Gender and dementia national strategy policymaking: Working toward health equity in Canada through gender-based analysis plus

Abstract

This article discusses the results of a content and critical discourse analysis of Canadian federal policy documentation relating to the development of a national Canadian dementia strategy. These documents span from 2013 and focus upon Canadian federal policy directives and directions up to the release, and including the release, of a national strategy in June 2019. The analyses, supplemented by a subtextual examination of these documents guided by Bacchi's (2012) “What's the Problem Represented to be?” framework, focuses upon the treatment of gender in policy documentation and the specific gender related policy framework, known as GBA+ (gender-based analysis and intersectionality), which is intended to bring about health equity to disadvantaged groups. As women, particularly, working class women and their carers, as well as women with additional intersecting factors, such as being lesbian or bisexual, are less likely to receive the dementia related care and services they need, precipitating a premature move to residential care, GBA+ is an essential policy framework in the attempt to address these inequities. However, findings point to a superficial treatment of gender, GBA and GBA+ in federal policy documents and lack a meaningful invocation of women's gendered and intersectional lived experiences of dementia. Additionally, the Canadian federal government's Dementia Strategy for Canada: Together We Aspire (2019) is grounded in a rendition of citizenship that do not work to unearth the complex relationships between citizenship, old age, gender and intersectional factors. As a result, the Dementia Strategy for Canada: Together We Aspire (2019) presents a version of citizenship that homogenizes older adults and prevents representations of older adults as diverse, complex and continually changing groupings. Therefore, inspired by Bartlett et al. (2018), I advocate for the application of a feminist and intersectional citizenship lens in Canadian federal dementia-related policymaking documentation going forward.

Keywords

dementia gender policymaking Canada intersectionality citizenship

Introduction: Impact of dementia in Canada and the gendering of dementia, senior women and health equity in policymaking

In Canada, the “average female to the male ratio of Alzheimer’s disease prevalence is approximately 2.29” (Alzheimer’s Society of Canada, Rising Tide: The Impact of Dementia on Canadian Society, 2010, p. 18). This gendered trend is expected to continue, and by 2038, it is estimated that approximately 64% of people diagnosed with dementia in Ontario will be female (Government of Ontario, Dementia Strategy Consultation, 2016). As per the Government of Canada, more than 402,000 Canadians over the age of 65 years are currently living with dementia and approximately two-thirds of these individuals are women (Government of Canada, National Dementia Strategy, 2018, p. 1). This last statistic is not surprising as per a 2006 Canadian Federal Ministry of Industry Report, “women made up 69% of persons 85 years and older, 59% of those aged 75–84 years, and women aged 85 years and over comprised the fastest growing segment of the senior population” (Leipert & Smith 2009, p. 136). Women tend to live longer than male partners and can be vulnerable to social isolation. Senior women are, generally, poorer than their male counterparts and can have lower education levels due to historical impediments to post-secondary educational achievement. Racialized, indigenous, and immigrant women experience even greater income disparities with men and, historically, have low levels of post-secondary educational attainment, although more recent generations are seeing strides in this area (Chundamala et al., 2009; Dion Stout, 2009; Scott & Thurston 2009). These factors can result in “less ability to purchase services and negotiate with complex bureaucracies to get those services” (Leipert & Smith 2009, p. 136). As these figures indicate, there is a pressing need to take gender and intersectional factors into account when developing national dementia strategies as women, particularly women of low socioeconomic status, are vulnerable to not having access to the dementia care they currently need or will need in the future. Missing out on the therapeutic value of care services, such as Adult Day Services programming, which can slow down the progression of the disease (Mossello et al., 2008), allow individuals with dementia to live in their communities longer and provide much needed family/caregiver respite would be tragic.

Despite the compelling figures relating to the gendering of dementia, existing dementia-related policy literature focuses solely upon comparative recounting of national dementia strategies around the world (please see Broda et al., 2017; Bynum, 2014; Chow et al., 2018; Edick et al., 2017; Gajardo et al., 2017; Hoffman, 2014; Koch & Iliffe, 2011; Lin & Lewis, 2015; Lock 2013; Whitehouse et al., 2018) and critical renderings of dementia-related conceptualizations, such as notions of personhood, in policy documentation (please see Dixon et al., 2018; Hennelly & O’Shea, 2017; Gilliard et al., 2005; Innes & Manthorpe, 2012). This body of literature sidesteps discussions of gender or gender-based analysis in dementia-related policy. Therefore, this article discusses the results of a content and critical discourse analysis of Canadian federal policy documentation relating to the development of a national Canadian dementia strategy. These documents span from 2013 and focus upon Canadian federal policy directives and directions up to the release, and including the release, of a national strategy in June 2019. The content and critical discourse analyses, supplemented by a subtextual examination of these documents guided by Bacchi’s (2012) “What’s the Problem Represented to be?” framework, focus upon the treatment of gender in policy documentation and the specific gender-related policy framework, known as GBA+ (gender-based analysis plus intersectionality), which is intended to bring about health equity to disadvantaged groups. As women, particularly, working class women and their carers (Peel & Harding 2014), as well as women with additional intersecting factors, such as being lesbian or bisexual, are less likely to receive the dementia-related care and services they need, precipitating a premature move to residential care (Westwood, 2016) GBA+ is an essential policy framework to address these inequities. However, findings point to a superficial treatment of gender, GBA, and GBA+ in federal policy documents and lack a meaningful invocation of women’s gendered and intersectional lived experiences of dementia. Additionally, the Canadian federal government’s Dementia Strategy for Canada: Together We Aspire (2019) is grounded in a rendition of citizenship that does not work to unearth the complex relationships between citizenship, old age, gender, and intersectional factors. As a result, the Dementia Strategy for Canada: Together We Aspire (2019) presents a version of citizenship that homogenizes older adults and prevents representations of older adults as diverse, complex, and continually changing groupings. This particular representation of citizenship does not provide the policy “space” for women’s subjugated and situated knowledges. Therefore, inspired by Bartlett et al., (2018), I advocate for the application of a feminist and intersectional citizenship lens in Canadian federal dementia-related policymaking documentation going forward.

