Union are affected by or threatened with female genital mutilation.61
Most existing studies evaluate the costs of male violence against women in economic terms. For the 27 EU
Member States, it has been estimated that the total annual cost of domestic violence could reach the sum of
16 billion Euros, amounting to 1 million Euros every half hour.62 The annual budgets for programmes designed
to prevent male violence against women, in the 27 EU Member States, are 1 000 times less. Still, it is very
difficult to measure the incidence of male violence against women, whatever the form. Current social norms
make it very difficult for women to report such violence and ignore its prevalence; indeed, women are often
blamed for inciting violence rather than being considered victims.
Male violence against women can have serious health consequences, which are often either not recognised or
minimised in the same manner as the existence of the violence itself. These health consequences are costly,
but the full nature of the impact cannot be measured in economic terms. In addition to physical trauma,
including many types of sexual suffering, becoming a victim of any form of male violence in the professional,
private or public sphere can have serious mental health consequences for women. Experience of violence
can lead to post-traumatic stress disorder, depression, anxiety, panic attacks and high-risk health behaviour
(including substance addiction, unsafe sexual behaviours and abusive relationships).63 Male domestic violence
has severe and persistent effects on womens physical and mental health and carries an enormous cost in
terms of premature death and disability.64 Sexually transmitted diseases and unplanned pregnancy are other
consequences that women victims can experience in cases of rape (including in marriage), incest, prostitution,
pornography, etc.65 Women and girls who are subjected to female genital mutilation are exposed to short and
long-term effects on their physical, psychological, sexual and reproductive health.66
A variety of factors contribute to the way different forms of male violence impact on womens health,
including poverty, economic dependence, lack of social support, different forms of discrimination based on
age, migrant status, sexual orientation, disability, etc. The current economic recession impacts strongly on the
protection of women from male violence, as funding and support for NGOs, the public and/or specialist
services have decreased or are subject to significant cuts. The increase of extreme poverty gives also rise to
prostitution, exploitation of all kinds, trafficking in women, and to general male violence.67 The prevalence of
male violence against women, couple with the economic crisis, has a great impact on womens health as it
leads to the increase in use of health-care services and the challenges such services face in preventing and also
reporting violence.68

60

UN Office on Drugs & Crime, Trafficking in Persons Analysis on Europe, 2009.


Association of European Parliamentarians with Africa, 2009.
62
Daphne Project on the cost of domestic violence in Europe, 2006.
63
Thummler, K. et al., Data and Information on Womens Health in the European Union, 2010.
64
Ibid.
65
Martin, S. and Macy, R., Sexual Violence Against Women: Impact on High-Risk Health Behaviors and Reproductive Health, National
Online Research Center on Violence Against Women, 2009.
66
Amnesty International Campaign Strategy against Female Genital Mutilation.
67
European Womens Lobby and Oxfam International, An Invisible Crisis? Womens poverty and social exclusion in the European Union
at a time of recession, 2010.
68
Ibid.
10
61

POSITION PAPER
b. Discrimination against women in relation to health
Apart from the lack of gender mainstreaming in health policies and the inadequacy of health services catering
to womens needs, there are also instances of discrimination against women in relation to health, in particular
for some groups of women who face multiple discrimination.
Council Directive 2000/43/EC forbids discrimination based on ethnic or racial origin as regards both the public
and private sectors, including public bodies that offer social protection, including social security and
healthcare and access to and supply of goods and services *+.69 Still, this Directive is not fully applied in EU
Member States in relation to access to health-care for women from different ethnic and racial background. For
example, women from the Roma community face such (double) discrimination. Roma women use health care
services less than the rest of the population, partly due to the discrimination and harassment they often face
from medical professionals. Language and other cultural barriers also restrict Roma womens access to healthcare.70 This discrimination can even lead to violence, with the forced sterilisation of Roma women a serious
violation to bodily integrity, freedom of choice and the entitlement to self-determination of reproductive life
receiving increasing attention.71
Forced sterilisation is an issue with regard to women with disabilities,72 who also face a variety of barriers in
accessing health-care. There is very limited adaptability of health services towards the specific needs and
rights of women with disabilities, especially in the field of sexual and reproductive health. They are often
stigmatised as asexual unable to make decisions concerning their sex lives independently. Guaranteeing safe,
informed, and adaptable access to sexual and reproductive health and rights to women with disabilities
represents one of the greatest challenges to health services in the majority of EU Member States. Disabled
women are entitled to freedom of choice, including as regards bodily integrity and informed consent. Women
with disabilities also have the right to family life and privacy and thus their right to informed family planning
and assisted reproduction must be guaranteed.73
Very little research has been carried out on the specific health situations of lesbian women, including their
vulnerability to particular diseases and needs in terms of health services.74 Sexual orientation per se does not
directly influence the prevalence of cancer or any other disease. Nonetheless, reports show that double
discrimination based on gender and on sexual orientation can have a significant impact on mental and physical
wellbeing, and can prevent some women from seeking assistance from health-care providers. Lesbian and
bisexual women visit gynaecologists less regularly than heterosexual women. The little investigation carried
out evidences widespread mistreatment and discrimination of lesbian women at the hands of medical

69

Council Directive 2000/43/EC of 29 June 2000 implementing the principle of equal treatment between persons irrespective of racial
or ethnic origin, in the O.J. L 180 from 19/07/2000, Art. 3 (e) and (h).
70
Corsi, M. et al., Ethnic minority and Roma women in Europe: A case for gender equality?, European Commission, 2010, pp. 111-115
71
For more information, see the work of European Roma Rights: http://www.errc.org
72
th
European Disability Forum, Statement Against The Forced Sterilization of Girls and Women with Disability on 25 November 2009,
accessible at www.edf-feph.org . These cases have not been documented in a comprehensive Report at the European level, but cases
are known and signalised by NGOs working in the area.
73
See the work of European Disability Forum and several public interventions on this topic: www.edf-feph.org
74
Genon, C. et al., Pour une promotion de la sant lesbienne : tat des lieux des recherches, enjeux et propositions, in Genre, sexualit
& socit, No. 1, pp. 1-24. The majority of research sited as reference for the study was carried out in Canada and USA.
11

POSITION PAPER
professionals and personnel.75 The fear of a lesbophobic reaction from health-care providers and a stronger
reluctance to share private matters with a stranger play a significant role, causing lesbian women to often
seek medical assistance only in cases of strict necessity and forego preventive visits.76
c. Poverty
Poverty in Europe is multidimensional and is linked not only to material deprivation but also to different issues
including poor health. Women lag behind men on virtually every indicator of social and economic status and
are more likely to experience poverty than their male counterparts. Women are the majority of part-time
workers and those on temporary contracts with poor medical insurance coverage or none at all.77 There are
more women than men active in informal work, including in the home, and are not covered by health-care
provisions.
Poverty is frequently associated with many of the factors contributing to poor health as it deprives individuals
of the possibility to satisfy basic needs and rights, namely to achieve sufficient nutrition, to obtain remedies
for treatable illnesses, and to have access to clean water and sanitary facilities.78 In some EU Member States,
these fundamental health services are not necessarily covered by basic public health insurances, the quality of
the services is poor, and most of the time their costs are excessively high.79
3. Womens access to health and existing barriers
Existent gender inequalities are reflected in the way women and men can access health and in the types of
health services provided specifically for women or for men. Several EU comparative reports and other
documents on health issues support the conclusion that health care systems have a crucial role to play in
improving the health status of the population, in diminishing health inequalities and in preventing diseases.80
Access to quality health services is an important health determinant and the range of barriers women can face
in accessing these services prevent them from fully enjoying their fundamental right to health. These barriers
to access may stem from factors within the health system itself, including gaps in population coverage of
health insurance; limited scope of public health benefits; high costs; geographical factors such as distance or
lack of infrastructure; organisational factors, e.g. waiting lists and limited opening hours; or insufficient or
inappropriate information. They may alternatively relate to the characteristics of the potential service user,
such as income, education, age, language, disability, sexual identity, cultural background and/or civil status. 81
In all these categories, gender plays a significant role.

75

Fundamental Rights Agency, Homophobia and Discrimination on Grounds of Sexual Orientation and Gender Identity in the EU
Member States: Part II The Social Situation, 2009, pp. 7682.
76
ILGA, Lesbian and Bisexual Health Womens Report, 2006.
77
Huber, M. et al., Quality in and Equality of Access to Healthcare Services, 2008, European Commission, p. 66.
78
Hogstedt, C. et al., Health for all? A critical analysis of public health policies in eight European countries, 2008, Stockholm, Sweden.
79
It is the case of new EU Member States from Central and Eastern Europe, like Hungary, Romania, Bulgaria, and Czech Republic. See
Ziglio, E. et al., Health Systems Confront Poverty, World Health Organization, Regional Office in Europe, 2002.
80
Huber, M. et al., Quality in and Equality of Access to Healthcare Services, 2008, European Commission. Health Systems, Euro
Observer - The Health Policy Bulletin of the European Observatory on Health Systems and Policies, Vol. 8, No.2, 2006.
81
Huber, M. et al., Quality in and Equality of Access to Healthcare Services, 2008, European Commission.
12

POSITION PAPER
a. Inequalities between women and men in access to health
Women use health-care especially primary-care services more often than men. This is mainly related to
womens reproductive health and child-bearing functions, but also to their persistent social role as the primary
caretakers of dependents, whether children or other family members. In spite of this higher level of use by
women, health-care systems and services are not particularly women-friendly or considerate towards
womens health needs. Furthermore, there are practices and barriers that discriminate against women.
Studies show inequalities between women and men in access to specialist doctors and treatments. For
example, women with angina are less likely to be referred to a specialist or to undergo a revascularisation, a
process that prolongs life.82 Also, it is not widely accepted or understood by medical professionals that
differential approaches and treatments, including counselling, indirectly discriminate against women service
users.
At the same time, women are the majority of employees within the health sector, especially as caregivers,
nurses and general practitioners. Nonetheless, they dominate in lower-paid and lower-status positions rather
than for example as specialised doctors.
b. Financial barriers
Financial barriers in particular restrict womens access to health and health-care. Recent reforms of health
systems in European countries have led to a weakening of universal health-care coverage and a change in the
balance between public and private contributions to health-care costs. This has a detrimental impact on
women as they generally have less access to resources and/or private health coverage. According to the
European Commission, in several EU countries, some of the typical gaps in health baskets include limited
coverage for dental and ophthalmic services, and limited access to specialised services, which frequently
require going through a GP *general practitioner+ gatekeeper.83
c. Migrant and refugee womens access to health
Linguistic and cultural barriers as well as restrictive legislation limit migrant and refugee womens access to
health and health-care. Health insurance, for example, is generally strongly connected to employment status,
which makes it out of bounds in particular for migrant refugee women. It can also be conditioned on marital
status.84 The lack of an independent residence status for migrant women, especially those benefiting from
family reunification procedures or having immigrated to work for a specific employer, creates a dependency
factor, which puts migrant women in a vulnerable position and can have a severe impact on their access to
health-care.
Access to womens shelters for victims of violence is in some cases denied to third country nationals. Even
when available, many women victims of violence at the hands of either their husband or employer fear
82

Gender equity in use of treatment for cardiac heart disease in Fernandes A. et al., Health and Health Care in Portugal: Dies gender
Matter?, 2009, pp. 57-71. The Gender and Access to Health Services Study. Final Report, Department of Health, UK, 2008, pp. 15-26.
83
Huber, M. et al., Quality in and Equality of Access to Healthcare Services, 2008, European Commission, p. 66.
84
Xuseyn, A., Access to Health Services. Migrant Womens Experience, presentation given during the EWL Thematic Seminar on
Womens Health in Europe, January 2010, Dublin, Ireland. Alwiye Xuseyn is a Womens Health Officer with AkiDwA, African womens
organisation in Ireland.
13

POSITION PAPER
leaving an abusive relationship because it would mean losing their legal status and becoming undocumented.
Without documentation, women victims are often denied access to shelters and in some countries access to
health-care more generally. Even when this is not strictly the case, undocumented migrant women are often
hesitant to access health services, fearing expulsion.85
d. Women in rural areas
The majority of the rural population in several new EU Member States such as Romania, Hungary or Bulgaria,
are women, older women in particular. Their access to health-care services and even health information - is
greatly affected by a lack of infrastructure and transport facilities. Pregnant women living in remote areas
have difficulty accessing medical assistance during pregnancy or child-birth. In Lithuania, a recent report
emphasised that women and girls living in rural areas do not have access to contraception and family planning
services, that sexual and health education is not taught in schools, that there is limited access to information
and that the accessible contraceptive methods are very expensive.86

4. The need for a dual approach of specific measures for women and gender mainstreaming in health
policies
In the majority of EU Member States, the universality of the right to health and access to health-care
according to needs is enshrined in the constitution or equivalent legislation. At European Union level, the
Council has endorsed universality, access to quality care, equity, and solidarity as common values and
principles underpinning the health systems of the EU Member States.
The concept of universality requires that no person be barred access to health-care. Solidarity is related to
the financial structuring of national health systems so as to ensure this universal access. Equity implies equal
access according to need, regardless of ethnicity, gender, age, social status or ability to pay.87 In addition, the
European Charter of Fundamental Rights guarantees that everyone has the right of access to preventive
health-care and the right to benefit from medical treatment under the conditions established by national laws
and practices.88 These principles are complemented by a general gender-mainstreaming obligation enshrined
in the European Treaty which applies also to the work of all European and national decision-makers in the field
of health policy.89
Health systems should aim to reduce health inequalities, among which gender is recognised as a
determinant.90 It is therefore both a legal and a social responsibility for relevant decision-makers at the
85

Women Against Violence Europe (WAVE), Fempower Magazine No. 4, 5, 6, 2002.


http://www.wave-network.org/start.asp?ID=16
86
st
Supplementary Information on Lithuania Scheduled for Review during the 41 Session of the CEDAW Committee, 2008, pp.7-8
87
Council of the European Union, Annex: Common Values and Principles, Council Conclusions on Common values and principles in
European Union Health Systems (2006/C 146/01). The application of these principles across the EU Member States is evaluated
through the Open Method of Coordination.
88
EU Charter of Fundamental Rights, Art. 35, OJEU, 2000.
89
Art 3(3) in TEU (ex. Art. 2 TEC). Art. 8 TFEU (ex. Art. 3(3) TEC).
90
Council of the European Union, Council Conclusions on Common values and principles in European Union Health Systems (2006/C
146/01) and Council Conclusions on Womens Health, (2006/C 146/02).
14

POSITION PAPER
European and national level to fully integrate womens experiences and needs when defining public policies in
the health sector. Unfortunately, the panorama of the current situation shows that this is at present not the
case.
a. Specific health policies and measures to address womens health needs
Putting people first is supposed to be one of the objectives of health services. However, although women are
the majority of health-care users, insufficient attention is given to their diverse needs throughout the lifecycle, and to the constraints they face in protecting their health and that of persons dependent on them or in
fully accessing available services.
Key concerns for women seeking health-care include respect, trust, privacy, confidentiality and nondiscrimination. This means eliminating gender biases and discrimination in health services, ensuring services
are fully available and inclusive of all womens needs and situations. Health policies need to take into account
the needs of different groups of women and the social role of women, who remain the primary carers for
children and other dependants while increasingly also working outside the home.
As shown above, public health policies at all levels need to better address womens specific needs in terms of
prevention, medication testing, treatment, service provision, etc. Research focused on womens health status,
needs, illness development and prevention must to be developed, funded and supported as a matter of
emergency. Health systems must build capacity to address the broader range of health issues that affect
women, including, but not limited to sexual and reproductive health. In Europe, medical services dealing with
womens health issues including sexual and reproductive health, and specifically abortion are too often understaffed. Finally, both public and private health-care providers need to be adequately trained to take action
against practices that violate rights and harm the health and/or integrity of women and girls, such as for
example female genital mutilation.
b. Health policy at European Union level and its lack of a gender equality perspective
The primary responsibility for health-related policies in the EU lies with the Member States. The EU
nevertheless has a competence in health promotion and disease prevention and a role to play in coordinating
and providing support to Member States in order to attain a high level of human health protection.91
Womens health has been addressed as a policy issue at the EU level in the context of the social and economic
determinants of health and specific age groups. In theory, the EU recognises that gender alongside age,
education, economic and civil status is a significant determinant for health and health-care. The European
Commission Directorate General for Public Health has published several reports including data on the
situation of womens health and access to health-care.92 However, these documents were not followed-up
with concrete policy actions and programmes to address womens health needs and European public health
policies broadly remain gender blind.

91

Art. 168 TFEU.


