Shirin Heidari

Gender-based violence: a barrier to sexual and reproductive health and rights

The extent of violence against women and girls across the world is alarming and is increasingly recognised not only as a grave human rights violation, but also as a public health problem that affects the lives and physical and mental health of millions of women and girls globally. Rooted in gender inequality, violence against women and girls constitutes a major barrier to their sexual and reproductive health and rights. The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) adopted in 1979 has so far been ratified by 187 countries. The importance of bringing an end to all forms of violence against women and girls has further been reiterated in the Sustainable Development Goals (SDGs), which for the first time recognise this as central to the achievement of SDG 5 on gender equality and women’s empowerment, as well as several other SDG targets, including those related to health (SDG 3). Despite these commitments, violence against women remains pervasive, and according to global estimates 35% of women and girls are subject to physical and/or sexual violence by an intimate partner or sexual violence by a nonpartner during their lifetime. Reproductive Health Matters has dedicated the 47th issue of its journal to violence, aiming to deepen our knowledge about the different dimensions of gender-based violence, and expand our insights into effective responses. The journal issue sheds light on some of the many circumstances and forms of gender-based violence that

Not without a fight: standing up against the Global Gag Rule.

It is sadly ironic that as we celebrate International Women’s Day 2017, sexual and reproductive health and rights (SRHR) researchers, advocates and practitioners around the world are bracing themselves for the inevitable impact of US President Trump’s re-enactment and expansion of the Mexico City Policy, widely known as the “Global Gag Rule”. Yet, International Women’s Day also provides an important moment to recognise and reflect upon the commitment and tenacity that characterise the ongoing efforts of so many in the SRHR community as they unite against the Global Gag Rule, attempting to find new partnerships, new solutions, and new directions for their work. The Global Gag Rule is, unfortunately, nothing new. Since 1973, the Helms Amendment under the Foreign Assistance Act has prohibited US funding from being used to pay for the provision of abortions. In 1984, US President Reagan took this approach much further by ensuring that non-governmental organisations receiving US funding could not promote or provide access to – or even information about – safe abortion, even using their own funds. Doing so would mean the loss of US funding for any activity provided by that organisation. On 23 January 2017, in one of Trump’s first acts as President, the Global Gag Rule was reinstated. Unlike previous occasions, the new policy applies not only to funding earmarked to organisations that focus on reproductive health (approximately US

Disability and sexuality: claiming sexual and reproductive rights

575 million in 2016), but to all global health assistance “by all departments or agencies” – an estimated US

Care with dignity in humanitarian crises: ensuring sexual and reproductive health and rights of displaced populations

9.5 billion. Given the weight of US international aid, the reenactment of the Global Gag Rule will come at a heavy cost, and will undoubtedly have an impact on services worldwide and, by extension, on women’s health, well-being and human rights. To illustrate with one example of an international actor on the SRHR landscape: Marie Stopes International estimates that without alternative funding, the loss of their services due to the imposition of the Global Gag Rule could result in 6.5 million unintended pregnancies, 2.1 million unsafe abortions, and 21,700 maternal deaths by 2020. During Global Gag Rule years under President George W. Bush, other documented impacts include staff lay-offs, disruptions of referral systems, clinic closures, and contraceptive and condom supply shortages amongst some of the world’s most vulnerable populations. The negative implications of the Global Gag Rule extend far beyond access to safe abortion information and services. In much of sub-Saharan Africa, the US Government provides significant funding for HIV prevention and treatment services through organisations that also provide sexual and reproductive health information and services, including in relation to abortion. Many organisations, particularly in lowand middle-income countries, provide a range of health services under one roof, including access to contraceptives, HIV services, sexual and reproductive education and counselling, immunisations, and maternal health screenings, alongside information or access to safe abortion care. Thus, the policy also has the potential to affect much broader public health programmes, including responses to the HIV epidemic, the Zika virus and other infectious diseases. In fact, the Global Gag Rule stands to reverse global progress in promoting integrated EDITORIAL

