The State of World Population 2000 Chapter 2: Gender and Health

United Nations Population Fund

Gender inequality and discrimination harm girls' and women's health directly and indirectly, throughout the life cycle; and neglect of their health needs prevents many women from taking a full part in society. Unequal power relations between men and women often limit women's control over sexual activity and their ability to protect themselves against unwanted pregnancy and sexually transmitted diseases including HIV/AIDS; adolescent girls are particularly vulnerable.

Mark Edwards/Still Pictures
Mark Edwards/Still Pictures
Cuban teacher shows how to use a condom. Young people need access to reproductive health information and services.

Box 6: Discrimination against Girls: A Matter of Life and Death

Inadequate reproductive health care for women results in high rates of unwanted pregnancy, unsafe abortion, and preventable death and injury as a result of pregnancy and childbirth. Violence against women, including harmful traditional practices like female genital mutilation, takes a steep toll on women's health, well-being and social participation. Violence in various forms also reinforces inequality and prevents women from realizing their reproductive goals (see also Chapter 3).

Men also have reproductive health needs, and the involvement of men is an essential part of protecting women's reproductive health.

Reproductive Health Services Help Empower Women

Providing quality reproductive health services enables women to balance safe childbearing with other aspects of their lives. It also helps protect them from health risks, facilitates their social participation, including employment, and allows girls to continue and complete their schooling.

The ICPD Programme of Action recognizes the important relationship between gender and reproductive health, and the 1999 ICPD+5 review underscored this connection. The agreement on key future actions stressed, "A gender perspective should be adopted in all processes of policy formulation and implementation and in the delivery of services, especially in sexual and reproductive health, including family planning."1

Reproductive health does not affect women alone; it is a family health and social issue as well. Gender-sensitive programmes can address the dynamics of knowledge, power and decision-making in sexual relationships, between service providers and clients, and between community leaders and citizens.2

A gender perspective implies also that institutions and communities adopt more equitable and inclusive practices. Clients must be listened to and involved in the design of programmes and services. As the primary users of reproductive health services, women have to be involved at all levels of policy-making and programme implementation. Policy makers need to consider the impacts of their decisions on men and women and how gender roles aid or inhibit programmes and progress towards gender equality.

Universal access to sexual and reproductive health care was a central objective of the ICPD. The ICPD+5 review agreed that progress towards this goal should be measured by monitoring the provision of services.

Box 7: Benchmark Indicators Adopted at the ICPD+5 Review

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Components of Reproductive Health Care

Family Planning

At ICPD+5, governments agreed to redouble efforts to find the resources needed to implement the ICPD Programme of Action. They recognized the importance of providing the widest possible range of contraceptive methods, including offering new contraceptive options and promoting underutilized methods.

The new benchmarks on closing the gap between the proportion of individuals using contraception and those expressing a desire to space or limit their families represent a significant challenge. About one third of all pregnancies — 80 million a year — are believed to be unwanted or mistimed.3 Over the next 15 years the number of contraceptive users in developing countries is projected to increase by more than 40 per cent, from 525 million to 742 million, as population continues to grow, programmes expand and an increasing proportion of couples want to practise contraception.4

Social and cultural factors, including gender norms, condition women's reproductive intentions — that is, the number of children they want and how they want their births spaced. If women could have only the number of children they wanted, the total fertility rate in many countries would fall by nearly one child per woman. The fewer children women want, the more time they spend in need of contraception, and the more services are required.

Women do not always get the support they need to fulfil their reproductive intentions. In some settings, fearing reprisal from disapproving husbands or others, many resort to clandestine use of contraception.5 Women interviewed in a five-year Women's Studies Project, carried out in eight countries by Family Health International, said that to attain their family planning objectives, they needed supportive partners, adequate information, unobtrusive methods and respectful services.6

Most modern contraceptives rely on women to initiate and control their use: oral contraceptives, intra-uterine devices (IUDs), diaphragms, cervical caps and injectables have no counterpart methods for men. Among the 58 per cent of married couples practising contraception worldwide, less than one third rely on a method requiring male participation (condom and vasectomy) or cooperation (rhythm and withdrawal). In less developed regions, nearly two thirds of contraceptive users rely on female sterilization or IUDs.7

The female condom is proving popular in many places where it has been introduced in recent years. However, in many countries, even where HIV/AIDS prevalence is high, condom use remains relatively low.

Periodic abstinence and withdrawal, to be used effectively, place demands on users which many find difficult, and there is widespread misinformation about proper use.8 Even committed and informed users experience higher levels of unwanted pregnancies than those using other methods.

Good family planning programmes share several characteristics:9

  • Government support is strong;
  • Providers are well trained, sensitive to cultural conditions, listen to clients' needs, and are friendly and sympathetic;
  • Services are affordable and a choice of contraceptive methods is available (a full range of modern methods includes oral contraceptives, IUDs, injectables, implants, male and female condoms, emergency contraception and voluntary sterilization);
  • Counselling ensures informed consent in contraceptive choice;
  • Privacy and confidentiality are ensured;
  • Facilities are comfortable and clean;
  • Service is prompt.

