Germany – EU Parliament Study Report

Country Reports to the European Parliament for:

Discrimination Against Women and Young Girls in the Health Sector

Germany

Germany has a high life expectancy (81.4 for women in 2004) but risky behaviours are also evident. For example, an increase in smoking figures since 1985 have most likely been affected by the merging of Germany. Cardiovascular diseases are the leading cause for mortality and cardiovascular risk factors such as physical inactivity, smoking, obesity, and alcohol consumption are widely spread.

The main percentage of births occur during the ages of 25-34, and the incidence of teenage births is relatively low. Indeed fertility itself is low, and figures indicate an increasing proportion of adults living in a household with no children.

Causes for concern are osteoporosis and the high rate of breast cancer. While the prevalence and incidence rates of osteoporosis in Germany not certain, it is noticeable that there is a dramatic increase in the incidence affecting women between the years of 50-65 (23.3%) and 75+ (59.2%).

The following material was submitted by Birgit Babitsch Center for Gender in Medicine, Charité-Universitätsmedizin Berlin and Ulrike Maschewsky-Schneider, Berlin School of Public Health, Charité-Universitätsmedizin Berlin.

Women’s health

Girls and women make up the majority of the population in Germany (51%) (StatBa 2006a). In general, the health situation and life expectancy have improved in Germany since 1970. In this time, mortality has declined and patterns of morbidity have begun to change (RKI 2006). Gender differences are still more or less the same; though some changes can be observed. The situation for German women can be characterised in more detail by the following features:

Low crude birth and total fertility rates

The total number of births decreased from almost 1,300,000 births in 1960 (Federal Republic of Germany) to 706,700 births in 2003. A reduction in the total number of births can also be seen in the GDR; but there were differences in the development of the total fertility rates in the Federal Republic of Germany and the GDR, with strong distinctions after the reunification (StatBa 2003). Due to the economic and social transformation, a dramatic reduction in the total fertility rate in the new Länder took place (1990 to 1994: 1.52 to 0.77). Since then the total fertility rate has increased in the new Länder (1.3, StatBA 2006a) and approached nearly the same level of the former territory of the Federal Republic. The fertility rate is low in Germany and has remained at 1.4 since 1997 (StatBa 2003). Germany ranks low worldwide and has the second lowest birth rate in EUR-A (reference 2002) (StatBA 2003, BMFSFJ 2006a, WHO 2006).

Increasing proportion of single parents

The family structures in which children live in Germany have changed drastically (i.e. with more single parents), with the number of families with only one child increasing, as well as the percentage of childless women, (most notably women with a high level of education) (BMFSFJ 2003, 2006). In the age group 35 – 44 years, 27.6% of women and 42.4% of men live in household without a child in the former territory of Federal Republic, and 18.1% of women and 38% of men in New Länder (BMFSFJ 2006a).

The proportion of single parents in the population is rising: In 2005, 2,600,000 single parents lived in Germany. The rate rose by 15% between 1996 and 2005. Different rates are noticed between the former territory of the Federal Republic (18%) and the new Länder (8%)) (StatBa 2006b, 2006c). Single parents are predominantly women (87% of this group are mothers and 13% are fathers). The main reason for becoming a single parent is divorce/separation (men: 43%, women: 40%). EuroStat data shows that 2.4% of all households are single parent households (BMFSFJ 2003). Using this rate, Germany ranks middle of the distribution compared with other European countries.

High abortion rates in single women and childless women

The total number of abortion is declining slightly in Germany. 124.023 abortions were reported in 2005 (StatBa 2005). Different patterns can be observed between the former territory of the Federal Republic and the new Länder (StatBA 2006a). Whereas the rate in the latter has declined by 19%, an increase can be found in the former territory of the Federal Republic (6%). In 2005, 40.6% of the women who had an abortion were childless and 50.9% were single. Both rates have increased since 2000. The rate of abortions in 18 years old and younger women/girls rose between 2000 – 2005 from 4.7% to 5.8%. The abortion rate in the 15 – 18 year age group amounted to 0.5% in 2005. The abortion rates in Germany were below the EUR-A average in 2004 (HFA-DB 2006).

A recently published study focusing on pregnancy and abortion in young women (15 – 17 years), who attended pro familia counselling, shows that the number of abortions in this particular group has exceeded the number of births since 1998 (pro familia 2006). The study shows that 8 – 9 per 1,000 women in this age group became pregnant and 5 per 1,000 of them decided to have an abortion. When compared with international data Germany features at the lower end of the distribution. Furthermore, the study has shown a strong relationship between teenage pregnancy and socioeconomic status. The ratio of young girls with a secondary general school certificate is five times higher than in the group of young girls with a general university entrance qualification. 92% of the pregnant young women did not use methods of contraception.