Policy contexts: Gender-based analysis in Canada

Gender-based analysis (GBA) is a policy development approach that the Canadian federal government has been using since the mid-1990s (see Greaves 2009; Health Canada, 2000, 2003a, 2003b; Status of Women Canada, 2004; Tudiver, 2009) and today, this policy exercise, within its new form of gender-based analysis plus, adding intersectionality to form GBA+, is mandated across all federal departments (Government of Canada, 2016b). As the name indicates, GBA places a primacy on “gender as an essential variable in policy analysis” (Hankivsky, 2012, p. 172). Thus, gender is the pivotal axis through which policy is analyzed and programs are developed, regardless of their aims or orientation. Health Canada describes GBA as “a catalyst for change” by ensuring that a “gender equality perspective” is folded into the development of health policy (2003b, p. 1). Health Canada also uses GBA “to promote sound scientific research and provide relevant health information and evidence” (2003b, p. 1). Accordingly, the framework has been adopted in women’s health research conducted at Canadian universities and nonprofit, health-oriented organizations (please see Abramson, 2009; Jackson et al., 2009; O’Sullivan & Amaratunga, 2009). Such studies have examined topics as far reaching as wait times for surgery, diagnostic tests, and communicable disease outbreaks. Within health research and program design, GBA is a tool that amplifies the difference between men and women and puts in place “a semblance of order,” where, on the ground, difference is often difficult to demarcate (Douglas, 2002 [1966], p. 5). Such a move works to “impose system on an inherently untidy experience” (Douglas, 2002 [1966], p. 5). Therefore, conceptually, GBA in health research and program design pits men against women, views them as undifferentiated “wholes,” and places a primacy on the effects of gender on health. Hankivsky (2012) argues that much debate has taken place over the adoption and application of GBA in health research and program design but not much discussion has been focused on the underlying theoretical tenets of the framework. Hankivsky (2012) critiques GBA in health research and program design for its conceptual treatment of gender. As such, in practice, the reference to gender within prevailing health oriented GBA frameworks generally refers to women and not men and obscures the diversity found among women in terms of class, race, ethnicity, religion, education, age, and geographic location.

GBA discourses harken back to standard second wave feminist fare when scholars focused on the wide-sweeping subordination of women (Ortner, 1974; Rosaldo, 1974). While seeking to understand “why sexual asymmetry [is] a universal fact of human societies” (Rosaldo, 1974, p. 22), academics within the second wave developed totalizing theories to address this polemic. For example, Rosaldo posited that women’s oppression stemmed from the positive cultural values associated with men’s activities in the public sphere of business and politics which were then contrasted with the negative cultural values associated with women’s activities in the private sphere of the home (1974, p. 41). Ortner also drew on cultural associations of gender to account for the subjugation of women. Ortner argued that women’s inferior status was linked to her association with nature (mothering, breastfeeding, nurturing, and so on), whereas men were seen as belonging to culture (higher office, business, politics and general spheres of influence, and so on) (1974, p. 54–87). However, Rosaldo’s and Ortner’s totalizing of women is problematic. Not all women face subjection in the same way, one’s class, age, education, geographic location, race, ethnicity, and religion also play a part as has been explored more exhaustively in more recent feminist anthropology (see Abu-Lughod, 2008[1993]; Di Leonardo, 1998; Scheper-Hughes, 1999; Tsing, 1993; Visweswaran, 1994). This more recent scholarship, which coincides with third-wave feminism, focuses on the intersection of race, class, marginality, and gender around the globe. However, as Visweswaran states, “it is not enough to consider race, class, and sexuality as additive categories to a central concept” (1994, p. 75), the central concept being gender. All aspects of intersectionality need to be given due consideration. GBA’s epistemological focus explains why indigenous groups, such as the Native Women’s Association of Canada, have been displeased with GBA. In a 2007 report, the Native Women’s Association of Canada (2007) declared, “Canada and others who have applied a GBA have failed to do so in a way that is sensitive to the multiple needs of Aboriginal women, who suffer not only from gendered discrimination but also from racism and other forms of oppression. For example, Aboriginal two-spirited women also suffer from discrimination based on their sexual orientation and women with disabilities also must deal with discrimination based on disability” (6).

In response to these critiques, in May 2013, the federal government announced it would be instituting an improved GBA framework called “GBA+.” Status of Women Canada (SWC) explained that “the ‘plus’ in the name highlights that gender-based analysis goes beyond gender and includes the examination of a range of other intersecting identity factors (such as age, education, language, geography, culture, and income)” (2013, p. 1). The Government of Canada also offers the following definition and description:

Gender-based Analysis Plus (GBA+) isn’t only about gender, and groups of people are not homogenous. Our experiences are affected by intersecting parts of our identity, the context we are in and our lived realities.

We all have multiple identity factors that intersect to make us who we are. This is called intersectionality. The “plus” highlights the fact that GBA has always gone beyond sex and gender. It examines how sex and gender intersect with other identities such as: race, ethnicity, religion, age and mental or physical disability (2019a, p. 1).

The Government of Canada also maintains that, “GBA+ is recognized as a key competency in support of the development of effective programs and policies for Canadians” (2019a, p. 1). Therefore, the Government of Canada released a report in 2015 outlining how SWC, the Privy Council Office (PCO), and Treasury Board (TB), which are federal government ministries and offices, would work to ensure the implementation of GBA+ across the Canadian federal governmental policy and programs. This report states, that the “PCO will continue to require that departments and agencies consider the application of GBA+, as appropriate, in the development of Memoranda to Cabinet (MCs) and will continue to challenge departments on their use of GBA through the normal policy development process” (2015, p. 4). These efforts are further reinforced by the PCO’s mandate to:

Work to develop and implement a policy considerations checklist to accompany the submission of MCs. This tool will guide departments and agencies in ensuring that proposed initiatives consider GBA+, as appropriate. A particular emphasis will be placed on ensuring that appropriate questions are considered when determining whether or not a full GBA+ is required, and a rationale is included in those cases where GBA+ is not conducted. This tool may also be used to ensure that other existing policies, acts, directives and considerations that are part of normal policy development process are appropriately considered in MC development (SWC, PCO, and TB Action Plan, 2015, p. 4-5).

Thus, the Canadian federal government is committed to implementing, where applicable, GBA+ across the whole of the federal government.

Pragmatically, GBA+ allows policymakers to investigate the “simultaneous interactions between different aspects of social identity” (Hankivsky and Cormier, 2009, p. 3), power structures, and health outcomes. Thus, factors such as gender and cultural patterns are examined within a holistic framework that also takes into account an individual’s or collectivity’s race/ethnicity, indigeneity, immigration/refugee patterns, class, sexuality, and religion. However, all of these intersectional or identity factors are mutually constituted, and, additionally, socially constructed, elastic, and in constant production within a specific time and place (Weed & Butler, 2011). One’s intersectional or identity factors, such as gender or class, do not necessarily dominate as an influencer and predictor of health outcomes—all of the factors will intertwine to have an effect on aging. As a result, intersectionality should not be an “additive approach” (Hankivsky, 2012, p. 1713), whereby identity factors are collected to assess their effect on health outcomes. Instead, the enmeshment of multiple identity factors within power structures and hierarchies are analyzed within their specific temporal context.