Thummler, K. et al., Data and Information on Womens Health in the European Union, 2010; European Institute of Women's Health,
Womens Health in Europe. Facts and Figures Across the European Union, 2006.
15
92

POSITION PAPER
Neither gender and sex differences in health nor a broad gender equality perspective are systematically taken
into account in EU health-related policies and activities. Rather, they are addressed sporadically and in very
general terms. Despite the existing Treaty obligation to integrate a gender equality perspective in all the
activities of the EU (gender mainstreaming), this is rarely done in European Commission policy papers and
even less so in actions and programmes. In particular, insufficient resources and attention are given to gender
equality issues and womens needs in EU-sponsored research in relation to health. The European Womens
Lobby five year review of EU public health policies in 2010, From Beijing to Brussels An Unfinished Journey,
emphasised the lack of gender sensitivity of several key EU public health documents and policies.93
c.

Gender mainstreaming within health policies

Gender mainstreaming is a tool for reaching equality between women and men through challenging and
transforming institutions and policies so that they fully reflect the particular needs and situation of women. It
is also a Treaty obligation for the European Union and its member countries. The goal of gender
mainstreaming within public health policies should be to ensure that women and men have equal access to
the resources they need to realise their health potential.94 These resources must include high quality and
appropriate medical care and other social, economic and cultural goods that are necessary for the
sustainability of their wellbeing. Public health policies need to be gender sensitive in design, delivery and
evaluation; this should be accompanied by objectives that need to be transposed into indicators and further
developed.
In recent years, evidence of gender health status differences both general and in comparative terms across
the EU Member States have increasingly been collected and made available at European level for decisionmakers.95 Nonetheless, this knowledge and the recommendations that have flown from it have rarely been
translated into efficient public health policies or well-funded projects and programmes to address the existing
gender inequalities, discrimination and barriers that women constantly face. There are few countries where
gender as a determinant of health has been adequately integrated into public health policies (Denmark,
Germany, Sweden and the United Kingdom being the exceptions) or where specialised research institutes are
funded and supported to collect, produce and distribute information in relation to womens health and gender
as a determinant of health, as is the case in Sweden and Spain.96
In terms of funding, all 27 EU governments allocate a percentage of their GDP varying from around 5% in
Poland, the Czech Republic, Hungary and Slovakia to over 8% in Denmark, Germany, France to public
spending of health-care.97 Age and gender play a significant role when looking at the distribution of public
health-care spending. The health-care spending for both women and men over 54 or 60 years is much higher
compared to the spending allocated to younger age groups. Women between 25 and 40 or 45 (the key period
of fertility) are allocated more spending compared to men in the same age groups. However, on the whole,

93

European Womens Lobby, Women and Health, in From Beijing to Brussels An Unfinished Journey, 2010.
Doyal, L., Gender Equity in Health: debates and dilemmas, 2000.
95
Thummler, K. et al., 2010; European Institute of Women's Health, 2006; Mladovsky, P. et al.,2009; Zatooski, W. et al., Closing the
health gap in European Union, 2008.
96
The centre for the Gender Medicine at Karolinska Institute in Stockholm, Sweden; and the Women and Health Observatory in
Madrid, Spain.
97
European Community Health Indicators, DG SANCO, based on OSCE Health Data 2009.
16
94

POSITION PAPER
women are allocated a lesser proportion of health-care as compared to men.98 This demonstrate clearly and
unequivocally how funding is spent in Member States to address gender-specific and gender-influenced health
conditions. This needs to be addressed through the implementation of gender budgeting methods across the
spectrum of health-related policies.

EWL RECOMMENDATIONS
In order to ensure the integration of womens perspectives and needs within health policies, a multi-pronged
strategy is needed in different sectors and at different levels, including: medical research, data collection,
medical testing, training of the care and medical professionals at all levels and in all sectors, budgetary
provisions and allocations in the health sector, reform of health systems, gender-sensitive service delivery and
implementation of a gender budgeting approach to financing policies in the health sector.
The European Union and Member States must:
Ensure the integration of a gender perspective in all aspects of health policies, programmes and
research from their development and design to impact assessment and budgeting.
Introduce and use gender budgeting in public health policies at all levels.
Conduct gender impact assessments of the recent changes brought about by health sector reforms,
especially when addressing health-care financing and delivery.
Maximise the participation of all women in health policy development, programme planning and
service delivery, through positive action programmes that recognize womens role as paid and unpaid
providers of health care and as services users.
Support health research focused on womens health and womens health needs, including through the
creation of specific programmes, bodies or institutes. Ensure a wide distribution of the research
outcomes, especially amongst health policy-makers, practitioners and personnel.
Promote a greater participation of women in medical research, including at the highest levels and
through positive action measures.
Take stock of the specific health needs of women; and develop public health policies in accordance
with these needs and demands.
Promote and make mandatory the collection of comparable sex-disaggregated data at EU and national
level.
Recognise male violence against women as a public health issue, whatever form it takes.
Support civil society and womens organisations that promote womens human rights, including
womens sexual and reproductive rights, and work to ensure that women have a voice in European
and national health policy issues.
Grant migrant women an independent legal status within maximum one year of arrival.
Take measures to ensure the access to health-care services including womens shelters to all
women independent of their legal status, disability, sexual orientation, race or ethnic origin, age or
religion.
98

Graph 65: Age-related expenditure profiles of health care provisions, in European Commission and Economic Policy Committee, The
2009 Ageing Report, pp. 111-112.
17

POSITION PAPER
The European Union must:
Support health research focused on womens health and health needs, especially in the framework of
EU Research Framework Programmes; and include gender as a criterion for funding in all EU research.
Ensure that all EU-funded research projects include a balance between women and men among
researchers and fully integrates a gender mainstreaming approach.
Promote multidisciplinary research into the socio-economic determinants of health across the lifespan
of women.
Promote sexual and reproductive health and rights, adequate gender-sensitive information and
reliable, safe and affordable contraception, and provide the opportunity of safe abortion within and
beyond the European Union.
Take a strong position in favour of womens human rights, including by denouncing the forced
sterilisation of women, especially in cases of women with disabilities or Roma women, and female
genital mutilation.
The European Union Member States must:
Halt and reverse current cuts in public spending for services crucial to the attainment of a high level of
health protection for women and men.
Investigate, ban and prosecute direct and indirect discrimination against women in access to health
and health-care services. The public authorities specialised in combating discrimination and protection
of human rights must take the necessary measures in order to prevent any further discrimination
against women in access to health-care and health services. Women need to be informed in order to
be able to denounce such acts of discrimination and help to overcome such experiences.
Prevent, ban and prosecute forced sterilisation of women, notably in cases of women with disabilities
or Roma women.
Prevent, ban and prosecute female genital mutilation and provide health services specialised for
women victims of FGM.
Eliminate discrimination against women in relation to access to Artificial Reproductive Technologies
based on marital status, age and sexual orientation.
Ensure that health services addressed to women or developed particularly for women are covered
under public health services and are accessible by/through public health insurances.
Ensure a stronger focus on prevention, including prevention of women specific diseases, in public
health policy.
Make widely accessible and improve pre- and post-natal medical care to all women and pay more
attention to psychological trauma and other issues related to childbirth.
Identify and evaluate the outcome of good models of mental health care that both integrate
maternity care and mental health services for women.
Initiate research into womens birth experience and the relationship between the development of
mental health difficulties

18

POSITION PAPER
Fully implement the European Parliament target of screening coverage of 100% of the female
population for breast and cervical cancer.99
Recognise and guarantee sexual and reproductive health and rights, including safe abortion, and
ensure access to free-of-charge, safe and reliable methods of contraception for all women.
Develop new methods to prevent sexually transmitted diseases including free access to HIV-AIDS
testing and early medical treatment and dramatically increasing funding for the research, access to,
purchase and distribution of effective female condoms.
Develop and financially support educational programmes on sexual and reproductive rights and health
including information on contraceptives in schools; provide universal free access to sexual and
reproductive health education and information, targeted to the different needs of women and men
and also to various age categories.
Devote more attention and research to discrimination against lesbians and trans-women and their
specific health needs.

99

European Parliament, Opinion of the Committee on Womens Rights and Gender Equality on the Commission communication on
Action against Cancer: European Partnership, 2009/2103(INI), Feb 2010, 1&9.
19

III.

European Womens Lobby Position Paper: Womens Health in the European


Union, iunie 2010 http://www.womenlobby.org/spip.php?article90

1. Explicai pe scurt i exemplificai urmtoarele afirmaii:


a. nevoile care nsoesc sntatea femeilor nu sunt pe deplin integrate n politicile
europene i naionale de sntate.
b. O parte din aceste diferene biologice par s avantajeze femeile, ele sunt anulate de
inegalitile de gen din planul social care dezavantajeaz femeile n raport cu
brbaii.
2. Explicai ce nseamn dimensiunea de gen a sntii i discutai pe baza a trei
exemple.
3. Discutai despre sntatea reproducerii, mortalitate matern, infertilitate i
reproducere asistat. Introducei perspectiva diferenelor (etnice, geografice, de
orientare sexual).

EUROPEAN COMMISSION

The State of Mens Health in Europe

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Report

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ISBN 978-92-79-20167-7
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Writers
Prof.
Dr
Dr
Prof.
Dr
Prof.
Dr
Prof.
With

Alan White
Leeds Metropolitan University, England
Bruno de Sousa
Instituto de Higiene e Medicina Tropical, Portugal
Richard de Visser
University of Sussex, England
Richard Hogston
Leeds Metropolitan University, England
Svend Aage Madsen
Copenhagen University Hospital, Denmark
Pter Makara
Semmelweiss University, Hungary
Noel Richardson
IT Carlow, Ireland
Witold Zatoski
Centrum Onkologii-Instytut, Poland
thanks to: Dr Gary Raine, Nick Clarke

Management advisory group


Prof.
Prof.
Mr
Prof.
Ms
Prof.
Prof.
Dr
Prof.

Alan White
Ian Banks
John Bowis
Paulo Ferrinho
Peggy Maguire
Siegfried Meryn
Wolfgang Rutz
Luciano Vittozzi
Pter Makara

Leeds Metropolitan University, England


European Mens Health Forum, Belgium
Former MEP,
Instituto de Higiene e Medicina Tropical, Portugal
European Institute of Womens Health, Ireland
Medical University of Vienna, Austria
Academic University Hospital Uppsala, Sweden
National Centre for Rare Diseases, Italy
Semmelweiss University, Hungary

Reviewing group
Prof.
Dr
Dr
Dr
Prof.
Dr
Dr
Dr

Martin McKee CBE


Ineke Klinge
Alfons Romero
Elisabeth Zemp Stutz
Tom ODowd
Ralf Puchert
Rupert Kisser
Richard Wynne

London School of Hygiene & Tropical Medicine, England


Maastricht University, The Netherlands
University of Girona, Spain
Basel University, Switzerland
Trinity College Dublin, Ireland
Dissens e.v., Germany
Austrian Road Safety Board, Austria
Work Research Centre, Ireland

Reference Group
Prof.
Ms
Dr
Dr
Prof.
Dr
Dr
Prof.
Prof.
Prof.
Dr
Dr
Mr

Peter Achterberg
Nicola Bedlington
Plamen Dimitrov
Florentina Furtunescu
Dragan Gjorgjev
Asgeir Helgason
Eva Kralikova
Ulla-Britt Lilleaas
Oliver Razum
Anita Rieder
Christian Scambor
Edita Selvenyt
Ren Setz

Nat. Inst. for Public Health and the Environment, The Netherlands
European Patients Forum, Belgium
National Center of Public Health Protection, Bulgaria
University of Medicine and Pharmacy Carol Davila, Romania
National Institute for Health Protection, FYROM
Karolinska Institute, Sweden
Charles University in Prague, Czech Republic
University of Agder, Norway
University Bielefeld, Germany
Medical University of Vienna, Austria
Maennerberatung, Germany
Chief Specialist of Health Promotion and Resortology Division, Lithuania
RADIX Health Promotion and Prevention, Switzerland

Country codes
Austria
Belgium
Bulgaria
Cyprus
Czech Republic
Germany
Denmark
Estonia
Spain
Finland
France

Greece
AT
Hungary
BE
Ireland
BG
Italy
CY
Lithuania
CZ
Luxembourg
DE
Latvia
DK
Malta
EE
Netherlands
ES
Poland
FI
Portugal
FR
Romania

EL
HU
IE
IT
LT
LU
LV
MT
NL
PL
PT
RO

Sweden
Slovenia
Slovakia
United Kingdom
Croatia
FYR of Macedonia
Turkey
Iceland
Liechtenstein
Norway
Switzerland

SE
SI
SK
UK
HR
MK
TR
IS
LI
NO
CH

Foreword

Dear Reader,
This report provides a comprehensive overview of the state of mens
health across the 27 Member States of the European Union, the 4 states
of the European Free Trade Association (Norway, Iceland, Switzerland
and Lichtenstein) and the 3 candidate countries (Croatia, Turkey, Former
Yugoslav Republic of Macedonia). It highlights the broad range of mortality
and morbidity data arising from the many different health conditions which
affect men in Europe.
Gender equity is a high priority for the European Commission and this report
will help to close the information gap on mens health.
The first European mens health report provides information on various
topics such as cancer, alcohol and tobacco. Improving mens health also
has both direct and indirect benefits for women and children.
This report concentrates on data and information and is available in three
documents. If you wish to have a short overview of the situation of mens
health in Europe, a leaflet with the main findings is available in English and
French; the report at hand provides you with a more detailed version, while
the extended report is available should you be interested in obtaining indepth information.

Paola Testori Coggi

Director General DG Health and


Consumers

Contents

Executive summary............................................................................................................8
Introduction.......................................................................................................................... 10
Putting the spotlight on men and mens health................................................................................... 10
Social determinants of health........................................................................................................... 10
Mens health as an investment.......................................................................................................... 10

The male population........................................................................................................ 12


Total male population...................................................................................................................... 14
Birth rate....................................................................................................................................... 15

Lifestyle & Preventable risk factors...................................................................... 16


Tobacco Smoking............................................................................................................................ 18
Alcohol consumption........................................................................................................................ 19
Illicit drug use................................................................................................................................ 21
Drug-related harm.......................................................................................................................... 22
Physical Activity.............................................................................................................................. 23
Diet.............................................................................................................................................. 24
Obesity.......................................................................................................................................... 26

Accessing Health Services........................................................................................... 28


Hospital admissions......................................................................................................................... 30
Preventative Health......................................................................................................................... 31
Mens usage of primary health services.............................................................................................. 32
Barriers within health services.......................................................................................................... 33
Well man clinics and community-based health initiatives for men........................................................... 33

Health Status........................................................................................................................ 34
Self perceived health status.............................................................................................................. 36
Self reported chronic morbidity......................................................................................................... 36
Healthy Life Years (HLY)................................................................................................................... 37
Life expectancy............................................................................................................................... 38
Male mortality across the lifespan..................................................................................................... 39
Overall burden of disease................................................................................................................. 43

Cardio-Vascular Disease............................................................................................... 46
Cardiovascular disease..................................................................................................................... 48
Ischemic Heart Diseases (IHD)......................................................................................................... 49
Cerebro-Vascular Diseases (Stroke)................................................................................................... 50

Cancer. ...................................................................................................................................... 52
Lung cancer................................................................................................................................... 56
Colorectal cancer............................................................................................................................ 58
Prostate cancer............................................................................................................................... 59
Testicular cancer (TC)...................................................................................................................... 61

Accidents................................................................................................................................. 62
Accidents....................................................................................................................................... 66
Workplace Accidents........................................................................................................................ 67
Leisure Accidents and Injuries.......................................................................................................... 69

Mental Health....................................................................................................................... 70
Men and Mental Health.................................................................................................................... 72
Depression..................................................................................................................................... 73
Bipolar affective disorder.................................................................................................................. 73
Anxiety disorders/ Schizophrenia / Psychotic disorders......................................................................... 74

Communicable Diseases. .............................................................................................. 76


Pneumonia..................................................................................................................................... 78
Tuberculosis................................................................................................................................... 78
Sexually Transmitted Infections......................................................................................................... 79
HIV/AIDS....................................................................................................................................... 80
Viral Hepatitis................................................................................................................................. 81

Dental and oral health.................................................................................................... 82


Dental Caries.................................................................................................................................. 84
Periodontal disease......................................................................................................................... 84
Health implications of periodontal disease.......................................................................................... 84
Oral health care.............................................................................................................................. 85

Other health conditions affecting men............................................................... 86


Diabetes Mellitus Type II.................................................................................................................. 88
Chronic lower respiratory diseases..................................................................................................... 89
Osteoporosis.................................................................................................................................. 91

Epilogue. .................................................................................................................................. 92
Academic development of mens health.............................................................................................. 92
Research........................................................................................................................................ 92
Policy............................................................................................................................................ 92
Practice......................................................................................................................................... 93
Concluding comments...................................................................................................................... 93

References. ............................................................................................................................ 94

Executive Summary

his report provides a comprehensive overview of the state of mens health across the 27 Member
States of the European Union, the 4 states of the European Free Trade Association (Norway, Iceland,
Switzerland and Lichtenstein) and the 3 candidate countries (Croatia, Turkey, Former Yugoslav
Republic of Macedonia). It highlights the broad range of mortality and morbidity data arising from
the many different health conditions that affect men in Europe, and does so through the contextual
lens of mens lives.
We see patterns emerging from the data that show marked differences between the health of men and
women, and at the same time large disparities in health outcomes between men in different countries and
within male populations in each Member State. This variability demonstrates that mens health disadvantage
is not biological inevitability.
What is apparent is that although there is a large volume of sex disaggregated data collected across Member
States, there is little analysis or consideration of the broader socio-cultural factors underpinning the data,
and even fewer attempts to translate this into gender-proofed policy and practice in ways that enable mens
perspectives to become visible.
A main message from this report is that there is a high level of preventable premature morbidity and mortality
in men, which will only be addressed by targeted activity across the lifespan.

