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When Health Care Providers Refuse Care, Whose Rights Are At Stake?


Recently, an appeals court in Scotland ruled that a wide range of service providers have a right to object to helping with the provision of abortions, even if the care they provide is not directly related to the termination of a pregnancy. In the original ruling, last year, the duties carried out by the two Catholic midwives who brought the case had been considered so removed from the actual abortion that there could be no objection. The appeals court, however, disagreed. Everyone even tangentially involved, it said, has the right to object to providing a wide range of services. The only exception would be life-saving care.

This ruling highlights issues that have relevance beyond Scotland.

The tragic death of Savita Halapannavar in Ireland last year crystallized that no one really knows for sure when a woman is dying from pregnancy-related complications. Over the years, I have interviewed dozens of medical providers in countries with restrictive abortion laws. A key concern for the vast majority of them was how to make sure their actions were legal. Those working in countries where only life-saving abortions are permitted often expressed fear that they would either turn too many women away, with fatal consequences, or ultimately lose their license for providing care to someone who wasn’t “dying enough.”

Let’s apply this notion in a context where anyone involved, however tangentially, in the provision of abortion services, can refuse to treat a woman who is not dying.

This situation raises questions which, regardless of the answers given, compromise quality care. Who gets to determine how lethal each pregnancy is? Can a treating doctor compel assisting midwives or nurses to intervene if she or he believes the patient otherwise will die? And would midwives and others have the right to sue if they had been compelled to help provide an abortion to a woman who ultimately survived? There are no good answers to these questions, and any regulatory solution would almost inevitably lead to substantial delays in care.

Another key concern with a broadly defined right to conscientious objection in the context of health care is access to care in remote—or sometimes not so remote—areas. In the United States, much anti-choice activism is directed at making abortion impossible rather than illegal. Legislators, judges, and other officials in states including Mississippi, Virginia, and North Carolina have made it their goal to run every last abortion provider out of their state. Already, 35 percent of the U.S. population lives in counties without an abortion provider.

Moreover, broad conscientious objection clauses in combination with the stigmatization of abortion generally can stifle the provision of care anywhere. In small communities where everybody knows each other and where abortion is thought of as “evil,” doctors, nurses, and midwives often object to providing care out of fear rather than faith. After all, they still have to make their living where they are.

When I researched access to abortion for rape victims in Mexico, I came across various innovative “solutions” to this problem. In one area, abortion teams were circulated between public hospitals to ensure that no one had to provide care in his or her home town. In another, abortions were provided with the knowledge only of the senior-most officials at selected hospitals, with the result that many women in need of urgent care were turned away because “we don’t do that here” (even at hospitals where they, in fact, did).

Neither of these approaches solved the underlying problem: that abortions are seen as separate from other medical care (which they are not), and that abortion providers are considered different from other medical providers (again, not true). As a result, patients had to seek legal care in a clandestine manner, and in many cases the additional option of conscientious objection for anesthesiologists or nurses—who were not part of the core teams—made abortions virtually impossible to obtain.

Everyone has the right to freedom of thought, religion, and conscience. But international human rights standards do not protect our right to express those thoughts or that conscience in a manner that infringes on other people’s human rights. The more I learn about the concrete repercussions of conscientious objection in the context of health care, the more it is clear to me that there is no room for it. Ultimately, if you don’t want to provide the obstetric or gynecological services your patient needs—which may include an abortion—maybe you should choose another field of specialty.


Argentina Considers Bills That Could Criminalize Sex Trafficking—But Also Buying Sex


As I arrived in Buenos Aires this week, the Argentine Congress started discussing two bills purporting to deal with human trafficking. According to reports, one bill seeks to establish prison sentences for individuals who buy sex from victims of trafficking, while the other seeks to penalize anyone who buys sex at all, regardless of whether the person providing the sex is a consenting adult. (The government is not suggesting legislation to criminalize sex workers themselves.) No one would contest that actual sex trafficking is a problem in Argentina and that something should be done about it. The question is if it is ever helpful, in policy terms, to lump together trafficking and sexual exploitation with the buying and selling of sexual services between consenting adults.