Use of modern methods of contraception

A recent study conducted by the BzGA (2003) shows that 77% of all participants (20-44 year old women and men) use methods of contraception. The rate in women and men younger than 30 year-old amounts to 85%. Oral contraception was most frequently used (55%) followed by condoms (36%) and the loop (12%). The methods of contraception differ according to age and family situation. In the younger age group (under 30 ), a higher percentage use oral contraception than in the older age group (30 – 44 years) (74% vs. 45%). Women and men who are not in a relationship use condoms more often than women and men living in a partnership (69% vs. 31%).

Gender gap in life expectancy is declining

Life expectancy is increasing in Germany, but since 1990 it has been more pronounced in men. Gender differences in life expectancy at birth declined from 7 years in 1990 to 5.7 years in 2002/2004 (StatBA 2006d, RKI 2006). The gain in life expectancy in men reflects the EU-A average, whereas the gain in women is slightly lower than the EU-A average (reference frame 1990-2001, WHO 2006).

Low maternal mortality

Maternal mortality has declined considerably since 1960. In 1960, 106 women died per 100.000 live births, compared with 4 women per 100,000 live births in 2003 (StatBA 2006a). The maternal mortality rate in Germany is below the EUR-A average in 2001 (HFA-DB 2006)

Changing patterns in morbidity trends for many diseases

It can be stated that there has been a shift in morbidity (RKI 2006) even though the gender differences remain nearly unchanged. While cardiovascular diseases are still the leading cause for mortality, a decline in morbidity can be found as well as in mortality (RKI 2006). For cancer the trend is more diverse and related to the affected organ. A dramatic increase in lung cancer in women seen between 1990 – 2004 (48 %). Furthermore, the rates for mental disorders, diseases of the muscloskeletal system, and infectious diseases have risen (RKI 2006). In mental health conditions the increase is noticably stronger in women.

High prevalence of unhealthy lifestyle behaviours

Cardiovascular risk factors such as physical inactivity, smoking, obesity, and alcohol consumption are widely spread in the German population (RKI 2006). Every third person smokes, and every sixth woman and every third man drinks alcohol in amounts which are harmful to health. Half of the women and two thirds of the men are overweight or obese. An improvement can be observed in eating behaviours, where the intake of healthy food has increased. Smoking trends in women and men are opposed: The rates of men have decreased while the proportions for women have increased.

Specific health policies for women

There are only a few legal regulation/specific health policies for women in Germany. Most of them have been developed in the context of reproductive health and occupational safety and health (e.g. Protection of Working Mothers Act; Law on Parental Leave). Special attention is accorded to women in some areas of the new Medical Products Act (adopted since 2005). A breast cancer screening programme was adopted in 2004, to include women between 50 – 69 years of age. Implementation is still in progress (Kooperationsgemeinschaft Mammographie 2006). A disease management programme ‘Breast Cancer’ was also adopted in 2004 (BMG 2006).

There has been an increasing awareness in regard to gender-related issues and a gender mainstreaming strategy was adopted by the Federal Government in 1999. The equality of women and men is codified in Article 3, para 2, sentence 2 of the Basic Law as a national objective. Since then, the cabinet decisions in the Federal Government have applied gender mainstreaming strategies to achieve this goal. In 2000, gender mainstreaming was included in the Joint Rules of Procedure of the Federal Ministries and this approach is now observed in all political, normative, and administrative measures of the Federal Government. Additionally, an Interministerial Working Group on Gender Mainstreaming (IMA) was set up, lead-managed by the Federal Ministry of Family Affairs, Senior Citizens, Women, and Youth (BMFSFJ 2006b). Due to this obligation, specific gender projects have been conducted in each of the Federal Ministries and the reflection of gender and its impact has been included into new laws (e.g. §20, SGB V [social security statutes]) and as a requirement in research grants.