Material and methods

In order to illuminate how the Government of Canada has been deploying GBA+ within the framework of national dementia-oriented policy, content (Lieblich et al., 1998, p. 13) and critical discourse analyses (Leiss et al., 1990; Hall, 1997; Henry & Tator, 2002; Jhally, 1997) of Canadian-related federal documentation were conducted. The content analysis involved identifying how GBA+ was presented and discussed in the following publicly available federal documents: (1) G8UK— Global Action Against Dementia (2013), (2) National Dementia Research and Prevention Plan (2014), (3) Standing Senate Committee on Social Affairs, Science and Technology Report on Dementia (2016a), (4) Bill—233—An Act Respecting a National Strategy for Alzheimer’s Disease and Other Dementias (2017a), and (5) Dementia Strategy for Canada: Together We Aspire (2019b). These documents were chosen as they were the only federal-level publicly available documents for viewing on the Internet, thus representing the public position of the federal Canadian government on dementia policy. Year 2013 was chosen as the starting time point to source such documents as this is when the Canadian federal government officially introduced GBA+ into its policymaking mandate, thus, presenting the first opportunity to examine how GBA+ is positioned and framed within dementia strategy development. The documents reflect a growing federal government concern with dementia as they increase in size and scope as the years progress from 2013 to 2019. As such the first document—G8UK Global Action Against Dementia (2013)—is a brief four-page summit declaration showing Canada’s participation in the G8 Dementia Summit in London on December 11, 2013. The second document, entitled the National Dementia Research and Prevention Plan (2014), is a 14-page text which outlines the Canadian federal government’s research and prevention efforts, including the listing and description of various Canadian university-led studies with dementia within their remit, as well as a page on the government’s desire to support research involving support for caregivers. The third document, the Standing Senate Committee on Social Affairs, Science and Technology Report on Dementia (2016a), is a lengthy foray into outlining the framework required for an eventual Canadian National Dementia Strategy, including 16 specific recommendations focusing upon issues ranging from financing commitments to the creation of a public awareness campaign to federal taxation policy measures to reduce financial hardship for caregivers (p. 26–35). The fourth document—Bill—233—An Act Respecting a National Strategy for Alzheimer’s Disease and Other Dementias (2017a)—is a traditional piece of legislation which mandates that Canada develops a national strategy for Alzheimer’s and other dementias. The fifth and final document reviewed is the actual national dementia strategy, resulting from Bill—233, which was released in 2019. As the 2016 Senate Document and the 2019 Strategy are the most voluminous federally related dementia policy documents, the bulk of the content and critical discourse analysis below focuses on these two documents.

Pragmatically, the document content analysis was a two-part process, which examined how GBA+ was conceptualized, framed and explained in the documents. First, in order to conduct the content analysis, all documents were fully reviewed and then searched for the mention of gender, gender-based analysis, and GBA+ related terminology, particularly nomenclature relating to intersectionality and its various interwoven identity positions, including the healthcare delivery modalities of culturally sensitive care which are implemented to reduce healthcare disparities based upon intersectional factors. The content analysis “allows for a descriptive examination of the phenomenon of interest…using both inductive and deductive approaches” (Hennelly & O’Shea, 2017; see also Elo & Kyngas, 2008). When GBA+-related terms were identified, they were verified for a direct reference to GBA+ or intersectional factors and not a coincidental presentation. The terms searched are outlined in Table 1 and include: female, women, men, male, gender, gender fluidity, gender spectrum, gender-based analysis, gender-based violence, gender disparity, diversity, intersectionality, culturally safe, culturally competent, culturally appropriate, culturally acceptable, culturally sensitive, culturally based, at risk, race, racism, discrimination, GBA, GBA+ (sex and gender-based analysis and intersectionality), SGBA+, disability, disabled, disabilities, equity, equitable, lesbian, gay, bisexual, lesbian, gay, bisexual, transgender, lesbian, gay, bisexual, transgender, queer/questioning, two-spirited (LGBTQ2), lesbian, gay, bisexual, transgender, queer/questioning and allies, social class, and minority. Such a wide net of descriptors was cast in order to capture the full spectrum of intersectional possibilities as they may come to bear upon dementia and lived dementia experiences that may be re-presented and addressed in policy documentation. Additionally, each term found was contextualized within the policy document to determine if the term was a brief mention or if there was substantive engagement with the term, hence, the concept in the documents. When this was the case, the accompanying sentence was included in Table 1 in order to illustrate the nature of the engagement. Table 1 specifically lists the search results for the 2016 Senate Report and the 2019 Dementia Strategy as these two documents were the lengthiest of the federal-level policy documents. The findings for the other three federal-level documents are presented in prose form as these were relatively short documents but do set the policy “stage” (Bacchi, 2012) for the eventual national dementia strategy, which was released in 2019. Second, in order to capture whether or not the fluidity and nuanced nature of GBA+ was captured in policy documents, the “substantive” sentences were systematically coded as to whether or not they re-presented GBA+-related concepts as static or fluid.

Table 1.

GBA+ content and critical discourse analysis: 2016 and 2019 federal dementia strategy documentation.

Term	2016 mention	Representative substantive supporting wording	2019 mention	Representative substantive supporting wording
Female	11	Not applicable as substantive supporting wording was not found (n/a).	3	The majority of these caregivers are female, most commonly female intimate partners and daughters (2).
Women	11	As well, research has established that, in contrast to the general population, the rate of dementia among men in Aboriginal communities is higher than it is among women (9).	18	Of those aged 65 years and older living with diagnosed dementia in Canada in 2015–16, almost two-thirds (63 percent) were women (2).
		Informal caregivers, most of whom are women, sacrifice their own time, finances and health in order to care for a loved one with dementia (19).		The number of women in long-term care with dementia also greatly exceeds the number of men, which is only partially due to longer life expectancy among women (2).
Men	4	n/a	5	n/a
Male	0	n/a	0	n/a
Gender	2	n/a	5	n/a
Gender fluidity	0	n/a	0	n/a
Gender spectrum	0	n/a	0	n/a
Gender-based analysis	1	n/a	3	n/a
Gender-based violence	0	n/a	2	n/a
Gender disparity	1	This structure ensures that issues such as gender disparity in dementia are incorporated into all areas of dementia research funded through CIHR’s CCNA (8).	0	n/a
Diversity	0	n/a	10	n/a
Intersectionality	0	n/a	0	n/a
Culturally safe	0	n/a	14	Culturally safe care: Involves paying attention to the cause of health and healthcare inequities, by developing an ongoing personal practice of critical self-reflection, and by paying attention to how social and historical contexts shape health and healthcare systems, power and privilege, especially as these relate to indigenous peoples (82).
Culturally competent	0	n/a	0	n/a
Culturally appropriate	1	Therefore, sufficient resources must be provided in order to deliver culturally appropriate home and community care (40).	26	Culturally appropriate care: Involves giving consideration to a patient’s cultural background, personal experiences and norms (82).
Culturally acceptable	1	In addition, this component of care is critical for First Nations communities where alternative housing options may not be culturally acceptable (22).	0	n/a
Culturally sensitive	2	n/a	0	n/a
Culturally based	1	This program uses community resources, looks at the life-long learning continuum and is a culturally based model (11).	0	n/a
At risk	1	n/a	14	n/a
Race	0	n/a	1	n/a
Racism	0	n/a	3	n/a
Discrimination	0	n/a	6	n/a
GBA	0	n/a	0	n/a
GBA+	0	n/a	0	n/a
SGBA+	0	n/a	2	n/a
Disability	0	n/a	15	n/a
Disabled	3	For example, the committee was told that public transportation that is made available to the disabled is sometimes restricted to the physically disabled, rather than the cognitively disabled (17).	1	n/a
Disabilities	2	n/a	23	n/a
Equity	0	n/a	7	Health equity is achieved when everyone has an equal opportunity to reach their fullest health potential regardless of factors such as social class, gender, or ethnicity (51).
Equitable	0	n/a	9	n/a
LGB	0	n/a	1	n/a
LGBT	0	n/a	1	n/a
LGBTQ2	0	n/a	5	n/a
LGBTQA	0	n/a	0	n/a
Social class	0	n/a	2	n/a
Minority	0	n/a	11	n/a

GBA: gender-based analysis; SGBA: sex and gender-based analysis; CIHR: Canadian Institutes of Health Research; LGB: lesbian, gay, bisexual; LGBT: lesbian, gay, bisexual, transgender; LGBTQ2: lesbian, gay, bisexual, transgender, queer/questioning, two-spirited; LGBTQA: lesbian, gay, bisexual, transgender, queer/questioning and allies.