The push to eradicate trafficking for purposes of sexual exploitation is a legitimate goal for any government—in fact, it is an obligation. In Argentina, this objective has gained particular urgency in the wake of a decade-long, largely unsuccessful legal investigation into the abduction and forced prostitution of a young woman. In relation to that case, Amnesty International and other groups have criticized the lack of effective protection in Argentina against gender-based violence in general and trafficking for purposes of sexual exploitation in particular.

But the evidence suggests that Argentina’s latest approach to address the problem may not be the best one. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has carried out studies and generated guidance on anti-trafficking initiatives. The organization has come to the conclusion that brothel raids and “rescues” that treat all sex workers as victims of violence contribute to decreased safety for sex workers by forcing many of them to move constantly from one place to another, undermining the social networks that can help to keep sex workers safe.

UNAIDS suggests that governments should instead take a nuanced approach that on the one hand recognizes the autonomy of individual adult sex workers and clients who act on their own volition, while on the other clamps down hard on sexual exploitation. In this context, sexual exploitation should include not only trafficking into forced prostitution, but also violent acts against voluntary sex workers (such as rape) and the use, offer, or procurement of a child for commercial sex acts.

The question is, of course, if there is such a thing as voluntary sex work.

In general, people who believe governments should treat trafficking and sex work as one and the same would answer “no” to that question. To this group of advocates, sex work is inherently violent; they believe that the people who say they engage in sex work voluntarily are in reality forced to do so by circumstances or structural disadvantages they may or may not see. The goal for such advocates is to eradicate sex work, rather than trafficking, and the assumption is that the criminal law is an effective tool in advancing this goal.

It is undeniable that sex workers, like everyone else, make decisions about their lives and livelihoods that are at least in part informed by the opportunities available to them. For some sex workers, opportunities are severely limited because they belong to a disadvantaged group in terms of gender, income level, ethnicity, or sexual orientation, and many may have chosen a different path given a different context.

It is also undeniable that the notion of exchanging sexual services for money makes many people very uncomfortable. I would venture that most parents would rather not see their children having sex for a living. And it is certainly true that many people would prefer not to see sex workers at all, leading to initiatives to curb street solicitation that often do little to promote sex worker safety.

However, it is not clear why our discomfort with sex for money should lead us to disregard, wholesale, the decisions made by sex workers themselves. When I did research on access to reproductive health services in Argentina, I spoke to women who felt empowered by their sex work, because it was the only relationship in which they felt they had some measure of control. And when I did research on discrimination based on HIV-status in the Dominican Republic, I spoke to women who were mortified that sex work was the only avenue open to them after they were fired from hotel and factory jobs. Both groups of women had made decisions in an imperfect context, but neither group would benefit from brothel raids and the blanket criminalization of their clients. In fact, treating these women as if their choices do not matter is unlikely to empower them to overcome structural abuse.

In Argentina, trafficking into forced prostitution remains a problem. However, not all sex workers are trafficked or remain in commercial sex work against their will. As Argentina’s congress—and many other countries—debate how to deal with both of these issues, they would do well to remember that to be effective a policy approach must be grounded in evidence and supported by those who are meant to benefit from it.


What’s the Connection (If Any) Between Adolescent Drinking and Rape and Violence?


When two adolescent boys were found guilty earlier this month of raping a teenage girl in Steubenville, Ohio, there was much discussion about rape culture, social media, and whether taking advantage of a passed out girl is just boys’ nature. Many media reports highlighted the drunken state of many of the kids present at the rape, and some argued that the girl’s drunkenness made her at least partially responsible for the abuse she suffered. Meanwhile, the boys’ drunkenness either was not mentioned at all, or was seen as making them less responsible for the attack.

One thing that didn’t elicit much disagreement was the issue of teenage drinking itself. “Where were the parents?” was a frequently asked question. “Why were these kids allowed to drink?” Alcohol and bad parenting, many people agreed, were the real culprits of this rape.

But is that really true? Does alcohol lead to rape and violence? And are parents responsible for adolescent drinking?

The answers to these questions are less straightforward than one might expect.

It is certainly true that a large proportion of violent crimes involve alcohol use. This has been attributed to a variety of factors, including the fact that alcohol inhibits self-control and limits the ability to assess risk, and the fact that some people consume alcohol in preparation for their involvement in violent acts because they believe it will make them braver and stronger.

It is also true that people under the age of 21 consume alcohol regardless of the legal U.S. drinking age, and that many young people binge drink, that is, drink a lot of alcohol over a short period of time.