Women’s health is not coordinated or developed by a separate body or a separate minister for women’s health, though there is a department which is specifically devoted to women and health issues in the Federal Ministry of Health. The Federal Ministry of Health conducted two different gender mainstreaming projects (BMG 2006). Furthermore, in the Ministry of Family Affairs, Senior Citizens, Women, and Youth several initiatives have been conducted with respect to women’s health (e.g. national women’s health report, several activities in the field ‘violence and women’s health’, Bundeskoordination Frauengesundheit [Federal Coordination of Women’s Health] financed from 2002-2005). Additionally, other governmental institutions have been involved in policies and activities relevant to the field (e.g. Ministries at state level, Federal Centre for Health Education (BZgA), who run a database for women and health; the Robert Koch Institute (RKI), who integrate the gender perspective into health reporting; and Associations for Health Promotion at state level) For an overview of these initiatives, see: BZgA 2006 – a database on women’s health). The Landtag (State Parliament) of North Rhine-Westphalia (NRW) convenes a commission of enquiry on the future of women-centred health care in NRW (‘Zukunft einer frauengerechten Gesundheitsversorgung in NRW’).

Different university departments and scientific associations put specific focus on women’s health/gender health (for overview see the BZgA 2006 database on women’s health). Examples are: the Institute of Public Health Sciences at the Technical University Berlin, the Centre for Gender in Medicine, Charité – Universitätsmedizin Berlin, the Centre for Public Health at the University of Bremen, and the Bremen Institute for Prevention Research and Social Medicine (BIPS). There are work groups focusing on women/gender and health at Deutsche Gesellschaft für Sozialmedizin und Prävention e.V. (German Society for Social Medicine and Prevention), Deutsche Gesellschaft für Medizinische Soziologie e.V. (German Society for Medical Sociology); Deutsche Gesellschaft für Verhaltenstherapie (German Society for Behaviour Therapy); Deutsche Gesellschaft für Public Health (German Society for Public Health), and Deutsche Gesellschaft für Psychosomatische Frauenheilkunde und Geburtshilfe (German Society for psychosomatic gynaecology and obstetrics).

Many women, youth, and health-oriented non-governmental organisations have been very active in the area of women’s health, sexual and reproductive health and family planning, and have contributed to important debates and changes (for overview see the BZgA 2006 database on women’s health). Examples of NGOs working in this area are: the [Feminist] Women’s (and Girl’s) Health Centres, International centre for women’s health, who until 2006 offered the Koordinationsstelle Frauengesundheit (women’s health co-ordination office), women’s health networks on national level and federal state level (e.g. Berlin, Lower Saxony, Saxony-Anhalt), Arbeitskreis Frauengesundheit in Medizin, Psychotherapie und Gesellschaft (AKF – working group of women’s health in medicine psychotherapy and society), Deutscher Ärztinnenbund (German Association of Female Physicians), and Deutscher Frauenrat (a national council of more than 50 nation-wide women’s associations and organisations).

Gender-sensitive health policy design

In the Basic Law, the equality of women and men is regulated as a national objective. Several legal procedures and specific policies have been designed to address women’s and health issues (see above). To our knowledge, and despite the above mentioned, only one policy difference exists which reflects biological and/or epidemiological differences between women and men. The cancer screening covered by the statutory health insurance is different for women and men (women: malignant neoplasms of the genitourinary system (starting from 20 years), malignant neoplasms of breast and skin (starting from 30 years), and colon carcinoma (starting from 50 years); men: malignant neoplasms of skin (starting from 45 years), and colon carcinoma (starting from 50-55 years).

Three primary issues and how they apply to women

Alcohol

In 2004, the alcohol consumption was 10.1 litres per population (DHS 2006). The rates have declined since 1991 (GBE-Bund 2006, see also OECD 2006; RKI 2006). The most common consumed alcohol product is beer, though this is 50% more popular with men than with women (RKI 2006). Germany ranked fifth compared with other EU countries in 2005 (DHS 2006, see also RKI 2003).

Approximately 1,600,000 persons are addicted to alcohol (RKI 2006). The age-standardised mortality rates for alcohol-related deaths are 8.3 per 100,000 women in the former territory of the Federal Republic and 16.7 per 100,000 in the New Länder; the rates in men are 26.5 per 100,000 vs. 65.1 per 100,000 (RKI 2006). The data of the National Health Survey 1998 showed that 16% of women and 31% of men have a higher alcohol consumption than the tolerable upper intake level of alcohol (TOAM) (RKI 2003). The Drug and addiction report of the Federal Government showed that in the 19 -59 year age group 1,700,000 women consumed more than 20 g pure alcohol, and 3,800,000 men 30 g pure alcohol (RKI 2006).