Since the ICPD, many countries — among them Bangladesh, Brazil, Burkina Faso, Côte d'Ivoire, Egypt, Ghana, India, Indonesia, Jamaica, Jordan, Mexico, Morocco, Nepal, Pakistan, Peru, the Philippines, Senegal, South Africa, Sri Lanka, Uganda, the United Republic of Tanzania and Zambia — have acted to expand services beyond family planning to care for women's and men's broader reproductive health needs.10

Safe Motherhood

Ninety-nine per cent of the approximately 500,000 maternal deaths each year are in developing countries, where complications of pregnancy and childbirth take the life of about 1 out of every 48 women. It is not uncommon for women in Africa, when about to give birth, to bid their older children farewell. In the United Republic of Tanzania, mothers have a saying: "I am going to the sea to fetch a new baby, but the journey is long and dangerous and I may not return."11 In some settings, as many as 40 per cent of women suffer from serious illness following a birth.12

Infants and children also suffer as a result of poor maternal health. The same factors that cause maternal mortality and morbidity, including complications and the associated poor management of pregnancy and childbirth, contribute to an estimated 8 million stillbirths and newborn deaths each year. Tragically, when a mother dies, her children are also more likely to die. A study in Bangladesh found that if a woman dies after delivery, her newborn infant is almost certain to die. Another study in Bangladesh found that children up to age 10 whose mothers die are 3 to 10 times more likely to die within two years than are children with living parents.13 In the United Republic of Tanzania, children whose mothers died were likely to have to leave school to take on household tasks.14

Avoiding unwanted pregnancy through family planning reduces maternal mortality. So does antenatal care: only 70 per cent of births in the developing world are preceded by even a single antenatal visit. Each year, 38 million women receive no antenatal care. Only about half of all pregnant women receive tetanus injections; tetanus currently kills more than 300,000 children under age 5 each year.

It is also important to ensure that someone with midwifery training is present at every delivery. In the developing countries, only 53 per cent of all births are professionally attended.15 This translates into the neglect of 52.4 million women each year.

Figure 2: Percentage of Births with Skilled Attendants, by Subregion

The primary means of preventing maternal deaths, however, is to provide access to emergency obstetric care, including treatment of haemorrhage, infection, hypertension and obstructed labour. Life-saving interventions, such as referral to medical centres, antibiotics and surgery, are unavailable to many women in the developing world, especially in rural areas. Four common problems greatly increase women's risk in childbirth: delays in recognizing a developing problem, delays in deciding to act, delays in arranging transport and delays in reaching services. A community-based system for ensuring rapid transport to an equipped medical facility is crucial to save mothers' lives.

Post-partum care is especially important. Of women who die of pregnancy-related causes, 24 per cent die during pregnancy; 16 per cent during delivery; and 61 per cent after delivery, from post-partum haemorrhage, hypertensive disorders and sepsis.16 Community health workers can be trained to detect and treat post-partum problems, as well as to counsel on breastfeeding, infant care, hygiene, immunizations, family planning, and maintaining good health.

Box 8: Honduras Reduces Maternal Mortality

Communities are organizing to prevent mothers from dying in childbirth. Education efforts stress the importance of prompt reporting to health centres when complications arise. The Prevention of Maternal Mortality Network has introduced measures to improve safe motherhood services in parts of Africa. Improved quality in other aspects of health care has led to increased use of facilities for high-risk deliveries.

In Juaben, Ghana, a blood bank and an operating theatre were established at a community health centre. Midwives were trained in life-saving skills and given a central role in the delivery of services. The number of women coming in for care almost tripled, while the proportion referred to higher levels in the health system declined.17

Some communities in Africa offer self-financing transportation schemes for safe motherhood.18 Indonesia is experimenting with social insurance programmes to cover the cost of emergency obstetric care.19

Safe motherhood experts contend that more emergency obstetric care could be provided without large amounts of additional resources, by improving services already covered in hospitals and some health centres.20

Abortion and Post-abortion Care

Each year, women undergo an estimated 50 million abortions, 20 million of which are unsafe; some 78,000 women die and millions suffer injuries and illness as a result. At least one fourth of all unsafe abortions are to girls aged 15-19.21

The ICPD recognized abortion as an important public health issue, and called on governments to reduce unwanted pregnancies and prevent abortion by increasing access to family planning services. "In circumstances where abortion is not against the law," the Programme of Action states, "such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion."22

The Platform for Action of the Fourth World Conference on Women called on governments to "consider reviewing laws containing punitive measures against women who have undergone illegal abortions".23

Box 9: The Toll of Abortion

At the ICPD+5, governments agreed that to reduce the maternal deaths caused by unsafe abortion, "in circumstances where abortion is not against the law, health systems should train and equip health service providers and should take other measures to ensure that such abortion is safe and accessible."24

Effective post-abortion care would significantly reduce maternal mortality rates by as much as one fifth in many low-income countries.25

A number of countries, particularly in Africa and Latin America, are focusing on reducing the health impact of unsafe abortion by providing post-abortion care. This effort involves strengthening the capacity of health institutions to offer: emergency treatment for complications of spontaneous or unsafely induced abortion; post-abortion family planning counselling and services; and links between emergency post-abortion treatment and reproductive health care.26 Countries such as Ghana have trained midwives and other providers to offer post-abortion care.

