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Threatened by a woman’s sexuality

Female genital mutilation is not simply a health issue. It is a sexuality issue.
Original artwork by Naomi Vona; photo by Hana Lopez on Unsplash.

Culture, tradition and religion are among the most commonly cited motivations for performing female genital mutilation. Yet curtailed sexual desire is almost universally understood to be an outcome of the practice and, in fact, it is also a key motivator. Many proponents of female genital mutilation have argued that unbridled female sexuality is somehow a threat to chastity, honour and virtue (Berg and Denison, 2013).

Frank conversations about female sexuality, bodily integrity and bodily autonomy may offer an unexpected antidote to the practice, experts say.

Efforts to end female genital mutilation have historically underscored the physical harms caused by the practice, which can include haemorrhage, sepsis, future childbirth complications and even death. Emphasis on the physical consequences is more easily received in conservative communities, where discussing female sexuality is often taboo. But a sole focus on physical harms may risk inadvertently leading to the medicalization of the practice, or the practice of alternative types of cutting, rather than its abandonment altogether (Powell and Yussuf, 2021).

Broadening these conversations to include an honest accounting of the sexual harms caused by female genital mutilation has helped Wafaa Benjamin Basta, an obstetrician and gynaecologist in Egypt, convince parents to reject the practice. Clearly articulating harms, like inability to experience orgasm, pain during intercourse, and aversion to sex due to post-traumatic stress disorder, has been an effective deterrent, especially “if the mother had a very bad experience while undergoing female genital mutilation when she was young or had troubles in her marital life because of the circumcision,” Dr. Basta said.

She speaks with ease about the social and psychological repercussions women can experience. “This may affect her mental health, social well-being and her relation with her partner, which may affect deeply the concept of the family itself.”

One reason Dr. Basta is able to have these forthright discussions is her role as a physician. “There is this bond between the patient and the doctor,” she said. But even more critical is the growing acceptance of women’s rights and empowerment in Egypt. “Minds are changing, especially for the new generations.”

As fears of female sexuality diminish, and sexual well-being is increasingly considered within the frame of psychological and social health, it becomes easier to rethink the practice of female genital mutilation.

Dr. Basta says her observations are limited to the confidential conversations she is able to have with her patients, and that comfort with these topics will vary by community and practitioner. Still, she has seen great progress in recent years, and is hopeful about the future, both for ending female genital mutilation and for promoting women’s sexual health and well-being. “There’s no shame to talk about that,” she said.

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The masculinity trap

Alexander Armando Morales Tecún educates young people about gender equality.
Original artwork by Naomi Vona; photo © UNFPA/J. Serrano.

The lush beauty of Guatemala’s central highlands hides a dark reality for women and girls, says Alexander Armando Morales Tecún, an indigenous youth educator and gender equality advocate in the rural department of Quiché. “In many places, women are blamed if they are attacked, said to have tempted or seduced their aggressors or rapists, because of the way they are dressed, for example, or because of their way of acting.”

These attitudes are not unique to Guatemala, which ranks in the bottom third of countries and territories on measures of women’s safety and welfare, according to Georgetown University’s 2019 Women, Peace and Security Index. In fact, victims around the world are routinely blamed for inviting gender-based violence by being in the wrong place, wearing the wrong clothing, behaving the wrong way or simply being physically developed at an early age. And such factors are often considered mitigating or exculpatory for perpetrators.

In 1998, for instance, Italy’s Supreme Court overturned the rape conviction of a man whose accuser was wearing tight blue jeans at the time of the attack. In 2010, when an 11-year-old girl was gang-raped by more than a dozen boys and men in the United States, national media reported that she was known to dress inappropriately for her age. In Afghanistan, rape survivors may be imprisoned for “morality crimes”.

The blaming and shaming of victims rather than perpetrators can be traced back to norms that encourage men to take control—not only of women’s bodies but also of their families. Tecún recalled asking a group of young men why they wanted to get married. One of them answered, “I want to rule my family. Because I want someone to cook for me, someone to wash my clothes, someone to give me children and someone to keep my house.”

Jay Silverman, a professor at the University of California, San Diego School of Medicine who studies reproductive coercion, says these attitudes are universal. “Male entitlement to control female partners often also extends to children. The perception of that right is maintained by all sorts of different structures and norms in communities and nations across the globe.”

But the result is not a simple male-versus-female dynamic, Tecún cautioned. These gender norms—which he calls “a hegemonic model of masculinity”—can leave men feeling trapped, as well. “If you are not married, you are not a man. If you are not in a relationship, you are not a man.”

And women play a role in perpetuating these beliefs as well, he added. “Many women also reaffirm that it is acceptable to beat a woman when she has not fulfilled her duties, because she did not wash her husband’s clothes, because her husband’s food was burned… It is said that it is good that they beat you because you did not comply with satisfying your husband.”

These ideas are instilled early and reinforced “from music, games, images, advertising,” Tecún said. “In the locality where I am from, when a boy is born, a good creole chicken broth is made. When a girl is born, it is totally silent, as if the event were a wake.”

Anything that undermines these norms—including the very concept of bodily autonomy—can be regarded as a threat, according to Romeo Alejandro Méndez Zúñiga, another indigenous youth educator and activist in Quiché. “The few people who have heard of bodily autonomy associate it with negative ideas because it affects the patriarchal male chauvinist system,” he said.

Zúñiga wants men and boys to embrace new norms that liberate both men and women from traditional masculine ideals. “What our society deserves… are new masculinities, new ways of seeing manhood, ways that strengthen and promote equality of opportunity for development, that enable all of us to live with dignity.”

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Healing bodies, minds, spirits

Medical personnel at a health centre in the Ayacucho Region of Peru. Midwife Victor Cazorla is fifth from the left.
Original artwork by Naomi Vona; photo © UNFPA/A. Castañeda.