The male population

Accessing Health Services

The changing demographic picture across the EU


highlights the increasing longevity of much of the
male population. Based on current projections,
there will be nearly 24 million fewer working age
men (aged 15-64 years) than now across the EU27
by 2060 and an increase in the number of men over
65 by some 32 million.

We can learn much about health systems from how


men use them, and how they impact on the health
of men. Infrequent use of and late presentation to
health services lead to higher levels of potentially
preventable health problems among men and fewer
treatment options. The overall rate of admission
to hospital is higher for men than for women for
all of the principal diseases and health problems.
Mens poorer knowledge and awareness of health
also points towards the need for targeted health
information to be delivered to men.

Lifestyle
factors

&

Preventable

risk

Poor lifestyles and preventable risk factors account for


a high proportion of premature death and morbidity
in men. There is a strong gendered dimension to
lifestyle choices and risky behaviours that place men
at higher risk of ill health than women, yet these need
to be considered within the context of economic,
social, environmental and cultural factors. In all
Member States we see that men who live in poorer
material and social conditions are likely to eat less
healthily, take less exercise, be overweight/obese,
consume more alcohol, be more likely to smoke,
engage in substance misuse, and have more risky
sexual behaviour.
Although there has been a steady reduction in
smoking across Europe, the levels are still highest
amongst poorer men and in the Eastern European
countries. Alcohol consumption overall is higher in
men than in women and men are considerably more
likely to binge drink and to be exposed to alcoholrelated harm. Though men have higher levels of
physical activity than women generally, the majority
of men in the EU do not meet recommended levels.
Men tend to have less nutritiously balanced diets
than women, with high levels of dietary cholesterol
and saturated fatty acids and lower levels of
polyunsaturated fat, carbohydrate, and fibre. These
are exacerbated by high salt consumption. Obesity
is increasing across Europe and the male form of
overweight, with central fat deposition, increases
the risk of many health problems.

Health Status
Although mens overall life expectancy in Europe
as a whole is increasing, some countries have seen
a reversal of this trend in the past decade. Life
expectancy is lower for men than for women across
the EU, a difference that ranges from 11.3 years
for Latvia to 3.3 years in Iceland. This variation
can also be seen within countries, where significant
differences in life expectancy between regions and
within localities are closely tied to socio-economic
factors. For the EU27, the death rate is higher for
men in all age ranges, with a 24% higher rate in the
0-14 year age range, 236% higher rate in the 15-44
age range, 210% higher rate in the 45-64 age range
and a 50% higher death rate in the over 65 age
range. This situation persists across the majority
of conditions that should, on biological grounds,
affect men and women equally. Over 630,000 male
deaths occur in working age men (15-64 years) as
compared to 300,000 for women.

Cardio-Vascular
Cancer

Disease

and

Two of the main causes of premature death are


cardiovascular disease (CVD) and cancer. These are

Other health conditions affecting


men

the focus of more detailed analysis in light of the


large differences in the rates of premature death
between men and women and between men from
different countries. With CVD accounting for 36% of
all deaths among men, the differences across Europe
are striking with CVD mortality ranging from 61%
of total male deaths in Bulgaria to 25% in France.
Ischemic Heart Disease is responsible for 360,000
deaths among men in the EU27, about 15% of all
mortality. Male cancer patterns are changing; lung
cancer is declining but prostate cancer has become
the most diagnosed cancer, affecting around a million
European men. Testicular cancer, despite effective
treatment, still remains the first cause of cancer
death among young males (20-35 years) and, for
non-gender specific cancers mortality rates in men
are significantly higher than those seen in women.
Tobacco remains the largest single preventive cause
of cardio-vascular and cancer death.

Type 2 Diabetes is increasing in men due to the


rising tide of male form obesity and the metabolic
syndrome, causing high levels of premature mortality.
Osteoporosis is traditionally seen as a problem of
older women. There are however problems of low
bone density in young male athletes and men with
specific health problems and hereditary disorders. A
growing number of men also develop the condition
as a result of hormone ablation therapy for prostate
cancer. Across Europe there are higher levels of
chronic lower respiratory diseases men with over
4% of total male deaths across EU27 as a result of a
condition that is mainly caused by smoking.

Conclusion
This report provides the foundation for a wealth of
activity in and around the emerging field of mens
health and sheds light into the challenges men face
at the start the second decade of the 21st Century.

Accidents, Injuries and Violence


Throughout the EU, there is a clear and consistent
pattern of higher mortality rates from accident and
violence-related injuries among men compared
to women. Accidents and violence related injuries
contribute a significant proportion of deaths in
younger men, with road traffic accidents causing the
majority of those.

Mental Health
Though more women are diagnosed with mental
health problems, this masks the extent of the problem
for men. Mens depression and other mental health
problems are under detected and under treated in
all European countries. This is due to mens difficulty
in seeking help, health services limited capacity to
reach out to men, and mens different presentation of
symptoms to women with higher levels of substance
abuse and challenging behaviours.

Communicable diseases
Within countries undergoing major social upheaval,
communicable diseases are still an important cause
of premature death. Across the lifespan deaths
from pneumonia are more common in men than
women apart from in the very elderly. Tuberculosis
was in decline but is now on the increase among
sub-populations of men, with drug-resistant strains
making the management (and containment) of this
disease difficult. The risks from sexually transmitted
diseases continue to be a challenge that few health
systems have been able to address successfully to
date. Across Europe there are about 2 HIV cases in
men for every 1 case in women, and 3 AIDS cases
in men to every 1 case in women although patterns
vary across Europe.

Introduction
A better understanding of the health of men is essential for two main reasons. The
first relates to the need for our male population to be as fit and able as possible. The
second is tied to the fundamental values of equality and equity, as we are seeing many
men whose lives are blighted through a collective lack of awareness and action on the
problems they are facing. This has a huge impact not only on men themselves, but also
their families and the wider society.
This report helps create the baseline understanding of the state of mens health across the
27 Member States of European Union, the 4 states of the European Free Trade Association
(Norway, Iceland, Switzerland and Lichtenstein) and the 3 candidate countries (Croatia,
Turkey, Former Yugoslav Republic of Macedonia)

he report provides analysis of a broad range of health and social issues that affect the health of
men and attempts to give an insight into why men seem so vulnerable to premature death and so
challenging with regard to many aspects of their lifestyles.

Using routinely collected statistics on morbidity and mortality and data from academic literature, as
comprehensive a picture as possible has been compiled on the state of mens health across Europe. The
purpose of this report is to inform policy makers, health professionals, academics and the wider population
of the health challenges men face.

Putting the spotlight on men


and mens health

marked effect of poor socio-economic conditions on


the health of men means not just an issue of gender
equality, but a more fundamental equity concern,
which relates to the right of all men to be able to live
a long and fulfilling life.

Throughout European history, men have maintained


a central and prominent place in society and
have traditionally been the major holders of
political and religious office and of economic
resources. Nevertheless, the categories of men
and masculinity have remained largely taken for
granted, as the gender spotlight focused on women.
It was not until the latter part of the last century
that we began to witness an increased gender focus
on men, including mens health. This included two
important landmark events within the EU: the Men
and Gender Equality Conference through the Finnish
Presidency in 2006 and the Mens Health Conference
as part of the Portuguese Presidency in 2007.

Social determinants of health


Men are not a homogenous group - as demonstrated
in this report, there is much variation in health and life
expectancy between men living in different contexts
(e.g. different countries within Europe) and between
men living in the same context (e.g. age-related or
socioeconomic differences within the same country).
Mens health status is therefore more than simply a
consequence of biological, physiological or genetic
factors; it is affected by much broader economic,
social, cultural and environmental elements.

This report is particularly timely against a backdrop


of unprecedented political, economic and social
change that has occurred across Europe over the
past 30 years. There have been significant economic
changes with an overall decline of primary industry
and, more recently, increased labour market
vulnerability associated with economic recession.
This is coupled with a changing demographic picture
within Europe: with a declining younger population
and an expanding older population, the workforce
implications and pressure on resources are becoming
more intense.

Mens health as an
investment
Many of the solutions of addressing the social
determinants of mens health rely on the ability of
professionals to recognize that men have significant
potential to be a health resource rather than just
a consumer of health services. Such a policy calls
for a departure from the traditional focus on the
deficiencies of men with respect to their health. Public
debate on mens health tends to be dominated by
negative portrayals of men and masculinity, whereby

We need to acknowledge that currently we are


losing a significant proportion of our working age
men through premature mortality. This affects not
only our industry and commerce, but also can alter
the social and financial positions of families. The

10

men are blamed for failing the health services by


not attending, for being violent and for taking risks.
This report supports a positive and holistic approach
to mens health, one that addresses the underlying
causal factors that can be attributed to mens poorer
health outcomes and that create health-enhancing
environments for boys and men.

This report adopts a broad, social determinants


approach to defining mens health. It seeks to move
beyond an approach that focuses only on differences
between men and women to examine the many and
varied differences between men and the many and
varied ways of being a man in Europe. It recognizes,
in particular, that social and economic factors,
including poverty, are key determinants of the health
status of men across the EU.

Improving the health of men can also have both


direct and indirect benefits for women and children.
In the case of single-income, lower socio-economic
group families, absenteeism from work due to a
fathers ill-health is likely to have significant material
repercussions for the family as a whole.

11

Chapter 1

The male population

12

There is an increasing longevity of much of the male population, but this


is coupled with a decline in the birth rate. If the current projections for the
changing male population are correct, there will be a reduction of nearly 24
million working age men (aged 15-64 years) across the EU27 by 2060 and an
increase in the number of men over 65 by some 32 million.

Young men are living at home for longer and deferring the age of marriage.

Boys and girls are in the education system for longer, but boys seem to
be missing out on a full educational experience, with more leaving school
prematurely and fewer entering tertiary or adult education.

Patterns of work are changing, with men having higher unemployment levels
than women, and men being less likely to have a job for life.

o be healthy is not just about the absence of


disease; it is also dependent on being part of
society, having an education, a job, a family and
to be able to live a reasonably safe and secure
life. Examination of these broader determinants
of mens health and wellbeing and an exploration of the
way men live their lives creates a useful backdrop to
understand the context for the health challenges men
are facing.

There are emerging issues, however, that are seeing


men in more vulnerable positions, such as the shrinking
economy putting a strain on jobs leaving many men in
transient part-time work or unemployed.
It is also recognised that men are not a homogenous
group, with marked differences existing as a result of
their social position within society.

There has been a steady and continual change in the


male population structure across Europe. A falling
birth rate and longer life expectancy are creating a
growing mismatch between the young and the old.
There have also been major changes in the social roles
of the population and in many cases these have been
extremely beneficial and have improved the lives of both
men and women.

13

Total male population


Over the past couple of decades there have been
marked changes for many countries in the structure
of their male population; for most this has seen
an increasingly aged population, with a quite rapid
reduction in the number of young as compared to the
old. Few countries have seen an increase in their 0-

14 age group, with the Eastern European countries


showing the biggest decreases.
By 2060 EU 27 is expected to see 23.8m fewer men
in the 15-64 working age bracket and an increase of
32m in those men aged over 65 years.

Percentage change in male population from 2010 to projected numbers in 2060

Source Eurostat: proj_08c2150p

Population trends from 2010 to projected numbers in 2060

Source Eurostat: proj_08c2150p

14

Birth rate
There is a ratio of 105 boys for every 100 girls
born, with the rate of live births varying between
countries.
Ireland and Iceland have male live birth rates above
15 per 1,000 population as compared to Germany
with 8 per 1000 population and the EU27 average of
10 per 1000 population. A falling birth rate has been
noted (EC 2007) and highlights changing trends
in the age of having children, and the numbers
of children being born, rather than the survival of
children at birth.

iStockphoto.com/ZoneCreative

Live births per 1,000 population, by sex and country, 2008

Source merged data from Eurostat: demo_magec and WHO Health for all database.

15

Chapter 2

Lifestyle & Preventable


risk factors

16

Poor lifestyles and preventable risk factors are still some of the principal causes
of premature death and morbidity in men, with over 50% of premature deaths
being avoidable.

There are strong links between the socioeconomic and educational background
of men and their available health choices, which impact on their wellbeing.

A gender element exists with regards to mens lifestyle choices, with social
pressure increasing the likelihood of adopting risky behaviour.

ifestyle and health behaviours play a critical


role in influencing health, illness, and mortality.
Epidemiological studies implicate particular
lifestyle patterns as a major factor in premature
death rates1, particularly among men2.

This has been confirmed by a growing shift in health


care policy towards the importance of health behaviours,
disease prevention and lifestyle3. At both EU and
individual Member State level, policy statements clearly
implicate cigarette smoking, excess alcohol consumption,
physical inactivity and poor diet in the aetiology of
many of the principal causes of mortality and morbidity,
including cardiovascular and respiratory diseases, and
some cancers. It is, however, crucially important to
understand that lifestyles are not simply the product
of individual choice. They are influenced by economic,

social, environmental and cultural factors4,5. Across and


within Member States those who are in poorer material
and social conditions eat less healthily, exercise less,
consume more alcohol, and are more likely to smoke or
misuse drugs. In the context of addressing premature
mortality among men, there is a growing awareness of
the need for lifestyle modification early in life among
men engaged in damaging health behaviours.

17

Tobacco Smoking
Tobacco use is the major causes of preventable
death in Europe. It has been estimated that 15%
of all deaths in the European Union - including
25% of all cancer deaths - could be attributed to
smoking6. Every year, over half a million Europeans
die prematurely because of tobacco use or exposure
to tobacco smoke. In addition to the loss of life,
smoking-related deaths and illnesses impose
enormous economic burdens - over 100 billion
per year. Across Europe, men are more likely than
women to have ever smoked tobacco: 63% of men
have smoked tobacco at some point in their lives,
compared to 45% of women.

Men are also more likely to be current smokers


(32% vs 21%)7. However, some countries have
seen a reduction in the sex gap in smoking over
recent years due to decreases in the number of male
smokers and increases in the number of female
smokers8. Although men are more likely than women
to smoke, there is variability in smoking prevalence
between men in different countries and among men
within the same country. The proportion of male
daily smokers ranges from a low of 17% in Sweden
to a high of 51% in Latvia. In some countries half
of the population smoke; in others only 1 in 6 men
do so.

Proportion of daily smokers, by country, 2004

Source Eurostat: hlth_ls_smke

Male to Female ratio of proportion of daily smokers

18

Smoking prevalence varies with education level.


In nearly all countries, men with post-secondary
education and men in higher socioeconomic groups
are least likely to smoke9.
Among young people there is less clear evidence of
sex differences. In the majority of countries, girls
are more likely to be smokers, but the sex differences
are moderate in most. As observed among adults,
there is wide variation in the prevalence of smoking
among boys across Europe: the proportion of 16
year old male smokers ranges from 15% in Iceland
to 44% in Latvia. Although there are no definitive
patterns, rates of smoking among young men tend
to be higher in Central and Eastern Europe, and
lower in northern Europe.

Other European surveys reveal that boys and young


men perceive significantly less risk associated with
smoking tobacco10. In addition to being more likely to
smoke, men - particularly manual workers - are more
likely than women to be exposed to tobacco smoke
at their place of work (ibid). Furthermore, there
is wide variation between countries within Europe
in terms of the presence and comprehensiveness
of restrictions on smoking in workplaces. Among
people who work in enclosed workplaces, men are
less likely than women to be employed in smokefree workplaces (ibid).

Alcohol consumption
Alcohol-related harm is a major public health concern
in the EU, accounting for over 7% of all ill health
and early deaths11. Excessive alcohol consumption
is the third most important cause of morbidity and
mortality in Europe12.
Episodic heavy drinking increases the risk of
accidental injury or death, and the risk of being
the perpetrator or victim of violence. It is often
implicated in antisocial behaviour. Excessive alcohol
consumption may also lead to negative outcomes
for relationships, family, friendships, employment,
and finances.

The proportion of men who have drunk alcohol in the


last 12 months ranges from a low of 68% in Romania
to a high of 94% in Lithuania. Furthermore, the male
to female ratio of drinkers ranges from just over 1 to
nearly 2. In countries with high prevalence the male
to female ratio is practically constant and close to
1:1, increasing as the prevalence decreases.