Some countries have promoted the use of manual vacuum aspiration to treat incomplete abortion; this method has proven safer, more cost-effective and acceptable than curettage.

Sexually Transmitted Diseases, Including HIV/AIDS

HIV/AIDS continues to be a critical public health issue, particularly in Africa, which is facing the worst effects of the epidemic. HIV/AIDS is now the leading cause of death in Africa and the fourth most common cause of death worldwide. At the end of 1999, 34.3 million men, women and children were living with HIV or AIDS, and 18.8 million had already died from the disease. In 1999, there were 5.4 million new infections worldwide; 4.0 million were in sub-Saharan Africa; and around 1 million were in South and South-east Asia, where prevalence is increasing rapidly in some countries.27

The AIDS pandemic is causing untold suffering in individuals, families and societies. By the end of the year 2000, an estimated 13.2 million children, most of them in Africa, will have lost their mothers or both of their parents to AIDS.28 Women are rapidly reaching and surpassing the number of men infected with HIV. In Africa, HIV-positive women now outnumber infected men by 2 million.

Box 10: AIDS Is Now the Number One Killer in Africa

Because of culture as well as biology, women are more vulnerable to STDs than men. The burden of disease for women from STDs excluding AIDS is more than three times higher than for men.29 Anatomical differences make reproductive tract infections more easily transmissible to women but more difficult to diagnose. STDs are more frequently asymptomatic in women than in men, and when symptoms do occur in women, they are more subtle. Because of their lower social status and their economic dependence on men, women may be unable to negotiate the use of condoms as an STD-prevention measure.30

Studies by the International Center for Research on Women illustrate the critical role of gender and sexuality in influencing sexual interactions and men's and women's ability to practise safe behaviours. The studies, conducted in 10 countries in Africa, Asia and Latin America and the Caribbean, help define complex concepts like gender, sexuality and power. They also highlight the importance of increasing women's access to information and education, skills, services and social support in order to reduce their vulnerability to HIV/AIDS and to improve their reproductive health outcomes.31

Recognizing that the HIV/AIDS pandemic is far more serious than had been understood at the ICPD, the ICPD+5 document reiterates the importance of providing access to male condoms, calls for wide provision of female condoms, and urges governments to enact legislation and adopt measures to prevent discrimination against people living with HIV/AIDS and those vulnerable to HIV infection. The document calls on governments, where feasible, to make anti-retroviral drugs available to women during and after pregnancy, and to provide counselling so that mothers living with HIV/AIDS can make free and informed decisions about breastfeeding.32

Reproductive health programmes can reduce levels of STDs, including HIV/AIDS, by providing information and counselling on critical issues such as sexuality, gender roles, power imbalances between women and men, gender-based violence and its link to HIV transmission, and mother-to-child transmission of HIV; distributing female and male condoms; diagnosing and treating STDs; developing strategies for contact tracing; and referring people infected with HIV for further services.

The ICPD advocated the integration of family planning and STD/HIV/AIDS services within reproductive health services. Integration of these components is considered a potentially cost-effective way to reach sexually active women and their partners with information and services that can help prevent and treat infections. However, a study based on situation-analysis findings from several countries in Africa found insufficient infrastructure on which to base the promotion of clinic-based, integrated family planning and STD services.33 Many family planning clinics were not equipped to offer STD services, and the staffs were not sufficiently trained. Other studies have also cited the lack of conclusive evidence of the benefits of integrating family planning and STD services.34

Though health workers do not generally receive sufficient training and support to provide STD/HIV/AIDS information and services, case studies in Burkina Faso, Côte d'Ivoire, Uganda and Zambia found that providers were willing to discuss sexuality and STDs with clients and could understand the need to identify individuals at risk of sexually transmitted infections.35

In the Philippines, UNFPA and the Women's Health Care Foundation are working together to improve access to reproductive health services with trained community health workers, street youth and street vendors. The Foundation provides STD/HIV/AIDS clinical services, including referrals for testing, and conducts education and counselling sessions for urban poor women and female sex workers. UNFPA supports training service providers and volunteer health workers in counselling and community education, and has funded a telephone hotline to answer questions on STDs and sexuality.36

The newly formed International Partnership against AIDS in Africa is working to build on existing global, regional and national structures to address the devastating effects of AIDS in Africa.37 In mid-1999, finance ministers and other leaders from more than 20 African countries expressed their support, and about a dozen bilateral development agencies agreed to mobilize more resources to back the Partnership. Various NGOs have also agreed to play an active role. The Partnership is strengthening national programmes by: encouraging visible and sustained political support; helping to develop nationally negotiated joint plans of action; increasing financial resources; and reinforcing national and regional technical capacity.

Half of all new HIV infections are in young people between ages 15 and 24.38 According to a 1997 Joint United Nations Programme on HIV/AIDS (UNAIDS) review, high-quality sex education helps adolescents delay sexual intercourse and increase safe sexual practices.39 Since the ICPD, support has been provided in 64 countries for the integration of HIV/AIDS prevention into in-school and out-of-school education programmes.

