Medicine, social conditions, culture and politics are
inextricably bound as determinants of health and wellbeing.
In Cuba, perhaps this is nowhere more evident than in the
arduous struggle to consider non-discriminatory analysis of
gender-sensitive components as fundamental to population
health, medical practice and research; national policy; and
above all, public consciousness. Among the standard-bearers
of this cause is Mariela Castro, psychologist and educator
with a master’s degree in sexuality, who directs the
National Sex Education Center (CENESEX), its journal
Sexologia y Sociedad, and the National Commission for
Comprehensive Attention to Transsexual People. The Center’s
work is at the vortex of national polemics on sexuality,
approaches to sex education and health, and respect for the
human rights of people of differing sexual orientations and
gender identities.

The daughter of President Raúl Castro and the late Vilma
Espín - who, as founder and leader of the Federation of
Cuban Women, pioneered the defense of both women and
homosexuals - Mariela Castro nevertheless speaks with her
own voice in national as well as international debates.
MEDICC Review talked with her about the range of issues that
link gender to WHO’s broad definition of health as the
highest level of physical and mental wellbeing.

Gail Reed, MS

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MEDICC Review: How would you define gender perspective?

Mariela Castro: I understand gender perspective as a
methodological approach that allows you to identify the
needs and peculiarities of femininity and masculinity from
biological, anthropological, psycho-social and socio-
cultural angles. It does so in order to take them into
account for interpreting reality and establishing policy.

Although we are all of the same species, we are a “sexed”
species. But that isn’t the end of the story: we also need
to analyze the historical and cultural constructs built upon
birth-assigned sex, which produce either wellbeing or
discomfort, depending on how the assigned sex is lived from
the point of view of power relationships. These are gender
relations, and they are the basis for inequity,
discrimination and inequalities.

MEDICC Review: How were gender issues first introduced into
public consciousness and national policies in Cuba?

Mariela Castro: The theme of gender was first associated
with women’s rights and equality in the early 60s, when
women’s economic, social and reproductive rights became
explicit in the goals and actions of the revolutionary
transformations under way. The Federation of Cuban Women
(FMC) spearheaded efforts to confront machismo in many
arenas and women’s empowerment was enhanced; employment
opportunities soon opened up, with equal pay for equal work;
maternity leave, social security and other important social
policies were introduced into law; and in general, women’s
public participation increased dramatically.

The patriarchal model was in crisis, and paradigms shifted.
Old myths and taboos broke down - the idea that virginity
was a pre-requisite for marriage, that an unmarried older
woman was an “old maid,” and so on. In fact, such women
actually were regarded as people liberated from patriarchal
domination! But we were not speaking yet about several
important issues: gender-based violence being one of them.
Nor were sexual orientation or gender identity on the
agenda, since many patriarchal social and cultural norms
still prevailed, leading to severe discrimination on these
grounds.

In the health field, the notion of gender was limited to
ensuring reproductive rights, through family planning
counseling, including access to contraception and abortion;
as well as activities of the broader Maternal-Child Health
Program of the Ministry of Public Health, within the single,
universal health system being developed. Of course, it was
vitally important to women, as well as to men, that all
these services were being offered free of charge.

In 1975, the Family Code was passed, a law protecting
women’s and children’s rights within the family. For
example, it mandated sharing household and child-rearing
responsibilities between the man and the woman. But changes
at this “micro-social” level proved harder, slower and more
difficult, because they struck at the heart of consciousness
and cultural values.

MEDICC Review: How would you describe gender’s relation to
the health sector in Cuba today?

A gender perspective is a fundamental resource, especially
in the health field: it is part of our scientific arsenal to
develop evidence-based policies that lead to better health
and wellbeing. However, a gender perspective in Cuban health
is still a slogan, not a reality. It is an aspiration, which
we haven’t yet managed to implement, for lack of a
comprehensive approach. A rigorous gender perspective is
still lacking; the analysis fails to include all the
necessary components.

On the statistical front, health data collected include some
valuable elements, but not all. Sex, age, skin color,
geographic residence - these are all being considered. But
not gender: what it means to be a woman or a man in our
society and its effect on health.

In assessing health problems, a sexual-gender focus would
consider gender and the lifelong roles based on that gender
assigned to each person. It would also take into account,
for example, the evolution of the Cuban family: today, more
women are heads of households; same-sex couples form
households; the grandmother isn’t content any longer just to
be the “rearguard” for the rest of the family, but rather
has her own plans. Interestingly, we are also seeing more
men taking greater responsibility for their children, taking
paternity more seriously.

