The 2012 Global Family Planning Summit: Will Issues Be Adequately Addressed?

@RHRealityCheck

In mid-July, world leaders will gather in London to discuss a real and urgent need: increased funding for family planning. Over the past 15 years, the United States—one of the largest foreign aid donors in the world—has cut its funding level for family planning by at least 25 percent. Meanwhile, the demand for modern contraception and family planning information has only increased. By most accounts, an investment of approximately $6.7 billion is needed annually to meet current needs for family planning.

The summit documents, which is co-hosted by the Bill and Melinda Gates Foundation and the UK Department for International Development and supported by the US Agency for International Development and the UN Fund for Population Action, link the dearth of contraceptives and health services to poverty: women in “rich countries” have what they need, whereas women in “poor countries” don’t. This notion is supported by the fact that over 99 percent of maternal mortality happens in so-called developing countries.

This vision is not so much wrong as it is incomplete.

In early 2010, the medical journal The Lancet published new research on maternal mortality and morbidity. The research showed that improvements in maternal health — a good indicator for women’s access to health services overall — depend on 4 key factors, only one of which has to do with family planning: 1) lower fertility; 2) higher education levels for women and girls; 3) rising per capita income overall; and 4) access to skilled birth attendants.

Importantly, both the Global Family Planning Summit and research published in The Lancet potentially obscure the fact that adequate access to contraceptives and health services is a question of income rather than geography. To be blunt, a wealthy woman in a poor country is likely to have better access to care than a poor woman in a wealthy country.

Just as importantly, all four drivers of healthy motherhood depend on women’s ability to exercise their human rights, including the rights to quality health care, non-discrimination in education and health, and economic empowerment through job creation and protections for equality in the workplace.

But perhaps most to the point, the much-needed infusion of extra cash to development aid budgets for family planning is a means to an end. For the organizers of the London summit, that end is the provision of family planning services to poor women in the developing world. But even this very laudable objective is also a means to an end — or at least it should be.

Almost two decades ago the world’s governments for the first time promoted an understanding of individual empowerment as a vehicle for better policy outcomes on population growth, through the 1994 Cairo Declaration on Population and Development. The measures set out in this declaration supported the, at the time, radical notion that if individuals are empowered to make their own decisions about their family’s size and growth, these decisions, in the aggregate, will make for healthy and balanced societies. This notion departed from previous decades for population control through central planning and imposed government targets for fertility.

Of course a piece of paper is one thing. A real commitment to change is something else.  In the 18 years that have passed since the adoption of the Cairo declaration, few governments have shown a sustained commitment to actually empower all individuals, equally, to make decisions about their families.  

Some impose limits on family growth, punishing all women for wanting to have larger families than the government mandate. Others seek to limit the fertility of specific individuals within their population who for some reason or other are deemed unworthy parents, usually because of their color, class, family status, or gender identity. Still others force women to have larger families than that might have wanted through demonizing contraception, encouraging (or ignoring) early and forced marriage, and by perpetuating a culture where women without children are seen as somehow incomplete.

None of these situations promotes the kind of autonomy in family planning envisaged by the world community in 1994. And neither will merely stockpoling contraceptive methods.

The latter, however, will help. Here’s to hoping that the education, economic empowerment, and equality needed to ensure real family planning won’t be far behind.

Is Criminalization of HIV Transmission Effective? Swedish Case Reveals Why the Answer is No

@RHRealityCheck

Earlier this month, a 31-year-old woman in Sweden was sentenced to one and a half years in prison for having unprotected sex without disclosing to her partner beforehand that she is living with HIV.

Even a perfunctory news search reveals that this is not the first time the Swedish justice system has applied criminal sanctions to potential HIV-transmission. In January, a 20-year-old man was sentenced to eight months in prison for having unprotected sex without disclosing his status. In December 2006, a 34-year-old woman got two months, and in January 2003, a 32-year-old woman one year. All of these sentences also required the person living with HIV to pay monetary damages to their former sex-partners.

For anyone who cares about human rights from a health and discrimination angle, these cases raise multiple red flags.

