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.

When It Comes to Eating Disorders, Do We as a Society Know What We're Dealing With?

@RHRealityCheck

This week it is National Eating Disorder Awareness Week. Not that you’d know it. Three days in, Angelina Jolie’s leg at the Oscars on Sunday is still getting a lot more attention than the eating disorder usually associated with unnaturally thin and awkwardly poky limbs.

There’s a reason for that. Eating disorders make for an uncomfortable conversation topic. For one, they are incredibly insidious and prevalent. About 8 million individuals living in the United States have an eating disorder (7 million of them women and girls), and most never get the treatment they need. Essentially, this means everyone knows at least one person with a mental illness. Most people don’t like to think about that.

And then there’s the fact that eating disorders are deadly. Literally. Eating disorders are the mental illness with the highest mortality rate in the United States, and it is estimated that some 20 percent of those suffering from anorexia will die prematurely.

But mostly, many of us don’t like to talk about eating disorders because we’ve been very close to a sufferer.

In my case, me.

When I was 16, I arrived in the United States as a foreign exchange student from Denmark with a complicated, but manageable, case of bulimia, weighing approximately 110 pounds. I went home a year later with full-blown anorexia, weighing about 80 (which, considering my height, indicates a Body Mass Index of about 9.5, i.e. very underweight). It took fifteen years, 3 bouts of therapy, and a pregnancy to finally root out all obsessive thinking about food.

Now, when I think about food, it’s not obsessive. I may really want a cinnamon roll or crave salt. And I definitely get so hungry that thoughts of food take over until I eat. But I no longer think about the quantities I have eaten, or about whether or not I deserve food.

To say that this is “liberating” is beside the point. On the one hand, it feels like I am finally alive, that I can now concentrate on the real colors and textures of life. On the other, to be honest, it’s so basic that it’s mundane. When I don’t think about my past, I forget I ever obsessed over food. I eat when I am hungry and don’t when I am not. It seems uncomplicated, somehow. Yet, of course, I know it’s not.

There are any number of books and articles linking eating disorders to the depiction of boyishly (and unnaturally) thin women in fashion, movies, and television. In my experience, fashion has very little to do with it. Fashion will make perfectly well-proportioned and healthy women and girls want to lose five pounds, go on fad diets, and be miserable. Fashion dictates clothing that looks better on a stick-insect than on a person.

Fashion alone, however, does not make you live off half an apple a day. Fashion does not make you develop so much scar tissue in your throat that your gag reflex is inhibited and you need to use toothbrushes and pens to make yourself throw up. Fashion may be an impetus to lose weight. But it’s something else that makes you stop eating altogether.

And that something else is control. At least in my case.

I am not a reductionist, and years of working closely with victims of all kinds has taught me that while we all are experts on our own suffering, we can be woefully blind to the solutions that are necessary to deal with that of others.

Even so, I believe letting go of control is key to recovery for many. When my mother instituted a system of rewards for pounds gained with target body weight on certain dates, I’d carefully gain the required weight on the required date, then proceed to lose it all and more in the days after. In short, I never let go of control.

By contrast, when I returned to therapy briefly while dealing with a bout of bulimia during a particularly stressful time in my life, my therapist told me not to worry about it. “In the grand scheme of things,” he said, “you are just sticking a finger down your throat. Really, is that so bad? Just remember to brush your teeth.” My purging immediately got less frequent and then disappeared—it didn’t feel so imperative after I stopped worrying about it. In short, I gave myself license to let go.

The point is not that a cavalier attitude always generates the desired change. In this case, my therapist knew from previous interactions who I was and what my reaction was likely to be.

The point is that the perfection those suffering from eating disorders are longing for in themselves in most cases is neither physical nor real. It’s not that I wanted to be thin, or even that I liked my emaciated body. It’s that I was scared out of my wits of failing.

We will need to overcome our societal inability to see errors for what they are—an opportunity to learn—if we want to deal with eating disorders. So if you want to do something to counter eating disorders this week, sure, eat healthily and don’t assume that anyone who’s not a size 2 is unhealthy, stupid, or both.

But more than that: show through your actions that you appreciate effort and honest errors more than caution and control. It may seem three steps removed from eating disorders and food. Trust me, it is not.

New Pornography Regulations In LA: Are They Addressing the Right Problem?

@RHRealityCheck

On January 25, the mayor of Los Angeles signed regulation that requires the use of condoms by all performers in adult movies filmed within the city’s borders. The regulation conditions the issuance of film permits for adult movies on compliance with existing California worker safety rules, which already require barrier protection for workers exposed to blood and other potential contaminants (including semen). The ordinance spells out what these state safety rules mean in the context of the adult film industry, and requires producers to pay enough for film permits to finance workplace safety inspections.

Public health advocates have not surprisingly celebrated the regulation. Adult film producers have equally predictably been less enthusiastic, citing safe sex films as being less popular with viewers and actors alike, and threatening to move their filming elsewhere. This would not be too hard since the ordinance applies only to Los Angeles City and not to the broader Los Angeles County.