The Drug Affinity Study found that 34% of the 12 – 25 year old women and men consume alcohol regularly (meaning at least once a week) (RKI 2006). The rates are higher in young men than in young women (beer: 35% in young men and 8% in young women; spirits-based Alco pops: 20% in young men and 11% in young women). Young men consume on average 96.5 g of pure alcohol, with one quarter consuming up to 120 g of pure alcohol; the figures in women are 39.2 g of pure alcohol ( on average) with 8% consuming more than 120 g of pure alcohol (BZgA 2004a). The supply of spirits-based Alco pops has increased the alcohol consumption in adolescents dramatically. The Drug Affinity Study showed that 39% of young women and 45% of young men consumed once a month spirits-based Alco pops; with 7% of the females and 14% of the males in this age group consuming them at least once a week. Among young women, spirits-based Alco pops were the most popular alcohol product. Due to legal regulations (‘Act for Improving the Protection of Young People against the Dangers of Alcohol and Tobacco Consumption’), a special tax and the legal obligation to prohibit the sale of alcohol to underage youth were introduced in 2004 and have lead to a reduction in the consumption of spirits-based Alco pops in youth: The rates decreased from 28% in 2004 to 16% in 2005 (in young men: from 27% to 14%; in young women: from 30% to 14%) (BZgA 2005).

Binge drinking is common among young people in Germany. The Drug Affinity Study found that 25% of female and 43% of male 12 – 25 years-old had drunk five or more glasses of alcohol in succession in the last month; for 6% of young women and 14% of young men this occurred this 3 to 5 times in that time period (RKI 2006). Binge drinking is often connected with the consumption of spirits-based Alco pops (RKI 2006). Binge drinking is also found frequently among adults. The Epidemiological Drug-Survey data showed that in the age group 18 – 59 years 44.6% of men and 16.1% of women consumed an amount of alcohol which could be classified as ‘binge drinking during the last month’ (RKI 2006).

Different campaigns have been developed for primary and secondary prevention (for overview see: Drogenbeauftragte der Bundesregierung 2002, 2005, 2006). The Federal Centre for Health Education offers special programmes for young people (such as ‘Alcohol – Responsibility sets The Limits’) (BzgA 2006). Further alcohol prevention programmes are provided by the German Head Office for Dependency Matters (DHS) (DHS 2006) and by health insurances.

Smoking

The results of a representative German Telephone Survey (2003) conducted by the Robert Koch Institute showed that every third person in Germany smoked (RKI 2006). If persons who had ever smoked are included, the rate amounts to 60%. 28% of women and 37.3% of men were smokers. Since 1980, the rates in men have decreased, while the rates for women are increasing. Therefore, smoking behaviour in women and men has equalised. This is especially true for the younger age groups (BZgA 2004b, RKI 2006). In 2003, the proportion of smokers was higher in Germany than the EU-A average (HFA-DB 2006). In 2004, 35% of the 12 – 25 year age group were smokers (this figure refers to young people who classify themselves either as regular smokers (21%) or as occasional smokers (14%)). Four per cent of these are heavy smokers (BZgA 2004b). Differentiated by gender, the rates are 36% of young men and 35% of young women. A slightly higher percentage in young women than in young men has never smoked (52% vs. 35%). Young women and men start smoking at simila ages (average age of smoking the first cigarette: young men 13.6 years, young women: 13.7 years; average age of starting to smoke daily: young men 15.7 years, young women: 15.6 years) (BZgA 2004b). The proportion of smokers among young people has changed: From 1993 to 1997, a remarkably strong increase can be observed (young men: 21% to 27%; young women: 20% to 29%). The increase was more pronounced in the younger age group (12 to 17-olds). Since 1997, the rates are declining, but data diven in Health Behaviour in School-Age Children showed that more 13 to 15 year-old boys and girls in Germany are smokers, than in the other 35 European countries/regions (RKI 2006).

Further gender differences exist in smoking behaviour. Men are more often heavy smokers (20 cigarettes/day or more) than women (47% vs. 31.2%) (RKI 2006), though there are only minor differences in the age group 12 to 25 years (young men: 13%; young women 12%) (BZgA 2004b). Fortunately, a constant decline has been observed in the proportion of heavy smokers in this age group between 1993 and 2004 (young men: from 39% to 13%; young women: from 28% to 12%).

Young smokers (12 to 25 years) do not tend to be convinced smokers: only 35% do not intend to stop in the future (BZgA 2004b). This attitude is similar in both young women and young men. Asked if they intended to stop smoking: Young men are more likely than young women (31% vs. 27%) to quit smoking (BZgA 2004b). 72% of young smokers have already made one or more attempts to give up smoking. Since 2001, attempts at cessation have increased substantially (rising by 11%). The rates are similar in women and men.