For starters, consensual sex between consenting adults should, in principle, never be subject to government control or regulation. Moreover, the criminalization of HIV transmission has multiple negative outcomes. It leads to distrust in the health and justice systems; it can discourage people from seeking to know their HIV status; it adds to the stigmatization of those living with HIV; and it is ineffective in bringing down HIV transmission.

In fact, UNAIDS (the Joint UN Programme on HIV/AIDS) recommends that governments limit criminal sanctions for HIV transmission to cases where all of three conditions are met: the person charged 1) knows he or she is living with HIV; 2) acts with the intention of transmitting the virus; and 3) actually transmits it. UNAIDS also recommends that cases of such intentional HIV-transmission should be tried under generic criminal provisions for bodily harm or assault, and not under HIV-specific provisions.

Public health and human rights activists are clear on this. That is why the Swedish Embassy in France was defiled with paint-filled condoms in protest against the 2003 ruling. And that is also why my own reaction to the ruling was to declare it “bad” over twitter, a statement that was re-tweeted several times.

A closer read of the cases highlighted in the Swedish media, however, leads me to reconsider, at least in part. 

If the media-accounts are accurate, the Swedish government has, in fact, partially followed UNAIDS recommendations. The convicted individuals all knew their HIV status and the cases were brought under general criminal law provisions on grave assault, physical abuse, and attempt to cause physical harm. So far so good.

The two remaining questions — intent and actual transmission — are more difficult to gauge.

Consider this.  

In most of the cases, the convicted person either has multiple convictions over several years for the same thing, or the conviction is based on multiple unprotected sexual interactions with different partners without disclosure. It is perhaps valid for prosecutors to ask if, absent proof of intent which is hard to produce, the fact that an individual living with HIV repeatedly and knowingly exposes someone else to a deadly virus shouldn’t count for something.

Further, actual HIV transmission may not be the only harm caused. The 20-year-old convicted man was charged with having unprotected sex with eight women, none of whom ultimately ended up HIV-positive, though they all claimed to have suffered severe emotional trauma as a result of the experience. In cases of domestic violence we often ask prosecutors to consider emotional distress as real harm, so why require actual transmission in order to prove harm in this case?

Then again, consider this.

The 20-year-old man was born HIV-positive and is being charged as an adult also for those unprotected sexual encounters that occurred when he was a teenager. He was initially placed in solitary confinement, seemingly because of his HIV status.

Also, one of the convicted women alleged she had been raped.  The male partner produced evidence to the contrary and she later withdrew the allegation. Nevertheless, coercion and fear is highly relevant when it comes to decisions about how and when to disclose HIV status. Research indicates that many women in fact are reluctant to disclose their HIV status because they quite legitimately fear abuse.

And with regard to actual harm caused, it is at least possible that the ramped-up attention to the cases have contributed in some part to the severity of the emotional distress of the sex partners.

It is, of course, reckless to knowingly expose anyone to real danger, also through potential HIV-transmission, even if the danger ultimately does not materialize. This is a notion the UNAIDS recommendations to a large extent fail to acknowledge.

But the highly publicized use of the criminal law in Sweden to punish those living with HIV for being timid about their health status does not make it easier for anyone to disclose. So perhaps the real question with regard to any government’s approach to HIV transmission should not be whether it follows UNAIDS recommendations, but rather if it is effective.  An educated guess says, not so much.

Deserving vs. Undeserving? Everyone "Deserves" Human Rights

@RHRealityCheck

Most of the issues highlighted during this year’s run-up to the US presidential election are framed in terms of separating the deserving from the undeserving. Abortion for rape victims, but not those who want to have sex. Immigration for the politically persecuted, but not those who move across borders because they need to find a job. Marriage benefits for those who have sex with the right people in the right way.

This debate misses the point in two key ways.

At the most basic level, the issues at hand are basic human rights and not dependent on who "deserves" what: we have a right to access to abortion, health care, work, and freedom and movement because we are humans, not because we deserve it.

But also as a political process, it is ineffectual to focus policy debates on whether or not specific people deserve the services and public goods they clearly need.

I was reminded of this the other day as I was boarding a plane and the flight attendant asked me about the meaning of my t-shirt which read: “Immigration is the sincerest form of flattery.”