The results of the content analysis were then subjected to a critical discourse exercise, guided by Bacchi’s “What’s the problem represented to be?” (2009) framework. The critical discourse analysis explores how GBA+ was framed (Cairney, 2012) and the extent in which this framing reflects the fluidity of third wave feminist underpinnings that are prominent in the academic literature surrounding GBA+ and are meant to conceptually underscore GBA+ meaning and practice. Examining the policy documents as an act of discourse is important because, as per Foucault, discourse comprises “a group of statements which provide a language for talking about—a way of representing knowledge about—a particular topic at a particular historical moment. Discourse is about the production of knowledge through language. But since all social practices entail meaning and meanings shape and influence what we do—our conduct—all practices have a discursive aspect” (Hall, 1992, p. 201–202, emphasis in original). Moreover, discourse regulates how we discuss and implement concepts, including how they are infused into policymaking and acted upon. Discourse opens up how topics are circulated but also closes down alternative meanings and discussions. Therefore, discourse is a form of regulation and creates the conditions for what is considered “acceptable” to discuss and how it may be discussed. Also inspired by Foucault, Bacchi’s “What’s the problem represented to be?” framework is a “tool, intended to facilitate critical interrogation of public policies” (2009:1). Specifically designed to apply a critical discourse analysis within the policy domain, Bacchi’s framework dissects policy subtexts and their representation by asking six questions: (1) how is the policy “problem” framed? (2) what underlying cultural logics prop up the policy “problem”? (3) what is the history that has brought us to the representation of the “problem”? (4) What is not being covered in the representation of the “problem”? (5) What are the consequences to this representation of the “problem”? (6) how has the representation of the “problem” been circulated across multiple domains and how could it be interrogated across these domains? (2012, p. 2). It should be acknowledged that policy documents explored in this article are, however, only one node on the federal government’s discursive deployment of GBA+, and therefore, question six will not be examined nor will question three as this is out of the scope of the research conducted for this article. As such, the critical discourse analysis as is informed by Bacchi’s six-question framework brings into relief how, “the ‘public,’ of which we are members, is governed not through policies but through problematisations—how ‘problems’ are constituted” (Bacchi, 2012, p. 2). Pragmatically, it is important to assess whether or not the notion that multiple identity factors, such as gender and income, intersect in fluid- and context-dependent manners are featured in a meaningful fashion or if intersectional factors were indeed included as “additive” categories in Canadian national dementia strategy policy formation processes. The first approach is more likely to lead to sustained on the ground change in the everyday lives of those living with dementia and their caregivers as it will produce policy and programming informed by the lived experiences of individuals living with dementia and not a series of checklists to be completed through a formulaic policy process. Nevertheless, Bacchi’s questions will be answered in the upcoming discussion section.

Findings

How does the Canadian federal government frame gender, GBA, and GBA+ within dementia strategy documentation?

One of the first documents released regarding the Canadian federal government and a dementia strategy was the G8UK—Global Action Against Dementia document. The Health Ministers from the United Kingdom, Canada, France, Germany, Italy, Japan, Russia, and the United States signed this three-page document. While this document was signed in December 2013 after the Canadian federal government committed to GBA+, it does not mention gender or intersectional factors vis-à-vis dementia policy. The document, however, does emphasize the rights of older persons. Correspondingly, the document states that the signatories call:

“Upon the UN Independent Expert on the enjoyment of all human rights by older persons to integrate the perspectives of older people affected by dementia into their work; [and] Call upon all sectors to treat people affected by dementia with dignity and respect, and to enhance their contribution to dementia prevention, care and treatment where they can” (2013, p. 2).

How a human right is framed is not clear in this document, but the UN Independent expert’s office, which functions out of the Office of the Commissioner, UN Human Rights, defines a human as per the United Nations (1948) Universal Declaration of Human Rights, which includes the “recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice, and peace in the world” (1). However, as per Engle Merry (2006), how this translates into policymaking for those who are tasked with “mapping the middle”—the space policymakers construct and create that is situated between the rights agreements they draw from and the directives they create for those who will be charged with enacting the directives on the ground— is not clear. Nevertheless, in the G8UK Global Action Against Dementia document Canada is specifically tasked, along with France, to lead academia–industry partnerships within the signatories of the document.

Following the G8UK Global Action Against Dementia document signing, Canada released the National Dementia Research and Prevention Plan in 2014. In terms of gender, this short document highlights the Women’s Brain Health Initiative, which was founded in 2013 and is a fundraising organization geared to garnering funds for gender and dementia research, and the Canadian Consortium on Neurodegeneration in Aging (CCNA), which was created in 2014. The document explains how, “dementia affects women more than men, [and that] specific resources will be dedicated to study gender- and sex-related issues” (2014:5). The next Canadian federal document to appear was the 2016 Standing Senate Committee on Social Affairs, Science and Technology, which was also produced in the time of GBA+ and set the framework for the 2017 Bill—233—An Act Respecting a National Strategy for Alzheimer’s Disease and Other Dementias. The 2016 Senate Document does not place a primacy on health equity from a gender, GBA, or GBA+ perspective, but there is a focus on First Nations individuals and communities and rural older adults as needing consideration when developing a national dementia strategy. The 2016 Senate Document is lengthy at 52 pages and reads very much like a stakeholder consultation output document. The document provides an overview of the impact of dementia in Canada, the associated costs, programs that are currently working well, areas of improvement, a section on the patient perspective, including quotes from four individuals living with dementia (three women and one man) who advocate for their experiences to be folded into policymaking, and the requisite building blocks for a successful national dementia strategy, including significant increases in federal funding.