Younger adolescents are, however, less likely to be involved in alcohol-related violence than they are to be involved in any other violent crimes. And when you look at violent crimes committed by a male perpetrator on a female victim, there is no significant difference between the proportion of women attacked by men under the influence and the proportion of women attacked by men who did not appear to be drunk.

In other words, the fact that a man drinks does not make him any more or less likely to attack a woman.

The influence of parenting and parental drinking on teenage behavior is also not a straight shot when it comes to alcohol and violence. While adult binge drinking in the larger community is a strong predictor for binge drinking in teenagers and college students, parental problem drinking is not—or at least not directly. To summarize a number of quite complex family studies, drinking is not a problem for adolescents in and of itself, though it is obviously not healthy in excess. Rather, the problems are how they drink, how (not if) they see their parents drink, and what they learn to do generally about their emotions and conflicts.

Parenting matters, but, especially for older teenagers, so do peer pressure, societal norms, and genetic susceptibility to using alcohol.

My motivation for looking into the correlation between these issues is not merely academic. I come from Denmark, a country where alcohol use is normalized, even celebrated, among citizens, including teenagers. As I recall it, the main drink served at high school dances back home was beer. Did that make us rape each other? My recollection is that it did not.

This recollection seems to be substantiated by facts. In a recent survey of industrialized countries, Denmark topped the teenage drinking list, while the United States came in last. But rape estimates from Denmark and the United States suggest that women and girls are equally likely to be raped in both countries, or even slightly less likely to be raped in Denmark than in the United States. To put it differently, drinking more does not make Danish people rape more.

My point is not to say that alcohol was irrelevant to the Steubenville rape case. Obviously, the girl’s alcohol-induced unconsciousness enabled the crime in some way (not that it at all excuses the violent acts). I am also not trying to exonerate these teens’ parents of responsibility. I would like to think we have some influence over our children’s sense of right and wrong, and by that I include the notion that we have a responsibility to help people who cannot help themselves.

I do take issue with the notion that alcohol and bad parenting are what caused this crime. Alcohol is a poisonous substance that does damage to your health when consumed in large or even not so large quantities. Bad parenting has much the same effect. But neither ensures that you will commit a crime.


Demanding Abuse-Free Porn Is Great—But What About Everything Else We Buy?


Earlier this month, the European Parliament rejected a proposed ban on “all forms of pornography,” including online porn, throughout the continent. This news elicited a variety of reactions, including a piece by The Guardian contributor Tanya Gold, in which she argued that porn should be certified by a committee of “authentic feminists” before it is published—or, at the very least, consumers should learn how porn is made and where it comes from.

I am not sure what an “authentic feminist” is, and I do not particularly like the idea of someone with a specific mindset deciding what I get to see or read. I do, however, agree with the notion that we, as consumers, have a duty to try and ascertain if the products we buy are made in abusive or coercive situations.

But why only porn?

What about diamonds? Watchdog groups have long reported torture, slave-like situations, and the use of child labor in diamond mines in several countries, including Zimbabwe and Sierra Leone. Profits from diamond mines have fueled conflicts for decades, contributing to the deaths of thousands of civilians. Yet the diamond market continues to grow, both worldwide and in the United States. In the United States, this is likely linked to the fact that many women, for reasons I cannot fathom, find getting married without a sizeable diamond engagement ring objectionable, if not impossible. In fact, over 80 percent of U.S. women who get married receive a diamond engagement ring, averaging over $3,000 a piece. Anecdotal evidence suggests that the most frequent question women ask about engagement rings is “How much did it cost?”—not “Was anyone harmed while producing this?”

And how about shoes? A recent study released by Stop Child Labor examined 28 shoe-producing companies and found that at least eight used child labor at some point in their supply chain. Moreover, the study concluded that none of the 28 companies could guarantee that child labor was not used in their production chain, because they only supervise the final link in that chain. But how many of us first think about child labor when we see a gorgeous pair of heels or go shopping for new sneakers?

The same is true for chocolate. As a recent Oxfam campaign documented, women who pick cocoa beans used in products manufactured by the world’s largest chocolate companies are regularly subjected to labor rights abuses, including low pay, excessively long hours, and sex discrimination. Cocoa sold with the Fair Trade label, which guarantees a certain level of pay and labor rights, represents only about 0.5 percent of the current cocoa market worldwide. So it’s fair to assume that very few people think about such worker conditions before they buy a candy bar.