But there are other reasons the ordinance may not be as effective as one might hope.

The first is that fewer adult movies are filmed and produced professionally than was the case ten years ago. Over the past decade, free internet sites driven by home videos and other amateur content have taken over a growing slice of the porn image and film market. While it is clear that these sites are not posting free content for philanthropic reasons—indeed, online porn is said to be worth $5 billion a year—it is equally clear that the majority of US-produced porn content streamed online is not and will not be subject to filming permits.

As a corollary to this, the ordinance will not be very effective at influencing the overall depiction of sex in imagery and media. This outcome is all the more lamentable because encouraging condom use is so important. Let’s look at the facts.

Fact number one: young people in the United States act particularly clueless about the cause-and-effect links between unprotected sex, the spread of sexually transmitted infections (STIs), and unplanned pregnancies. In the United States, about half of the 19 million individuals newly diagnosed with an STI every year are between 15 and 24 years old. In addition, about 800,000 girls and young women between 15 and 19 years old get pregnant every year, mostly unplanned. Only about 60 percent of sexually active high school students say they used a condom during their last sexual encounter.

Fact number two: frighteningly few teenagers and pre-teens in the United States receive effective information and guidance about sex, despite the fact that 9 out of 10 kids in public secondary schools will receive some form of sex education at least once during their time from 7th to 12th grade. This is partially due to the fact that the federal government has invested several billion dollars in abstinence-only programs since 1997, including $5 million in the 2012 federal appropriations bill alone. Abstinence-only sex education teaches sexual abstinence until marriage as the only viable option for teenagers to avoid STIs and pregnancy. Under this logic, condoms are not only ineffective but also immoral because they “make” teenagers have sex. (Study after study has proven abstinence-only sex education to be ineffective at best and harmful at worst).

Fact number three: the internet is where kids go for the information they feel they need, including about sex. Successive Youth Internet Safety Surveys have shown that children between 10 and 17 years old are increasingly exposed to sexual content on the web, and, in fact, that to a growing extent they seek this content out. This is not surprising. Teenagers will always be curious about sex, and the availability of internet viewing on portable computers and other mobile devices such as MP3 players makes it easier for them to seek out sexual content in privacy.

The scary bit is that those children and adolescents who depend on the internet for information about sex—that is, those who do not receive effective sex education at school or at home—are more likely to be influenced by what they see. Already a desk study commissioned by the US Department of Health and Human Services notes that the general effects of pornography on the viewer include more permissive sexual attitudes, including a heightened tolerance for unprotected sex.

Which brings us back to condom use in pornographic movies and imagery. We cannot really prevent children from seeking out or inadvertently being exposed to explicitly sexual content online, including from porn sites. And we cannot mandate parental support for comprehensive sex education or even just an understanding attitude towards sex. As a result, if most online porn content depicts unsafe sex as the norm, a scarily large proportion of teenagers will see it as such.

We are not, however, as powerless as the Los Angeles City ordinance. We can think of creative ways to support adult content that features safe sex—for example, government-sponsored awareness campaigns or guidelines for amateur porn, potentially supported by financial incentives. And, by mandating comprehensive age-appropriate sex education in all schools, we can make sure that no teenager will have to depend on the internet for information on sex.

Sexual Harassment: Not Really About Sex At All

@RHRealitycheck

This week, a national study found that sexual harassment affects about half of the students in grades seven to 12. Some might see this as an indication that there is too much talk about sex in our schools. They would be wrong. Others have chalked it up to teenage hormones and suggested that we leave well enough alone. They would be equally wrong.

Sexual harassment is nothing new. In 2008, a study found that just over a third of middle and high school students had been sexually harassed. The National Coalition for Women’s and Girls Education put the percentage at almost 90 in 1997. And, indeed, discrimination based on gender has been an actionable offence under Title IX of the Education Amendments since 1972, and since then the courts have applied Title IX to various types of sexual harassment.

But the motivation for sexual harassment seems to be shifting. Bill Bond, a school safety expert for the National Association of Secondary School Principals, notes that attempts to exploit fellow students sexually have become less common, and that now students seem to use sexual remarks to degrade or insult someone else.

This sense, that sexual harassment nowadays is more about hostility than about sex, was validated by the study published this week as well as by the study published in 2008. Both concluded that most sexual harassment in middle and high schools in the United States is directed at girls and at children suspected of being gay or lesbian.

Where straight girls are targeted, the harassment is generally about their level of sexual activity, which is either deemed too much (they are “sluts”) or too little (they are “prudes”). In the case of youth who are thought to be gay, it is the mere fact that they might even want to have sex that is “wrong.”

In other words, the more frequent type of harassment suffered by children today—and the one they report as affecting them the most negatively—is expressing hostility at children who do not fit into some preconceived notion of what “normal” sexuality is. Normality in this connection apparently means that girls must display a level of sexual activity that can go unperceived (neither too much nor too little), and that everyone should be straight.