The first mention of gender in the 2016 Senate Document comes within the description of the Canadian Consortium on Neurodegeration in Aging’s (CCNA) research activities. All research conducted by the CCNA’s 350 researchers, who are divided into 20 teams, must “ensure…that issues such as gender disparity in dementia are incorporated into all areas of dementia research funded through the Canadian Institutes of Health Research’s CCNA” (p. 8). The next area where gender and intersectional factors could have come into the document entails the Public Health Agency of Canada’s “role in identifying the risk factors for developing dementia and to help mitigate the impact of these risk factors” (2016, p. 8). The document then lists many “lifestyle behaviors,” such as “poor diet, sedentary lifestyle, smoking, and alcohol abuse” increase the risk of developing dementia. This section of the 2016 Senate document is problematic as it individualizes risk, as is a mainstay in neoliberal health discourse (Coburn, 2010; Raphael, 2015). The neoliberal approach does not take into account how the social determinants of health (Raphael, 2010) affect one’s lifestyle choices, which in turn, negatively affect one’s health. This offering in the document is reflective of not only a neoliberal frame but also a biomedical lens (Lupton, 2011) and does not take into consideration the structural and intersectional factors that can influence the health environment that can result in an eventual dementia diagnosis. As such, gender, race, class, geographic location, ethnicity, etc. are not mentioned as considerations in developing or potentially developing dementia. The CCNA does, however, have a specific focus on Indigenous health and dementia. As such, the 2016 Senate Document states:

Dementia research specific to the Aboriginal population is another area of funding from CCNA. Research has shown that the rate of dementia in the First Nation population is 34% higher than in the non-First Nation population and that the age of onset is about 10 years younger than it is in the non-Indigenous population. As well, research has established that, in contrast to the general population, the rate of dementia among men in Aboriginal communities is higher than it is among women (p. 9).

Additionally, in terms of providing services and care to Indigenous individuals and communities, the 2016 Senate Report acknowledges the need for locally based home care programming but that existing programs require, “additional resources as…[their] budget has not been increased since the program’s inception and remains based upon 1997 population statistics” (p. 11). The report also highlights that remote Indigenous communities, as well as remote and rural communities in general, need better broadband infrastructure in order to improve the delivery of dementia-related telemedicine (2016, p. 21–22). Rural and remote Canadians are also of particular concern in the 2016 Senate Document as a stakeholder, Wayne Warry, states, “Remote communities face incredible challenges caring for older adults” (2016, p. 39).

Overall, the 2016 Senate Document makes only a few references to gender in the text. For example, it is acknowledged that “80% of informal caregivers are women” (12). Women as caregivers are also mentioned on page 19 of the 2016 Senate Report and referred to as “Canada’s silent patients” (p. 19). While this is not to be disputed and the report’s call for increased home care services and funding to alleviate caregiver burnout is laudable, there is not a focus in the proposed policy solutions for taking into account how women, as the lions’ share of Canadians who will age as individuals with dementia, should be addressed. Instead, the next mention of gender in the document is, again, vis-à-vis, research. The document reveals:

As noted earlier, as much as 72% of dementia sufferers are women. The reason, or reasons, for this are not yet known. Whether this is a result of women living longer than men, or a consequence of hormonal changes at menopause, lifestyle differences, a combination of these issues or something else entirely, has yet to be determined (2016, p. 16).

Thus, women are to be researched, as is the mandate of the CCNA, but actual policy directives, programs, and funding are not applied to them in the 2016 Senate Document. This framing is curious, indeed, but may be reflective of only a small body of literature of research conducted into the gendered lived experiences of those with dementia (please see Bartlett et al., 2018; Errol et al, 2015; Hulko, 2002, 2007; Sandberg, 2018; Westwood, 2016). Sandberg explains the inattention to gender in dementia research as being the product of “dehumanizing discourses on dementia, where people with dementia appear as abject” and are, thus, stripped of their gender and “positioned outside a heterosexual matrix of gendered intelligibility” (2018:30). However, as women comprise such a large portion of those living with dementia, their struggles, triumphs, and everyday travails must be reflected in policymaking processes and recommendations. It must be acknowledged that the 2016 Senate Document does have a section “The Patient perspective” (2016, p. 24–25), which emphasizes that those with dementia, “deserve nothing less than a dementia-friendly Canada in which they are not only accepted but embraced” (2016, p. 25). As such, the 2016 Senate Report highlights that individuals with dementia are “entitled to participate as equals in discussions about the programs and services that affect them” (25). This approach supports person- and family-centered care approaches, which recognize the autonomy, rights, and embodied personhood of individuals experiencing dementia (Kontos, 2005; Kontos & Martin, 2013; Kontos & Naglie, 2007, 2009; Smebye & Kirkevold, 2013) and the importance of their caregivers and/or families in their care journeys through ethical and participatory research (Smebye et al., 2012, 2016). As the World Health Organization stresses, “Fundamental to upholding a person’s rights is the recognition of capacity in persons with dementia” (2012, p. 3).

The 2016 Senate Report recommends that a national dementia strategy be developed and implemented through a newly created governmental office called the Canadian Partnership to Address Dementia, which should be structured along the lines of the existing Canadian Partnership Against Cancer. Recommendation #2 suggests that the new Canadian Partnership to Address Dementia should include representation from, “but not limited to, federal, provincial, and territorial governments, dementia and other health-related organizations, individuals affected by dementia and their caregivers, healthcare professionals, housing organizations, researchers, and the Indigenous community” (2016:28). The last recommendation of the 2016 Senate Report, which is recommendation 29, suggests, “The committee therefore recommends that the proposed Canadian Partnership to Address Dementia ensure that persons with dementia are included in all aspects of its work” (p. 42). Adding these lived experiences could change dementia-related policy, although only if this engagement is meaningful.

In Canada, in May 2017, the federal government did act on the 2016 Senate Report recommendation to establish a national strategy by introducing Bill C-233—the National Strategy for Alzheimer’s Disease and Other Dementias Act, which has received Royal Assent. This bill recognizes the need for applied research, collaboration and partnerships to support early diagnosis of dementia, treatments and programs, and the search for a cure. The bill specifically calls for, “encouraging greater investment in all areas of research relating to Alzheimer’s disease and other forms of dementia, and in particular, the areas of biomedical and clinical research as well as research relating to health systems, health services, and population health” (2017, p. 2). The need for best practices “for improving the quality of life of people suffering from dementia and their caregivers” is emphasized, and, specifically, evidence-based best practices, “in care delivery and daily programming focused on the needs of the persons suffering from those diseases” (Bill C-233 2017, p. 2–3). As an aside, it is important to note that the use of the word “suffering” is not optimal as the lived experiences of people living with dementia vary from slight changes to negative experiences (Hulko, 2007). Nevertheless, the main purpose of Bill C-233 is to encourage the, “development of a national strategy for the care of people living with Alzheimer’s disease or other forms of dementia, as well as their families and caregivers” (Bill C-233 2017, p. 1). The advisory board was formed after the passing of the bill and the conference was held in May 2018. However, Bill C-233 the National Strategy for Alzheimer’s Disease and Other Dementias Act does not mention gender or intersectionality or refer to any similar concept. This should be noted as GBA+ had been in force at the federal level for four years when this Act was introduced. As Foucault states, “unsaids” (Foucault 1989[1969], p. 124) can be just as important as the “saids.” This point is also brought to the fore by Bacchi who asks that we consider “Where are the silences?” (2012, p. 1).