Health-care providers have a unique responsibility in affirming and safeguarding the bodily autonomy of their patients. “My advice for any health worker would be to have empathy,” said Víctor Cazorla, a male midwife working in the Andes mountains of Peru. He has spent more than two decades working with indigenous communities in Ayacucho Region, and he knows all too well the challenges that threaten the well-being and autonomy of the most vulnerable patients.

“The work system for health workers often revolves around production, and production is synonymous with quantity,” he said. “We’re forgetting about quality in the care we give to our patients.” There are also cultural barriers, he added. “Many colleagues, many people, have gone to rural areas without knowing Quechua, the mother tongue of the communities there,” leading to misunderstandings and even discrimination.

At the same time, many patients are not sensitized to their sexual and reproductive rights. “Among the general population, maybe 80 to 90 per cent, I dare say, cannot make their own decisions about when to have sex with their partner… Male chauvinism prevails,” he said. Women patients often feel unable to speak candidly about issues pertaining to their sexual health, and they can be shy about expressing their discomfort about gynaecological procedures, particularly with male health providers, he noted.

These factors, together, are a dangerous combination: doctors are left struggling to understand the needs and boundaries of their patients, and patients are left without the words or tools to advocate for themselves.

Such concerns are all the more harrowing when health workers tend to survivors of sexual and gender-based violence. “In Syria, more than half of women are ignorant of their sexual, physical and general rights,” said Mouna Farhoud, a gynaecologist in Damascus who specializes in treating survivors. “Even the educated women are exposed to violence and unable to address it. They consider that talking about these topics harms their dignity and their reputation.”

Dr. Farhoud says even health professionals hold views that undermine the health and rights of their patients. She recalled teaching a course to health providers on treating sexual assault survivors: “There were many objections from the participants... There was a denial and lack of recognition about the existence of sexual assault cases.”

Doctors must communicate non-judgmentally with their patients, and recognize when their patients are uncomfortable or when they may have experienced abuse. Sometimes, this means being a detective, Dr. Farhoud explained. “Maybe the patient’s symptoms are not commensurate with her complaint. Her way of walking, her look, her words, her companion, the physical examination—all these come together to flag that there is a problem.”

And health workers must know when to back away. “It is your right to refuse. When I examine the patient, such as a gynaecological exam, I explain its importance, especially for people who have been subjected to sexual assault,” Dr. Farhoud said. “I make it clear that this is a medical procedure to find out if there are infections, wounds, bleeding, bruises or things that help document the case. Do they consent? Even when people realize that the goal is for documentation, if they are not prepared psychologically, we must respect their choice. Maybe this time we are not able to examine her, but next time we will be able to do so after she feels respected and valued.”

Cazorla added that showing respect for one’s culture is paramount. But what is most important, he says, is empowering patients themselves to become defenders of their own bodies and autonomy. “We teach them to expect respect, that nobody has a right to touch their bodies: not me, not their aunts, not their fathers, not their mothers, not staff, not police, nobody.”

He and his colleagues conduct education sessions for the community, and issues such as rights, self-esteem, sexual health and healthy relationships are also discussed during individual and family counselling sessions. These efforts are making a difference, he said, especially among younger people. But the burden of providing this information falls heavily on health providers. “I am the only midwife, for example, working on a shift at the health centre and I have to stay there to attend to patients who arrive with emergencies.” He says there is a need for more health resources, including staff, so that they can do more community education, such as targeted programmes for men and boys.

Dr. Farhoud echoes the call for support. Her organization also holds awareness sessions for the community. But she wants to see more education and accountability among health staff, as well. They have a special duty of care, as sexual and reproductive health service providers, to respect and empower their patients. “We have sworn a professional oath,” she said.

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The language of violation

Leidy Londono has worked in person, over the phone and via online chat to provide support and information to survivors of sexual assault.
Original artwork by Naomi Vona; photo © UNFPA/R. Zerzan.

In her years as a survivors’ advocate in the United States, Leidy Londono has grown accustomed to the language of shock, fear and shame that people use when grappling with the aftermath of sexual assault. And she has listened to people struggle to put into words one particular form of sexual violation, a phenomenon that is pervasive yet poorly understood, even by those who experience or perpetrate it: reproductive coercion.

“It involves behaviours that a partner or someone uses to maintain power and control in a relationship that are connected to reproductive health,” explained Londono, who has accompanied survivors to hospitals and provided hotline counselling. She now works as an educator and programme manager at Planned Parenthood in Washington, DC. “It can take a lot of different forms. There are explicit attempts to impregnate a partner against their own wishes. It could be about controlling the outcomes of a pregnancy, coercing a partner to have unprotected sex, interfering either explicitly or implicitly with birth control methods, or lying or deceit around birth control methods.”

Survivors lack a common language to describe the specific violation felt when they are denied ownership of their fertility or sexual health, whether or not they consented to a sexual encounter. Without the words to identify this experience, they often express confusion and self-recrimination. Londono recalled one young person who discovered that their partner had secretly removed a condom during consensual sex—a practice known as stealthing. “At first they were like, ‘Am I just exaggerating this?’”

The concept of reproductive coercion is relatively new, with most studies on the topic taking place in the last 20 years, often in the United States, where the prevalence of reproductive coercion is estimated at 15 to 25 per cent (Park and others, 2016). But recent inquiries show that it is widespread globally, perpetrated not only by partners but even by families and community members (Grace and Fleming, 2016). It may even be abetted by health systems, via policies that require husbands’ permission before a woman can use family planning, for example.

Dipika Paul has worked for decades as a researcher in sexual and reproductive health in Bangladesh, yet even she says she was not familiar with the term reproductive coercion. Rather, she and health workers and advocates spoke more generally about “barriers in family planning”.