Or to be a bit more blunt about it: sexual harassment in middle and high schools today is motivated by either misogyny or homophobia. Neither has to do with sex. And neither would be helped by treating sexual harassment between children as a result of overactive hormones to be dismissed.

In fact, the solution is just the opposite: active and broad engagement about sexuality and sex roles. Because misogyny and homophobia are fuelled by ignorance and fear. And ignorance and fear can be fought with knowledge.

Unfortunately, broad knowledge-building is not generally the objective of sex education in US middle and high schools. At best, sex education deals with sexuality as a matter of biology: how do male and female bodies engage in (heterosexual and procreative) sex. At worst, the message is that all sex is bad unless you are married and want to procreate. These types of sex education do not transfer much needed tools to our children as they grapple with their evolving sexuality. Indeed, by ignoring (or vilifying) sexuality altogether, limited sex education may instead feed the fear that expresses itself as sexual harassment.

Comprehensive sex education, on the other hand, provides the broader knowledge our children need and want. At its best, comprehensives sex education engages children on their own level of comprehension in a conversation about what sexuality means, how to relate to ourselves and each other with respect, and how to make responsible and informed choices about our sexual and reproductive lives. Comprehensive sex education not only combats the fear and stereotypes that fuel sexual harassment, it also works in terms of delaying the age of sexual initiation and lowering the number of teenage pregnancies.

All children have a right to comprehensive sex education. Giving them the information they need and are entitled to has obvious benefits for their reproductive and sexual health. It is also a way to reduce the chances that they will subject their peers to sexual harassment.

Why the Use of Steve Jobs As An Anti-Choice Political Stunt Is Flawed

@RHRealitycheck

Steve Jobs' premature death has generated much online activity, some seeking to exploit his demise for political gain. In this category are articles suggesting that Jobs' status as an adoptee is a reason to restrict abortion access in general. The arguments put forward in this regard are flawed on two levels.

First, no individual circumstances can change the overarching reality that women and girls have abortions when they need them, regardless of the legal context. Restricting abortion access does not make the practice scarce, it merely makes it unsafe.

More than 30 percent of women in the United States will have at least one abortion before they are 45 years old, even though many live in states with few or no abortion providers. Most women who have abortions already have one child or more, and many refer to their desire to have time to parent as a key reason for needing an abortion. 

In fact, in my experience interviewing women around the world about pregnancy and child-bearing, abortion is the end rather than the beginning of their decision-making processes. Women talk to me about food for their children, time to play and concern with paying for their children's education. They talk about expensive birth control and child care and about limited health care options. They talk about how difficult it is to decide when and if to become a mother. And they talk about abortion as an option where other options have failed. 

They rarely, if ever, refer to the legality or availability of abortion services as a decision-making factor.  If a woman or girl feels she needs to terminate her pregnancy, she will find a way. I once spoke to a girl who had fired a gun into her abdomen because she felt too young to be a mother and abortion was illegal in her country.

It is also noticeable that abortion, in the United States, is more and more the recourse of women without financial resources.  In 2008, more than 40 percent of those having abortions in the United States were living under the poverty level, and this proportion is growing.  There is a reason for that: children are expensive and the United States provides few legal protections for parents. There is no federal law to protect paid parental leave or sick days, and there are no allowances for time off to breast feed. Federal law guarantees 3 months of unpaid extended sick leave to be used as parental leave, and only for those who are eligible, which excludes about 40 percent of American workers. There are no general provisions for health care--not even, in most states, for children. In 2010, almost 10 percent of all children (15 percent of children living in poverty) in the United States had no health insurance.

In short, though access to abortion services is becoming more expensive in the United States mainly because service providers are farther away, some women and girls see abortion as the only viable choice available to them.  In cases where women or girls might initially be inclined to carry a pregnancy to term and give the infant up for adoption, many would not be able to pay for prenatal care and to give birth--or even get time off for visits to the doctor and for the birth itself.  This in addition to the many very valid--and private--reasons women and girls might have to not want to carry a pregnancy to term, even if adoption were an easier and less costly option than it currently is.

Secondly, Steve Jobs' life experience doesn't work as an argument for limited abortion access, even by its own logic.

It is a fact that Steve Jobs was born before the legalization of abortion in the United States.  It has been suggested that Jobs' biological mother, faced with an unwanted pregnancy, contemplated having an abortion before she decided to carry the pregnancy to term and give the infant up for adoption. Her decision to do so was based on personal, and private, considerations.  This is as it should be.

Had Steve Jobs' biological mother decided to terminate her pregnancy in 1954 when she discovered she was expecting, she would have had to have an illegal and therefore potentially unsafe abortion.  And she might have died as a result, as more than half a million women worldwide continue to do every year because abortion access is illegal or severely restricted in their countries. Let us not wish ourselves back.