Per capita alcohol consumption in Europe is the


highest in the world13. Although sex differences in
alcohol consumption are decreasing in some parts of
Europe, men are more likely to drink and to drink in
harmful ways. Men are more likely to be dependent
on alcohol, and alcohol related injury and mortality
rates are significantly greater among men. Across
Europe, deaths due to chronic liver disease are more
common among men: in 23 out of 31 countries the
male death rate is at least double that for women.

iStockphoto.com/grekoff

19

Male to female ratio of proportion of drinking alcohol in past year

Age standardised death rates for Chronic liver disease, by sex and country, all ages, latest year1

Source Eurostat: hlth_cd_asdr. 2008 except: BE (2004). DK, LU, PT (2006). BG, IT, MT, PL, RO, FR, SE, UK, CH, EU27 (2007).

20

Proportion of men drinking alcohol in past year, by country, 2004

Source Eurostat: hlth_ls_dk12me

The proportion of drinkers increases with increasing


education. This pattern is found for all men in
Europe, and is observed within different age bands
and across countries.
Among men, alcohol consumption also varies
according to age. The 2007 ESPAD survey of over
100,000 16-year olds revealed lower levels of
alcohol use than among adults, but did also find

clear sex differences for most measures for alcohol


use, particularly excessive and unhealthy levels of
consumption. In all countries, the majority of 16
year old boys had consumed alcohol in the last year
(ranging from a low of 52% in Iceland to a high of
96% in Denmark).

Illicit drug use


Parity of drug use in men and women is only found in
young people, and only in some countries: in general
drug use is considerably more common among men.
However, it is important to note that male to female
use ratios vary for different drugs and that across
Europe, there is wide variation in mens patterns of
illicit drug use14.
Men are more likely to have ever used cannabis and
to have used cannabis within the last year. In no
country were women more likely to have ever used
cannabis, and in only one country (Ireland) were
women more likely to have used cannabis in the last
year.
Men are also more likely than women to have ever
used ecstasy, with the exception being Latvia where
equal proportions of men and women had used
this drug. Among young people, there is less clear
evidence that boys are more likely than girls to have
ever used ecstasy. Large sex differences also occur
in the use of cocaine, with about 2:1 more men
using this drug.

The 2007 ESPAD survey of over 100,000 16-year


olds in 35 European countries revealed that boys
were approximately twice as likely as girls to have
used steroids (ibid). However, the proportion of
young men who had used anabolic steroids ranged
from 1% or less in 9 countries to 7% of boys in
the Czech Republic. A clear exception to the general
finding of higher levels of drug use among boys was
the finding that girls were markedly more likely than
boys to have used tranquilisers or sedatives without
a prescription.
Sex differences in patterns of illicit drug use
correspond to sex differences in attitudes and beliefs
about drugs. A survey of 15-24 year olds revealed
that although there were no sex differences in the
perceived health risks of heroin and cocaine - the two
drugs with the highest risk ratings - boys and young
men perceived significantly less risk associated with
use of ecstasy and cannabis15.

21

Drug-related harm
Reflecting the fact that men are more likely than
women to use illicit drugs, there are clear sex
differences in negative outcomes associated with
illicit drug use. For example 82% of heroin overdose
deaths occur in men, with men in their 30s most
likely to die from heroin overdoses. In all European
countries, drug-induced mortality rates are higher
among younger people (15-39) than in the rest of
the population.

Furthermore, among younger people, drug-induced


mortality rates and the proportion of all deaths
attributable to drug use are greater among men.
However, among young men there is enormous
variation between countries in terms of absolute
mortality rates and the proportion of all deaths due
to drug use.

Age specific death rates for Drug dependence, toxicomania, by sex, EU27, 2007

Eurostat: hlth_cd_acdr

Age standardised death rates for Drug dependence, toxicomania, by sex and country, all ages, latest year1

Source: Eurostat hlth_cd_asdr.1 2008 except: CH, CY, EU27, FR, IE, IS, IT, SE, SI, UK (2007). DK, LU, LV, PT (2006). EE,
MK (2005). BE, SK (2004)

22

Physical Activity
iStockphoto.com/jacomstephens

There is a long established positive relationship


between physical activity16 and health. Physical
activity helps to prevent a range of chronic diseases,
including cardiovascular disease, type 2 diabetes,
some cancers, and obesity. It has a positive effect
on musculoskeletal health and psychological
wellbeing17.
Physical activity also modifies other risk factors such
as hypertension, total cholesterol and high-density
lipoproteins and is associated with other healthy
behaviours such as healthy diet and non-smoking18.
Physical inactivity, on the other hand, is recognised
as a major independent risk factor for chronic noncommunicable diseases, accounting for 3.5% of
the disease burden and up to 10% of deaths in the
European Region19.
In the 21st century, there are fewer opportunities for
physical activity in everyday life, with the result that
sedentary lifestyles have increased: Over half of men
in the European Union do not reach recommended
levels of activity, whilst approximately one in
three are sedentary. This has been paralleled by a
fivefold increase in obesity between the beginning
and end of the last century20. A study focusing
on physical activity prevalence in 20 countries
(including 7 countries from the EU), reported that
age-related declines in physical activity were much
more frequently observed among men than among
women21.

A recent study22 found that men in the EU were


found to exercise or play sports more than women;
nevertheless, 56% of men in the EU were found not
to engage in exercise/sport weekly.

How often do you exercise or play sport, by sex and age, EU27, 2010

15-24

25-39

40-54

55-69

Source Eurobarometer 2010

23

70+

With regard to non-sport related physical activity,


the same study showed that 34% of men in the EU
were found not to engage in physical activity weekly
and this ranged from 15% in Denmark to 66% in
Italy.

Their findings also suggest women are motivated to


exercise more for health reasons, to improve physical
appearance and to lose weight; the motivating
factors for men are to have fun, to improve physical
performance and to be with friends.

Non-sport related physical activity, by country, 2010

Source Eurobarometer 2010

Diet
Unhealthy diets and physical inactivity are among
the leading causes of the major non-communicable
diseases including cardiovascular disease, type 2
diabetes and certain types of cancer, and contribute
substantially to the burden of disease, death and
disability within the EU23. Mens diets are generally
less healthy and less nutritiously balanced than
womens diets.

Despite the high prevalence of overweight/obesity


within the EU, daily energy intake for men is below
reference values24 in most of the participating
countries25. The share of protein in total energy
intake is within or slightly above the recommended
range of the WHO26. Only men from Norway are
within the recommended range for carbohydrate
intake.

Intake of carbohydrates in adults (ages 19-64), by sex and country, 2009

Source: Elmadfa27, 2009. HU 18, UK = 25-64.

24

Likewise, the Eurobarometer28 report shows only


German, Norwegian and Polish men meet the
recommended daily dietary fibre intake. The majority
of European countries are above the recommended
range of the WHO share of fat in total energy intake
and saturated fatty acids (SFA) for males, with
the share of polyunsaturated fatty acids (PUFA)
below the recommended intake range in most of
the participating countries. Intake of cholesterol is
higher in men and above recommended levels in
most countries.

Men tend to be less likely than women to associate


a healthy diet with eating more fruit and vegetables
or with not eating too much fatty foods (ibid).
Whilst the vast majority of EU citizens report having
a healthy diet, there are quite striking east/west
differences between Member States. For example,
whilst almost all citizens in the Netherlands (95%)
and Denmark (91%) consider that they have healthy
eating habits, this is much lower among citizens in
Latvia (58%) and Lithuania (55%).

There are a number of instances of vitamin


deficiencies among men in the EU and the intake
of certain minerals is at odds with recommended
levels.

What do you think eating a healthy diet involves?

Avoid/ not eating too


much fatty food

Eating more fruit and


vegatables

Male
Female

Eating a variety of
different foods
0

10

20

30

40

50

60

70

Percentage

Source Eurobarometer 2006

The Eurobarometer report (ibid) also highlights that,


with the notable exception of having attempted to
reduce alcohol consumption, men were less likely
than women to have attempted to change their diet
over the past 12 months. Motivation for making
dietary changes was prompted more by the desire
to lose weight for women (39% v 26% for men)
compared to staying healthy for men (34% v 27%
for women).
Mens nutritional knowledge tends to be more
limited than womens29, and men are less likely
than women to read food labels30. This may have
particular negative consequences for the dietary

habits of single men living alone31. Men also tend


to lack control over their diet, as the purchasing
and the preparing of food have traditionally been
womens responsibility32. This may reinforce more
traditional gendered norms for men, depicting them
as nave about healthy food choices. Dietary habits
are also influenced by working hours, in particular
for those working shift hours, and commuting long
distances, which tend to be associated with an
increased reliance on convenience foods, snacking
and eating out33.

25

Obesity
The relevance of weight to men is that they tend
to deposit fat intra-abdominally leading to the
apple-shaped android form of obesity, compared
to pear-shaped gynoid form of obesity in women34,
whose fat tends to be deposited in their hips and
thighs. However, this position is changing with more
women developing central obesity, especially from
premenopause on35.
This visceral fat is not an inert substance. It has
its own endocrine function, with the creation of fat
toxins that can lead to the fat related cancers, such as
prostate, testis, bowel, liver, kidney or oesophagus.
It also leads to a higher risk of hypertension,
hyperlipidaemia and diabetes as a result of the
metabolic syndrome. Other consequences of excess
weight include an increased risk of dementia and
sleep apnoea.
The growing number of overweight men across
Europe is partially attributed to societal changes
such as:

Increasingly sedentary lifestyle


Decline in manual labour
Reduction in walking
Reduced opportunity for exercise
Changes in eating patterns
Alcohol consumption
Long working hours

iStockphoto.com/vojtechvlk

Mens weight tends to be accumulated at a faster


rate than women; there are already more men
overweight by age 15-24 than women, with a mean
of 22% over a BMI of 25 in men and 14% in women.
The rate of increase in overweight in men is also
noticeable, with an increase to 46% over BMI25 in
the 25-34 age range in men compared to 25% in
women.
Across Europe, the burden of overweight varies. In
Germany, UK, and Malta over 65% of men have a
BMI greater than 25. In Norway, Estonia, Latvia and
France, fewer than 45% of men are overweight or

Weight status by age and sex, 2004

Source Eurostat: hlth_ls_bmia

26

Weight status for males, by country, 2004

Source Eurostat: hlth_ls_bmia

It appears that the level of educational attainment


seems to have a different relationship with levels
of obesity and overweight in men as compared to
women. With regard to overweight (BMI 25-30) it
appears that the higher the educational attainment in
men the greater the proportion who are overweight,
and the converse for women.

Persistent obesity is not been associated with any


adverse adult social outcomes in men, though in
women it is associated with a higher risk of never
having been gainfully employed and not having a
current partner36. There is also a strong cultural
component, with being big being seen as a sign of
strength and prosperity.

These seemingly anomalous trends may be due


to men in lower socioeconomic situations being
engaged in more manual work and therefore having
greater energy expenditure, or due to lifestyle
factors, including higher smoking levels. There may
also be issues in relation to greater social acceptance
of overweight in men than overweight women.

Median percentage of population overweight (BMI 25-30), by sex and educational attainment, 2004

Source Eurostat: hlth_ls_bmie

27

Chapter 3

Accessing health
services

28

Infrequent use of and late presentation to health services are associated with
men experiencing higher levels of potentially preventable health problems and
having reduced treatment options.

The overall rate of admission to hospital is higher for men than for women for
all of the principal diseases and health problems.

Men are also less likely than women to engage in routine or preventative health
checks.

Mens poorer knowledge/awareness of health points towards the need for


targeted health information to be delivered to men.

nalysis of mens use of health services offers


insight into the relation of health systems
to the overall health status of men. It also
allows the effect of mens health promotion
and disease prevention strategies to be compared across
countries (especially those with more sophisticated
measures in place).

Hypertension (35% for men, 37% for women) and


muscle, bone and joint problems (17% for men, 28%
for women) are cited as the most common reasons for
medical long-term treatment. There is a higher incidence
of all reported health problems in women than in men.
Hypertension is more of a problem in East-Central Europe
and the Mediterranean, whilst muscle, bone and joint
problems are more prevalent in East-Central Europe.

Men are less likely than women to report a longstanding illness or health problem (26% v 31%) or to
be undergoing long-term medical treatment (22% v
28%)37.
Are you undergoing a medical long-term treatment?

Source Eurobarometer 2007

Not surprisingly, men are less likely to report long-term


disruption of activities due to health problems (26% v
31%);

to report pain in the past week that affected their daily


living (27% v 37%), or to report chronic restrictive pain
(22% v 28%)(ibid).

29

Hospital admissions
Despite reporting less ill-health and less disruption
to normal activities due to ill-health, the overall rate
of admission to hospital is higher for men than for
women for all of the principal diseases and health
problems.
Diseases of the circulatory system (16%), injuries,
poisoning and external causes (11%) digestive system
(10%), respiratory system (10%), neoplasms (9%)
and mental and behavioural disorders (4%) account
for the highest proportion of hospital admissions for
men.

iStockphoto.com/KenTannenbaum

Diseases as a percentage of all in-patient admissions, by sex, EU_V1.

Source: HMDB 1 EU_V aggregate which varies according to countries available

There is considerable variability between countries,


with differences in age standardised admission
rates per 1,000 population for the six main health
categories for men ranging from 10.7 (Cyprus and
Portugal) to 40.6 (Lithuania) for Circulatory Diseases;
7.2 (Portugal) to 31 (Austria) for Injuries, Poisoning
and External Causes; 9 (Netherlands and Cyprus) to
24 (Austria) for Digestive Diseases; 8 (Netherlands)
to 33.6 (Lithuania) for respiratory problems; 5.3
(Cyprus) to 26 (Hungary) for neoplasms; and 1
(Poland, Cyprus, Netherlands) to 17.5 for mental
and behavioural disorders.

considerably higher in Hungary for men (26/21),


whilst a reversal of this pattern is seen in Latvia
(15/20). Mental and behavioural disorders are notably
higher for men in both Latvia (18/10) and Lithuania
(14/8). These same countries have the highest rate of
admissions and the largest male/female differences
in rate of admissions for respiratory diseases (34/24
for Lithuania and 32/25 for Latvia). Whilst admission
rates for injuries poisoning and external causes are
higher for males than for females across all countries,
the gap is particularly pronounced in Austria, Latvia
and Lithuania.

There are some notable male/female differences in


admission rates within countries. For example, the
age standardised admission rates for neoplasms are

30

Age standardised admission rates per 1000 population for Diseases of the circulatory system, by sex, and
country, latest year 1

Source: HMDB.1 2007 except HR, DK, IS, IT (2006). NL, PT, ES (2005)
Percentage of male inpatient hospitalisations in past 12 months, by level of education and country, 2004

Source Eurostat: hlth_co_inpe

Preventative Health
Different patterns emerge between men and women
in terms of engaging in other health checks (scans,
heart tests and cancer checks). Men are more
likely to have had a heart check-up (29% vs 26%
of women), but less likely to avail themselves of xray or other scans (34% vs 41% of women). Whilst
colorectal cancer testing is similar between men and
women at 8%, men are far less likely to undertake
other tests for cancer (6% vs 16% of women).
Men are less likely than women to have had their
blood pressure checked in the past year (55%

vs 62% of women) or to have had a cholesterol


screening test (35% vs 39% of women). Overall,
the testing rates for blood pressure range from 70%
or above in Luxembourg, Estonia and Portugal to
46% in Ireland, with just over half of blood pressure
checks being carried out upon doctors initiatives.
Among those with hypertension, similar proportions
of men (48%) and women (50%) had recently made
lifestyle adjustments with the aim of reducing their
blood pressure.

31

The overall rates of reported cholesterol testing were


highest in Luxembourg (57%), Portugal (56%) and
Greece (55%) and lowest in Romania (21%) and
Bulgaria (23%). The main initiative for cholesterol
testing comes from doctors (20%) followed

by patients themselves (13%) and screening


programmes (5%). Some 13% of respondents
reported having changed their lifestyle in order to
lower their blood cholesterol38.

Have you received any of the following tests in the last 12 months? EU25, by sex and test type

Source Eurobarometer 2007

Mens usage of primary health services


Across Europe, men access primary care services
less frequently than women do, with this sex-differences gap ranging from approximately 5 percentage
points in the Czech Republic and Austria to approximately 18 percentage points in Cyprus and Greece.

There are also considerable variations between men


in different countries, with the percentage of men
attending a doctor within the past 12 months ranging from 89.2% in the Czech Republic to just 32.6%
in Romania.

Percentage consulting a medical doctor during the past 12 months, by sex and country, 2010

Source Eurostat hlth_co_doca

A Danish study that was based on 35.8 million GP


contacts and 1.2 million hospitalisations in 2005
demonstrated an overall pattern among men of lower
contact rates with GPs but higher hospitalisation
and mortality rates39. This, in the authors view, is
consistent with the hypothesis that men react later
in seeking help for severe symptoms, resulting in
higher rates of hospitalisations among men for the
causative condition.

The proportionally greater use of primary care


services by women in the early years reflects the
provision of antenatal care and screening services
that are more likely to habituate women into regular
contact with health services. The general absence
of male-targeted health care programmes hinders
the surveillance capability for mens health problems
and mens ability to identify as participants in health
care.