In June 2019, the federal government released its Dementia Strategy for Canada: Together We Aspire document. This document represents a shift from earlier policy documents as what is termed SGBA+ plays a more prominent role, and chapter six is devoted to this policy framework. Chapter six begins with the following introduction:

Health equity is achieved when everyone has an equal opportunity to reach their fullest health potential regardless of factors such as social class, gender or ethnicity. Integrating health equity into Government of Canada policies, programs and practices is achieved in part through Sex and Gender-based Analysis Plus (SGBA+). The SGBA+ for this strategy identified individuals at higher risk of developing dementia and/or who experience significant barriers to diagnosis and access to dementia supports and services. Considerations for the following populations and individuals are detailed below: Indigenous peoples, individuals with intellectual disabilities, individuals with existing health issues, older adults, women, ethnic and cultural minorities, LGBTQ2 individuals, official language minority communities, rural and remote communities, and young onset individuals. Further research is required to determine whether there are other populations at risk or facing equitable barriers to care [2019b, p. 51].

Chapter six then breaks down the populations who are considered at risk and briefly describes each one with a paragraph or two. For example, women are described as:

Of those over 65 years of age and living with diagnosed dementia in 2015-16, two-thirds were women. The number of women in long-term care with dementia substantially exceeds the number of men with dementia. Emerging research indicates that non-modifiable risk factors for dementia, such as genetics, impact women more significantly than men. As well, the majority of caregivers for people living with dementia are women and they are usually daughters and female intimate partners (2019b, p. 52).

This is a homogenous rendering of the category women and harkens back to second wave feminism as covered earlier on in this article. There are references to “ethnic and cultural minority communities” (p. 53) in the document, but this category appears as an “add on” and is not presented as an identity location that intersects with gender. All of the “at-risk” categories in chapter six are presented as separate phenomena, when they, in lived experience, play out in conjunction and in friction with one another. In addition to the static representation of SGBA+, the 2019 Dementia Strategy for Canada: Together We Aspire lacks SGBA+ implementation guidelines. Chapter seven is dedicated to implementation. While in chapter seven, there are directives for preventing dementia, supporting the development for advanced therapies, and finding a cure, as well as concrete “aspirational” steps for “improving quality of life of people living with dementia and caregivers” (2019b, p. 59), SGBA+ is not featured in this chapter.

How is gender, GBA, and GBA+ specifically deployed in the Standing Senate Committee on Social Affairs, Science and Technology Report on Dementia (2016) and Dementia Strategy for Canada: Together We Aspire (2019)?

As Table 1 indicates, and is discussed in the previous subsection, there appears to be an initial shift from the Standing Senate Committee on Social Affairs, Science and Technology Report on Dementia (2016a)’s use, and treatment of gender and GBA+ to the Dementia Strategy for Canada: Together We Aspire (2019) document’s orientation toward the concepts. For example, a search of the term GBA+ and synonyms, like gender, diversity, and intersectionality (please see Table 1 for a full list of synonyms searched) totaled 81 mentions in 2016, whereas 245 such terms were featured in the 2019 document. Additionally, terms, such as “men,” “disabilities,” “disability,” “diversity,” “equitable,” and “minority” were not mentioned in the 2016 Document but were featured in the 2019 Strategy. However, the increased mention of GBA+ and related concepts did not lead to deep engagement with the terms in the 2019 Document. In order to illustrate this, when searching for the term GBA+ and synonyms, the accompanying sentences which were deemed substantive, meaning there was accompanying text that explained the concept or placed the concept in a context, were highlighted. It was found that more often than not that GBA, GBA+, and intersectional terms in the 2019 Strategy were merely identified or briefly mentioned in sentences, as is exemplified in the following:

The strategy places an emphasis on those groups who are at a higher risk of dementia as well as those who face barriers to equitable care. These groups include but are not limited to Indigenous peoples, individuals with intellectual disabilities, individuals with existing health issues such as hypertension and type 2 diabetes, older adults, women, ethnic and cultural minority communities, LGBTQ2 individuals, official language minority communities, rural and remote communities, and those with young onset dementia (11).

Sentences such as the one above do not delve into how the terms were going to be applied in the 2019 Strategy, nor the anticipated effect of applying GBA+ on policy or dementia-related health outcomes. The content analysis reveals that the 2016 Senate Document featured only 10 substantive supporting sentences, which went beyond identifying gender, GBA+, intersectionality, or related concepts. An example related to the word “women” includes:

Informal caregivers, most of whom are women, sacrifice their own time, finances and health in order to care for a loved one with dementia (19).

The 2019 Strategy featured fewer substantive sentences surrounding gender, GBA+ and intersectionality, and related concepts with only five sentences, despite 245 words featured relating to GBA+ and accompanying concepts. Examples of substantive phrasing related to the words “culturally safe” and “equity” include:

Culturally safe care: Involves paying attention to the cause of health and health care inequities, by developing an ongoing personal practice of critical self-reflection, and by paying attention to how social and historical contexts shape health and health care systems, power and privilege, especially as these relate to Indigenous peoples (82).

Health equity is achieved when everyone has an equal opportunity to reach their fullest health potential regardless of factors such as social class, gender, or ethnicity (51).

Additionally, each sentence highlighted in Table 1 was examined for its treatment of concepts related to GBA+— for example— were these concepts positioned as static and as an “additive” to GBA? The results indicate that the spirit of GBA+, which is to allow for investigation of the “simultaneous interactions between different aspects of social identity” (Hankivsky & Cormier 2009, p. 3), power structures, and health outcomes and their fluidity, was not present in the descriptions of GBA+ and its synonyms. Gender and other intersectional factors, such as ethnicity, are not static and bounded entities, which can be inserted into policy and programs (Benedict, 1959; Boas, 1911, 1927; also see Santiago-Irizarry, 2001). To further underscore this, chapter six of the 2019 Strategy lists 10 risk groups as separate categories. These include: Indigenous Peoples, Intellectual Disabilities, Individuals with Pre-Existing Conditions, Seniors, Women, Ethnic Groups, LGBTQ2, Individuals who speak English or French as minorities in their provinces, Rural and Remote Individuals and Communities, and Individuals with Early Onset Dementia (2019 National Dementia Strategy, p. 51–54). The differentiation of these identity categories does not reflect that intersectional identities are mutually constituted, and, additionally, socially constructed, elastic, and in constant production within a specific time and place (Weed & Butler 2011). As Figure 1 indicates, the 2016 Senate and 2019 Strategy Documents represent GBA+ in static, as opposed to fluid, conceptualizations. Moreover, Chapter 7: Moving Towards Implementation provides guidance for moving forward for the following areas: preventing dementia, advance therapies and find a cure, and improve quality of life of people living with dementia and caregivers (58–59); an implementation framework is for GBA+ is not offered.

Figure 1.

Fluid and static gender-based analysis plus representations.