In health, we have to face the high costs of gender
stereotyping - which render both men and women more
vulnerable - in terms of morbidity and mortality. For
example, take cancer, diabetes or other chronic illnesses,
the main causes of death and disability in Cuba. Their
prevalence, context, and expression aren’t the same for men
as for women. More specifically, consider lung cancer: rates
are higher among men, who also smoke more. But women’s lung
cancer incidence has also shown rising tendencies, and their
smoking habit is not declining as fast as men’s. Why is
this? We need to know.

The same is true of diet and exercise: our country’s obesity
and overweight problem is primarily among women. Why? Does
it have to do with the “second shift,” in which most women
still shoulder the main burden of household responsibilities
after they return from their paying jobs?

A woman gets home from work, cooks dinner and prepares
snacks for her children’s school the next day. She’s also
the one who usually reviews the children’s homework. She may
be an activist in her community, too, in the FMC, or have a
leadership role at work or in her community. Meaning she
even has an intellectual overload to contend with. So when
does she get to go dancing, participate in other cultural
activities or do regular exercise? She’s too tired, and
often simply alienated. These are just some of the factors
that need to be considered from a gender perspective in
order to confront the dangers of obesity among women.

MEDICC Review: What about gender stereotyping of men and its
effect on their health?

In Cuban society, the traditional concept of masculinity is
a real danger to men’s health. The stereotype says that men
who go to the doctor must be weak - so they only go at the
last minute, when their conditions have already progressed.
If their ailment has to do with their genitalia, their
sexual potency, then they put the doctor’s visit off even
further. And in the meantime, they may even tend to blame
their female partners for their affliction.

MEDICC Review: Since CENESEX was founded in 1989, it has
been dedicated to formulating and changing sex education
programs in the country, building on earlier momentum
created by the FMC and the National Task Force on Sex
Education. What has been achieved? What are the challenges?

By way of background, the National Sex Education Program
receives the most support from MINSAP and, in the realm of
civil society, from the FMC - the latter has really led the
field throughout the decades - and we also work with the
Ministries of Education (MINED) and Culture (MINCULT), as
well as other entities.

At first, there was strong resistance by officials in
education to offering sex education in the schools at all.
In the 1970s, only a few references to reproductive health
could be found in textbooks, and they were very biologically
oriented. In the 1980s, researchers identified the need to
learn and teach about sexuality, and some movement took
place. For example, sex education was introduced as a
subject in all of the university-level teacher-training
schools in the country. I was a student at one, and I liked
the subject so much that later it became one of those I
taught.

Finally, in 1996, the National Sex Education Program for
Cuban schools was developed by CENESEX and MINED, with
participation by the Ministry of Culture. It started out
very tentatively; “sex education light.” It didn’t include a
comprehensive, integrated concept of sexuality, omitting
themes of diversity for example. Today, their inclusion is
still timid, and some resistance persists.

From a 2008 MINSAP-MINED initiative, an agreement was
reached called “Prevention through Education,” providing a
very good approach. It concentrates on STI-HIV/AIDS
prevention, involves CENESEX, the National STI-HIV/AIDS
Prevention Center, MINED, the Ministry of Higher Education
and others, in a process of appreciative inquiry. This
resulted in a working group to look more closely at school
curricula, social communication and legislation. The group
has proposed that sex education be included as a separate
subject in the core curriculum for teacher training. It had
been eliminated from the pedagogical universities; and to
date, sex education in the technical-level teacher-training
schools is still scattered throughout other subjects, which
isn’t working. What is needed is a complete review of the
sex education programs in all schools.

Last year, a new MINED resolution mandated sex education in
schools from nursery through high school, but again, not as
a separate subject. And that is its Achilles heel: because
when these themes are incorporated throughout all subjects,
their treatment is more vulnerable to the teachers’ own
level of awareness - or lack thereof - and bias. In
addition, it doesn’t provide for work with families, a
strategic starting point.

MEDICC Review: What about sex education as a subject in
medical schools?

Mariela Castro: CENESEX has proposed a project to promote
sexual health throughout the national health system. It has
been well received, and we expect implementation soon. We’re
beginning with courses for medical school faculty, built on
a series of rights-based themes emerging from eight goals
that define a comprehensive approach to sexual health
promotion.

These objectives were proposed by the World Association for
Sexual Health as a contribution to achieving the Millennium
Development Goals. They include conceptualization and
specific actions to: 1) Recognize, promote, ensure and
protect sexual rights for all; 2) Advance toward gender
equality and equity; 3) Condemn, combat and reduce all forms
of sexuality related violence; 4) Provide universal access
to comprehensive sexuality education and information; 5)
Ensure that reproductive health programs recognize the
centrality of sexual health; 6) Halt and reverse the spread
of HIV/AIDS and other sexually transmitted infections; 7)
Identify, address and treat sexual concerns, dysfunctions
and disorders; and 8) Achieve recognition of sexual pleasure
as a component of holistic health and wellbeing.