Uganda, for example, has taken a direct and comprehensive approach to addressing the problem of STDs and HIV/AIDS, in particular among young people; HIV prevalence rates among youth are now stabilizing. In Swaziland, the Swaziland Schools HIV/AIDS and Population Education Programme (SHAPE) was launched in 1990 to prevent the spread of HIV/AIDS and to reduce pregnancy in school pupils aged 14 to 19. In 1997, the programme was introduced in primary schools. The programme has improved knowledge and attitudes more than behaviour.40

At ICPD+5, governments agreed that youth (aged 15-24) are at high risk of HIV infection, and set goals for reducing prevalence in this age group (see Box 7).

Box 11: Sri Lanka Succeeds in Promoting Women's Health

Female Genital Mutilation

Many societies in Africa and Western Asia practise FGM, often referred to as female circumcision. Worldwide, some 130 million girls and young women have undergone this dangerous and painful practice, with an additional 2 million at risk each year.

FGM is practised in about 28 countries in Africa — where the prevalence varies widely, from 5 per cent in the Democratic Republic of the Congo to 98 per cent in Somalia — and in the Arabian Peninsula and the Gulf region. It also occurs among some minority groups in Asia, and among immigrant women in Europe, Canada and the United States

FGM refers to the removal of all or part of the clitoris and other genitalia. Those who perform the more extreme form, infibulation, remove the clitoris and both labia and sew together both sides of the vulva. This leaves only a small opening to allow passage of urine and menstrual blood. Infibulation accounts for an estimated 15 per cent of all cases of FGM, and 80-90 per cent of cases in Djibouti, Somalia and the Sudan.

Other, less extreme, forms involve removing all or part of the clitoris (clitoridectomy), or the clitoris and inner lips (excision). About three quarters of all young girls subjected to this degrading procedure have undergone one or another of these less radical forms.41

This terrible violation of girls' and young women's human rights is based on prevailing beliefs that female sexuality must be controlled, and the virginity of young girls preserved until marriage. Men in some cultures will not marry uncircumcised girls because they view them as "unclean" or sexually permissive.42

Genital mutilation is nearly always carried out in unsanitary conditions without anaesthetic. It is also extremely painful and may result in severe infection, shock or even death. If the girl survives, she may experience painful sexual intercourse, degrading the quality of her life.43 The reduction of a woman's sexual experience by FGM is both a physical and mental health problem for women and an impediment to the development of deeper and more satisfying relationships between the partners.

The immediate health risks of FGM include haemorrhage of the clitoral artery, infection, urine retention, and blood poisoning from unsterile, often crude, cutting implements. Later complications are mainly due to the partial closing of the vaginal and urethral openings, which trigger chronic urinary tract infections, repeated reproductive tract infections and back and pelvic pain. Particularly where the more drastic forms of this practice have been carried out, the girl will be at increased risk of experiencing a difficult delivery and dying in childbirth.

In some cases, FGM can lead to sterility. A study carried out in the Sudan found that women who had undergone FGM were twice as likely to be infertile as women who had not.44 This is due to pelvic inflammatory disease caused by repeated infections as a result of the retention of urine or menstrual blood that spread throughout the reproductive tract, causing inflammation and scarring of the fallopian tubes. In traditional societies, infertility is a particularly devastating condition, since a woman's worth in many of these cultures is measured by her ability to bear children.45

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Reproductive Health Programme Issues

Public Health Concerns

Improving women's and men's reproductive health requires a community-oriented public health approach, emphasizing prevention. Poor reproductive health is directly related to gender-based inequality in the distribution of social power and resources.

Community involvement can help to counter this — by ensuring that men and women are equal partners in social and economic development, and that women's voices are heard along with men's voices in the community,46 by ensuring that girls as well as boys are raised in healthy environments and have equal opportunities to go to school and to develop physically before they take on the role of parenthood; by guaranteeing women's rights to live free of sexual coercion and the threat of violence, and to have sex without the fear of infection and unwanted pregnancy; and by providing all women with access to safe pregnancy care, including emergency obstetric care if their pregnancies or deliveries face trouble.

Figure 3: How Often Couples Have Discussed Family Planning

Although reproductive health is not part of every country's essential services package, Bangladesh, India, Mexico, Senegal, South Africa, Uganda and Zambia, among others, include it. For example, Bangladesh's package includes maternal health (antenatal, delivery, and post-natal care, menstrual regulation, and post-abortion complication care); adolescent health; family planning; management and prevention/control of reproductive tract infections, STDs and HIV/AIDS; and child health.47

Cultural Restrictions Limit Choice

Beliefs about appropriate behaviour can reduce access to health information and care and impair its quality. Direct taboos and indirect restrictions deter women from discussing their health needs and risks, while women who cannot read or readily associate with others have difficulty finding health information.

These restrictions mean that women are dependent on the decisions of others about medical attention; whether to delay or prevent pregnancy; have antenatal exams during pregnancy; arrange for a skilled delivery attendant; or obtain transport in an obstetric emergency.