Discussion

One must ask why gender, GBA, and GBA+ mentions in policy documentation only scratch at the surface of women’s gendered and intersectional lived experiences of dementia? A cynical response could be that the Canadian federal government’s inclusion of gender, GBA, and GBA+ in dementia strategy documents is merely “window dressing” or multiple Canadian governments’ (which include both Conservative and Liberal ruling parties) attempts to seem “feminist” (Ditchburn, 2015) in order to garner the female vote. I posit, though, that the answers run deeper than this. To unearth the subtext to the superficial treatment of gender, GBA, and GBA+, which is challenging due to the lack of gender, GBA, and GBA+ substance that is offered in the policy documentation, Bacchi’s questions provide a useful framework through which to work through this task. To reiterate, Bacchi’s questions follow: (1) how is the policy “problem” framed? (2) what underlying cultural logics prop up the policy “problem”? (3) what is the history that has brought us to the representation of the “problem”? (4) what is not being covered in the representation of the “problem”? (5) what are the consequences to this representation of the “problem”? (6) how has the representation of the “problem” been circulated across multiple domains and how could it be interrogated across these domains? (2012, p. 2).

Therefore, in this discussion section, the following questions, which have been inspired by Bacchi but tailored to the subject matter at hand, will be summarily answered: (1) how is the dementia policy problem framed? (2) what underlying cultural logics reinforce this framing? (3) what is not being covered in this rendition of the problem? and, finally, (4) what are the consequences to this framing? Bacchi’s third and sixth questions will not be addressed for these are out of the scope of the research conducted for this article but point to further research that should be conducted in the future.

The central thread to answer the tailored Bacchi-inspired questions is the notion of citizenship for the “problem” of dementia in Canada is framed in terms of citizenship in a fashion that prevents meaningful engagement with the concepts of gender and intersectionality, even though in 2013 GBA+ was made a mandatory exercise for all federally created policy and programming. Dementia is positioned as a challenge for the whole of government as is reflected in the following quote from the Dementia Strategy for Canada: Together We Aspire (2019):

Canada’s first national dementia strategy sets out a vision for the future and identifies common principles and national objectives to help guide actions by all levels of government, non-governmental organizations, communities, families and individuals. In developing the strategy, we sought at all times to ensure that people living with dementia and the family and friends who provide care to them were at the heart of these efforts (p. IX).

The Dementia Strategy for Canada: Together We Aspire (2019) also states:

The vision for this strategy is bold and reflects the aspirations of the many individuals and organizations who contributed to its development. The actions undertaken to achieve the strategy’s national objectives may evolve over time, but every action will bring Canada closer to the vision of a Canada in which all people living with dementia and caregivers are valued and supported, quality of life is optimized, and dementia is prevented, well understood, and effectively treated . (emphasis in original, p. IX).

These two excerpts indicate that Canada’s response to dementia is based on “common principles and national objectives” and “the vision of a Canada in which all people living with dementia and caregivers are valued and supported.” This language is reflective of a particular type of country Canada is aspiring to be and one that supports its citizens. As per Beaman, this is a nod to include individuals living with dementia through citizenship with a “legislative or formal membership within a nation-state” (2016, p. 849). Marshall refers to citizenship as “as a status accorded to full members of a community” that involves three factors: (1) civil citizenship which accords an individual “freedom and equality before the law”; (2) political citizenship that permits political participation, including advocacy and voting; and (3) social citizenship that permits all individuals to “share basic rights and welfare” (Beaman, 2016, p. 850). If all three elements are not in force, individuals are deemed to be partial or “second-class citizens” (Beaman, 2016, p. 850). While Marshall’s rendition of citizenship is prominent in the academic literature, it has also been critiqued for not articulating how, “citizenship as a status operates in practice and creates and perpetuates social inequality and differential citizenship statuses” (Beaman, 2016, p. 850). For example, Marshall’s citizenship framework does not work to unearth the complex relationships between citizenship, old age, gender, and intersectional factors. In terms of citizenship and old age, in trying to position older adults as active members of society, hence citizens, who should have a say in their health care even though they are not necessarily any longer part of the wage economy (historically citizens were viewed as earners, tax payers, and those who followed the laws of the state), older adults can often be homogenized into an “undifferentiated group who need to be made equal” (Higgs, 1995, p. 538). Giddens, who expands upon Foucault, also notes that conceptualizations of citizenship can create entire “populations,” or homogenous groupings, that can then be surveilled. Higgs notes that this process “concentrates on abstract factors and not concrete individuals” (1995, p. 546). Following this reasoning, notions of citizenship, such as are represented in the Dementia Strategy for Canada: Together We Aspire (2019), particularly as citizenship intersects with old age preclude representations of older adults as diverse, fluid, and multi-layered groupings.

The results of the content analysis indicate a lack of meaningful engagement with the diverse, fluid, and multi-layered groupings of older adults in Canada, as a strong invocation of intersectionality would have produced. Moreover, the lack of a GBA+ implementation plan in the Dementia Strategy for Canada: Together We Aspire (2019), when implementation frameworks are included for other elements, such as supporting the development for advanced therapies and finding a cure, as well as concrete “aspirational” steps for “improving quality of life of people living with dementia and caregivers” (2019b, p. 59) speaks volumes toward the Canadian federal government’s lack of a sustained commitment toward implementing GBA+ in dementia-related federal policies and programs. Canada is not alone in this regard, however. Bartlett et al. (2018) found, after surveying 17 countries, including Australia, Denmark, England, and Finland, that engagement with gender was overlooked in national dementia strategies (15). Bartlett et al. posit that “Given the strategic importance of these plans, which provide the language and set the agenda for the development of healthcare services, it is both curious and of concern that national dementia strategies throughout the world should neglect gender” (2018, p. 15). Bartlett et al. (2018) argue that “Integrating a feminist perspective into health policy is a global priority; it is widely recognized that gender-based differences in access to and control over resources, in power and decision-making, and in roles and responsibilities have implications for women’s and men’s health status, health-seeking behaviors, and access to health services (24). In this call, Bartlett et al. highlight that there is a “need for a feminist citizenship lens in the field of dementia studies; people living with dementia will then be recast as political agents and oppressive power dynamics can be challenged” (2018, p. 25). I extend the call for a feminist citizenship lens in dementia policymaking and advocate for a feminist and intersectional citizenship lens to be applied to dementia policymaking. However, how can gender, intersectionality, and old age citizenship be meaningfully engaged with in Canada’s national dementia strategy? This requires reinvigorated understandings of gender and intersectionality and the integration of women’s lived experiences into dementia related policymaking processes. As Weed and Butler (2011) underscore:

[G]ender is formed in relation to other social and political modes of social organization and is itself actively producing and reproducing such modes, including the family, labor, class, slavery, imperialism, immigration politics, and the state, to name a few. . . . Since gender is not an isolated factor or element on such a map but is itself mobilized in a constitutive and productive relation to those other modes of organizing political life, the only way to gauge its usefulness is by tracking those effects. [4-5]