Sexuality and older people: a neglected issue

More than 15% of the world’s population are affected by disability, including physical and sensory impairments, developmental and intellectual disability and psychosocial disability. While it goes without saying that people with disability have equal rights to sexual and reproductive desires and hopes as non-disabled people, society has disregarded their sexuality and reproductive concerns, aspirations and human rights. People with disabilities are infantilised and held to be asexual (or in some cases, hypersexual), incapable of reproduction and unfit sexual/marriage partners or parents. The sexual and reproductive health and rights (SRHR) of people with disabilities continue to be contested, and there are particular concerns in relation to women with disabilities. For women, disability often means exclusion from a life of femininity, partnership, active sexuality and denial of opportunities for motherhood. Analysis of the United Nation Convention on the Rights of Persons with Disabilities negotiations at the beginning of the twenty-first century demonstrates how sexual rights were downgraded to focus on family life, resulting in nomentions of sexuality, sexual agency or non-hetero-patriarchal identities. However, activism has resulted in positive changes at regional level. For instance, the ASEAN Incheon Protocol proposes strong advocacy for SRHR. In negotiating the Sustainable Development Goals, activism achieved limited impact. Whilst disability is listed within some articles: education, growth and employment, inequality, physical accessibility, data collection and monitoring, they leave out any specific article on disability itself. For a long time SRHR have been largely overlooked, including by the disability rights movement, and neglected in policy, planning and service delivery by social, health and welfare services. This follows an initial long silence in the early days of disability activism, where SRHRs were seen as lying within the private sphere. Debates and campaigns addressing the SRHR of people with disabilities are now increasingly common and of public relevance. They are frequently fronted by statements that imply a commonality of global experience for people with disabilities in the failure of society to recognise them as sexual beings. Nevertheless, societies are moving at different rates in recognising SRHR of people with disabilities, with organisations in countries as diverse as India and Australia pushing the debate forward. As people with disabilities gain increasing agency and control in other areas of their lives, like education and employment, it is essential to better understand the context and outcomes of demands for choice and agency over sexuality and relationships. Debates and campaigns are emerging, recognising people with disabilities as sexual beings with equal rights to aspirations for sexual pleasure, intimacy, love, friendship, relationships and sexual and reproductive choices. Inter-movement coalitions and alliances between gender and disability rights activism are playing an important role in making these issues visible. Feminist and sexual rights organisations are actively promoting this inter-movement dialogue and collaboration in their advocacy and research work. While disability, sexuality and reproductive rights have gained significant visibility in research, policy and activist discourses in the high-income regions of the world, it is only now taking shape in public debates in many lowand middle-income countries. This is in part due to the small-scale action research funded and led by organisations in high-income countries. Much of this action research combines exploratory research with pilot interventions focussing on changing perceptions, raising awareness and sensitising key stakeholders in the community. Often, such efforts are guided by key questions such as: how are sexuality and reproduction of people with disabilities understood at the local level by people with disabilities EDITORIAL