It can be difficult for women to raise reproductive health concerns: topics such as menstrual bleeding irregularities are especially hard to discuss. Women may be unable to get their problems addressed until their conditions are serious and treatment options are more restricted or costly.

Couples and families who discuss family planning are more likely to use the services. Where discussion is proscribed, some women will resort to covert use. Even when "covert use" is really a shared secret, this restriction inhibits close and supportive relationships. Whether mutually agreed or covert, the choice of contraception can be affected by cultural rules and preferences.

Quality programmes recognize and are responsive to cultural understandings. Programme developers are becoming more sensitive to the need to work within the cultural context of client's lives. A programme in Tunisia draws on the local custom of ending a new mother's seclusion on the 40th day after childbirth, to provide post-partum and family planning services to women and neonatal care for infants in a single clinic visit.48 A study in 1987 found that 84 per cent of mothers came in for the 40th-day visit, and 56 per cent of these women began to use a method of contraception.

Professional Roles and Gender Roles

It is hard for women to discuss their reproductive health needs frankly with male professionals, for reasons of both gender and status. Women service providers may be easier to talk to, but there is still a difference in status, especially for poor women. Moreover, certain procedures (for example, IUD insertion or pill prescription) may be restricted to doctors, who are usually men.

Where cultural rules forbid men (even physicians) from directly examining women patients, the quality of care suffers greatly.

Men are frequently unwilling to go to public clinics for reproductive health services since they are defined as "women's places", largely used by women for maternal and child health services. Where possible, having a separate space for men (for example, a separate entrance, waiting area and cashier with shared staff) even within a joint facility can increase use.49 Integration of STD/AIDS-prevention and treatment activities with family planning programmes can also help make clinics more male-friendly.

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Adolescent Reproductive and Sexual Health and Behaviour49a

Young men and women face different social pressures affecting their ability to approach sexuality responsibly. Boys often face pressure to become sexually active to prove their manhood and be accepted by their friends.50 Girls may face pressure not to seek information about sexual matters for fear of being thought "loose", or alternatively to have sexual intercourse in return for benefits.

Box 12: Sexual Activity Differs among Young Men and Women

Pressures on young people also come from within. They wish to become men or women and so may pattern their behaviour on male and female stereotypes learned from the media, adults and their peers. Following these gender stereotypes can result in risky behaviour.

For example, young men who believe strongly in male stereotypes have more sexual partners, a lower level of intimacy with partners, a higher level of adversarial sexual beliefs, lower consistency of condom use, and a higher concern about condoms reducing male pleasure. They also put less value on partner appreciation of condom use, feel a lower level of responsibility for preventing pregnancy, and have a greater belief that pregnancy validates masculinity.51

In Mexico and the United States, adolescent girls who sought contraceptive methods had a weaker association with traditional female sex roles than similar girls who became pregnant.52 In Thailand, Zimbabwe and many other places, the admired stereotype of quiet, innocent "good" girls prevents girls from negotiating condom use.53

Both boys and girls often share beliefs in a double standard that can lead to poor reproductive health behaviour. Many surveyed adolescents in India and Thailand supported multiple sexual partners for males but not for females, and premarital sexual intercourse for males but not for females.54 Often both adolescent males and females reported that young men who did not initiate and control sex were weak — an attitude that sometimes leads boys to coerce girls into sexual relations.55

Parents need to be more involved. Parents say they would like their children to be taught about sex, but most fail to do so. Many feel ill-informed or embarrassed talking about the subject, and they fear being asked a question they cannot answer.56

Figure 4: Percentage of All Births to Women under Age 20, by Region/subregion

Girls do talk with their mothers about menstruation and pregnancy but rarely about communicating with a sexual partner. Boys receive even less information from their parents, certainly not as much as they would like.57 Fathers are often silent or absent and thus provide an uncaring male role model. Indeed, a study from Zimbabwe reported that fathers were "frequently absent from the home environment and were usually viewed as remote, fearsome, moody, and unpredictable people whom it is safest to avoid."58

Social and sexual inequalities learned during childhood and adolescence increase girls' vulnerability to pregnancy and HIV infection because they cannot negotiate safe sex as equals in a relationship.59 Girls are also at greater risk than boys of sexual abuse and physical violence from a partner.

Young married women may be at a particular disadvantage. Young brides who would prefer to wait before having children may find that their husbands, families, even some health providers will not give them contraceptives until they have a child.60 Where women are dependent on their husbands, they may also lack the power to negotiate safe sexual practices.61

Programmes Can Help Change the Rules

These attitudes can change and programmes can help. Of course, programmes are only one of many factors that influence gender norms, but they are a place to start.

Sometimes simply calling attention to unequal gender norms can lead to improvements. At local fairs in India, the Centre for Health Education, Training and Nutrition Awareness presented dramas that illustrated how assumptions that women should not travel without permission and should do all the housework could interfere with families' getting good health care. Local leaders commented that they had never thought about these issues and strongly supported changes that gave women more freedom.62

Helping young people become aware of their gender assumptions can lead to better cooperation. In Thailand, the Bangkok Fights AIDS Project used focus groups of young men and women to discuss condom use. They found that Thai men and women viewed sex differently. While the girls wanted romance, the boys wanted sexual intercourse and sometimes forced the girls to have unprotected sex. Based on their findings, the project printed separate pamphlets for young men and women. Each pamphlet included a description of what the other sex wanted and expected as well as ways to talk about these issues.63 The pamphlets were so popular that other projects bought thousands of copies.