32

Barriers within health services


A range of factors have been identified at a
service level that can be described as barriers
to mens more frequent or more prompt use of
health services, particularly primary care services,
such as weight loss groups, smoking cessation
services, anger management groups, etc. as well as
access to family doctors40,41. The reasons for such
difficulties for men include cost of services, services
only being available during traditional working
hours, lack of flexibility in many mens working
days, excessive delays for appointments, rushed
consultations, a perception that GP waiting rooms
and other services are designed around the needs

of women, a lack of understanding of the process of


making appointments and negotiating with female
receptionists, and lacking the vocabulary required to
discuss sensitive issues. Conversely, the provision of
services that have been found to be more effective
are those that offer flexible opening hours, longer
consultation times, individualised and male-specific
health assessments and the provision of lifestyle
and behaviour modification programmes42,43. The
importance of doctor-male patient communication
has also been highlighted44,45.

Well man clinics and community-based health initiatives for


men
The more successful well man clinics have been those
that offer flexible opening hours, longer consultation
times, at sites that are separate from primary care,
and offer individualized and male-specific health
assessments46. Other characteristics of successful
clinics include the use of targeted advertising, the
provision of personalized letters of invitation to
prospective male patients, the provision of lifestyle
and behaviour modification programmes, and the
inclusion of a comprehensive referral system.
In response to the reluctance of some men to access
more conventional health services, there have been
increasing attempts to develop community based
services that specifically target men. In this context
of bringing health services to men, pubs (ibid) ,
sports clubs47, schools48 and other settings (e.g.
work environments, youth centres, places of worship
and barber shops49 ; have been identified as settings

in which to target those men who may be less likely


to use more conventional services (ibid).
Targeting mens health in leisure time has been
successfully achieved through associations with
professional sports teams. The Premier Football
League Health initiative50 for example is a 1.68m
programme funded by the UK New Football Pools, in
which Premier League football clubs help to improve
the state of mens health in deprived areas. The
Leeds Rhinos Rugby League club in partnership with
the Centre for Mens Health, Leeds Metropolitan
University and the Regional Department of Health
ran a season long campaign at the ground on match
days offering free health checks and a weight loss
group51.

33

Chapter 4

Health Status

34

Men generally identify themselves as having better health than women, though
this may not accurately reflect their actual level of health and wellbeing.

Life expectancy is lower for men than for women across all the EU Member
States, ranging from 66.3 yrs for men in Latvia (77.6 yrs for women) to 80 yrs
for men in Iceland (82.2 yrs for women). However, there are more variations
found between mens life expectancy between different countries and regions
than between mens and womens life expectancy.

The rate of premature death in men still far exceeds that for women, and is
evident across the majority of disease states.

Over 630,000 male deaths occur in working age men (15-64 years) as
compared to 300,000 female deaths.

Cardiovascular disease is the biggest cause of premature death, but this is


rapidly being replaced by cancer.

n analysis of morbidity and mortality data


gives an indication of those conditions where
men seem to be particularly vulnerable and a
key observation is that the majority seem to
fall within what could be classified as avoidable
or deaths that are amenable to health interventions52.
These are conditions where an alteration in either the
risk factors that cause the problem or in the way the
disease is managed would see a marked reduction in the
mortality rates.

With age and socioeconomic circumstances being such


an important component in mens increased vulnerability
it would appear that more concerted efforts to reduce
mens preventable risk factors in their early life would
have considerable effect on their overall health and
wellbeing.

35

Self perceived health status

iStockphoto.com/STEVECOLEccs

Despite high levels of premature mortality among


men, it is surprising that many have high levels of
satisfaction with their own health. The reasons for
this apparent anomaly may reflect how questions are
worded and the meaning of health being different
between men and women53. A further possibility is
that men may have a poorer perception of their own
health status54.

It is also likely that although women live longer


than men, the quality of life and well-being they
experience may not be always satisfactory55. Women
suffer from a raft of conditions that do not necessarily
become life threatening in their early years. This
can lead to a clustering of health conditions and
multi-morbidities that contribute to their poorer self
perceptions of health.

Self reported chronic morbidity


For all ages, 33% of women and 29% of men
classify themselves as having a long term condition.
The number of men reporting a long-term condition
increases with age, rising from 9.6% of 15-24 year
old men, to 43% of 55-64 year old men, and 64%
of 75-84 year old men reporting having a long term
condition.

For young men, Norway stands out with nearly a


fifth of their 15-24 year old men reporting a long
standing condition as compared to 2% of young men
in Greece.

Self perceived chronic health problems, by sex and age, EU27, 2008

Source Eurostat: hlth_silc_05

36

Healthy Life Years (HLY)


For the majority of countries, men and women
have very similar life expectancy without activity
limitation. However, women have a longer life
expectancy with severe activity limitation, meaning

that they can expect to live more of their lives with


chronic health difficulties as compared to men.

Life expectancy for 50 year olds without activity limitation, by sex and country, 2008

Source: http://www.healthy-life-years.eu/ (a) estimated value

Differences exist for men between countries with


life expectancy without activity limitation having a
similar pattern to overall life expectancy. There are
five countries where men of 50 can enjoy over 20

more years of life without activity limitation, but in


5 countries men cannot expect to live more than 12
years past their 50th birthday before experiencing
limitations.

Life expectancy for 50 year olds with severe activity limitation, by sex and country, 2008

Source: http://www.healthy-life-years.eu/ (a)Estimated value

37

Percentage of 50 year olds with severe activity limitation, by sex and country, 2008

Source: http://www.healthy-life-years.eu/ (a) Estimated value

Life expectancy
The average life expectancy for men in the EU is 76.1
years as compared to 82.2 years for women (6.1
years difference). Life expectancy across Europe as
a whole is increasing.

It is increasing at a slightly faster rate for men


(2.1%) than for women (1.6%) over the period
2002 to 2007.

Time trends in life expectancy, by sex, EU27, 2002-2007.

There are marked differences in life expectancy


between countries, with Latvia having the lowest
life expectancy for men at 66.3 years (and also the
biggest gap between the male and female population
(11.3 years). Liechtenstein and Iceland have the
greatest average male life expectancy at 80 years.

Iceland has the lowest gap between men and women


with 3.3 years. It is noticeable that the difference
between the highest and lowest life expectancy for
men (13.7 years) is considerably more than the
corresponding figure for women (7.8 years).

38

Life expectancy at birth, by sex and country, latest year

Source Eurostat: demo_mlexpec.

2008 except EU27, BE, FR, IT, UK (2007)

With each passing year of life there is a change in the


estimated life expectancy as each successful year of
survival means that a longer life can be expected.
At the age of 60 the pattern is similar in that Eastern
European men have the lowest life expectancy
(Latvia 15.6 years, Lithuania 16 years) and the
biggest gap between the sexes (6.1 years and 6
years respectively), whilst Switzerland, Lichtenstein,

Iceland, France, Sweden and Italy can all expect to


have another 22 years of life or more. At age 60
a man in Latvia could expect to live to 76 years as
compared to a similar aged man in Switzerland living
to 82 years a 6 year difference.

Life expectancy from aged 60 years, by sex and country, latest year1

Source: Eurostat demo_mlexpec 1 2008 except EU27, BE, FR, IT, UK (2007)

These aggregations of data do not do justice to the


large intra-country variations that exist. Averages
can mask inequalities that paint a quite different
picture of the problems some men face. At the
NUTS2 (regional data) level, we can see that in
the It-Suomi region of Finland the average life
expectancy is 75 years as compared to 81.8 years
in land, which has the distinction of being the

only region in the EU that has a higher average life


expectancy than women56 (80.8 yearrs).
It is notable that the difference in life expectancy
between the highest and lowest regions is 10.3
years for women and 15.5 years for men, offering
a far greater challenge than tackling any differences
between the sexes57.

Male mortality across the lifespan


In order to explore the impact of mortality across
the lifespan a numerical analysis of the number of
deaths occurring at each age was undertaken. This
revealed that the higher burden of death in men
appears to occur at every age until the age of 80.

What is noticeable is the high number of deaths that


occur in the working age population of 15-64 years,
with nearly 630,000 men dying across the EU27 in
these years, as compared to 300,000 deaths for
women.

39

Total number of deaths, ages 0 to 64 years, EU27, 2007

Total number of deaths, ages 65+ years, EU27, 2007

Source Eurostat: hlth_cd_anr

For the working age population the number of


deaths occurring in the age range 15-64 years was
compared to the overall total number of deaths for
men to show the percentage that occur in this age
range. For some countries, over 40% of male deaths
occur at an age when men should be at their peak
of activity.

The ratio of deaths suggests that the biggest


differences between men and women are found in
the younger age ranges, with over 3 times more
men than women aged 20-29 dying, but the excess
extends right up until age 75-79.

Even across the majority of the Western European


countries over a fifth of male deaths are occurring
within this age range.

40

Deaths in 15-64 age range as a percentage of total deaths, by sex and country, latest year. 1

Source Eurostat: hlth_cd_anr.


(2004).

2008 except EU27, BG, CH, FR, IT, MT, PL, RO, SE (2007). DK, LU, PT (2006). BE

Sex ratio of total number of deaths, by age, EU27, 2007

Source calculated from Eurostat: hlth_cd_anr

Rates of death between men and women were


calculated for 5 age groups: 0-14 years, 15-44
years, 45-64 years, 65+ years and all ages. For the
EU27, it can be seen that overall men have a 64%
higher rate of death for all ages than women, with
that rate ranging from 24% higher rate in the 0-14
year age range, 2.36 time higher rate in the 15-44
age range and just over twice as high a rate in the
45-64 age range.
In the over 65 age range there is now a 50% higher
rate of death in men, such that though numerically
there are fewer male deaths in this older age group,
the lower number of men in this age group means
that the rate is greater for men.

In the 0-14 year age range, Luxembourg stands


out as having over twice as many male than female
deaths. Malta and Iceland both have over 60%
more deaths among boys. There are more marked
differences between countries in the 15-44 years age
range. Lithuania and Estonia have over 3 times
more male deaths as compared to 1 times higher
in the Netherlands for the same age range.
In the 45-64 year age range, Estonia has over 3
times more male deaths. In the over 65 age range
Lithuania, Latvia and France have nearly 70% higher
male death rates.

41

Sex ratio of rates of death, for all conditions, by age and country

Source rates calculated from Eurostat: hlth_cd_anr

42

Overall burden of disease


There is a marked age effect on mortality data for
men when compared to women. Across all the
classification groups males have a higher ratio of
rates of death in the 0-14 age range and a similar,
but more marked picture is seen for the 15-44 and
the 45-64 age ranges (the exceptions being deaths
as a result of Diseases of the musculoskeletal
system and connective tissue and Certain conditions
originating in the perinatal period for the 15-44 age
group).

A further exception is in relation to Neoplasms,


where there is an excess of female deaths in the
15-44 age range, though it must be noted that
the majority of the sex specific cancers only affect
women in this age range and for the other cancers
there is a male excess. In the over 65 age group the
higher rate of death persists across the majority of
the classification groups.

Sex rate ratio of death rates, main classification groups1, by age, EU27, 2007

Source calculated from Eurostat: hlth_cd_anr 1Excluding Pregnancy, childbirth and the puerperium as this only relates to
female mortality.

43

Following on from a previous study, an analysis was


undertaken for the EU27, with the same selection
of causes of death but over the 15-49 age range.
What can be seen is that Transport Accidents are the
main cause of death in men in the 15-29 age range,
with suicide having the highest rate of death in the
30-39 age range. Large increases are seen in the
deaths as a result of ischaemic heart disease and
cancer between the ages of 30-34 years and 4549 years (over 11 fold increase and 9 fold increase
respectively).

Liver disease is also seen to be increasing (a 6 fold


increase). Assault is not a major contributor to
mens high death rates.
The impact of cancer on womens premature death
is noticeable, but it is also important to note that
suicide remains the second highest cause of death
from 25-39 years of age across the EU27 for women,
with more deaths from liver disease than ischaemic
heart disease.

Age specific death rates, for selected causes, 15-49 years, EU27, 2007

Male

Female

Per 100,000

Source: Eurostat hlth_cd_acdr

Breaking down the causes of death for men within


each country shows that different diseases take
on a greater or lesser impact on the total deaths.
For example, deaths as a result of cardiovascular
disease account for a greater proportion of deaths in
Eastern European countries than in Western Europe
(i.e. 62% in Bulgaria vs 26% in France).

Deaths as a result of neoplasms are more common in


the West (e.g., 35% in Italy and the Netherlands). It
is notable that nearly 12% of male deaths in Portugal
are assigned to the classification Symptoms, signs
and abnormal clinical and laboratory findings, not
elsewhere classified.

44

Male mortality from underlying causes of death as a proportion of total deaths, by country

Source Eurostat: hlth_cd_anr. 1 2008 except EU27, BG, CH, FR, IT, MT, PL, RO, SE (2007). DK, LU, PT (2006). BE (2004).

45

Chapter 5

Cardio-Vascular Disease

46

There have been marked reductions in cardiovascular morbidity and mortality.


Nevertheless, Cardio-Vascular Disease (CVD) is still one of the biggest risks to
mens health and in the older population it is the principal cause of death.

Whilst CVD accounts for a mortality rate of 36% of all deaths for men, the
differences across Europe are marked ranging from 61% of total male deaths in
Bulgaria to just 25% in France.

Ischemic Heart Disease, (IHD) is responsible for 360,000 deaths among men in
the EU27, about 15% of all mortality.

Cerebro-Vascular Disease (stroke) constitutes 8% of all male deaths or nearly


200,000 lives lost.

lthough there have been great improvements


in cardiovascular health, marked differences
exist between different parts of the EU. In
some countries cardiovascular disease (CVD)
accounts for half of all premature male deaths.
In the most vulnerable regions, such as the Baltic States,

CVD premature mortality is almost 6 times higher than


in those countries with the lowest risk rates such as
Switzerland, Iceland and Italy. These inequalities are
found not just at the national level: a significant degree
of social stratification with regard to CVD is also seen
within countries across Europe58.

47

Cardiovascular disease
There has been a decline in CVD mortality in both
sexes and all age groups in most countries of
Western Europe since the beginning of the 1970s
and in Eastern Europe since the 1990s. This has
reduced the influence of CVD on premature mortality.
Among women, CVD has ceased to be the number
one cause of premature mortality (before age 65).
A similar phenomenon is occurring with a time delay
for men. This is leading to a more concentrated CVD
mortality in the oldest age groups59.
CVD constitutes 36% of all mortality among men
(900,000 deaths) and 44% among women (1 million
deaths). The percentage of male deaths resulting
from CVD is very different across the EU27; it is
the highest for Bulgaria (61%) and the lowest for
France (25%). Generally, in the countries of the
Eastern part of the EU, CVD constitutes around 50%
of all death causes, while in the Western part of the
EU they amount to about one-third. Similarly, agestandardised mortality rates from CVD by country
are much higher in Eastern Europe.

iStockphoto.com/kupicoo

There is, however, a marked age effect. In 2008,


CVD caused 160,000 deaths among men and 60,000
deaths among women before 65 years of age. It
accounted for around 1/4 of all male deaths in this
age group in Eastern Europe, and around 1/5 of all
male deaths in Western Europe.

Time trends of CVD mortality, by sex, all ages, EU27, 1969-2008

Source: WHO Morticd10

48

Age standardised mortality for premature CVD, by sex and country, ages 0-64 years, latest year1

Eurostat hlth_cd_asdr.1 2008 except: BG, CH, EU27, FR, IT, MT, PL, RO, SE, UK (2007). DK, LU, PT (2006). BE (2004)

Ischemic Heart Diseases (IHD)


Ischemic Heart Diseases (IHD) was responsible
for 360,000 deaths among men in the EU27 in
2008. This amounts to almost 15% of all mortality
(among women IHD accounted for 330,000 deaths,
equivalent to 14% of all mortality). In 2008, IHD
caused almost 80,000 deaths before age 65 in the
EU, constituting 12% of all mortality (among women
the figures are respectively 20,000 and 6%).

There are wide variations between countries broadly


reflecting an eastwest disparity across Europe. The
highest mortality rates are in the Baltic States of
Lithuania, Latvia and Estonia together with Slovakia
and Hungary.
The historical trend of low IHD mortality in the
Mediterranean region is today much less apparent.

Age standardised mortality for Ischemic heart disease, by sex and country, all ages, latest year1

Eurostat hlth_cd_asdr.1 2008 except: BG, CH, EU27, FR, IT, MT, PL, RO, SE, UK (2007). DK, LU, PT (2006). BE (2004)

49

Age standardised mortality for Ischemic heart disease, by sex and country, ages 0-64 years, latest year1

Source: Eurostat hlth_cd_asdr.1 2008 except: BG, CH, EU27, FR, IT, MT, PL, RO, SE, UK (2007). DK, LU, PT (2006). BE
(2004)

Cerebro-Vascular Diseases (Stroke)


iStockphoto.com/Aguru

Stroke leads to the death of almost 200,000 men


in the EU every year, accounting for 8% of all
deaths (among women the rate is 270,000 deaths,
constituting 11% of all mortality). Stroke accounts
for about 28,000 deaths among men under age 65,
which constitutes 4% of all premature mortality
(among women the figures are 16,000 and 5%).
The Balkan regions of Bulgaria, Macedonia and
Romania have the highest rates of stroke mortality.
Greece and Portugal exhibit the highest stroke
mortality in Western Europe.