Addressing disrespect and abuse during childbirth in facilities

Each year, the number of people affected by humanitarian emergencies continues to increase, and the contexts become more complex, requiring thoughtful, intentional innovation and the creation of an evidence base that informs programme design, implementation and practice. In 2015, the numbers of people forcibly displaced from their homes hit a record high, with a 75% increase in two decades, rising from 37.3 million in 1996 to 65.3 million by the end of 2015. This translates to 24 persons being displaced from their homes every minute of every day in 2015, as a result of persecution, conflict, generalised violence or human rights violations. This trend is expected to continue. In addition, there were 19.2 million new displacements associated with natural disasters in 113 countries. The right to sexual and reproductive health (SRH) is an indispensable part of the right to health and is dependent upon a number of factors that include availability and accessibility to quality evidence-based services. While entire populations benefit from access to SRH services and rights, women and adolescent girls face a host of particular vulnerabilities. It is estimated that around 26 million women and girls of reproductive age are living in emergency situations around the world and face increased threats to their sexual and reproductive health and rights (SRHR), requiring access to quality services. While services such as food aid, shelter, water and sanitation, security and basic health services are crucial in the early stages of a humanitarian crisis, the provision of reproductive health services has been recognised as an additional priority early in an emergency. Commendable progress has been made to make SRHR services available since the mid-90s, when a landmark report highlighted the lack of comprehensive SRH care among populations in crises. This state of affairs triggered the 1995 formation of the Inter-agency Working Group on Reproductive Health in Crises (IAWG), a network of organisations dedicated to addressing the gaps in the provision of SRH services to communities affected by conflict and disaster. For more than two decades, organisations and individuals affiliated to IAWG have made concerted efforts to advance reproductive health through advocacy, research, standard setting and guidance development. To this end, major strides have been made, although much more remains to be done. In 2008, Reproductive Health Matters (RHM) dedicated a journal issue to the theme of conflict and crises, a well-timed issue that shed light on the devastating implications of conflict and crises on women and girls, highlighted ongoing response efforts and identified the unmet SRHR needs of populations in these fragile settings. Nearly 10 years later, with record numbers of people facing crises and displacement, it is once again time to draw attention to advances made, share best practices and discuss challenges in service implementation in crises and protracted humanitarian settings. A global evaluation conducted from 2012 to 2014 revealed that while considerable advances have been made, some of the concerns raised and gaps identified in RHM’s 2008 issue still ring true today. Building on previous work, the articles published in this journal issue cover a range of complex and sensitive topics such as safe abortion care, gender-based violence, sexual violence against men and sex work among refugees. Studies also address quality improvement and training of health workers with the aim of improving practice and care for better maternal and newborn health outcomes. EDITORIAL

Gendered bodies and reproduction in the Arab countries and Turkey

Globally, life expectancy has been rising rapidly over the course of the last century, thanks to technological advances in medicine, rises in public health expenditure, overall socioeconomic develo...

Sexual rights and bodily integrity as human rights.

Global policy attention to maternal health only began in the mid-twentieth century, and has had a controversial past. While the promotion of maternal and child health and welfare was included in the World Health Organisation’s (WHO) Constitution (Article 2(l)) in 1948, international cooperation for maternal health began seriously only in the mid-1960s. In the 1970s and 1980s, instrumental rather than intrinsic rationales for maternal health came to the fore. As pointed out in Rosenfield and Maine’s influential paper, “Maternal mortality – a neglected tragedy. Where is the M in MCH?”, child health was the engine driving attention to pregnant women, not women’s own health, let alone human rights. More questionably, family planning programmes in this period typically used prevention of maternal mortality as a key justification for their aggressive expansion and intensification. Even where women’s own health gained intrinsic attention, much of it was technical and medical, focusing, for example, on the relative importance of antenatal versus intrapartum care, the best methods for reducing micronutrient deficiencies in pregnancy, and the role of traditional birth attendants in maternal care. It was the push by feminists for sexual and reproductive health and rights (SRHR) at the International Conference on Population and Development in 1994, preceded by almost two decades of mobilisation, that brought women’s human rights to the centre of maternal health. Alongside the technical controversies, there arose political contention about the impact of gendered and intersecting power structures, and the deeper societal roots of sexual and reproductive ill-health, and violations of human rights. Feminist concerns were many. They included, among others, the physical and mental health effects of early marriage, female genital cutting and mutilation, intimate partner violence during pregnancy, maternal ill-health and deaths due to unsafe abortion, and unavailability and inaccessibility of health services, especially for poor marginalised women. Debates at and around ICPD laid the basis for greater attention to sexual and reproductive rights and wrongs, including in the context of pregnancy. Mistreatment, abuse and violations of girls’ and women’s human rights during pregnancy and childbirth are all too common and occur in households, communities, work-places and in health and other institutions. This Special Issue focuses specifically on what happens when pregnant women approach health institutions to deliver babies. Its importance derives from recent policy drives in lowand middle-income countries (LMICs) to increase the number of institutional births. Unfortunately, as the papers in this Special Issue argue, disrespect and abuse of women in the maternal care provided by health institutions is wide-spread. Far too often, and especially if they are poor or otherwise marginalised and oppressed, women suffer violations of their dignity, unnecessary procedures, harmful practices, and physically and psychologically abusive treatment. In the 1980s and 1990s feminists in Latin America, responding to excessive medicalisation of maternal care in the region had begun calling to humanise childbirth in institutions and to prevent obstetric violence. EDITORIAL

Knowledge, evidence, practice and power.