Tobacco consumption is the cause of approximately 110,000 to 140,000 deaths per year. Different campaigns have been developed to prevent smoking or to encourage smoking cessation (for overview see: Drogenbeauftragte der Bundesregierung 2002, 2005, 2006). The Federal Centre for Health Education offers special programmes to young people (such as the ‘Smoke-free’ youth campaign for tobacco prevention or the ‘Be Smart – Don’t Start’ campaign), as well as to pregnant women or families with (young) children (BzgA 2006). A new NGO – ‘FACT’ – (‘Women Active Contra Tobacco’) was founded in 2006, to advance prevention strategies for girls and women.

Osteoporosis

Prevalence and incidence rates of osteoporosis in Germany are uncertain (GBE-Bund 2006, RKI 2006). However, some sources give an insight into the occurrence rate. The BoneEVA-Study analysed data from statutory health insurance and billing data for outpatient health visits (2000-2003) (Häussler et al. 2006). Based on this data, prevalence rates were estimated at 9.7% in men and 39% in women of at least 50 years of age. This means that around 6,482.086 women and 1,321.672 men are affected. A dramatic increase can be seen in regard to ageing in women and men (women: from 23.3% (at 50-65 years) to 59.2% (at 75+); men: from 7.1% (at 50-65 years) to 16.1% (at 75+)). 4.5% of this group suffered from fractures. Gaps in pharmaceutical treatment were identified in this study.

Women have a higher risk for osteoporosis and fragile fractures. The risk for fragile fracture is two to three times higher in women than in men (RKI 2006). The results of the representative 2003 German Telephone Survey showed that 14.2% of women at least 45 years old were diagnosed with osteoporosis (Scheidt-Nave & Starker 2006). 15% of this group reported a physician-diagnosed fragility fracture. Prevalence rates increase with age: 3.4% in the age group 45-54 years had osteoporosis vs. 23.7% in age 75 years and older. The same pattern can be observed regarding fragility fracture: 0.3% in the youngest age group vs. 6.1% in the oldest age group. Guidelines for physicians on osteoporosis were developed and published in 2003 and updated in 2006. These made recommendations on prevention, diagnosis and therapy for women after menopause, and for men of 60 years and older (AWMF 2006, DVO 2006). Different NGOs such as Bundesselbsthilfeverband für Osteoporose e.V. (the National Self-help Organisation for Osteoporosis), Kuratorium Knochengesundheit e.V. (the Board of Trustees for Bone Health), the National Initiative Against Osteoporosis, and medical/scientific associations such as the German Academy of The Osteological and Rheumatological Sciences are focusing on osteoporosis, and provide patient as well as expert information (IOF 2006).

Specific healthcare policies for young girls

There are no special health care policies designed particularly for girls/young women in Germany. There are however a lot of activities focusing on the health of young girls. There are several organisations/institutions which are particularly aiming at girls/young women such as e.g.:

– BzGA, which developed several campaigns for adolescents regarding addiction, HIV/AIDS, contraception, relationships and pregnancy/motherhood (www.loveline.de, http://www.prevnet.de/) Women’s and Girls’ Health Centres offer special programmes, activities and counselling for girls.

An example of ‘best practice’ in women’s health

Young Girls/Boys: The Federal Centre for Health Education (BZgA) offers different approaches and programmes including scientific research and surveys regarding health promotion/prevention to young girls and boys. The BZgA developed also gender-specific material for drug prevention in this age group.

Women’s Health: A database for “Women’s Health and Health Promotion” is provided by the Federal Centre for Health Education (BZgA) . The database collects different sources of information (e. g. reports, links, scientific publications) related to the following topics: scientific basics, life course, life style, diseases, social conditions, addiction, and organisations.

Health Reporting: The principle of gender mainstreaming has been integrated in the Federal Health Reporting. Different health reports have recently been published, such as GBE-Booklets, which focus on specific health or social conditions; focus reports which provide more in-depth information to certain topics (the latest focused on health of women and men in middle age) and the national health report which is broader in scope. The main responsibility for the federal health reporting is taken by the Robert Koch Institute on behalf of the Federal Ministry of Health. All health reports can be downloaded free of charge.

Violence: Until now, violence is often not taken into account as a cause of injury and health problems in the health care setting. The aim of the NGO S.I.G.N.A.L. e. V. (www.signal-intervention.de) is to improve the health care for women who have been abused. Good experiences have been collected in the „SIGNAL Intervention Project Ending Violence Against Women” at the Charité Universitätsmedizin – Campus Benjamin Franklin. The main approaches are raising awareness, sensitisation of the providers in the health care system, improving the contact between provider and patient, initiating prevention and intervention of violence by providing the abused women with reliable and appropriate support and treatment. The NGO develops educational material for health professionals and offers train-the-train workshops.