"But does that mean you are for it or against it, though,” he asked. I was stumped for words.

Immigration is a reality, just like so many other issues people insist on declaring themselves “for” or “against.” Abortion, adolescent pregnancy, sex outside marriage, sex work, identifying as lesbian, gay, bisexual, transgender, or intersex… the list could go on.

None of these issues is fringe. One in three women in the United States will have an abortion by the age of 45. Every year, 750,000 girls between the age of 15 and 19 get pregnant in the United States. Ninety-five percent of all Americans have sex before they get married (or have sex and may never get married). While it is difficult to estimate the number of sex workers, the National Task Force on Prostitution estimates that over one million people in the United States have worked as sex workers. And a 2011 study shows that almost 9 million adults identify as lesbian, gay, bisexual,transgender, or intersex, i.e. about 4 percent of the US population. As for immigration, very few people in the United States do not trace their ancestry—even their recent ancestry—to immigration.

But more to the point, none of these issues will change through declaring them good or bad. The focus for a policy maker should be how to generate policies that most effectively guarantee the maximum level of welfare and human rights-enjoyment for everyone. And from that perspective, whether someone is “deserving” or not is irrelevant.

Abortion and adolescent pregnancy numbers depend on access to comprehensive sex education and contraception. Choices about sex work and immigration to a large extent depend on available work and whether individuals are able to provide for themselves and their families in any other way. And those who believe they can change someone’s sexual orientation or gender identity just by saying they “don’t believe in homosexuality” are more delusional than most. Even those who make a career out of not believing in homosexuality can’t change their own (completely legitimate) sexual orientation.

There is, of course, an enormous difference between the issues high-lighted here: some are medical procedures, some life experiences, some innate traits. However that may be public policy on health, sexuality, immigration, and employment should not be designed to punish us for being who we are or for doing what we feel we need to do, but rather make sure everyone is equally empowered to make the best choices for themselves.

Fatal Consequences: Women, Abortion, and Power in Latin America

Lucila was twenty-two when I spoke with her in 2004 in the mud-floored office of a women’s group on the outskirts of Buenos Aires, while conducting research for a report on reproductive rights in Argentina. During her first pregnancy two years earlier, the doctors at the local public hospital had diagnosed her with a rare heart condition, which converted her otherwise healthy pregnancy into a potentially lethal situation. Lucila was told, in no uncertain terms, that another pregnancy could kill her.

Nevertheless, when Lucila begged these same doctors to sterilize her, they refused the operation, telling her that she was “too young” to stop procreating. Lucila suffered regular beatings and rape at the hands of her husband and was unable to prevent another pregnancy—when I talked to her, she was already showing. And though she qualified for a legal abortion, even under the very strict Argentina law, she was barred from having one due to lack of proper regulation and the extreme stigma attached to abortion.

I later learned Lucila had managed to terminate her life-threatening pregnancy illegally. I did not hear under what conditions, though chances are they were not good. The Argentine health ministry admits that illegal abortions account for approximately one-third of maternal deaths in the country.

(This post is chapter from a newly published book, The Unfinished Revolution: Voices from the Global Fight for Women's Rights)

While Lucila’s situation probably is extreme, it is by no means exceptional. Latin America is home to some of the world’s most restrictive abortion laws. Three countries criminalize abortion in all circumstances, even when the pregnant woman’s life can only be saved through terminating her pregnancy: Chile, El Salvador, and Nicaragua.

Across Latin America, most countries apply an “exceptions” model where abortion generally is outlawed but penalties are waived in specific circumstances, such as if the pregnancy threatens the life or health of the woman, if the pregnancy is the result of rape or incest, or if the fetus is so seriously damaged it is unlikely to survive birth. Only in Mexico City and Cuba is abortion freely available to all women and girls who need the intervention, as long as they seek an early termination.

The restrictions placed on access to legal abortion have not made the practice scarce. In Argentina, an estimated 40 percent of all pregnancies terminate in induced abortions. In Peru, that proportion is 37 percent, and in Chile 35 percent. Most other countries in the region, including Mexico but also the United States, maintain a 20 percent ratio—one induced abortion for every 4 live births.