Today, Paul is an expert in the topic. As an adviser at Ipas in Dhaka, she sees many forms of reproductive coercion. “With husbands... it can start with telling them, ‘do not use any contraception’, then women will follow their husband’s opinion. And it also ranges to severe violence. Sometimes husbands withhold food or money if she wants to continue using contraception,” Paul said. Often this pressure is related to “husbands’ or other family members’ desire for more children or desire for sons”. Forced use of contraception and forced abortion are also seen, she added.

These coercive acts are not widely regarded as forms of violence because reproduction may be seen as a family decision. “In-laws, they play a big role,” Paul said. This is particularly true for younger and underage wives; the median age of marriage is 16, according to a Demographic and Health Survey from 2018. “It is difficult for young women to take decisions alone.”

And yet there is a clear link between reproductive coercion and violence. Paul estimates that, in a study she is currently conducting, about three in five women who said they had experienced reproductive coercion also experienced sexual or physical violence from their husbands.

Jay Silverman, a professor at the University of California, San Diego School of Medicine, began his career working with men and boys who had perpetrated intimate partner violence. He has since studied reproductive coercion in Bangladesh, India, Kenya, Niger and the United States. Even though reproductive coercion may sometimes be carried out by female family members, the violation is rooted in gender inequality, Silverman said.

“There’s a universal involved here,” he explained, “and it is male entitlement to control female partners… On some level, that sense that men do have, that entitlement to that control, is something that’s ubiquitous in, I think, most of our societies.”

Silverman and his colleagues, including Ipas in Bangladesh, are piloting tools to help health workers identify reproductive coercion, such as questions about partner attitudes and behaviour. Once coercion is acknowledged, women can reassert bodily autonomy by, for example, selecting family planning methods that are undetectable by a partner.

Even as women lack the language to describe reproductive coercion, Silverman explained, “I also believe human beings innately resist against being controlled… There are many different coping strategies that women in communities around the world have developed to cope with reproductive coercion, including women supporting women. That is something that is just happening organically, everywhere. It always has, whether it be a neighbour or female family member hiding your pills for you or helping you get to a clinic.” Where clinics give out pamphlets about reproductive coercion, partner violence and how to seek help, women often “take handfuls” so they can share the information with other women.

Much of the burden of addressing reproductive coercion falls to service providers, who often face a double bind: they must strike a balance between engaging men in reproductive health matters without ceding full decision-making power to them. “The ideal of male engagement in sexual and reproductive health and maternal and child health internationally has become a priority,” Silverman said. Male involvement has been associated with increased family planning and contraceptive use and improved maternal and child health outcomes (Kriel and others, 2019; Assaf and Davis, 2018). But when men wish to control the reproductive choices of their partner, “involving men is obviously detrimental”.

And men—indeed, people of all genders and sexual orientations—can also be victims of reproductive coercion. “Anyone can experience reproductive coercion,” said Londono. “Women in marginalized communities experience levels of violence at disproportionate rates, and that includes reproductive coercion… but that doesn’t negate the fact that I have talked to young boys and young men—men in general—who are trying to identify their own experiences and put it into words and contextualize it.”

Fluency in the language of reproductive coercion is needed, particularly among policymakers. “When our laws and our policies are vague and our language is ambiguous, it doesn’t provide for survivors,” Londono said.

And learning about bodily autonomy is also crucial. In one recent project, Paul said, “we talked to women, and they chose this terminology: ‘my body, my rights.’... They all agreed that we need to disseminate this among the population—that my body is mine.”

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Putting the unity in community

Ayim says she felt isolated before finding the LGBTI community.
Original artwork by Naomi Vona; image courtesy of Ayim.

Daniyar realized he was transgender at age 7, but believed for years that he was alone. “When I was 15 or 16, I was very depressed. I was not accepting myself… I didn’t know that there were LGBTI communities or organizations in Kyrgyzstan.” It was not until someone tipped him off about a local LGBTI group that he felt equipped to take control over his body and life. “I understood that this is my environment,” he said. “Before that, I felt I was not living in my own body. But I learned about transgender people, and started reading about it, and then I started my transition.”

Daniyar, now 23, knows this experience is far from unique. In fact, advocates and researchers have long observed the creative and collective ways people come together to reclaim their bodily autonomy when it is threatened. LGBTI people have created safe spaces for each other in even the most restrictive settings around the world. And there are other examples. Sex workers come together to share information about violent clients. Women help each other conceal contraceptives, escape abusive partners, or terminate unwanted pregnancies in countries where abortion is hard to access or illegal. When and where possible, these informal networks tend to formalize into advocacy groups that are a driving force for change.

That is happening in Kyrgyzstan, said Ayim, a 24-year-old transgender woman. She, too, felt isolated for years before finding acceptance and solidarity in the LGBTI community. “I would wear my mom’s skirts. My mom would make fun of me and scold me at the same time… When I started my studies at a university, I understood that I needed to disclose who I am. If I disguised it all my life, I would be trapped. In 2016, I started actively getting acquainted with people from the LGBTI community.”

Today, both Daniyar and Ayim are LGBTI activists. They work with a local non-governmental organization, Kyrgyz Indigo, to provide services to LGBTI people in need, including housing assistance and access to health information and care. This support is critical in a country where LGBTI people face frequent discrimination. Transgender people are especially vulnerable, they say, with high rates of unemployment in part because they cannot update their identification documents to reflect their gender identity. “The latest amendments in the law prohibit people from changing their passports to correct their gender,” said Daniyar. There are also very few medical specialists helping transgender people transition, making the process extremely costly. “Many sacrifice their nutrition or do not sleep [to work around the clock], so they can save money for surgery to correct their bodies.”

There is always a threat of violence looming over them. Both Daniyar and Ayim have been threatened, and they have friends who have been assaulted. “There are many stories like this,” Daniyar said. “They beat up or take the person somewhere, to the mountains, outside of the city… beat them almost to death or maybe to death and leave them in a wasteland.”