50

Age standardised mortality for Stroke, by sex and country, all ages, latest year1

Source: Eurostat hlth_cd_asdr.1 2008 except: BG, CH, EU27 FR, IT, MT, PL, RO, SE, UK (2007). DK, LU, PT (2006). BE
(2004)

Age standardised mortality for Stroke, by sex and country, ages 0-64 years, latest year1

Source: Eurostat hlth_cd_asdr.


(2004)

2008 except: BG, CH, EU27, FR, IT, MT, PL, RO, SE, UK (2007). DK, LU, PT (2006). BE

51

Chapter 6

Cancer

52

Cancer kills around 700,000 men in the EU27 each year which accounts for a
1/3 of all male deaths, with premature mortality affecting some 198,000 males
under the age of 65 years.

Men develop and die sooner from those cancers that should affect men and
women equally.

Male cancer patterns are changing; lung cancer is declining but prostate cancer
has become the most diagnosed among European males affecting around one
million men.

Lung cancer will remain a major cause of premature mortality.

Colorectal cancer is a leading cause of cancer death in Europe and requires


population-based screening.

Testicular cancer, despite effective treatment, still remains the first cause of
cancer death among young males (20-35 years).

ith an ageing European population and


advances in both the prevention and
management of cardiovascular disease,
cancer is becoming the most significant
cause of premature death in men. Around
700,000 men and over 540,000 women die every year,
which account for 29% and 22% respectively of all male
and female deaths across the EU27. In those aged under
65, some 198,000 men and 143,000 women die every
year from cancer, 31% and 45% respectively of total
deaths from all causes. Given that there are no significant
sex-specific cancers for men during the early adult years
(in contrast to the situation for women), male deaths are
from cancers that should affect men and women equally.
Men are more likely to develop and also more likely to
die prematurely from these cancers60.
There are many causes of cancer. Some originate
through inherited factors, but most are as a result of
lifestyle or the environment in which men live and work:

smoking, alcohol, diet, lack of physical activity and


exposure to industrial chemicals especially in factories
and on farms61. In addition, there is growing awareness
of the risks the male form of overweight and obesity
play in the development of fat-related cancers62. There
may also be issues relating to delay in presentation with
symptoms, which reduces the treatment options.
Another relevant factor when considering cancer
mortality data is that men and womens ability to survive
cancer differs across Europe63. During the period 20002002, the average survival rate in Europe is 47% among
men and 56% among women. The same study found
that women have significantly higher survival rates than
men for all cancers combined in each age class64. Age at
diagnosis is a major determinant of womens advantage.
A strong link to sex hormone patterns is implicated: with
increasing age, differences between men and women
almost disappear.

53

Time trends of all cancer mortality, by sex, all ages, EU27, 1978-2008

Source: WHO Morticd10

Male cancer mortality rates in the EU27 are showing


a twofold difference. The highest mortality rates
are observed mainly in the eastern part of the EU
(Hungary, Latvia and Slovakia).

The lowest mortality rates are observed in Sweden,


Finland, Malta and Luxembourg.

Age standardised death rates for cancer, by sex and country, all ages, latest year1

Source: WHO Morticd101 2008 except FR, IT, SE, UK (2007). DE, DK, LU (2006). ES, PT, SK (2005). BE (2004).

The male to female profile of cancer deaths changes


with age: more young men and boys dying (mainly
of cancers related to congenital problems); more
women dying in the middle years; more men than
women die in older age.

If the sex specific cancers are removed from the


data, the profile shows a far higher proportion of
men dying from other cancers. The male excess
of cancer death rates for non-sex specific cancers
persists across the age range.

54

Sex ratio of standardised death rates as a result of Cancer, by age, EU27, 2007

Source: calculated from Eurostat hlth_cd_anr

This high level of premature mortality is mirrored


in incidence rates for all the major cancers that are
not sex-specific. As many of these are not directly
associated with tobacco consumption, this higher
incidence suggests that the problems of men and
cancer are influenced by other lifestyle factors.

It also compounds problems men may have with


accessing services: they are not just more likely to
die from the cancer but more likely to develop them
as well.

55

Age standardised incidence rates for the major cancers, by sex, EU27, 2008

Source Globocan65

Lung cancer
The current incidence rate for lung cancer is
47.6/100.000 for men and 15.6/100,000 for women.
Lung cancer death rates in some Eastern European
countries are 3 or 4 times greater compared to the
lowest incidence rate in Sweden. It is noticeable
that in some countries the female incidence rate is
approaching that of males (e.g., Denmark, Iceland
and Sweden). In 2008 around 180,000 males died
from lung cancer in the EU27, with around 60,000 of
these deaths being in men under the age of 65 years,
which constitutes circa 10% of all deaths for all age

groups before 65 years of age. Lung cancer deaths


for women in the same year amounted to 70,000 for
the entire female population and 23,000 for women
under 65 years of age. This constitutes circa 7% of
all deaths. Lung cancer male/female ratio is 3.3:1.
The sex ratio ranges from 8-10:1 in Latvia, Lithuania
and Spain; while it amounts to 0.9 in Iceland.
Large differences in death rates between men and
women are evident across the life span.

56

Age standardised death rates for Lung cancer, by sex and country, all ages, latest year1

Source: WHO Morticd101 2008 except FR, IT, SE, UK (2007). DE, DK, LU (2006). ES, PT, SK (2005). BE (2004).

Male to female ratio of standardized death rates of malignant neoplasm of lung

Age specific death rates for Lung cancer, by sex, EU27, 2008

Source: WHO Morticd10

57

Colorectal cancer
Cancers of the colon and rectum (colorectal cancer)
constitute a significant proportion of the male
burden of cancer morbidity and mortality. Annually
in the European Union 183,000 men and 150,000
women are diagnosed with colorectal cancer: 78,000
men and 67,000 women die from this disease. This
constitutes around 11% of all cancer mortality (12%
for women). There is a marked age effect for men.
Generally, colorectal cancer rates have fallen since
the early 1980s in Western European countries. In
Eastern Europe, mortality rates were generally higher

until the early 2000s, when the rate of increase


started to fall. The prevalence and preventable nature
of colorectal cancer make it one of the primary focal
points of cancer control66.
The average age-standardised colorectal mortality
rate for the EU27 in 2008 was 25/100,000. However,
the mortality rates range from around 48/100,000
in Hungary, Slovakia and the Czech Republic to
16/100,000 observed in Greece and Finland.

Age standardised death rates, colorectal cancer, by sex and country, all ages, latest year1

Source: WHO Morticd101 2008 except CY, FR, IT, SE, UK (2007). DE, DK, LU (2006). ES, PT, SK (2005). BE (2004).

The higher rate of death mirrors the incidence data


at being about 5-10 years ahead of women, which

has implications for the age screening programmes


begin.

Age specific death rates for Colorectal cancer, by sex, EU27, 2008

Source: WHO Morticd10

58

Male to female ratio of standardized death rates of malignant neoplasm of colon

Prostate cancer
Despite significant advances in the treatment of
prostate cancer, it remains a growing problem for
mens health. In 2008 around 70,000 men died of
this disease. This constitutes about 10% of all male
cancer deaths and 3% of all male deaths. Over 92%
of these deaths occurred in the oldest age group
(65+).

Mortality rates vary across the EU27, ranging from


over 35/100,000 in Estonia and Latvia to 15/100,000,
in Malta and Romania. Of the Western European
states Sweden and Denmark are noticeable at both
having a rate of over 33/100,000, nearly a higher
than the nearest other Western state.

Age standardised death rates, malignant neoplasm of Prostate, by country, all ages, latest year1

Source: WHO Morticd101 2008 except FR, IT, SE, UK (2007). DE, DK, LU (2006). ES, PT, SK (2005). BE (2004)

59

Currently, around 3 million European men are living


with prostate cancer and this number will grow due
to population ageing. There were 350,000 new cases
of prostate cancer diagnosed in the EU27 in 2008,
which amounts to about 70 new cases per 100,000
men across the EU27 each year. However, this
varies considerably between states, ranging from
14 per 100,000 in Turkey to over 123 per 100,000
in Ireland. Prostate cancer has a higher incidence
in certain ethnic groups, most prominently AfricanCaribbean men. The incidence is also higher in first
degree relatives of men with prostate cancer: such
men have up to 5 times higher risk of developing
the disease67.
From the beginning of 1960s there has been a
slight growth of prostate cancer incidence (but not
mortality). The reason for this apparent discrepancy
is that the majority of prostate cancer cases are slow
growing and do not pose an immediate threat to the

individual. Many men die with the disease rather


than of it. There is, however, a type of prostate
cancer that can occur in younger and older men
which is more aggressive and leads to a more rapid
death if not detected early enough. These tiger
tumours are very different from the majority of slow
growing tumours that affect the majority of men.
The increased use of Prostate Specific Antigen
(PSA) screening during the last decade resulted
in a problem of too many non-life threatening
prostate cancer cases being identified. This led to
unnecessary treatment with long term side effects68.
Although large-scale US and UK epidemiological
interventions are available, some governments have
decided against national screening programmes for
prostate cancer69.

Age standardised incidence rate for Prostate cancer, by country, 2008

Source: Globoscan70

Male standardized death rates of malignant neoplasm of prostate

60

Testicular cancer (TC)


Testicular cancer (TC) is the most common
malignancy amongst young adult men (20-44 age
group) in Europe. On a population scale, testicular
cancer deaths are, however, quite rare: fewer than
1000 deaths out of over 15,500 new cases annually
in Europe and constitutes 1%-1.5% of all male
cancer deaths.
Comprehensive treatment - including chemotherapy,
radiotherapy and surgery - is characterised by
excellent cure rates: 95% cure for early stages of
TC, and slightly less in more advanced stages of
the disease. It is the best example of a controllable
human cancer. The availability of specialist centres
is of paramount importance for successful testicular
cancer treatment71.
Because the causes of testicular cancer are still
unknown, the only effective control is through early
diagnosis and treatment.

Testicular cancer incidence and mortality/age curves


display a bimodal pattern, which is different to other
cancers. The frequency increases after the age of
about 15 years to reach the first peak at the age 2530, after which it declines to about age 60, when it
increases again.
Over the last 60 years there has been a steady
increase in testicular cancer morbidity in almost
all countries. Testicular cancer incidence in Europe
oscillates around 3 to 6/100,000, with the highest
rates in Denmark and Norway (over 11/100,000).
The reasons for this difference are not clear.
In 2008 mortality rates for the EU27 amounted to
0.4/100,000. The highest levels were observed in
Bulgaria, Estonia and Latvia. The lowest mortality
rates were observed in Spain and in the UK (Malta
had no reported deaths).

Age standardised death rates for Testicular cancer, by country, all ages, latest year1

Source: WHO Morticd101 2008 except FR, IT, SE, UK (2007). DE, DK, LU (2006). ES, PT, SK (2005). BE (2004).

61

Chapter 7

Accidents

62

Throughout the EU, there is a clear and consistent pattern of higher mortality
rates among men compared to women from accident and violence-related
injuries.

Accidents account for the biggest proportion of deaths within this classification
group (some 36,000 male deaths in EU27) with death rates from road traffic
accidents being 3 times higher in men than women. Men account for 95% of
fatal workplace accidents.

Road injuries and suicide are the principal causes of accidental fatality among
all male age groups.

Deaths as a result of Injury/ External causes


of morbidity and mortality accounted for over
156,000 male deaths (6.5% of all deaths) and
79,000 female deaths (3.3% of all deaths)
for EU27 in 2007. Injury/ External causes of
morbidity and mortality is the leading cause of death in
all age groups below 60, and the fourth most common
cause of death in the EU after CVD, cancer and respiratory
disease. This broad category72 comprises accidents
(unintentional injuries, including road traffic accidents,
workplace accidents, home and leisure accidents) and
violence (intentional injuries, including interpersonal
violence and self-harm. The biggest cause of death
within this classification group is accidents accounting
for 63% of male deaths (73% female deaths).

a major cause of death, accidents and injury cause a


huge drain on health and societal resources, resulting
in an estimated seven million hospital admissions and
60 million medical consultations annually73. The burden
of healthcare costs associated with accident and injury
in the EU is estimated at approximately 15 billion per
year74.
Boys and men are over represented in most fatal and
non-fatal accident and injury categories. The burden
of accident and injury varies widely between and within
Member States. The prevalence of accident and injuryrelated mortality and morbidity is generally higher in
Eastern European countries75 and higher among lower
socio-economic groups within countries.

Despite improved surveillance systems and prevention


strategies, accident and violence-related injuries continue
to be a public health problem in the EU. As well as being

63

Male to Female rate ratio of deaths due to injuries, by country1

Source: Eurostat hlth_cd_ycdrf; hlth_cd_ycdrm.1 2006 except BG, CH, FR, MT, PL, RO, SE, UK (2005). DK, EU27, LU, PT
(2004). IT (2001). BE (1997).

There are considerable differences between


countries76 with the standardised injury death rate
being almost 7 times higher in Latvia (where 16%
of all deaths result from accidents) than in the
Netherlands.

This is indicative of an overall pattern of much higher


standardised injury death rates in Eastern Europe
than Western Europe.

Age standardized death rates and percentage of all deaths for External causes of morbidity and mortality,
by sex and country, latest year1

2008 except BG, CH, EU27, FR, IT, MT, PL, RO, SE, UK (2007). DK, LU, PT (2006). BE (2004)

64

The percentage of all deaths for External causes of morbidity and mortality, by sex and country, 2007

Source Eurostat: hlth_cd_asdr

It is estimated that 100,000 lives could be saved each


year if every country in the EU27 reduced its injury
mortality rate to the level of the Netherlands77. If
we were able to bring the male mortality rate down
to that of females, then we would see over 82,000
male lives saved across the EU27. This equates to
a potential decrease in overall mortality of 35 per
100,000 population across the EU27.

Injuries affect men and women disproportionately


throughout the lifespan, with overall risk of injury
being approximately twice as high in men (72 injury
deaths per 100,000) than women (35 deaths per
100,000) (ibid). Fatal injury rates rise sharply up to
the age of 15-19, are higher for boys/young men
than girls/young women, and are much higher in
older men than older women.

Unintentional injuries are responsible for about


two-thirds (68%) of injury fatalities and intentional
injuries represent one third (32%) of injury
fatalities78. The vast majority of injury fatality is
attributable to suicide (24%), road traffic accidents
(21%) and falls (19%).

Age specific death rates per 100,000 and percentage of all deaths for External causes of morbidity and
mortality, EU27, 2007

Source Eurostat: hlth_cd_asdr

65

Road traffic accidents (48%) and suicide (20%)


account for over two-thirds of all fatal injuries among
adolescents and young adults (15-24 years) (ibid).
In both cases, the death rates are approximately 34 times higher for men (transport: 24, suicide: 10)
than women (transport: 6, suicide: 2). The result
is a relative injury mortality rate of 70% in men
aged 20-24 years (ibid). There are large differences
between countries in injury fatality rates for young
people.

For example, injury accounts for 54% of all


adolescent deaths in the Netherlands compared to
76% in Estonia. Each year, 8.4 million people aged
15-24 years require hospital treatment for an injury
This represents 20% of all hospital injury related
treatments, even though this age group represents
only 13% of the total EU population.

Accidents
Mortality rates from accidents are consistently higher
for men than for women across Member States, with
the gap being most pronounced in Eastern European
countries79.

iStockphoto.com/36clicks

Age standardised death rates for Accidents, by sex and country, all ages, latest year

Source Eurostat: hlth_cd_asdr. 1 2008 except BG, CH, EU27, FR, IT, MT, PL, RO, SE, UK (2007). DK, LU, PT (2006). BE
(2004).

66

Deaths from road traffic accidents account for 23%


of all deaths due to External causes within the EU27,
with 36,166 men (11,1181 women) killed in the
EU27 in 2007. Death rates are 3 times higher for
men than for women80. An estimated 4.3 million road
injuries per year are treated in EU hospitals, with
approximately two-thirds of these being vulnerable
road users. Considerable differences exist between
countries, with higher rates in Eastern European
countries.
Although the disparity in road death rates across
the EU has decreased since 2001, there is still a
fourfold difference between the lowest (Malta) and
the highest countries (Lithuania).

Deaths from road traffic accidents are 1.5 times


greater in lower and middle income countries than
in higher income countries81 and are also higher
among men with lower socio-economic status and
less education82. The WHO estimates that more
than 1 in 3 road traffic fatalities in the EU are due
to alcohol, with men accounting for 15,000 of the
17,000 alcohol related traffic deaths83. Of these an
estimated 10,000 deaths in drink-driving accidents
are in people other than the driver. Property damage
due to drink-driving is estimated to be 10bn.