In fact, if you look at criminal law as only one of many potential policy instruments to affect the social phenomenon that is abortion, it would appear to be a very ineffectual choice: where abortion is illegal, it is equally—if not more—prevalent than in jurisdictions where it is legal. Also where abortion is illegal, it is much more likely to be unsafe. “You get overwhelmed by desperation,” a thirty-five-year-old mother of ten children told me in Argentina. “You seek all the ways out, pills, anything. But if there is no way out, then you take a knife or a knitting needle.”

Despite these facts, there are harsh criminal consequences for abortion in most Latin American countries. When it comes up in political or legislative debate, the criminalization of abortion is justified with reference to a need to protect the right to life of the unborn, and to a reluctance to “promote” abortion, which is considered a moral evil. In Peru, a prominent member of congress reportedly said it is better for a pregnant woman to die—and for her unborn child to die with her—than for her to have an abortion. This same argument was aired in Nicaragua when the parliament in 2007 decided to criminalize so-called therapeutic abortion (to save a woman’s life and health), which had been legal since 1893.

Complex Notions of “Right” and “Wrong”

It is of course true that any government has a vested interest in promoting a civic sense of right and wrong. As human rights activists we routinely expect governments to promote laws that dictate certain morals, such as equality between men and women, the inappropriateness of corporal punishment, and the need to abolish the death penalty. The difference between these issues and abortion is not that abortion is too complicated. There is actually quite broad agreement in most Latin American countries that while abortion is “wrong,” so are blanket bans of the practice.

The difference is that laws that promote equality and ban violence are generally effective in doing just that. Constitutional protections of equality, for example, have led to guarantees of equal pay for equal work. And the effective prosecution of domestic violence and even jaywalking has been proven to deter those practices, at least in part.

By contrast, the morals expressed through the stigmatization and criminalization of abortion are routinely set aside by women and girls who feel they need to terminate their pregnancies. In fact, of the hundreds of women I have interviewed over the years about pregnancy and choice, many have only a rudimentary or confused understanding of the law, but they have a clear sense of what is right. I have spoken to many women from various countries in Latin America who have expressed beliefs about the moral acceptability of abortion in specific circumstances, depending on the financial, marital, or emotional situation of the pregnant woman, and her ability to love the child if he or she were ever born.

“I don’t think [abortion] is really all that criminal during the first month,” Marienela, a thirty-seven-year-old mother of six, confided in me, as we were huddling in the corner of a dark old stable that functioned as a social hall in a slum quarter outside of Santa Fe, Argentina. “But if you already are seven months pregnant, then you have to have it.”

“Sometimes abortion is the best option,” a staunch pro-life activist said to me in 2006. The same woman declared not to believe in the need for modern contraception, but readily conceded the untenable nature of the current setup in her neighborhood, a muddy slum on the outskirts of Tucumán, Argentina: “The most usual form of contraception here is nothing: people either have children or badly done abortion...It’s still something I am thinking through, but I know we have to work on making sure that no one needs to get to that point.” She then looked at me and said quietly, “You cannot even imagine what women end up putting in their uterus.”

The sentiment that abortion is not a moral evil if you didn’t want to be pregnant in the first place is both prevalent and pragmatic in the many women I have spoken to, and also surprisingly clear. “Abortion is necessary,” said one woman in Nicaragua in 2007. “You can’t just bring an undesired child into this world, especially when you didn’t try to have one.” In fact, women and girls already know what they need in order not to need abortions. The vectors that influence real choice are neither fetal rights nor physical autonomy in the abstract. It’s a very concrete sense of what is possible and what makes for a better life—mostly for the child.

Time and time again, women articulate concern about economic stability and the need to feed an existing family. They talk about apprehension with regard to bringing a child into an abusive relationship, often only commenting in passing on their own suffering and pain. They talk at length about difficulties in accessing affordable, easy-to-use, safe, and effective contraception of their choice.

And they always describe variations on a theme that sounds ideologically motivated but happens to be empirically true: that while women in Latin America are socially dependent on men, men are not held responsible for the reproductive disasters that ensue from the unprotected sex they often pressure women into having. “She got herself pregnant” is invariably the response I get from public officials to questions about why a particular woman should suffer through an unwanted pregnancy or unsafe birth. At times it is delivered with a dismissive shrug: “She is responsible for herself.”