Despite these risks, they are motivated by an intimate understanding of the struggles in their community. “We have common problems and we know how to support each other,” explained Ayim. “We stick with each other.” And expressing one’s authentic gender identity is non-negotiable, they say. It is a matter of life or death. If transgender people were forced to hide completely, “I think there would be many suicides,” said Daniyar. Or they would “leave Kyrgyzstan and become a refugee, because living in a body that is not yours is terrible,” added Ayim.

Circumstances for the community have worsened under the COVID-19 pandemic, with job losses leaving many homeless, hungry or unable to afford medication. Kyrgyz Indigo has been delivering food and essential supplies, including soap, toilet paper and sanitary napkins, to those in need. It is helping ensure continued access to hormone therapy for transgender people and antiretrovirals for people living with HIV. And it has been operating three shelters throughout the pandemic to meet the increased need for emergency housing.

Their experiences hold lessons for other marginalized communities working to advocate for their rights and bodily autonomy, they say. Firstly, “there is a need to empower the community and to increase visibility,” Ayim noted. Acceptance of LGBTI issues within the country is greatest in Bishkek, the capital, thanks to the presence of activist groups and efforts there, she explained.

But advocates must also be prepared for opposition, and they must protect themselves: “You need to be ready for any reactions and move with no fear,” Ayim said. “When you fully devote yourself to activism, to such work, you burn out.” And most important, she said, is trust: “The main thing is to trust yourself, trust your power… Do not be afraid of anyone. Because there is you, there is us, and together we can all go further.”

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Going to labour: the job of a surrogate

Policymakers seldom consider the perspectives of surrogates when crafting surrogacy laws, experts say.
Original artwork by Naomi Vona; photo by Alexander Krivitskiyz on Unsplash.

Josefina remembers making the choice to become a surrogate. “Part of it was for the money, but what really moved me was having the power to make real the dream of many women of having a baby,” she said. What she did not anticipate was how poorly run—and abusive—the surrogacy agency would turn out to be.

“I thought there would be other women like me: confident in their decision, with a minimum of one child, just like the requirements established. But the place where I arrived wasn’t like that. There were a lot of young women who had not had any children before. I remember thinking ‘where am I?’” A few months into her pregnancy, she, along with two or three other surrogates and some of their children, were taken to a dilapidated house with no water, electricity or food—and then locked inside.

The situation was only temporary. But Josefina (not her real name), who lives in Mexico, said she suddenly started worrying that the pregnancy wasn’t actually for the purpose of being a surrogate. “A lot of ideas came to my mind such as child trafficking or organ trafficking.” She still had her mobile phone and was able to surreptitiously contact the intended parents of the baby, something she had been expressly forbidden to do. “I found the parents through Facebook,” she said. “They were very nice to me and supportive.” They moved to another surrogacy agency, bringing Josefina with them. “I continued the process in a safer place, where I felt more confident.”

Yet even after that perilous experience, Josefina says she never doubted her decision. “I was sure that I wanted to have the baby. I don’t regret it. It was an adventure,” she said. “Once I met the parents, I was pleased with the process.”

She would even consider doing it again.

The issue of surrogacy has long been considered ethically and legally fraught. Highly publicized lawsuits and custody battles in the United States, India and elsewhere have raised questions about the rights and responsibilities of surrogates and intended parents, as well as the rights of the baby produced by the surrogacy arrangement (Nadimpally and others, 2016). Laws vary widely across and within countries. Some ban surrogacy; some ban commercial, also called compensated, surrogacy but allow so-called altruistic surrogacy; some permit both; and others have no specific surrogacy laws at all (UCLS, 2019).

Where compensated surrogacy is permitted, a lucrative industry often emerges, comprising assisted reproductive technology clinics, medical tour operators, law firms, recruiters and others. Countries with lower costs can become sought-after destinations for commissioning parents. Yet, in such places, surrogacy is often one of the few well-paying opportunities available to economically marginalized women, creating the potential for exploitation. Brokers and agencies may control the exchange of money and information as well as the provision of health care. Surrogates may be left underpaid, underinformed and medically underserved (Nadimpally and others, 2016).

The highly gendered nature of surrogacy and motherhood also creates vulnerabilities on both sides of the agreement. Infertile women may face intense cultural pressure to become mothers while same-sex couples or single parents are often barred from commissioning surrogates because they fail to meet accepted norms of parenthood. And surrogates may be criticized for betraying the perceived sacred bond between a woman and the fetus she carries. Josefina kept her surrogacy arrangement quiet for just this reason. “It’s a taboo. A lot of people get scared when they hear about it, so I decided not to tell that many people. Actually, a lot of people from my own family don’t know,” she said.

“Stigma has grown a lot in the last 10 years,” said Isabel Fulda, Deputy Director of Grupo de Información en Reproducción Elegida, a reproductive justice organization in Mexico, which has advocated on behalf of both surrogates and commissioning parents. Surrogacy laws vary across Mexico, but have generally grown more restrictive in recent years. “Even if the initial intentions of reform are good, and intended for better protection of every party, it has unfortunate consequences, especially for surrogate women,” she said. In places that have implemented strict prohibitions, “the practice still goes on, but now in an underground and unsafe way.”

Josefina bore many of these consequences. “When I was with the first agency, we didn’t even have a contract. A contract would have given me safety that everything would be okay.” She believes the restrictions are only pushing surrogacy further into the shadows, where unethical agencies can thrive without regulation and surrogates themselves are penalized.

“If it was legal, people would feel safer,” she said.

Rather than bans, there must be more nuanced policies that account for the input and perspectives of those affected, said Sarojini Nadimpally, a founding member of the Sama Resource Group for Women and Health in India and expert on the social and legal issues surrounding surrogacy. “Have the surrogates and infertile couples been involved in the policy formulations? Were they asked what they want in the policy or in the legislation? How accessible will these legal provisions be for surrogates?”