In this quotation, Weed and Butler attempt to establish gender as a wide open concept, not one that is entirely predetermined. To this point, one must acknowledge that gender “is a practice of improvisation within a scene of constraint. . . .The terms that make up one’s gender are, from the start, outside oneself in a sociality that has no single author (and that radically contests the notion of authorship itself)” (Butler, 2004, p. 1). Thus, one’s subject or identity formations are scripted and enacted in our social worlds and a multitude of factors, particularly intersectional influences, shape how these scripts play themselves out in everyday and subjective experiences. Hulko explains that intersectionality can unearth the “subjective experiences of dementia” (2007, p. 133). In other words, intersectionality can illuminate what Butler describes as “improvisation within a scene of constraint” (2004:1). As a result, “As a theoretical framework, ‘intersectionality and interlocking oppression’ is invaluable in seeking to understand experiences of marginalization and privilege” (Hulko, 2007, p. 133). An individual holds multiple subject or identity positions and can tautologically exhibit advantage and disadvantage, such as an older white female living with dementia may have a certain degree of class advantage, but her gender makes her vulnerable within patriarchal power structures. Moreover, another female living with dementia may experience multiple disadvantages due to her gender, race, ethnicity, or being a newcomer in the form of an immigrant or refugee. Thus, the interactions of intersectional influences vary from individual to individual and context to context. Hulko explains that intersectionality works to unearth these “subjugated knowledges” (2002:232), which is a reference to Foucault (1994). I would, however, expand this notion further by positing that intersectionality also reveals “situated knowledges” (Haraway, 1988), whereby the knowledges of marginalized and multiply marginalized women are brought into relief but also the context, or structural frameworks, through which this knowledge and disadvantage is formed. Current research suggests these subjugated and situated knowledges reveal Indigenous women can have difficulty in Alzheimer support groups due to “feeling out of place” due to culturally insensitive care and that the female relatives of those with dementia can experience much higher care responsibilities than male relatives (Bartlett et al., 2018, p. 24). Lesbian and bisexual women also experience difficulties in accessing care that acknowledges their sexual preferences, a core aspect of their identity, which leads to poor care experiences that can “compound their anxiety, confusion, and distress”. These are only a few examples of how intersectional factors affect women’s lived experiences of dementia as the existing body of literature exploring gender and intersectionality and dementia is relatively small. However, even though the existing literature on gender, intersectionality, and dementia is emerging, these lived experiences are entirely absent from Canadian dementia-related policy documentation, producing loud “unsaids” (Foucault 1989[1969], p. 124). This absence renders Canadian federal dementia strategy documentation void of depth, nuance, and complexity when gender, GBA, or GBA+ is explored vis-à-vis policymaking. As women, who live their daily lives with intersectional influences and affects/effects, comprise such a large portion of those living with dementia, their struggles, triumphs, and everyday travails—or subjugated and situated knowledges—must be reflected in policymaking processes and recommendations. This would, indeed, be a step in the direction toward meaningful implementation of a feminist and intersectional citizenship lens in dementia-related policymaking.

Conclusion and policy recommendations

This article has examined the representation of gender, GBA, and GBA+ in Canadian federal dementia-related policy documents from 2013 until the release of the Dementia Strategy for Canada: Together We Aspire in 2019. This has been an effort in understanding how conceptualizations of gender, GBA, and GBA+ have been deployed in these documents as policy tools for attaining health equity, particularly for women with intersectional influences, such as low-income women. In order to do so, I traced the history of GBA policy frameworks in Canada and the move toward implementing GBA+ in 2013 and conducted a content analysis of the publicly available documentation from 2013 to 2019, which was supplemented by a critical discourse analysis of these documents guided by Bacchi’s (2012) “What’s the Problem Represented to be?” framework. Content and critical discourse analysis findings reveal that gender, GBA, and GBA+ mentions in policy documentation only scratch at the surface of women’s gendered and intersectional lived experiences of dementia. Moreover, the Canadian federal government’s Dementia Strategy for Canada: Together We Aspire (2019) is steeped in notions of citizenship that do not work to unearth the complex relationships between citizenship, old age, gender, and intersectional factors. In fact, Dementia Strategy for Canada: Together We Aspire (2019) presents a view of citizenship that homogenizes older adults and precludes representations of older adults as diverse, fluid, and multi-layered groupings. As such, women’s subjugated and situated knowledges are not folded into the Dementia Strategy for Canada: Together We Aspire (2019). Therefore, I call for the application of a feminist and intersectional citizenship lens in Canadian federal dementia-related policymaking documentation.

However, how are governments to implement a feminist and intersectional citizenship lens in dementia-related policymaking? This will be a two-part process. First, as is outlined in the discussion section of this article, policymakers must reinvigorate their understandings and applications of gender and intersectionality vis-à-vis citizenship in policymaking processes. It is imperative that policymakers are trained to apply the complexity of gender and intersectional conceptualizations and these nuanced and fluid categorizations in policymaking processes. The Government of Canada has instigated an online GBA+ training campaign (2017b, please see https://cfc-swc.gc.ca/gba-acs/course-cours-en.html). While this is a laudable exercise, it appears to be geared toward the general public and does not delve into the required nuance and complexity of gender and intersectionality in order to produce policy through a feminist and intersectional lens. Perhaps, more in-depth training is available to Canadian public servants as a part of their professional skills development, but this information is not publicly available, pointing to a policymaking “black box” (Callon & Latour, 1981) that has not been opened to researchers to date. Second, meaningfully folding the lived experiences of women with dementia, beyond the experiences of only three women, which are referenced in the 2016 Senate Documents (24), with a focus on how intersectionality plays out in daily living with dementia is crucial. Of vital importance is incorporating subjugated and situated knowledges into policymaking processes in their depth and breadth. This can be achieved by introducing public policy codesign (Blomkamp, 2018) which prioritizes gender and intersectionality in dementia-related policy development. Public policy codesign would comprise three components, as is inspired by Sanders’ (2014) writings on codesign; these include: (1) iterative processes, (2) the principle that those with lived experience bring valuable knowledge to policymaking processes, and 3) the development of practical tools for “telling, enacting, and making” (Blomkamp, 2018, p. 732). Thus, individuals with the lived experiences of gender, intersectionality, and dementia bring valuable information to the policymaking process and can take an active part in the development of policy tools, including national dementia policy frameworks. Older adult women in Canada, who are and will continue to be disproportionately affected by dementia, and particularly low-income older adult women, who have difficulty accessing dementia-related care and services, deserve a seat at the policymaking table through public policy codesign in order to ensure nothing less than the full application of a feminist and intersectional citizenship lens in Canadian dementia-related policymaking going forward.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Michelle Wyndham-West

Michelle Wyndham-West, PhD, is the Graduate Program Director of the Design for Health and Inclusive Design programs at OCAD University. Dr. Wyndham-West is a critically applied medical anthropologist specializing in gender, health, aging, and public policy. These thematic areas have been explored through ethnographic research concerning emerging medical technologies, including correlated gendered policymaking processes and lay take-up of these policies. Dr. Wyndham-West pays particular attention to the convergence of, and friction between, culture, power relations, and gender conceptualizations in policy processes and the everyday experiences of individuals negotiating their decision-making vis-a-vis health policy and programming. Currently, Dr. Wyndham-West is researching gender-based analyses (including intersectional frameworks), public health policy processes, and healthy aging through the case studies of dementia strategy development and seniors living with HIV. Dr. Wyndham-West has published in international journals, such as Health, Risk & Society and Evidence & Policy.

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