Why Legalize Abortion?

These very real experiences should make for excellent public policy: tackling the three issues of violence against women, access to contraception, and gender-based discrimination is what will make abortion less needed. The legalization of abortion will make the practice safe. Most of these facts are undisputed. The real question is why none are adequately addressed in Latin America today.

The short answer is power. Everywhere in the region, proposals to legally limit access to abortion, and even absurd moves to extend the right to child support for all ova fertilized through rape, are used as political chips.

In Nicaragua, a 2006 vote to eliminate access to abortion for women whose lives were threatened by their pregnancy was scheduled a mere ten days before the presidential elections, and most accounts suggest that this was no accident. The fact is that in all of Latin America, churches are powerful players in national politics—in particular the Catholic church—and few candidates want to be seen as “pro-abortion” and thereby lose the support of the church and other politically influential conservative groups. In this particular election, parliamentarians from the Sandinista party were reportedly ordered to vote for the penal code reform so that their candidate, Daniel Ortega, would win, but with an oral promise from the Sandinista party leadership that the issue would be “solved” after the elections. Meanwhile, Ortega went on record saying that “abortion is murder.” More than five years after the blanket ban on abortion went into effect in Nicaragua, it is still in force with disastrous effects on women’s health and lives.

In Mexico, after the Supreme Court in August 2008 upheld a Mexico City law to legalize abortion in the first trimester, several federal states in the country moved to amend their state constitutions to ban it.

Most of these constitutional changes have little effect on women’s real access to legal abortion in those states: it was nearly impossible before and obviously not much better after. However, the fact that state legislatures were willing to spend time and energy on laws that are likely to have little effect on their stated objective is testament to how politically viable anti-choice arguments are, and how little power can be gained by raising the fact that women and girls continue to have abortions—some safe and most unsafe—regardless the legislative framework. And during the presidential campaign in Brazil in 2010, the ruling left-wing party dropped the support of sexual and reproductive rights from its draft human rights plan, perhaps in the hopes that this would ensure the support of the Catholic church which had started publicly referring to then-President Lula as “Herod,” an allusion to the king who, according to biblical accounts, ordered baby boys to be killed. During the Pope’s 2007 visit to Brazil, Lula had already publicly pledged that his government would never propose the legalization of abortion, but this further step was thought necessary to appease the church.

The point is not that morality-based arguments for the criminalization of abortion are always a cheap veneer on actions that are motivated by political gain. In fact, my interaction with activists on both sides of the apparent abortion divide suggests to me that most people who profess to be either staunchly pro-life or staunchly pro-choice in fact are deeply attached to their beliefs and the morality on which they base them. With civility and mutual respect, these beliefs should be aired in public debate.

The point is that the morality of public policy depends on both its intention and its effect. The effect of abortion bans—in particular in the Latin American context of gender inequality and limited access to contraception—is death and suffering for the women who need abortions, with no discernable effect on lowering the number of abortions. As such, abortion bans are both ineffective and immoral.

Unfortunately, the bans continue. Six years after I talked with Lucila, I interviewed another woman in the same impossible situation. Silvia, who suffers from a serious kidney disease that could make another pregnancy near fatal for her, told me she received no help or even sympathy from the doctors who would tell her almost in the same breath, on the one hand, that she couldn’t be pregnant and, on the other, that she had to carry the pregnancy to term: “I said, ‘But you told me that I shouldn’t have it! . . . I am close to needing dialysis as it is.’ . . . I said, ‘Are you going to guarantee that nothing will happen to my health?’ . . . She said, ‘I can’t guarantee that.’”

Winds of Change

Despite this grim state of affairs, there are indications that things are slowly starting to change for the better. In April 2007, abortion was decriminalized in Mexico City, and this law was later upheld as constitutional by Mexico’s Supreme Court. In 2008, Uruguay’s congress approved a law to legalize abortion in the first trimester of the pregnancy. At the time, the law was immediately vetoed by the president, but a similar proposal is currently under consideration with much better prospects. In November 2010, the Argentine Congress also started a series of hearings on the legalization of abortion.