Not only are surrogates’ experiences neglected in the crafting of legislation, but stigmas and punitive rules have made it harder for them to raise their voices. “The more political the issue becomes, the more they are silenced,” Fulda said. In place of surrogates’ real stories, a caricature has emerged, in which compensated surrogates are depicted as victims while altruistic surrogates “are often portrayed as angels who are willing to breed for nine months, and expose themselves to possible risks just for the love their hearts carry. It becomes unbelievable to think they would want money for it,” Fulda said.

The distinction between compensated and altruistic surrogacy doesn’t make sense to Josefina. For her, being a surrogate was both a job and a gift. She did not resort to it because of poverty: “My economic situation at that time was not really that bad. My choice was made because I wanted to do something different with my life and to do something positive for someone else... I am a mother as well, and I know the happiness a child can bring.”

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When sex is work

Liana advocates for the rights of sex workers in Indonesia.
Original artwork by Naomi Vona; image courtesy of Liana.

“Knowing that I have a say and that I’m in control of my own body, I really only learned those things after becoming a sex worker,” Liana explained through a translator in Indonesia.

By now, Liana is used to shattering expectations; as a middle-class university graduate and former accountant, she does not fit the stereotype of a sex worker. “When my baby was four months old, my husband passed away,” she recalled. Her income did not stretch far enough and, at the same time, her family’s business was struggling and her sister was facing financial hardship.

“I visited one of the established venues for sex work and applied to work there,” she said, emphasizing that this was her choice. “I did it independently and without force.”

These days, Liana is the national coordinator of OPSI, a network that supports sex workers with services including health care. OPSI is supported by UNFPA. “Sex workers are actually quite diverse,” she explained. “There are male sex workers, transgender sex workers, and the reasons people choose to engage in sex work vary from person to person. The majority are seeking a source of income.”

Monika, in North Macedonia, became a sex worker after she lost her job and got divorced. She, too, is firm when she says this was her decision. “I was 19 or 20 years old. I was sufficiently aware and mature to think about what I did and what I didn’t want.” Today—as the regional coordinator of STAR, the first sex workers collective in the Balkans, also a UNFPA partner—she says she has observed that this is the norm: “I am most often surrounded by sex workers who voluntarily engage in sex work.”

Still, both Liana and Monika acknowledge that sex trafficking—sexual exploitation through force, coercion, fraud or deception—is a serious concern within the industry. Their respective organizations work closely with victims and survivors, helping them to secure services and exit sex work if they choose.

The prevalence of exploitation and abuse has driven much of the conversation around the legal status of sex work. Both proponents and opponents of decriminalization cite the need to protect people from abuses.

But for opponents of decriminalization, the notion of consent within the sex industry is inherently fraught. Indeed, studies show that many entrants into sex work have experienced heightened vulnerablities, such as a history of childhood poverty, abuse and family instability, as well as barriers to the formal economy, including lack of education (McCarthy and others, 2014). These conditions are seen as undermining their free and informed consent. Additionally, a significant proportion of sex workers—estimated at between 20 and 40 per cent—report entering sex work as children (Parcesepe and others, 2016), a clear human rights violation.

Human rights instruments have responded to these vulnerabilities. The Convention on the Elimination of all Forms of Discrimination against Women calls for “all appropriate measures, including legislation, to suppress all forms of traffic in women and exploitation of prostitution of women”. And the Protocols of the United Nations Convention against Transnational Organized Crime include “the giving or receiving of payments or benefits to achieve the consent of a person having control over another person for the purpose of exploitation” within the definition of trafficking in persons.

But many sex worker advocates say the focus on vulnerability actually strips away their safety and autonomy. Both Liana and Monika say they freely chose to continue sex work even while earning decent incomes outside the sex trade.

“Please don’t assume that all sex workers are victims of trafficking. There are people like me who choose this work intentionally. We’re not being tricked,” Liana said. “When we ask OPSI members whether they would want to stop sex work if they could find other jobs, most of the time the answer is no.” Other jobs available to sex workers are often low wage, she explained, and sex work offers flexibility that many find desirable. “They can manage their own time. They can fulfil their obligations in society, and they can feel closer to their kids.”

Sex work, or aspects of it (such as facilitation), is illegal in the majority of countries, according to the Global Network of Sex Work Projects. Liana and Monika say such laws only drive the profession underground, where sex workers have a harder time screening out violent clients. Criminalization also leaves sex workers vulnerable to arrest and fearful of reporting abusers, they assert. Some police also harass and abuse sex workers, Monika said, “knowing that sex work is not legal and thinking that we cannot report it and that there is nothing we can do”.

They want to see the criminalization—and prosecution—of sexual violence and exploitation rather than sex work. “Violence is not just an issue among sex workers. It’s an issue for all women and minority groups,” Liana emphasized.

The movement to decriminalize sex work has gained ground in recent years at the United Nations, with many agencies and programmes, such as the World Health Organization and UNAIDS, embracing it as an effective means to prevent HIV transmission and end discrimination against vulnerable populations (WHO, 2014; UNAIDS, 2012).

At the same time, the United Nations is stepping up efforts to eliminate sexual exploitation and abuse. Concerns over peacekeepers and humanitarian workers entering exploitative relationships with sex workers and vulnerable and marginalized individuals have prompted the institution to strengthen the enforcement of rules that prohibit staff from exchanging money, goods or services for sex, even in countries where sex work is legal. These positions—that decriminalization will help safeguard the health and rights of sex workers, and also that staff members must not purchase sex, even where legal—are not contradictory, say United Nations officials.

“UN personnel must not participate in any activity that could even potentially result in sexual exploitation. This is not a judgment on voluntary sex work by consenting, informed adults, but we must acknowledge the reality that legality alone does not ensure that participation in sex work is voluntary,” said Eva Bolkart, who coordinates UNFPA’s efforts to prevent sexual exploitation and abuse.