Age standardised death rates for Transport accidents, by sex and country, all ages, latest year1

Source Eurostat: hlth_cd_asdr.


(2004).

2008 except BG, CH, EU27, FR, IT, MT, PL, RO, SE, UK (2007). DK, LU, PT (2006). BE

Workplace Accidents
In 2005, 141 million work days were lost due to
accidents at work (EU15), with an average 35 days
of absence per accident (ibid) Although a large
proportion of accidents entailed fewer than 14 days
of absence (46%), the number of accidents leading
to more than one month of absence accounted for a
quarter of overall absence (ibid).

Estimated Member State costs due to work accidents


range from 1% to 3 % of gross national product
(ibid).
Men account for 95% of fatal accidents and 76% of
non-fatal accidents in the workplace.

Fatal and non-fatal accidents at work, by sex

67

There are considerable variations between countries,


with the highest number of fatal accidents occuring
in Italy and Germany. It is acknowledged that
such differences are, to a large extent, the result
of methodological differences in surveillance of
workplace accidents.

Construction,
manufacturing
and
transport,
storage and communication account for the highest
proportion of fatal accidents.

Number of fatal accidents (NACE A_D_TO_K), by country, Male, 2007

Source Eurostat: Hsw_aw_nnasx

Number of fatal accidents, Male, EU27, 2007

Source Eurostat: Hsw_aw_nnasx

68

Construction and manufacturing also account for the


majority of non-fatal accidents in men. Approximately
two-thirds (68%) of non-fatal accidents occur
among craft and related trade workers, machine
operators, or workers employed in an elementary
occupation84.

manufacturing, transport; stationary and mobile


plant operators; and extraction and building trade
workers. Over 70% of injuries arising from nonfatal accidents are sustained as wounds, superficial
injuries, dislocations, sprains and strains.

Incidence rates for non-fatal accidents are


highest among labourers in mining, construction,

Distribution of non-fatal accidents by sex and by sector for victims of shock, fright, violence and aggression,
2005, EU27

Advances in occupational health and safety have


resulted in reductions in the rate of accidents at
work. Between 1997 and 2007, there has been a

decline in the standardised incidence rate of fatal


accidents at work, with Ireland having achieved
the most notable reduction.

Leisure Accidents and Injuries


Sport makes an important contribution to the health
and physical fitness of society and to the EUs overall
strategic objective of solidarity and prosperity85.
Many sports, however, carry inherent risks. It is
estimated that approximately 6 in 1000 unintentional
fatal injuries are attributable to sports such as rock
climbing, boating, or horse-related sports86. This
equates to approximately 1,000 fatalities per year
in the EU27. When drowning (in natural water and
swimming pools) and non-traffic bicycle accidents
are included, 36 in 1,000 unintentional injuries can
be attributed to sporting activities. This equates to
an estimated 7,000 fatalities per year.
Adolescents/young people are over-represented
in most categories of sports-related injuries. For
example, in an audit of sports injuries in children
attending an Accident & Emergency department in
Scotland, the incidence of injury was much higher

in boys (71%) than in girls, with football (39%)


and rollerblading (14%) accounting for the highest
proportion of injuries87.
The overall incidence of sports-related injuries is
higher in men (67%) than in women, reflecting, in
part, mens higher participation levels in sport88. Men
tend to engage in sports that are physically dangerous
such as scuba diving, parachuting, hang-gliding and
body contact sports89, and take greater risks in sport
than women90. For men, taking risks and foregoing
safety through sport, have long been regarded as
masculine, and are practices that are valorised and
sustained through wider gendered systems and
structures within sporting organisations91,92.

69

Chapter 8

Mental Health

70

Mens depression and other mental health problems are under detected and under
treated in all European countries. This is due to mens difficulty in seeking help, health
services limited capacity to reach out to men, and mens different presentation of
symptoms to women with higher levels of substance abuse and challenging behaviours.

Sex differences between EU countries regarding incidence, occurrence and admission


to treatment for bipolar disease are evident, but difficult to explain.

Schizophrenia onset is earlier in men than women. Men have poorer long term
outcomes, longer inpatient stays and extended periods of impaired functioning.

ental ill-health in European men is underdiagnosed and under-treated. Many men


seem to find it challenging to seek help
when it comes to mental or emotional health
problems.
It may be difficult for health
professionals themselves as well as individual men to
identify changes in health behaviour as signs of mental
disturbances. There is a lack of adequate assessment
tools suitable to diagnose mens symptoms, and a lack of
suitable ways of referral for gender specific treatment.

In order to address mental health issues more effectively


in men, there is a need to address gendered patterns in
the upbringing of boys, and to improve our understanding
of gendered dimensions to mental health disorders,
mental health service delivery and in the behaviours of
men themselves.

71

Men and Mental Health

Mental ill health includes mental health problems and


strain, impaired functioning associated with distress
symptoms, and diagnosable mental disorders such
as schizophrenia and depression. The mental health
and wellbeing of people is determined by a multiplicity
of factors, including biology (e.g., genetics, sex
differences), individual differences (e.g. personal
experiences), family and social factors (e.g. social
support) and economic and environmental factors
(e.g. social status and living conditions). Data from
the WHO-5 mental well-being score show that in
all countries, men report better mental well-being
than women93. However, although more women
are diagnosed with depression and anxiety (or
internalizing disorders) men commit suicide more
often, and men have higher levels of substance
abuse and antisocial disorders (or externalizing
disorders)94.

When asked about feeling well or distressed numerous


studies show that men report higher levels of wellbeing and much less distress: across the EU, one
in five women compared to one in ten men report
psychological distress96. However, the findings of two
other European Reports97,98 revealed that men report
work-related stress more frequently than women.
Mental stress symptoms, such as overall fatigue
and irritability, were also slightly more frequently
reported by men. Anxiety and sleeping problems were
reported by similar numbers of men and women.
Their findings, however, revealed great differences
among EU countries. Large differences were also
seen from country to country with the highest level
reported in Greece (55%), and in Slovenia, Sweden,
and Latvia (all around 38%). Lowest stress levels
were reported in the UK, Germany, Ireland, and the
Netherlands (all around 15%).

Analysis of health service usage demonstrates that


men have less contact with health services in general
and even less with mental health services.
When men do contact health services, they tend to
be less likely to discuss psychological problems95.
This is reflected by fewer men being known to the
health care system prior to suicide, and often not
being regarded as depressive or suicidal. Men may
be compelled to use other coping strategies such
as acting aggressively, being uncooperative with
health professionals, rejecting help that is offered
to them and, in some cases, reverting to alcohol
abuse. However, men with such behaviour often
suffer feelings of powerlessness, desperation and
depression. In men these feelings are more often
combined with aggressive acting out behavior and
a lack of impulse control.

72

Depression
Depression (mood affective disorder) is one of the
most prevalent health problems in many European
countries and there are marked gender differences,
with hospital admission rates and attendance at a
general practice showing women outweighing men
by a ratio of 2:1. The reason for these large diffeences between European countries with regard
to admission rates is not explained by current
research.

Sex differences in the prevalence of depression


have been shown to be much smaller than the figures from hospital admission and general practice
attendance99. The study showed that particularly
among men, depression is under treated. This
partly reflects known sex differences in help-seeking behaviour.

Age standardized hospital admission rates per 1000 population due to Mood affective disorder, by sex and
country, latest year1

Source:HMDB.

2007 except LV, LT (2008). HR, DK, IS, IT (2006). NL, ES (2005).

Bipolar affective disorder

When looking exclusively at Bipolar Affective


Disorder more women are treated and there are
large variations among the European countries
for hospital admission rates, despite this being an
inherited genetic disorder. The gender differences
are explainable but it is surprising that there is a
5- to 10-fold greater occurrence of the affective

gene leading to this disease in Austrian, Finnish,


and Icelandic populations, as compared to the
populations of Denmark, Cyprus, Norway, and Poland.
Alternatively, such differences may be explained by
social, economic and cultural factors, which will only
be determined through future research.

73

Age standardized admission rates per 1000 population for Bipolar affective disorder, by sex and country,
latest year1

Source: HMDB.1 2007 except LV, LT (2008). HR, DK, IS (2006).

Anxiety disorders/ Schizophrenia / Psychotic disorders

Anxiety disorders are the largest diagnostic group of


Neurotic, stress-related and somatoform disorders
(ICD-10 F40 & F41). There are marked sex
differences in their occurrence: 12 month prevalence
in men is around 8%, but around 17% in women100.
Although there are differences between anxiety and
depression, many of the reflections written above
about gender differences in depression are also
relevant for the data on anxiety.

Men and women have similar occurrences of


schizophrenia and other psychotic disorders: 12
month prevalence is 2.6% in men and 2.5% in
women101. There are large differences between
countries in hospital admissions. This is probably
caused by differences in treatment policies, where
some countries prefer social and district psychiatry
than hospital treatment.

74

Age standardised admission rates per 1000 population for Schizophrenia, by sex and country, latest year1

Source: HMDB.1 2007 except LV, LT (2008). HR, DK, IT (2006). NL, ES (2005).

Average age of onset is earlier for men than


for women.
Women also tend to have better
functioning, more periods of recovery, fewer longterm adverse outcomes, and fewer and shorter stays
in hospital102.

This might be due to social or biological differences


as well as to gender differences that have been
discussed previously.

75

Chapter 10

Communicable Diseases

76

Men have a higher risk of dying prematurely from the major infections as a
result of reduced immunity and their greater likelihood being exposed to a
lifestyle or social circumstances that makes them more susceptible.

Pneumonia kills more men than women across the lifespan up until age 80
years. Its strong association with alcohol abuse, smoking, pre-existing lung
disease and HIV/AIDS makes men more likely to develop and die from this
disease.

Tuberculosis was in decline, but it is increasing in sub-populations of men.


Drug-resistant hamper the management (and containment) of this disease.

Across Europe there are about 2 HIV cases in men for every 1 case in women,
and 3 AIDS cases in men for every 1 case in women. Differing patterns of
incidence are found across Europe.

Viral Hepatitis affects more men than women by a ratio of about 4:1.

ithin countries undergoing major social upheaval, communicable diseases are an important cause
of premature death. The risks to men in all Member States with regard to pneumonia, tuberculosis,
sexually transmitted diseases and HIV continue to be a challenge.

77

Pneumonia
Pneumonia is the biggest cause of death from a
communicable cause. In 2007, it accounted for some
59,414 deaths in men across the EU27 (66,197
deaths in women). Pneumonia is responsible for
some 2.5% of male deaths across the EU27 (2.8%
female deaths).
Despite the higher absolute
number of deaths among women, men have a
higher standardised death rate: more deaths in
women occur among those over age 80 years (77%
compared to 55% for men).
The causes of pneumonia include a number of different
infecting agents. It can result from external causes
which have specific importance to mens increased
vulnerability. The risk of developing pneumonia is

greater in people with general ill-health or with preexisting lung disease. It is also greater in smokers,
users of immunosuppressant drugs, and users of
intravenous drugs. A further significant factor is
alcohol abuse, which results in a diminished immune
response and increases the risk of developing the
disease and of its severity103. The most common
AIDS associated disease in 2008 was Pneumocystis
pneumonia (22%).
There has been an overall steady decline in the agestandardised death rate for pneumonia, with the
rate of decline similar for both men and women.

Time trends of Pneumonia mortality, by sex, all ages, EU27, 2000-2007

Source Eurostat: hlth_cd_asdr

Tuberculosis
In the majority of the populations across the countries
covered by this report, the number of cases of
Tuberculosis (TB) is declining. However, this trend
is not true for all countries or for all groups within
individual countries: TB is now seen as an increasing
public health risk.
TB thrives in populations which have difficulty in
accessing public health services. The European
Region has the highest number of drug resistant
cases in the world. Across 30 of the 34 countries
covered by this report for which data are currently
available, there were 53,424 new cases of TB in men
and 29,108 cases in women in 2008104.

Although the median number of cases is relatively


small in relation to total population in the majority
of countries, some States have far higher numbers:
Romania had 17,293 male cases in 2008 (a
considerably reduction from the 21,331 cases seen
in 2004), and Poland, Spain and the UK all had over
4,000 cases.

78

Sexually Transmitted Infections


In the absence of vaccines or effective cures for
many STIs, safer sexual behaviour is an important
aspect of epidemiological control. It is also important
to monitor risk behaviour. Although surveys of
representative samples have been conducted in
many European countries, it is often difficult to make
comparisons because of variations in sampling,
data collection and measurement. Comparisons
of STI rates between EU nations are hampered by
substantial differences in national systems of STI
surveillance and behavioural monitoring105.

European STI surveillance data106 reveal important


sex differences in STIs. Although less than half
(45%) of all diagnoses of chlamydia occur in men, in
four of the 13 countries with valid data men comprise
the majority of chlamydia diagnoses. Furthermore,
the age distribution among men is different to that
for women, with a greater proportion of diagnoses
in men occurring in those aged over 25 than is the
case for women.

Proportion of sexually transmitted diseases, male, by country, 2008

Source: ESSTI Annual Report 2008

The sex distribution of gonorrhoea and syphilis is


markedly different to that for chlamydia. Across the
18 countries with valid comparable data, 71% of all
diagnoses of gonorrhoea infection occurred in men.
Although direct comparisons are confounded by
differences in definitions, men are also more likely
than women to have been diagnosed with syphilis:
in 14 of the 18 countries, the majority of syphilis

diagnoses occurred in men, and in 8 countries over


80% of diagnoses occurred in men.
Male:female ratios do not appear to be affected by
the stage of infection used in different countries
surveillance data.

79

HIV/AIDS
Within Europe, there are more men than women
infected with HIV, and men continue to be more likely
than women to become infected with HIV. Across
Europe there is wide variation in the rate of new HIV
diagnoses among men, with Estonia standing out as
carrying a particularly high burden of the disease.

iStockphoto.com/robynmac

Rate of new HIV cases, by sex and country, latest year

Source calculated from ECDC.

2008 except IT, DK, TR (2007)

The data show that in all but 4 of the 26 countries


there was an overall increase in the rate of new
cases of HIV in men over the last decade107. In
the Netherlands and several Central and Eastern
European countries (Slovenia, Turkey, Slovakia,
Bulgaria, Hungary, Czech Republic, Croatia),
there was at least a doubling in the rate of new
HIV diagnoses in men over the last decade. Only
Portugal, Romania, and Latvia observed declines
in HIV cases among men. The largest change is in
small countries reporting small numbers at the start
of the AIDS epidemic. All other negative changes are
due to anti-retroviral (ARV) drugs, underreporting
and under diagnosis.

The overall increase in HIV cases over the last decade


was greater among men than women. In 17 of the
26 countries, changes in HIV cases were less positive
among men than among women. HIV infections have
increased in most countries despite substantial health
promotion activities in many countries. For several
countries, changes in surveillance system may have
contributed to variations. For several other countries
there was a peak of the HIV epidemic in 20002002, therefore it is most likely in subsequent years
the change would be less pronounced (Lithuania,
Estonia) or even negative (Latvia). Some countries
have important reporting delays.

80

Age specific death rates for HIV, by sex, EU27, 2007

Source Eurostat: hlth_cd_acdr

Comparison of the data highlights the importance


of not relying too heavily on simple AIDS diagnosis
figures when making between-country comparisons.
It is important to consider the size of the population
in which the incident cases are found, and the link
between diagnosis and deaths. For example, in terms

of simple numbers, the UK has the fourth highest


number of AIDS diagnoses each year, but only the
18th highest AIDS death rate. There are clear age
trends with men in their forties seeing the highest
death rates for HIV.

Viral Hepatitis
There are a number of forms of hepatitis, namely
those as a result of liver damage due to alcohol
abuse, autoimmune diseases, as a result of damage
caused by drug overdose or through bacterial or
viral infection. These diseases cause inflammation
of the liver and have varying degrees of impact on
the health of the individual, from acute to chronic
and from mild to life threatening. Hepatitis A is
transmitted through infected stools or contaminated

food, Hepatitis B is transmitted through contact


with an infected individuals blood or through direct
contact with an infectious person and is common in
migrants from countries where the condition is more
commonplace (such as Asia and South East Asia).
Hepatitis C is spread by contact with contaminated
blood and is most common in injecting drug users
(IDUs).

Standardised death rates for viral hepatitis, by sex and country, all ages, latest year1

Source Eurostat: hlth_cd_asdr.


LU (2005). BE (2004).

2008 except BG, CH, CY, EU27, FR, IS, IT, MT, PL, RO, SE, UK (2007). DK, PT (2006).

81

Chapter 11

Dental and oral health

82

Dental and oral ill-health problems cause many systemic diseases as well as
being the source of marked discomfort to the individual.

Dental caries and missing teeth are a bigger problem for women than men.

Periodontal disease affects a significant proportion of the population and has a


greater prevalence in men

Older generations are most at risk, but obese young men are emerging as
another at risk group.