We’ll be using popular education methodology, which will
also be applied by faculty in subsequent courses offered to
students in medical and other health sciences studies, as
well as to physicians completing their residencies in family
medicine. Our hope is that the Cuban and nearly 20,000
international students in Cuba’s medical schools will be
able to use this knowledge and popular education approach in
their communities in Cuba and abroad upon graduation -
respecting cultural and ethnic differences - to promote
sexual health and responsible sexual conduct.

MEDICC Review: Gender-based violence and domestic violence
in general was long absent from the media and public
discussion in Cuba, but now we are seeing much more in the
newspapers, on television, etc.

Mariela Castro: Yes, and more needs to be done. Thus far,
our studies show that psychological violence, rather than
physical or economic violence, is more common in Cuba. Why?
First, because women have achieved relative economic
independence, and divorce is thus not only an option, but
one chosen more often as compared to other countries (the
reasons for choosing divorce are multi-factorial of course).
Second, when there is a case of violence against a woman,
child or elderly person in Cuba, the community tends to get
involved. The family doctor as well. Nevertheless, violence
is embarrassing to the victim, who feels defenseless,
vulnerable and ashamed all at once. It often takes that
person time to seek help, if they do at all. And there is no
place in the world that has dedicated sufficient resources
for victims to find immediate help. Nowhere.

Cuban laws are quite harsh against domestic abuse; but
learning how to recognize psychological abuse and how to
deal with it is another matter, which depends on education
through organizations like CENESEX and through the mass
media.

MEDICC Review: How has the focus on gender-related issues
changed in public discourse, debate and law in more recent
years?

Mariela Castro: Historically, the FMC has been a leader in
this process: in its last Congress, discussion focused for
the first time on the need to include gender-sensitive and
discrimination issues in training for people in public
administration and political leadership, in conjunction with
focusing on other inequalities.

By the middle of the last decade, CENESEX had adopted a
human rights approach to the debate on respect for free
sexual orientation and gender identity. Thus, in our social
communication strategy, we’re consciously seeking a cultural
transformation based on identifying homophobia and
transphobia as forms of discrimination. In 2008, joint
efforts with MINSAP and others resulted in a resolution
mandating comprehensive care for transsexual persons.

Importantly, in January of this year, the Communist Party
Conference stipulated as an objective its aim to "confront
prejudices and discriminatory conduct on the basis of sexual
orientation" (and in practice, on the basis of gender
identity).

Still our biggest challenge is to achieve greater influence
on formulation of social and public policies addressing
gender equity. For instance, we have proposed legislation
that would allow transsexual persons to change their
identity without sex-reassignment surgery. And we have
worked on amendments to the Family Code, currently under
consideration by Parliament, which we expect to be approved
this year. These amendments would more forcefully guarantee
the rights of women, children, disabled persons and older
adults in the family context; further democratize gender
roles; and recognize the legal rights of same-sex couples.
Furthermore, CENESEX has proposed an article respecting
sexual orientation and gender identity.

MEDICC Review: For the past five years, CENESEX has led the
organization of annual Cuban Celebrations against Homophobia
in May. Can you tell us more about this year’s events?

Mariela Castro: In 2008, we began celebrating “days” against
homophobia, essentially as an educational forum. Over time,
this has turned out to be an entire month dedicated to
activities against homo- and transphobia. We’ve found it
useful to hold the main events in different provinces each
year - last year in Santiago de Cuba, which was a wonderful
experience, and this year in Cienfuegos. Of course, we’ll
also have activities in Havana and elsewhere in the country.

Last year’s public debates, open to everyone in parks and
other venues, resulted in something very special, which
we’re continuing this year [see Program in box - Eds]. And
the gala as well. We need more support from the media in
publicizing the month, and in general in giving greater
visibility to efforts against homo- and transphobia. The
social networks associated with CENESEX are very active, and
provide a good example of what is possible, but the national
media, which reaches the whole population, is still an
underutilized educational tool.

We hope the 2012 Celebration Against Homophobia will
contribute to national discussions on prejudice of all kinds
still present in Cuba that contribute to inequities - not
just sexual orientation and gender identity, but also about
discrimination based on skin color, religious beliefs, where
someone lives, disabilities or any other....none of these
have any place in our society, now or in the future.

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