Monika and Liana agree that legality alone is not enough. For them, decriminalization must come alongside destigmatization. Until sex workers are afforded the respect and dignity of normal citizens, they will continue to be forced to operate in the shadows, where abuses can be hidden. “We are parents. We are someone’s children. We have families,” Monika said. “There is no need for anyone to treat us differently from others because of the choice of our profession. Sex work is work.”

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Able to choose

Lizzie Kiama is a champion for the rights of persons with disabilities.
Original artwork by Naomi Vona; image courtesy of Lizzie Kiama.

In 1999, Lizzie Kiama was commuting to work in Mombasa, Kenya, when her minibus collided, head-on, into another vehicle. “I was seated in the front,” she remembered. “The accident resulted in me becoming disabled.” But it would be 11 years before she fully accepted this new reality.

“I did not identify as a person with a disability for a long time,” Kiama said. “That’s because there was always a very negative connotation that surrounded the word ‘disabled’.”

The turning point was becoming a mother and deciding she would improve the world for her children. For her, that meant identifying as a person with a disability—and redefining what it means, she explained. Kiama went on to found This Ability Trust, a social enterprise focusing on the rights of persons with disabilities, through which she has observed the many ways people with disabilities are denied agency, particularly when it comes to their sexual and reproductive health and rights.

Those with visual or hearing disabilities seldom have access to interpreters or Braille when seeking health services, she said, and persons with caregivers face reduced privacy and confidentiality. Many persons with disabilities lack accessible transport options, and many health facilities lack the infrastructure, equipment and trained staff to serve them.

And then there are the horror stories.

“I have heard stories of women who would rather give birth at home than face nurses or midwives who question why, in their disabled condition, they would be having children or getting pregnant,” Kiama said. “Society, in general, has associated persons with disabilities, women in particular, as being asexual... Simple things like legal capacity, bodily autonomy, the right to decision-making are not considered the norm.”

Women and girls with disabilities face high rates of gender-based violence in Kenya (Salome and others, 2013). But too often, in response, their bodily autonomy is further violated, Kiama said. “You find in some cases girls with disabilities whose families collude with medical professionals to sterilize them as a means of ‘protecting them’, because they are constant victims of sexual violence,” she explained. “Nothing happens to the perpetrators.”

But these issues are in no way unique to Kenya alone. People with disabilities confront serious obstacles to sexual and reproductive health decision-making almost everywhere.

In Mongolia, for example, there have been reports of health workers performing abortions on women with disabilities without consulting them. Instead, the doctors seek consent from the women’s guardians, according to Enkhjargal Banzragch, a social worker at the Mongolian National Wheelchair Users Association. One study by the Association found 22 per cent of persons with disabilities have been forced by family members or health-care providers to use contraception.

Refusing contraception can have consequences. Women with intellectual disabilities are often denied their allowances or extension of their disability status if they have not received required doses of injectable contraceptives, Banzragch explained.

Individuals with disabilities and their caregivers may be given little to no explanation, says UNFPA Assistant Representative in Mongolia Iliza Azyei, who worked with activists and the health ministry to raise these issues.

She recalled the story of one girl: “As soon as she turned 16, the public health doctor came to her house and they started providing quarterly injectable contraceptives.” Azyei asked the girl’s mother if they had questioned what was happening. “She said, ‘No, I trust my doctor.’”

Still, there are reasons for hope.

“Looking at policies and the legal framework from an advocacy point of view, there has been progress,” Kiama said, citing Kenya’s 2003 disability act, the country’s constitution, the ratification of international conventions on disability rights, and increasingly accessible building standards.

Mongolia, too, has seen progress. During a 2015 review of Mongolia’s human rights records, reproductive health violations against persons with disabilities were brought to light. The Government “made immediate revisions in the health ministerial order to provide sexual and reproductive health services to women, including disabled women,” Azyei said.

Policy-level change is just one step, she added. “But how do we deal with the actual practices?”

For that, experts agree, attitudes must also change. “Women with disabilities have a right to fall in love, have a baby, get services and have a life,” Azyei emphasized.

Persons with disabilities must be protected from sexual abuse, but these protections must support—rather than undermine—their bodily autonomy. And they must be empowered to claim their rights.

“As persons with disabilities, we imagine that we need to have our hands held and to ask for permission,” Kiama said. But she sees change in the younger generation of persons with disabilities. “We’re seeing more young women taking up space and using social media for advocacy. They are advocating for sexual and reproductive rights in different ways, and that’s incredible to see.”

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First, do no harm

Suraya Sobhrang describes how medical and legal personnel perpetuated nonconsensual virginity testing in Afghanistan.
Original artwork by Naomi Vona; photo © UNFPA/A. Mohaqqeq.

Virginity testing violates individuals’ human rights and dignity, the United Nations has resoundingly asserted. When performed without consent, it constitutes torture and a form of sexual violence. It is also scientifically useless, and a violation of medical ethics (WHO and others, 2018). Yet it persists in every region of the world; its continued practice has recently made headlines in the United Kingdom, for instance, where a bill is under review to ban the practice. Virginity tests are used to enforce or encourage abstinence among unmarried women and girls, with justifications ranging from the preservation of their “purity” and family “honour” to the prevention of HIV transmission and adolescent pregnancy (Olson and García-Moreno, 2017). And yet many of its defenders invoke feminist language to argue for its continuation.