I’ve deliberately mentioned products that are indulgences, because none of us needs diamonds, chocolate, or multiple pairs of shoes. So in these cases, it would be possible for us to ask the right questions and refrain from buying products fueled by abuse. But most of us do not. Why is that?

One reason is transparency. As in the case of the shoe suppliers, it’s not always possible to determine whether a shoe company sources its products using child labor, because watchdog groups cannot always see through the multiple supply chain links. Sometimes even the companies themselves have a hard time with that.

Another reason is convenience. I know environmentalist vegans who smoke, ignoring what tobacco farming does to the environment and farm workers. And I know Fair Trade lobbyists who drink Diet Coke like it’s water, even though Coca-Cola and its subsidiaries have had their share of alleged child labor issues. In short, I know any number of people who choose to examine some of the products they consume in detail but leave the rest alone. I am OK with that. As someone clever once said, the examined life is no picnic. We all choose our battles.

This does not mean governments can abdicate their responsibility to implement and enforce human and labor rights. And it does not mean that we shouldn’t demand transparency in sourcing for everything we consume. Pornography, like shoes and diamonds and chocolate, should be abuse-free.

It does, however, mean that it is hypocritical to demand abuse-free products only for things we don’t use or like. In her piece, Tanya Gold compares porn to meat (another product we don’t really need), arguing that we should demand the same transparency for both. I say we should demand transparency for all products and then leave people to decide which, of the abuse-free alternatives, they want to consume.


Women Wake Up Grumpier? Look Around and You’ll See Why


This week, Duke University published a new study, which found that women wake up grumpier than men. The study’s authors attribute the additional grumpiness to women needing more sleep than men. Me? I think there is just a lot to be grumpy about lately.

First, the wage gap between men and women grew over the past year, instead of narrowing like it is supposed to. Economic downturns usually hit those who are already suffering discrimination the hardest, so it is no surprise that, when the going gets tough, women and racial minorities are the first to get cut, the last to find jobs, or the most likely to find themselves in lower-paid and less secure positions. Still, considering the fact that female-headed households in the United States are more than twice as likely to be poor than male-headed households, maybe it should also not come as a surprise if we are sour.

Secondly, women are still being discriminated against in applications for new mortgages or refinancing, at least in Chicago (and there is no reason we should think Chicago is the worst case scenario when it comes to gender discrimination). The disparity is even greater when it comes to African American loan applicants. Given that Wells Fargo agreed to pay $175 million in 2012 to settle accusations that it discriminated against non-white mortgage applicants before the economic turndown, this news is not earth-shattering. Then again, having definite proof that your mortgage broker might turn your loan application down just because you don’t have the right genitalia can make a girl grumpy.

Third, a quantitative review of women in literary arts in 2012 shows that we are depressingly under-represented in the media, both as authors under review and as writers. Whether this under-representation is because women write about topics that are not considered “serious” enough for these periodicals, or because women themselves are seen as “light,” it is sad. And sad is just another word for grumpy.

And then there is this: a new survey showing that most women in the United States say we should have dated a guy for at least a month before he sees us without makeup. Sixty percent of the respondents said they wouldn’t take their makeup off while sleeping if spending the night with a new boyfriend.

I cannot decide which part of this survey makes me the maddest. First, there is the obvious exclusion of the three to five percent of the respondents who are dating women. Then there are the questions about the true state of equality in the United States and the stereotyped visions of women needing to wear makeup to be properly clad.

But I think what really got to me is what this survey says about the rock-bottom levels of women’s self-esteem in this country. Why would so many women believe wearing makeup is essential to the future of their relationship with a man? Why would they choose to sleep with someone they do not trust enough to see them naked?

Don’t get me wrong: I enjoy wearing lipstick as much as the next person, and I absolutely understand the power of putting on a mask. But that is precisely the point. Makeup is a mask. That so many women believe they have to wear one, even in bed and with their partner, is a measure of just how mad we should be.

So for Duke University to say that women wake up grumpy because we need more sleep is a bit like the typical comment about pre-menstrual syndrome. Sure, on certain days we may need more sleep or be hormonally disposed to flare up. But this does not mean there isn’t plenty to be mad about.

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