All of these developments are fueled by a growing empathy for the plight of poorer women, in particular. Most people know someone who has had an abortion, and it is increasingly an open secret that the criminalization of abortion mostly affects women who can’t afford to go to the United States or to a private clinic for an illegal but safe intervention. The general rhetoric of the Latin America media on abortion has changed radically, even just over the past five years: questions and comments are now more about why women need abortions, not how to punish them for it.

Indeed, surveys confirm that most people in the region have a much more nuanced understanding of abortion than their elected officers: it must be legal, accessible, and rare. It is only a matter of time before policymakers catch on.



Limbaugh is Sorry for Calling Fluke a "Slut," But Why Were We ALL Sorry, Too?

@RHRealityCheck

This week’s back-and-forth over Rush Limbaugh’s use of the words “slut” and “prostitute” illustrates our deep discomfort with women’s sexuality.

And in saying this, I am not referring to the fact that Rush Limbaugh massively misstated, misunderstood, and misrepresented Sandra Fluke’s congressional testimony on the medical need for contraception. Anyone with even a basic knowledge of the subject matter will know that 1) private health insurance is not paid for with tax dollars; and 2) you have to take birth control pills with the same frequency (once a day) regardless of the amount of sex you have.

I am talking about the discomfort with women’s sexuality demonstrated in the outpouring of support for Sandra Fluke. Lawmakers, pundits and even the president have reached out, expressing sympathy for the pain it must have caused her to be called a slut. Advertisers have pulled support for Limbaugh’s program. And Limbaugh himself found it necessary to apologize for his use of words, all the while reiterating his absurd read of the content of Fluke’s original testimony.

Implicit in all of this is the notion that it is a very bad thing to be called a slut. But why? There is, as Yasmin Nair pointedly says, nothing wrong with women who like to have sex “with one person or with many, at the same time, or sequentially.” And if that is true, how is it that advertisers can be convinced to pull support for a highly profitable show solely on the premise that it is bad for business to be seen to support someone who calls a woman a slut?

Part of the reason is historic. Perceived chastity has traditionally been linked to the legal definition of defamation and libel. In this way, English common law historically considered it libellous or defamatory “per se”—that is, without the need for further explanation—to insinuate that a woman is unchaste. Interestingly, some definitions of defamation per se considered impotence and a want of chastity to be equally damaging notions. Rush Limbaugh might agree with that, considering his run-in with prosecutors over carrying Viagra and his somewhat frequent use of the word “slut” as an insult.

What is disheartening is that some of the of sympathy for Fluke comes from a similar place of discomfort with and judgement of liberated female sexuality. If we say that slut is a bad word, we are implicitly saying it is bad for women to want to have sex. If we say that prostitute is a bad word, we are saying that taking money for sex is an insult. Neither is automatically true.

Limbaugh’s negative judgement of a woman having sex for anything other than procreative purposes is obvious and direct. After all, that is what his rant was about in the first place.

For many others the judgement is more insidious and in some cases directed at ourselves. Many of my most actively feminist friends have at some point or another expressed genuine concern that some man will think they are a slut because they had sex with him on a first, second, or third date. Apart from the obvious double-standard (the man had sex on a first, second or third date too—is he also a slut?), most people in the United States, at some point, have sex outside marriage and without a deep and lasting emotional connection. In other words, most people may be sluts, but only women pay a social price for it.

Limbaugh’s juvenile tirade illustrates the many levels on which women are held to different standards than men. A woman who speaks publicly about sex, even clinically, is automatically a slut, but no such term automatically attaches to men who routinely affirm their sexual needs and desires. Women who ask that the insurance they pay for cover contraception are not only freeloaders but are also prostitutes, while the men who rely on their female partners to take care of their contraception needs are presumably virile.

In addition, both Limbaugh’s carefully worded apology, and quite a lot of the anti-Limbaugh media flurry this week miss an essential point in Fluke’s testimony: women and men have different health care needs because of their different physiology, and those needs should be met equitably.

But more than that: until we stop assuming that women are bad if they have sex with someone they don’t know, don’t love, or aren’t married to, we will never be a modern democracy with equal protection under the law.