A virginity test, also known as a hymen exam or “two-finger” test, typically involves an examination of the hymen, a thin tissue often, but not always, present in the vagina. The test relies on the assumption that physical characteristics of the hymen or vagina can demonstrate whether a woman or girl has engaged in vaginal intercourse—a belief overwhelmingly discredited by medical studies. Unscientific examinations to “prove” or “disprove” intercourse only reinforce harmful social norms and must be banned, medical and human rights experts assert. These include not only virginity tests but also forced anal exams, which involve the insertion of fingers or objects into the anus of a man or transgender woman with the purported objective of finding “proof” of homosexual conduct. Forced anal tests have been reported throughout the Arab States and East and Southern Africa regions, yet they are “medically worthless” and “amount to torture or ill-treatment”, said the 2018 report of an independent expert to the United Nations Human Rights Council (UN HRC, 2018).

Virginity tests, as well as forced anal exams, are physically invasive, painful and stigmatizing. Suraya Sobhrang, a medical doctor and former human rights commissioner in Afghanistan, says the tests used to be ordered punitively after any perceived transgression, such as sitting next to a member of the opposite sex. “All this was a ‘moral crime’,” Dr. Sobhrang described.

Examination conditions were often neither sanitary nor private, and women could be forced to undergo the test repeatedly, she said. “This was traumatizing these women… One woman told me, ‘I feel that the second time, somebody raped me.’”

Women could be imprisoned for failing a virginity test. “Some women did self-immolation after this testing,” Dr. Sobhrang recalled. Others were killed by their families.

Dr. Sobhrang and her colleagues helped to ban nonconsensual virginity tests in Afghanistan in 2018. Today, virginity tests can only be performed in Afghanistan when there is a court order and consent of the patient—though enforcement of this rule remains a concern, especially in rural areas. And both doctors and patients can still face consequences if they decline the test. Mozhgan Azami, a forensic medicine specialist in Kabul, recalled one girl who refused twice, despite a court order: “The third time, the court sent her back to us saying that if the doctors do not perform the test this time, they will be placed under investigation. Therefore, after two hours of talking to the girl, we convinced her to do the test.”

Dr. Azami agrees that virginity tests, particularly when performed under duress, can “hurt them psychologically”. Yet she defends the test in some instances, if performed confidentially, with dignity and full informed consent. Those views are shaped by real fears and realities: in places without scientifically sound medical procedures, such as DNA testing, virginity testing offers one of the few ways survivors can submit evidence to support an allegation of rape. “For the victim, the hymen test is a tool through which to seek justice and fight back against social and traditional blame,” Dr. Azami said.

The test, if its results are favourable, can also help women avoid violence in places where a perceived loss of virginity can be a death sentence. “On a marriage night, a white cloth or paper is given to the couple that should be coloured red by the blood of the hymen after the marriage is consummated,” Dr. Azami added. If “the man doesn’t see the signs of virginity, the virginity test will be performed... based on the request of the girl,” typically in the hope that her hymen will show an indication of tearing.

In some communities, such as in South Africa’s KwaZulu-Natal Province, virginity testing is also seen by some as protection from adolescent pregnancy, HIV and other harms (UN HRC, 2016). “It is believed that virginity testing will prevent girls being coerced into having sexual relations and abuse by ‘iintsizwa’ [older men], especially girls in grades 10, 11 and 12,” said Chief Msingaphansi of Umzimkhulu in KwaZulu-Natal. He suggests the tests, largely performed by women elders, emphasize the cultural value on abstinence, thereby encouraging girls to reject peer pressure and delay sexual activity. Chief Msingaphansi couches the ritual in the language of empowerment: “Following the tests, the girls are made aware of their rights,” he said, adding that they learn to identify exploitative relationships. Yet these tests are often nonconsensual, making them illegal. “The parents decide,” acknowledged a “virginity inspector” from uMgungundlovu and uThukela districts.

Despite these justifications, the test contributes to the erroneous belief that a woman’s virtue is dependent on her sexual history, and it perpetuates a flawed understanding of human anatomy. Lending credibility to the test will inevitably lead to harm, Dr. Sobhrang stressed. “The hymen, some women don’t have one. And sometimes the structure is very elastic. I saw one woman who had her first baby and at the delivery, she still had a hymen. So it does not assure that a girl has not had intercourse.”

Someone who reports a rape could be found to still have a hymen, and the complainant could be being jailed for making false accusations while the perpetrator goes free, the doctor explained. And virginity tests are not a substitute for post-rape medical examinations, which assess and treat physical trauma without requiring the insertion of anything into the vagina (WHO and others, 2018).

“This is a violation of human rights and it’s against human dignity,” said Sima Samar, a medical doctor and former state minister for human rights in Afghanistan, who also championed the ban on nonconsensual virginity tests. “It requires education in the public, to everyone, particularly to the youth. Secondly, I think it is required to educate police, to educate the prosecutor, to educate the medical doctors.”

Most importantly, individuals must be emboldened to know and claim their bodily autonomy, Dr. Samar added. “How many of them know their rights?”

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Laws aside: the reality of unequal abortion access

No matter the legal status of abortion, women with means tend to find a way to access the procedure while women without resources face heightened risks.
Original artwork by Naomi Vona; photo by JESHOOTS on Unsplash.

“One woman, she was brought from a remote village and she was in very severe condition… She’d tried to induce an abortion by herself,” recalled Nuriye Ortayli, who worked as an obstetrician and gynaecologist in Turkey in the 1980s and 1990s. “Everybody, younger residents, more senior people, tried for more than 12 hours, close to 24 hours. We tried everything we could. But she died.”

Yet Dr. Ortayli’s story is not about an illegal, back-alley abortion. Safe abortion services were legally available in Turkey at the time. “If she had been able to come to the hospital… you could do it under local anaesthesia,” she said. Instead, her story is about a reality facing women and health providers around the world: abortions happen, frequently, even in places where the procedure is highly restricted or illegal (Bearak and others, 2020), and women are regularly denied access to safe abortion even in places where it is legally permitted (Gerdts and others, 2015). No matter the law, then, it is often other factors—such as economic resources, distance from services or social norms—that determine whether a woman will be able to access a safe abortion.