Some programmes look at young people who do have good communication and cooperation skills to see what they are doing right. In Brazil, some boys do not act according to the prevalent cultural stereotypes of aggressive, uncommunicative males. These boys all had a relative or friend who set an alternative example. Boys who could reflect on their lives or who were seen as competent in some realm of their lives — school, work, sports or music — were better able to ignore traditional male stereotypes. Programme responses might include working with young men to reflect on their actions, offering them mentors who promote safe sex, providing them with skills, and helping them to question traditional role models.64

Box 13: Gender Norms Can Prevent Safe Sex

The experience of past programmes indicates that young people need programmes that are accessible, non-judgemental, and responsive to what young people want.65 Because there are so many kinds of youth — male and female, married and unmarried, sexually active and inactive — no single approach will suit them all.66 Although there should be separate efforts to meet the needs of boys and girls, having them listen to one another is epecially effective in facilitating open communication between partners.

Training young people to be peer educators can legitimize discussions of sexual responsibility. Young men meet others like them who speak easily and openly about sexuality and promote responsible behaviour as an attractive "male" quality. Being a peer educator can also allow girls to talk about sex without risking being called promiscuous.67

Programmes can meet the needs of young people at lower cost if they avoid treating adolescent sexuality as a medical issue. Many, perhaps most, young people need only information, life skills and sound advice. These needs can be met in the community settings that young people prefer. The resources will differ for boys and girls, young and old, and may include sports clubs, scouting groups, pharmacies and workplaces.68 Health services can support these efforts.69

Programmes also need to be directed at adults so that they do not prevent youth from practising sexual responsibility by limiting their access to information and health services. For example, health care personnel often refuse to treat young people who seek health care, parents fail to inform their children, and teachers omit material on sexual health.

In a Kenyan study, 71 per cent of parents reported having talked with their children about school work in the past year, but only 28 per cent had talked with them about sexual behaviour.70 Parents need to examine their own assumptions about gender and sexuality and decide whether these are the values they wish their children to have. Once parents recognize the importance of their own role in the education process, programmes can focus on providing information and helping parents develop approaches for talking with their children.

Parents are not the only adults who should be involved. The United Nations Children's Fund (UNICEF) in Uganda uses a broad definition of parents — all adults who care for children: mothers, fathers, grandparents, aunts, uncles, step-parents, guardians and family friends. Health workers, teachers, coaches and others who work with young people can also become effective sources of information for youth. As with parents, these adults need insight into their own assumptions as well as access to accurate information.

Several kinds of programmes teach inter-generational communication around sexuality. In Kenya, for instance, the Family Planning Association is testing a parent-centred model for expanding information and services to young people living in the town of Nyeri. Through the programme, parents are trained to be friends to their children, to provide adolescents and other parents with information, basic counselling and referrals. In addition, private and public providers are trained to receive referrals of those adolescents who need more advanced information, counselling or clinical care.71

Box 14: Gates Foundation Helps Protect African Youth against HIV/AIDS

UNFPA has supported several parent education projects in Africa and elsewhere. In Malawi, for example, one project is working to integrate parent education into a community-based training programme. In Egypt, a UNFPA-supported interregional project has successfully trained Muslim theologians to conduct non-formal education and counselling of parents on reproductive health, sex education and family planning. In Mexico, Gente Joven aims at improving inter-generational communication and developing among adults and parents a clear and positive attitude towards the sexuality of young people. The programme offers basic courses in sexual guidance for parents of youth 11-20 years old. The training was also provided for 110,000 youth promoters in 1991.

Policies Promoting Partnerships

Current social norms support withholding accurate information from young people, while popular culture glorifies and encourages sexual activity.72 Policy makers can help change these norms. They can pass and enforce laws that protect girls and boys from adult abuse and early marriage. Working with health professionals, they can give adolescents access to information, skills, and services if needed. They can support efforts to keep young people, especially girls, in school.

Most important, policy makers and political leaders can become new role models validating capable women and compassionate men. Through their actions, they can demonstrate that men and women can, and do, communicate and cooperate.

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Men's Reproductive Health Needs

While women are at higher risk of reproductive illnesses than men, men are also subject to sexually transmitted infections and suffer from other reproductive health problems such as impotence or infertility. The death or illness of their wives resulting from inadequate reproductive health care is also a burden affecting many men.