Strong links are evident between periodontal disease and cardio-vascular


disease.

ral disease is the fourth most expensive


disease to treat in the industrialised world108.
Men are more at risk of cancer of the lip, oral
cavity and pharynx (C00-C14), and in addition
there are some conditions that can both occur
in the mouth and aggravate or be caused by other
serious health conditions in men. The WHO identify the
most important risk factors for oral health problems as

tobacco use, excessive alcohol consumption, stress, and


diabetes mellitus109. Many of these aggravating factors
are more prevalent in men. Careful and regular oral
hygiene can make significant differences in oral health
and consequent systemic health, but evidence suggests
that men are less effective in this regard than women
and are less likely to use preventative dental services.

83

Dental Caries
Within the WHO Oral Health Country / Area
Profile Programme database110 it is evident
that dental caries are more prevalent
in women than in men111. This appears
to be a multifactoral issue with no one
definitive answer but it is possible that
different salivary composition and flow
rate, hormonal fluctuations, dietary habits,
genetic variations, and particular social
roles among families are associated with
the increased risk for women112. Due to this
increased risk women are more likely to wear
a removable denture and to have lost more
natural teeth113.

Periodontal disease
Periodontal disease is a broad term encompassing
several different conditions that can affect the
mouth, but are separate from conditions affecting
the teeth themselves. Most often oral diseases are
related to infections with many factors influencing
their ability to take hold and progress to advanced
chronic conditions. These risk factors include both
the local environment within the mouth and any
disease which compromises the immune system,
repair system (e.g., poor diet), or alters the mouth
environment (e.g. diabetes) can have significant
impact on oral health. In addition there are a
number of other important associated conditions
that also have relevance to the higher prevalence
this disease has in men.

Dental Health Survey identified a high prevalence of


periodontal disease in adults aged 3544 years and
6574 years115. Men and those from East Germany
had significantly higher prevalence.
A study exploring the relationship between
socioeconomic
disadvantage
and
periodontal
disease found lower income and lower educational
attainment to be related to worse periodontal
disease116. Age is an important factor, with older
men having more oral health problems than younger
men. However, younger men and boys have more
signs of poor oral hygiene than girls117. There is also
an increasing number of younger people affected
due to obesity118.

Periodontal disease tends to be more prevalent


in men than women114. The recent fourth German

Health implications of periodontal disease


Periodontal disease has been implicated in the
development of atherosclerosis119.
A study in
Sweden found that increasing periodontal disease
was also significantly associated with hypertension
and in the middle aged with myocardial infarction120.
It has been suggested that the identification of
periodontal disease may be used as a marker of the
metabolic syndrome, and that improved oral health
care in those with the metabolic syndrome may
help to reduce the incidence of various systemic
diseases121.

A number of oral conditions are linked to HIV/AIDS.


A study in Spain found that oral candidosis was
highly predictive of immune failure in those receiving
highly active antiretroviral therapy (91% for men
who have sex with men, 96% for heterosexuals, and
96% for intravenous drug users)122. It may also be
an important sign of non-adherence to therapy123.
However, studies are not yet available to show if this
is more prevalent in male patients.

84

Oral health care


In a Swedish study on oral health girls scored more
favourably on behavioural measures, showed more
interest in oral health, and perceived their own oral
health to be better than did boys124. Studies of the
Danish and German adult populations found that
women were more likely to clean their teeth, use
toothpicks, and have regular dental check-ups and
take better care of dentures125,126.

life, mood, appearance, and general well-being128.


Women are more likely than men to visit a dentist.
The median proportion of men who had made a
consultation with a dentist in the previous year was
45% as compared to 55% for women. There are
marked differences between countries with only 13%
of Romanian men having had a visit to the dentist as
compared to 78% of men in Sweden.

The strongest predictor of poor oral health behaviour


is being male127. Women tend to see good oral
health as having a greater impact on their quality of

Consultation with a dentist during the previous 12 months, by sex and country, 2004

Source Eurostat: hlth_co_dente

The association between education and consultation


with a dentist varies markedly between countries.
For example, only 27% of the most educated
men (33% of women) in Romania access dental
services129. For men who have only the most basic
education this level drops to 4% of men and 5% of
women. The main reason given for not visiting the
dentist was cost, but this was not the case in all the
countries, with some countries such as the UK, the
Czech Republic, Austria and Luxembourg having this
as a minority issue. Fear of treatment is an issue in
a number of countries as, is does having no time to
attend for consultation.

When the data are broken down by age, across all


the income groups expense and a feeling of lack of
time predominate in the younger age band (18-44
years). In the older age bracket cost is still one of
the main problems, with lack of time becoming a
less relevant reason for delayed use of services.
Comparisons between the highest and lowest income
quartiles for having unmet dental needs suggest that
in some countries there are no barriers to services.
In others a more marked inequality exists, with
Bulgaria having a 20% difference between the rich
and the poor.

85

Chapter 12

Other health conditions


affecting men

86

Type 2 diabetes is increasing in men as a result of obesity. The death rate


in men is twice that of women in those under the age of 65years, and across
Europe men have higher admission rates for diabetes.

Obese diabetics have a 40-60% higher risk of cardiovascular mortality.

Across Europe there are higher levels of chronic lower respiratory diseases in
men. Around 4% of all male deaths result from this condition, which is mainly
caused by smoking.

Osteoporosis is traditionally seen as a problem of older women. There are


however problems of low bone density in young male athletes, men with
specific health problems and hereditary factors. A growing number of men
develop the condition as a result of hormone ablation therapy for prostate
cancer.

number of health conditions can be seen to


have a gendered component, through men
being more liable to die prematurely (e.g.
diabetes), lifestyle factors making men more
likely to contract the disease (e.g. chronic
lower respiratory disease), or conditions that are often
thought to specifically affect one sex despite while having
a marked effect on the other (e.g. osteoporosis).

Within this section a sample of these conditions will be


considered, with the implication being that there will
be other health conditions that may also be influenced
by the sex and gender of the individual and that we
should include an analysis of any potential sex or gender
effects.

87

iStockphoto.com/STEVECOLEccs

Diabetes Mellitus Type II


Diabetes Mellitus Type II is associated with an
inability to keep up with the bodys demands for
insulin. Although there is a genetic link associated
with diabetes, the majority of cases are due to
amendable/ avoidable causes, the most important of
which is central (or visceral) obesity and development
of the metabolic syndrome. This complex condition
has insulin resistance as a principal component. With
the obese, the incidence of diabetes rises alongside
the risk of developing the metabolic syndrome. This
then significantly increases the risk of cardiovascular
mortality.
Estimates of the prevalence of diabetes are
complicated by a significant number of people
(estimated at over 50%) being unaware that they
have the condition130. The current estimate by the
International Diabetes Federation131 is that 285
million people worldwide have diabetes, with a
projected rise to 438 million cases within 20 years.

Current prevalence estimates for the EU are 9% of


the population, with a 10% increase expected over
the next 20 years (ibid). There is a suggestion
that men are more likely to remain undiagnosed
for longer as a result of less frequent use of health
services (see section on health service usage)132.
Although there are marked and important impacts
of diabetes on womens health133, men have a higher
rate of mortality from this condition. There has
been little change in the overall rate of death from
diabetes since 2000, with men consistently at about
15 deaths per 100,000 population and women at
about 11-12 deaths per 100,000 population.

88

Proportion of total male deaths as a result of Diabetes mellitus, by country, latest year1.

Eurostat database: hlth_cd_anr.

2008 except BG, CH, EU27, FR, IT, MT, PL, RO, SE (2007). DK, LU, PT (2006). BE (2004)

The broad category of chronic lower respiratory


diseases (CLRD) - consisting of bronchitis,
emphysema, asthma, bronchiectasis, and other
chronic obstructive pulmonary diseases - accounts
for a significant degree of morbidity and mortality
across Europe.
Currently this condition causes
more deaths in men than women, but it is likely that
there will be increases in morbidity and premature
mortality among women due to the increasing
number of women smoking.

CLRD death rates are just over 29 per 100,000 for


men and 12 per 100,000 for women. There has been
a small but steady decline in the death rate from
CLRD since 2000 across the EU27 as a whole (17%
for men), but this decrease is not seen in all countries.
Slovakia stands out as having a greater than 50%
reduction in the rate of CLRD deaths, while Bulgaria
saw a decrease from 2000-2004, but a subsequent
20% increase on their 2000-2004 rate.

Chronic lower respiratory diseases


Percentage change in age standardised death rates for Chronic lower respiratory diseases, 20001 to latest
year2

Source: Eurostat hlth_cd_asdr.1 Except FR, 2001,


LU, PT (2006)

2008 except BG, CH, EU27, FR, IT, MT, PL, RO, SE, UK (2007). DK,

89

The highest rates of death are found in Hungary


(age standardised mortality of 55 per 100,000) and
Belgium (48 per 100,000).

These are a long way above the EU27 average of


29 per 100,000 and the 13 per 100,000 found in
France.

Age standardised death rates for Chronic lower respiratory diseases, by sex and country, all ages, latest
year1

Source Eurostat: hlth_cd_asdr.


(2004)

2008 except BG, CH, EU27, FR, IT, MT, PL, RO, SE, UK (2007). DK, LU, PT (2006). BE

Overall CLRD accounts for just under 4% of all male


deaths across the EU27, with a high of just over
6% of all male deaths in Belgium. It is noticeable
that the Eastern European countries have a lower
percentage of their total deaths as a result of CLRD

than many of the Western European countries,


despite their higher levels of smoking. This may be
due to their higher levels of cardio-vascular deaths.

90

Osteoporosis
Some conditions are more associated with a particular
sex than others. Osteoporosis has commonly been
seen as a problem of post-menopausal women and
rarely thought of as an issue for men. It is now
acknowledged that men have a significant risk of
developing osteoporosis, with some 20% of men
over the age of 50 suffering fractures and disability
as a result of this disease. Maximum bone density
has to be attained by the age of 40 years and this
is influenced both by sex and gender. The age of
puberty is known to occur earlier in girls than in
boys, such that the rate of bone deposition is higher
in females, who reach peak bone mass faster than
males.
Young mens increased bone density is partly
explained by the extent of their participation in
manual labour. However this may be affected by
current demographic trends in which men are now
more likely to be in similar jobs to women and have
more sedentary lives.
Mens heavier bone structure puts them at advantage
with regard to bone loss as a result of ageing, such
that they tend to develop osteoporotic fractures some
10 years later than women. At this point, however,
their clinical condition has usually also deteriorated,
such that the morbidity and mortality associated
with fractures and their (surgical) treatment is
considerably greater than in women. The one year
mortality rate for men following hip fracture is twice
that of women. Following a first fracture, the risk

of having a second is the same in men as it is in


women. Even though more older women than men
experience falls, men have a higher mortality as a
result of falls.
The most significant predictors of risk in men
developing osteoporosis are increasing age and
low body mass134. The role of androgen deficiency
(hypogonadism) and androgen ablation therapy
for the treatment of prostate cancer (which
affects oestrogen levels in men) are also major
contributors to developing this condition135,136,137.
There are a number of other factors associated with
the development of the disease in men, including
heredity138, low body mass, weight loss, smoking,
physical inactivity and chronic alcoholism139.
A further important factor is that with women
having increased screening opportunities, they
more frequently come into contact with health
professionals who can pick up emerging problems
at an earlier stage. Health literature, and indeed
general health messages about bone health, are
often focused onto women, and may contribute to
mens lack of awareness of the problem.

91

Epilogue

ens health is complex and multifaceted, and


it moves well beyond those male specific
conditions resulting from mens differing
biology with women.

Looking at the mortality and morbidity data through a


gendered lens has allowed fresh insights to be gained
on key physical and mental health issues. A major
observation from the report relates to the patterns
emerging from the data that show marked differences
between the health of men and women, and at the same
time large disparities in health outcomes between men
in different countries and within male populations in
each Member State.
The extent and depth of the problem of premature
mortality is one of the most striking and worrying findings,
especially as it involves nearly the whole spectrum
of health conditions. Mens greater risk of developing
and dying from nearly all the cancers that, biologically,
should affect men and women equally; the high rate
of premature deaths from cardio-vascular disease; the
increased risk from the major communicable diseases;
and the vulnerability of men to accidents, both in the
workplace and at leisure are but some of the life-limiting
factors impacting on men which lead to such a high
number of early deaths.
The marked rise in the number of overweight and obese
men, especially when linked to the reduced physical
activity levels seen in most mens lives, are also creating
significant increases in life-limiting disease. Other
lifestyle related factors such as a high alcohol intake,
dietary deficiencies, and various forms of risk-taking
continue to increase the likelihood of premature death
and disability.
The report also demonstrates, however, that mens
health encompasses much more than simply disease
related mortality; there are significant issues relating to
mens overall health and well-being that have emerged
through the analysis. As we move from an industrial
base to a post industrial society, it would seem that
many men are struggling to cope with problems relating
to their mental and emotional well-being as well as their
physical health. Many of the indicators relating to social
exclusion can be seen to be an issue for men i.e. there
are worsening opportunities for men with regard to work
and full time employment and men are less likely to
have post secondary level education.
An increasingly aged population is also starting to create
new challenges for men with regard to their physical and
mental health; with more chronic problems emerging.

92

Academic development of mens


health
The literature search for the completion of this report
has highlighted that there is only a relatively recent
focus on men and their health, with a short time frame
of activity to really develop a good understanding of men
and their relationship to their physical and mental health
and wellbeing. There are many unanswered questions,
for instance, how does masculinity and the heritage
of male socialisation processes over the generations
influence mens health behaviour, and how are mens
changing roles in a post industrial society influencing
their health patterns? These are tied in closely with the
question of how the social determinants of health impact
on men and whether these differ from their effect on
women.
It would appear from the scope and complexity of the
data covered in this report that a field of practice and
academic endeavour around the emerging field of mens
health is warranted, in a similar way to that seen around
the field of womens health. There would also seem
to be scope for much more deconstruction of mens
physical and mental health before we can fully begin to
understand what is happening.

Research
This academic development is closely tied to our
observations relating to the relative lack of a research
base for mens health. Many of the key research studies
that we hoped to be able to use for this report were
found to be redundant as they lacked a breakdown by
sex of their data.
We also see in reports that children are grouped into one
category, rather than exploring the differing influences
of the biological and social development of boys and
girls.
There is still much data that is not disaggregated
according to sex differences within the main databases.
Where there is data broken down by sex there is also a
tendency for the data to be presented as age standardised
and, judging from much of the findings within this report,
there is a need for a much clearer focus on age specific
analysis as the large differences that exist between the
physical and mental health of men and women is most
obvious in the early years of life.

There have been calls for more research into mens


personal experiences of health and ill-health so that we
can learn from their own perspective what influences
their lives.

Policy
Successes are being seen, with the most significant being
smoking legislation, which is starting to bring down the
tobacco related health conditions.
Other key legislation relates to health and safety in the
workplace, and transport related legislation which is
seeing major improvements in those countries where it
is more strictly enforced.

The policy documents explored through this report were


notable in their lack of comment on the male specific
issues. It would appear from our analysis that, although
individual countries have developed health policies and
strategies aimed at improving their populations health a
one size fits all approach is evident, which would seem
to be to the detriment of both men and women.

Practice
There appeared to be few initiatives that were directly
focused onto the needs of men, either in a form that
men would use or in places that men would more easily
access. Most of the targeted activity appear to be small
local initiatives. While it is acknowledged that male
socialisation tends not to lead men to be as aware of
health and wellbeing issues as women, men are seldom
the focus of specific or targeted health education or
health promotion initiatives.

It would seem that current configuration of health


services makes it difficult for many men to utilise them
as effectively as they should do. This moves beyond
direct access to family practitioners, as it also extends
into weight loss groups, counselling services and health
promoting activities. Where a male focused approach has
been adopted there have been marked improvements in
up-take and success of health initiatives.

Concluding comments
This report highlights that:
The lives of both men and women can be severely
affected by the health challenges men face and how
they respond to them.
Consensus is starting to emerge on what constitutes a
mens health issue.
Men are dying from heavy impact diseases that are
strongly related to their biology, their lifestyle and other
social determinants of health.
Key health policies are indirectly affecting mens health
in a positive way, such as smoking bans, road safety
legislation, health and safety in the workplace.
Gender equality initiatives will have a positive impact
on the way mens needs are taken into account within
government health strategies and at the more local
practitioner level.

93

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99

European Commission
The State of Mens Health in Europe - Report
Printed by the services of the European Commission
2011 99 pp. 21 29.7 cm
ISBN 978-92-79-20167-7
doi:10.2772/60721

ND-30-11-110-EN-C
doi:10.2772/60721

IV.

The State of Mens Health in Europe. Report, 2011,

Directorate

General

for

Health &Consumers.
1. Explicai rolul noiunilor de sex i gen n analiza sntii brbailor. Oferii dou
exemple.
2. Care sunt aspectele particulare pe care le comport sntatea reproducerii pentru
brbai ?
3. Care sunt aspectele particulare pe care le comport sntatea mintal pentru brbai ?