The Middle East has been a hub of geopolitics since the end of the Cold War and the site of near-constant interand intra-state conflicts. Despite the growing interest in the region as a result of these conflicts, reporting – whether academic or journalistic – has often focused on political authoritarianism and radical religious movements. Given these preoccupations, discourses on health, well-being and gender relations have too often been framed in macro-level terms with insufficient attention to context. Moreover, these trends have combined with the enduring influence of Orientalism to produce a depiction of Middle Eastern women as lacking in agency and in need of defence by Western actors. At the same time, their health and wellbeing have been too often assessed in terms of decontextualised aggregate indicators employed by international and other agencies. Such reports have singled out the Middle East, for example, for its seemingly belated decline in fertility; the low uptake of essential health services; the high prevalence of obesity and non-communicable diseases among women; or the exceptionally low levels of female labour force participation despite rising educational access. Yet, nowhere in these macro-level descriptions are the perspectives of Middle Eastern women taken into account, including their perceptions of their own health, of the health care offered to them, and of how they manage the everyday challenges of maintaining their own or their households’ well-being in the context of growing poverty and inequality, and above all, regional turmoil. This supplement is the first collective product of the work of members of a research network encompassing the Arab region and Turkey, the Reproductive Health Working Group (RHWG), that has been active for nearly three decades. Since its founding in 1988 as a small, multidisciplinary research group, it has provided a platform for the voices of researchers living in or working in the region addressing gender, well-being and the health of women, men and young people from multiple geographic, disciplinary and other perspectives. They have done so despite multiple practical, bureaucratic and political constraints and often amidst political conflict and instability. The idea for this supplement grew out of a conversation among the network’s regional governing committee over lunch in the mountains of Lebanon, as the group struggled with the fact that the interesting and timely research presented at the network’s annual meetings does not always get published in international, peerreviewed journals. This supplement aims to provide a dissemination forum for research presented at these meetings and to highlight complementarities among the individual studies. Recognising that several of the authors are students or recent graduates who are relatively new to publication, authors of each paper were assigned a mentor from the network who could provide support and constructive comments before submission. Papers particularly relevant to RHM were selected from among many presented over the network’s 30-year history. Thus, papers included in this supplement have been presented at RHWG annual meetings, or, in some cases, have been supported by RHWG “seed grants” and all have been supported by a mentor from the network. The articles that are included in this supplement can be broadly organised into themes that have also been recurrent at the RHWG’s regular network meetings. The history of the network since its inception is presented in the paper authored by EDITORIAL

The gendered system of academic publishing

Sexuality is a political struggle and, as one of the authors in this issue reflects, it is caught between “repression and danger on the one hand and exploration, pleasure and agency on the other” (Muhanguzi). Although sexuality can be deemed intimate and personal, it is often subject to power relations in both the private and public domains, and is highly politicised. Human rights standards have been applied by authoritative human rights bodies to a wide range of sexuality and sexual health-related matters to form the content and meaning of sexual rights, and the public health benefits of respecting and fulfilling these rights are indisputable. Yet, political negotiations on matters related to sexuality and sexual health remain contentious and polarised. This issue of RHM focuses on sexuality, sexual rights and sexual politics, offering a wide range of analysis, perspectives and evidence that highlight the nexus between sexual health and human rights and deepen our knowledge about the challenges and opportunities for individuals of any sexual orientation or gender diversity to achieve the highest attainable level of sexual health.