Gender in Medicine: The Center for Gender in Medicine (GiM) was established in 2003 at the Charité – Universitätsmedizin Berlin. The main aims of the GiM are to study sex- and gender-specific differences in the biological basis of clinical syndromes, in the manifestation and course of diseases, in prevention, diagnostics and therapy as well as in health care structures; to promote this specific research in the above areas; to implement research findings in medical practice; to mediate the research findings to the public, policy makers, authorities, and institutions of the health care system, to adopt the findings into medical education at the Charité; to create a curriculum and to integrate it into medical education.

Further gender influences on patterns of health

Gender differences on the health of the German population can be summarised as follows:

    Crude and age-specific mortality rates distinctions

There has been a decrease in all-cause mortality since 1970 though the leading main causes of death have remained the same during this time period. The crude and age-specific mortality rates are considerably higher in men than in women. A reduction in all-cause mortality in Germany occurred for both sexes between 1990 and 2004 (men: 29.4%, women: 25.3%) (RKI 2006). However in the same time frame, the age-specific mortality rates decreased to a greater extent in men (from 1,119.2 to 790.6/100.000 inhabitants) than in women (670.1 to 500.8). Furthermore, the decline is more pronounced in the new Länder than in the former territory of the Federal Republic (men: 34.8%, women: 36.7% vs. men: 27.7%, women: 22%). Germany ranks 8th in its mortality rates when compared with European countries (RKI 2006).

  • Life expectancy indicators

The life expectancy at birth has improved for women and men, especially for those in the new Länder (RKI 2006, StatBA 2003). Between 1990 and 2002/2004, the life expectancy increased in Germany by 2.8 years in women and 3.8 years in men (RKI 2006). This increase is more pronounced in the new Länder (men: 5.3 years, women: 4.6 years; former territory of the Federal Republic: men: 3.4 years, women: 2.4). While the differences in health between Western and East Germany have been reduced, the life expectancy of women in the former territory of the Federal Republic and the new Länder (former GDR) is now nearly the same. Slight differences still exist in men’s life expectancy.

The life expectancy at birth for women is 81.6 years in 2002/2004 and 75.9 years for men. From 1990 to 2002/2004, the gap between male and female life expectancy at birth narrowed slightly: from 7.3 years in 1990 to 6.6 years in 2002/2004 in the new Länder, and from 6.4 to 5.4 years in the former territory of the Federal Republic. Furthermore, regional differences in life expectancy exist. The life expectancy of Germany is lower than the European average (EU-15 and EU-A) (RKI 2006, WHO 2006). Women live longer than men with similar complaints and illnesses (7.6 years vs. 5.9 years). The healthy life expectancy in Germany is 74 years in women and 69.9 years in men in 2000-2002. Compared with other European countries Germany is above the EU-A average (WHO 2006).

Disease specific morbidity and mortality gender distinctions

Over four-fifths of all deaths are due to non-communicable conditions (WHO 2006). 4 out of 10 deaths are caused by cardiovascular diseases (CVD), 2 by cancer, and 1 by external causes. The two main diseases accounted for 69.3% of all death in men and 73% in women in 2004. Since 1990, a considerable decline in the mortality of cardiovascular diseases, and to a smaller degree for cancer, can be stated for both sexes. The mortality rates have decreased for cardiovascular diseases by 38.2% in men and 33.1 in women; for cancer by 18.7% in men and 15.8% in women (1990 to 2004). An increase in mortality exists for diseases of the nervous system and sensory organs (men: 13.2%, women: 10.1%), endocrine, nutritional and metabolic diseases in men (12.7), and lung cancer in women (48%) (RKI 2006).

Gender differences exist in the ranking of the causes of death:

in women:
1: chronic ischemic heart disease,
2: heart failure,
3: acute myocardial infarction,
4: stroke,
5: malignant neoplasms of breast;

in men:
1: chronic ischemic heart disease,
2: acute myocardial infarction,
3: malignant neoplasms of trachea, bronchus, and lung,
4: heart failure,
5: other chronic obstructive pulmonary diseases (StatBA 2006d).

Important to mention is the dramatic increase of lung cancer in women; in 2004, for the first time, it ranked under the first ten most important causes of death (7th rank). Diseases where the death rates for men are at least twofold higher than those for women are behavioural disorders, diseases of the respiratory system, and external causes. Lower rates in men than in women can be found for diseases of the musculoskeletal system and diseases of the skin and subcutaneous tissues.