It has been estimated that more than 1.9 million disability-adjusted life years of men aged 15-59 will be lost each year to STDs, excluding HIV/AIDS, and another 16.8 million to HIV/AIDS itself.73 Infertility, frequently a consequence of untreated STDs, affects millions of men, but statistics are poor since male reproductive health is often not medically assessed and is under-studied.74

Men as well as women want to space their children or limit their family size, but their needs are not being met. In some developing countries, for example, between one quarter and two thirds of men say that they do not want to have any more children, but neither they nor their wives are using contraception.75

Reproductive health services directed towards men have concentrated on STD treatment and control. Efforts have also been made in many countries to provide information and services to military recruits.76 UNFPA- supported programmes in Bolivia, Ecuador, Nicaragua, Paraguay and Peru are generating greater awareness within the armed forces and police forces on the sexual and reproductive health of men, unequal gender relations and violence against women.77

The proportion of contraceptive use attributed to men (including condoms, withdrawal, periodic abstinence and vasectomy) has been falling in recent years. It has reached 26 per cent, a drop of 11 per cent since 1987 and 5 per cent since 1994.78 Vasectomy (male sterilization) is a safer and less invasive procedure than its female counterpart (tubectomy), but it is much less widely practised.

Potential users cite various reasons for finding particular methods unacceptable (for example, concerns about permanence or reversibility, interruption of spontaneity, adverse affects on libido or sexual performance). But these methods offer benefits: HIV prevention in the case of condoms, the permanence of many vasectomies, and financial cost-freedom for abstinence and withdrawal.

Information on avoiding pregnancy and preventing HIV/AIDS and other STDs is still limited among unmarried men in many countries. Sexually active unmarried men report some use of condoms (from 7 to 50 per cent in sub-Saharan Africa and from 27 to 64 per cent in Latin America).79 However, information gaps, embarrassment and provider reluctance block greater use.

Programmes to affect male attitudes and support for reproductive health including family planning, and to teach gender sensitivity80 have shown progress. Peer counselling programmes have been especially useful in addressing male adolescents.

The Planned Parenthood Federation of Ghana has increased men's interest in using contraception with an approach that combines media efforts with clinic staff outreach to promote a broad range of reproductive health concerns, including impotence and infertility.81

In Mexico and Colombia, peer counselling has increased acceptance of vasectomy. Training of counsellors and paramedical staff in Mexico has increased acceptance by 25 per cent, reducing reliance on female sterilization. In Turkey, counselling couples about vasectomy following an abortion has promoted acceptance and reduced recourse to abortion.

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Reproductive Health Needs of Migrants and Refugees

Attending the health needs, including the reproductive health needs, of people that normal infrastructure does not or cannot reach is a priority public health concern. These include people affected by war or natural disaster, remote populations and other communities living in poverty, or countries adversely affected by economic setbacks or transition. Women and children make up a disproportionately large share of these communities, increasingly as heads of households.

Worldwide, it has been estimated that there are currently about 125 million international migrants and 15 million refugees seeking better lives for themselves and their families abroad, or fleeing wars, civil strife, famine and environmental destruction. Another 20 million people are classified as internally displaced within their own countries. Most of these migrants and refugees end up in urban areas and most of them — up to 80 per cent in some areas — are women and children.82

Nearly all refugees and half of all migrants live in developing countries, where services are usually woefully inadequate to meet their reproductive health needs. Even more than other groups, migrants and refugees need reproductive health care, including protection from HIV/AIDS and other sexually transmitted infections, safe motherhood, and freedom from sexual and gender violence. All too often they lack access to these important services. Clustered on the margins of cities, housed in temporary camps in remote areas, many without any place to call home, these groups are among society's most vulnerable people.83

Box 15: UNFPA and Reproductive Health Needs in Emergency Situations

Since migrant families in developing countries are usually poor, living in squalid conditions in shanty towns, squatter settlements or on the streets, they are more at risk than the general population from unwanted pregnancies, complications and domestic violence. Women and children are also at risk from sexual exploitation, STDs (including HIV/AIDS) and gender violence.84 Women and adolescent girls often fall prey to the sex trade.

Through the Office of the United Nations High Commissioner for Refugees (UNHCR), the international community is working to restore the lives of displaced persons, particularly women and children. Through job and skills training, and access to tools, equipment and credit programmes, women and their families are rebuilding their lives.85 Similarly reproductive health programmes must reach women — and men — in transitional societies and in refugee situations with services to protect them from unwanted pregnancy and disease and to help them ensure healthy childbearing.

People displaced from their homes as a result of civil conflict, war or natural disaster are often vulnerable to reproductive health risks and without regular access to services and information. In such situations, many women find themselves as heads of households or alone without family protection, increasing their vulnerability to sexual exploitation and the accompanying dangers.

Sexual violence is common in many armed conflicts, especially where combatants mix with civilian populations. In several recent conflicts, large numbers of rapes have been documented. There is, therefore, a critical need to provide women and young people who have been subjected to sexual violence with treatment, counselling and services including emergency contraception, prevention of STDs, including HIV/AIDS, and the management of deliveries and of abortion complications.

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Partnerships for Reproductive Health and Family Planning

Governments can promote community participation in improving reproductive health, and can make public-sector programmes more gender sensitive. A number of guides and curricula have been developed towards these aims, and some countries have expanded related training for programme staff.86 Non-governmental organizations often have more flexibility than government services in this regard, and often find it easier than governments to work in sensitive areas such as adolescent health and gender-based violence.