Gender differences can also be observed in the disability-adjusted life-years (WHO 2006). The top 5 conditions are:

for men:
1: neuropsychiatric conditions (24.3%),
2: cardiovascular diseases,
3: malignant neoplasms,
4: digestive diseases,
5: unintentional injuries;

for women:
1: neuropsychiatric conditions (24.3%),
2: cardiovascular diseases,
3: malignant neoplasms,
4: sense organ diseases
5: musculoskeletal diseases.

The following gender differences exist in regard to the most important diseases for the population’s health in Germany (RKI 2006):

Diabetes: In Germany approximately 4.000.000 million people live with diabetes, which mean every 20th person is affected. Up to the age of 70, men more frequently have Type-2 diabetes, in the older age groups the rates are higher in women. The rates are similar in men and women for Type-1 diabetes.

Myocardial infarction: The mortality rates have decreased in men and in women (with the one exception being women older than 90 years). An increase in the incidence rates can also be observed in men, though only partly so in women. In the 25 – 54 year age group, the incidence rate has risen in women. Gender differences in the occurrence of myocardial infarction decline with age and are strongest in the younger age groups.

Stroke: Men are more often affected by stroke than women. A reduction in mortality has been observed since 1990. One third of the patients die during the year following a stroke.

Cancer: The most important malignant neoplasms causing death are lung cancer for men and breast cancer for women. The incidence rates of lung cancer are declining in men, but rising in women. An increase in the incidence rates can be seen for prostatic carcinoma and colon carcinoma (in both women and men).

Muscoskeletal diseases: Chronic back pain during the course of a year was reported by 22% of the women and 15% of the men (1998, representative study results, age group 18-65). This difference persists in all age groups. More women than men have osteoporosis. 72% of all femoral fractures occur in women.

Depression: The prevalence rates for depression are 15% in women and 8.1% in men in Germany (1998, representative study results, age group 18-65).

Dementia: Every year 200,000 new cases of dementia are reported. Women are more affected than men (2/3 vs. 1/3). This due to the incidence of Alzheimer’s disease, where large gender differences exist.

Further examples of German initiatives for women’s health

Documenting available health data

Sources Short description Sex/Gender distribution (possible/standardised available) Provider Links
Health
Reporting
Online database with a broad scope of health related information Possible/ to some extent standardised available Information and Documentation Centre for Health Data (IDG) http://www.gbe-bund.de/
Routine
Data
Broad scope of health related topics (personnel, health costs, mortality) Possible/ to some extent standardised available Federal Statistical Office http://www.destatis.de/
In-patient and out-patient health care,data are not representative due to the structure of health insurance, no public access only if reports are produced or a cooperation exists Possible/ to some extent standardised available Health Insurances (private and statutory)
In-patient and out-patient health care (statutory health insurances) Probably possible/ not standardised available Verband der Angestellten-Krankenkassen e.V. (VdAK) http://www.vdak.de/
  Hospital quality reports regarding selected diseases Probably not possible/ not standardised available BQS Bundesgeschäftsstelle Qualitätssicherung http://www.bqs-online.de/
  Analyse of in-patient health care annually published as hospital report Possible/ not standardised available Wissenschaftliche Institut der AOK (WIdO) http://wido.de/
  Data regarding in-Patient health care Probably possible/ not standardised available German Hospital Federation http://www.dkgev.de/
  Monthly reports regarding pharmaceuticals (statutory health insurance) Probably possible/ not standardised available GKV-Arzneimittel-Schnellinformation (GAmSi) http://www.gamsi.de/
  Data regarding out-patient care and physicians Possible/ not standardised available Kassenärztliche Bundesvereinigung http://www.kbv.de/
  Data regarding out-patient care Possible/ not standardised available Zentralinstitut für die kassenärztliche Versorgung
Data regarding physicians Possible/ not standardised available German Medical Association http://www.bundesaerztekammer.de/
  Rehabilitation Probably possible/ not standardised available Forschungsportal der Deutschen Rentenversicherung http://forschung.deutsche-rentenversicherung.de/
Sources Short description Sex/Gender distribution (possible/standardized available) Provider Link
Health surveys (since 1998)
National Health Survey 1998 Nationwide health survey and additional medical examination. Data include a broad scope of health related topics. Possible/ not standardised available RKI – Robert Koch Institute http://www.rki.de/
Telephone Health Surveys Nationwide telephone health interview surveys since 2002. Data include a broad scope of health related topics. Possible/ not standardised available RKI – Robert Koch Institute http://www.rki.de/
  Health Information System dealing with different topics; one of them focus on Women’s Health and Health Promotion; Different surveys with special emphasis on reproductive health, health behaviour (e.g. smoking), HIV/AIDS and adolescents Possible/ mostly standardised available Federal Centre for Health Education (BZgA) http://www.bzga.de
Registry
Federal state level registry for cancer Possible/ not standardised available Gesellschaftder epidemiologischen Krebsregister in Deutschland e.V. (GEKID) http://www.gekid.de/
  Regional registry for myocardial infarction Possible/ not standardised available Berlin Myocardical Infarction Registry
KORA (Region Augsburg)
http://www.herzinfarktregister.de/
http://www.gsf.de/KORA/

Main reference documents:

 

AWMF – Association of the Scientific Medical Societies in Germany (2006): …more.

BMFSFJ – Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (2003): Die Familie im Spiegel amtlicher Statistik. Berlin.

BMFSFJ – Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (2006a): Gender Daten Report. Berlin.

BMFSFJ – Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (2006b): …more

BMG – Federal Ministry for Health: …more

BZgA – Federal Centre for Health Education (2003): Verhütungsverhalten Erwachsener.

Ergebnisse einer repräsentativen Befragung 2003. Köln.

BZgA – Federal Centre for Health Education (2004a): Drug Affinity among Young People in the Federal Republic of Germany 2004. Alcohol Report. Cologne.

BZgA – Federal Centre for Health Education (2004b): Drug Affinity among Young People in the Federal Republic of Germany 2004. Smoking Report. Cologne.

BZgA – Federal Centre for Health Education (2005): Development of Alcohol Consumption Among Young People giving particular consideration to consumption habits regarding alcopops Cologne.

BZgA – Federal Centre for Health Education (2006): …more

DHS – German Head Office for Dependency Matters (2006): …more

GBE-Bund (2006): ...more

Drogenbeauftragte der Bundesregierung (2002): Frauen und Sucht. Berlin.

Drogenbeauftragte der Bundesregierung (2005): Drogen- und Suchtbericht 2005. Berlin.

Drogenbeauftragte der Bundesregierung (2006): Drogen- und Suchtbericht 2006. Berlin.

Häussler, B; Gothe, H; Mangiapane, S. et al. (2006): Outpatient care for osteoporosis patients in Germany – results from the BoneEVA-study. Deutsches Ärzteblatt 103 (39): A2542-2548. HFA-DB (2006): European health for all database (HFA-DB). June 2006. …more

IOF 2006: …more

Kooperationsgemeinschaft Mammographie (2006): …more

Kraus, Ludwig; Augustin, Rita; Orth, Boris (2005): 2003 Epidemiological Survey on Substance Abuse in the Adult Population in Hamburg Reihe IFT-Reports. Volume 146. MunicView Pageh. OECD (2006):…more

Pro Familia (2006): Schwangerschaft und Schwangerschaftsabbruch bei minderjährigen Frauen. pro familia Magazin (2): 23-27.

Robert Koch Institute (2003): Bundes-Gesundheitssurvey: Alkohol. Berlin.

Robert Koch Institute (2006): Gesundheit in Deutschland. Gesundheitsberichterstattung des Bundes. Berlin.

Scheidt-Nave, C.; Starker, A. (2006): The prevalence of osteoporosis and associated health care use. Results of the first German Telephone Survey 2003. Bundesgesundheitsbl – Gesundheitsforsch – Gesundheitsschutz 48: 1338-1347.

S.I.G.N.A.L (2006): Domestic Violence against Women ...more

StatBA – Federal Statistical Office (2003): Population of Germany Today and Tomorrow. Wiesbaden.

StatBA – Federal Statistical Office (2005): Schwangerschaftsabbrüche in Deutschland. Wiesbaden.

StatBA – Federal Statistical Office (2006a): Women in Germany 2006. Wiesbaden.

StatBA – Federal Statistical Office (2006b): Leben und Arbeiten in Deutschland. Sonderheft 1: Familien und Lebensformen. Ergebnisse des Mikrozensus 1996-2004. Wiesbaden.

StatBA – Federal Statistical Office (2006c): Leben in Deutschland. Haushalte, Familien und Gesundheit

StatBA – Federal Statistical Office (2006d): …more

Ergebnisse des Mikrozensus 2005. Wiesbaden.

WHO (2006): Highlights on Health of Germany. Copenhagen.

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