Networks

One of the great strengths of NGOs is their ability to form partnerships and alliances among themselves and with governments and others. These networks of organizations apply a variety of perspectives and types of expertise to common concerns.

Box 16: Using Networks to Promote Reproductive Health

In Brazil, the Rede Nacional Feminista de Saude e Direitos Reprodutivos is a nationwide network of 60 NGOs and women's groups, 20 university groups working on gender and health issues, female legislators, health and law professionals and human rights activists. Since the ICPD, this network has facilitated women's participation in formulating and implementing policies on women's and adolescents' reproductive health and rights, strengthening the gender perspective and helping to create a new vision and new health indicators.

The International Planned Parenthood Federation (IPPF) unites family planning associations in 150 countries. IPPF's Sexual and Reproductive Rights Charter, developed in 1995, is used worldwide to revise legislation and undertake advocacy on sensitive issues such as unsafe abortion and unwanted pregnancies.

Health Empowerment Rights and Accountability (HERA) is an international NGO network of researchers and women's organizations formed during the ICPD process to advocate for gender equality and reproductive health and rights. Coordinated by the International Women's Health Coalition in New York, HERA's updates, briefing cards, consultations and workshops have been influential in making the international community aware of the importance of gender and women's rights in population and development strategies.

The International Reproductive Rights Research Action Group, established in 1992, collaborates with other women's networks such as the Development Alternatives with Women for a New Era, the Latin American and Caribbean Women's Health Coalition and the Women's Global Network for Reproductive Rights. Their policy influence is evident in the seven countries where they undertook research work (Brazil, Egypt, Malaysia, Mexico, Nigeria, the Philippines and the United States) as well as internationally, where they have helped to put the cultural, political and economic facets of reproductive rights on the intergovernmental agenda.

The Global Fund for Women was established in the mid-1980s to assist women and women's organizations in transforming their societies. The Global Fund studied the impact of its grants in eight countries, including the impact on women's attitudes towards family planning and contraceptive use. The study found that "participating in the activities of the organizations empowers women (through increased self-esteem, knowledge, skills and economic autonomy). This, in turn, has an impact on reproductive health and behaviour. For many women, it increases both their desire to use contraception and their ability to gain access to it."87

National NGOs and Community Health Services

National NGOs are promoting reproductive health and women's well-being, providing health care and social services, and participating actively in health-reform processes. In Bangladesh, for example, NGOs carry out 25 per cent of reproductive health activities. One is the Bangladesh Rural Advancement Committee, founded in 1972, which has a staff of over 20,000 and reaches 2.1 million women and girls in 65,000 villages and 34,000 schools.

In Bangladesh, Colombia, Jamaica, Mexico, Peru and Zambia, NGOs have taken the lead in expanding services — particularly in providing family planning in the context of reproductive health, and in offering services to men and adolescents. Profamilia, an IPPF affiliate in Colombia, provides more than 60 per cent of national family planning services. Since 1994 it has broadened its provision of reproductive health services, in addition to other women's empowerment activities. In Peru, the women's NGO Manuela Ramos is working with nearly 90 community-based women's organizations through a project called ReproSalud.88

In China, the Ford Foundation supported the Women's Reproductive Health and Development Programme to address women's reproductive health in the broader social and economic context that shapes their overall health.89 The programme enabled poor rural women to better understand, articulate and act on their health needs. Communities were involved in decision-making and programme design. The effort also trained national and local professionals to use a "bottom-up" approach to meeting individual and community needs.

Some IPPF-affiliated family planning associations are working to help communities identify their reproductive health problems, thereby building trust within the community for health care providers and ensuring that new services meet community needs. In Madras, India, this approach has fostered stronger communication skills among women, enabling them to talk to their husbands and to take a larger role in ensuring their children's well-being.90

NGOs and Adolescents' Reproductive Health

NGOs are working to involve adolescents in meeting their sexual and reproductive health needs. Giving girls a space to talk about their feelings and expectations on reproduction, health and sexuality is an important strategy towards better reproductive health and gender equality.

Traditional groups such as the World Association of Girl Guides and Girl Scouts are also advocating for girls' reproductive rights. Grass-roots NGOs such as Red de Salud de las Mujeres Latinoamericanas y del Caribe (Latin American and Caribbean Women's Health Network), CEDPA in India, Arrow in Malaysia, ISIS International-Manila in the Philippines, Tanzania Media Women's Association in the United Republic of Tanzania and the Women's Health Project in South Africa are using peer group discussions and gender-training techniques to encourage girls to talk about sexual and reproductive health and to be more assertive in their relationships with boys.

The Programme for Enhancing Adolescent Reproductive Life in Uganda, a UNFPA-supported, community-based programme aimed primarily at out-of-school youth, works to create a safe environment for adolescents that combines recreational activities with reproductive health counselling and services. Although targeted at adolescents, the programme also makes parents and religious and community leaders aware of the importance of providing such counselling and services.

Other groups such as the Women's Rehabilitation Centre in Nepal and members of the Women's Global Network for Reproductive Rights in more than 23 countries are tackling the difficult issue of improving the health, well-being and choices of rescued child sex workers.

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