Dr. Ortayli saw this phenomenon play out both as a physician in Turkey and as a programme manager and reproductive health adviser for health organizations, including UNFPA, in Eastern Europe, the Middle East, West Africa and the Americas. “We see it again and again. Independent of the legal status of abortion in a country, women make those decisions and they find a way,” she said. “Those who are affluent, somehow they manage to have better health than others, because they have opportunities, they have money, they have networks. Those who are disadvantaged economically or socially or culturally, they suffer more.”

By contrast, even when abortion was strictly banned in almost all circumstances in Ireland, large numbers of women who wanted the procedure were able to travel overseas to obtain it. “In an awful lot of cases, if women were determined to have an abortion, they would eventually manage to do it,” said Caitríona Henchion, the medical director at the Irish Family Planning Association.

For many—even most—women, the law did not prevent abortion, but it “often might result in a long delay in actually being able to get it,” Dr. Henchion said. “All of the time that they were waiting is a period of great stress and anxiety… [and] there would have obviously been the higher risk attached to the procedure that they were then having.”

Those who were unable to obtain an abortion by travelling internationally were “a, relatively speaking, small group,” she said, “particularly women who had either poor English or who didn’t have full citizenship and those rights that would go with it”—such as the ability to easily leave the country and return—“teenagers who might’ve required parental consent, people who didn’t have the money to travel at all… or people who did not have anybody that they could disclose [the pregnancy] to or nobody that could have helped them.”

Though Dr. Henchion could not provide abortions at the time, she could and did perform post-abortion care, typically after women illegally obtained pills to induce a medical abortion. “In most cases, it is safe and straightforward and people won’t have problems or complications,” so only a fraction of abortions performed this way came to the attention of the health system, she explained. Still, it was “regular enough” to receive patients with heavy or prolonged bleeding and “women who maybe took abortion pills at home at a more advanced gestation than either they thought they were, or than they should have been if they were going to use that method.”

These circumstances were challenging for doctors, Dr. Henchion recalled. Sometimes, patients literally begged for abortion information or referrals she legally could not provide. In the end, the rules seemed to create one outcome for people with money and resources, and another outcome for those without. ”That’s how I always felt,” she said. She was a leading proponent for the legalization of abortion in Ireland, a change that took place following a referendum in 2018.

But even today, those who are most disadvantaged continue to experience higher barriers and greater risks. “There are some parts of the country that really have almost no access in terms of providers,” Dr. Henchion said. Some women still have to travel to access safe abortion, incurring all the associated delays and costs. Undocumented immigrants and people who do not speak English also continue to face challenges.

Dr. Ortayli described a similar frustration. “I had a private practice for seven or eight years in Istanbul, and I had many clients coming from the Gulf, where [abortion] is more restricted. Of course, these women were women who could afford it.” At the same time, she knew that vulnerable women in her own country were struggling to receive the same level of care, whether because of distance to services or spousal permission rules. “I have seen men sometimes use this as a weapon towards women. For example, if a woman wants a divorce, but she gets pregnant, and he doesn’t let her have an abortion in order to tie her up.”

Still, she was glad the option to terminate a pregnancy was available in Turkey, even if access was uneven. She remembers being bereft when her patient died following the unsafe abortion. A more senior physician told her it used to be worse. “He said, before the liberalization of the [abortion] law, in the same ward, we lost women like her, maybe two or three of them every week.”

And paradoxically, Dr. Henchion says, the legalization of abortion in Ireland has given many women one more option: the choice to change their minds. Before, when women had to travel internationally for an abortion, they might feel compelled to undergo the procedure after spending the time and resources to arrange it. “The pressure on them to actually make the decision was huge… This is your only chance either to have it, or don’t.” But today, she says, “you can actually give people all of the information and give them space and time.”

She says these changes make an even bigger difference now during the COVID-19 pandemic. “When you think about the [pandemic-related] limitations on travel, we would be looking at a really, really serious situation if we hadn’t legalized when we did… There have been a lot of crisis pregnancies because of COVID, people who maybe have lost jobs or their situations have totally changed, and they can still access this care.”

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Your body: an owner’s manual

Olga Lourenço is used to facing resistance when providing comprehensive sexuality education, but she is undeterred.
Original artwork by Naomi Vona; photo © UNFPA/C. Cesar.

Few parents or community leaders object when a student brings home a chemistry or calculus textbook. Yet lessons in comprehensive sexuality education—accurate, age-appropriate information about one’s own body, sexual and reproductive health, and human rights—are widely considered taboo. Many schools do not teach the subject, or provide only incomplete information. This leaves students both ill-prepared for the changes their bodies are undergoing and ill-equipped to protect themselves from harm.

“We are in a constant struggle to include this topic in the school curriculum,” said Olga Lourenço, a coordinator for Project CAJ, a UNFPA-supported programme providing life skills and comprehensive sexuality education to youth in Angola. “Almost nothing is said about comprehensive sexual and reproductive health because of our taboos and prejudices.”

Opponents of comprehensive sexuality education often contend that it promotes sexual activity, yet studies show that this is incorrect. Rather, evidence indicates that this education, when provided to international standards, improves young people’s knowledge and constitutes a crucial and cost-effective strategy for preventing unintended pregnancy and sexually transmitted infections, including HIV. Some studies show it may actually help delay adolescents’ sexual debut (UNESCO, 2016).

Lourenço explained that, because she lacked accurate information at a young age, she actually felt pressured to engage in sexual relationships before she was ready, at age 15. “My friends already had their boyfriends. They already had sexually active lives. They made fun of me for being the ‘virgin of the group’,” she said. “In a way, this psychologically affected me... I think that, in a way, it violated my bodily autonomy.”

Dipika Paul, a longtime sexual and reproductive health researcher and an adviser at Ipas in Dhaka, Bangladesh, has seen the consequences of poor access to sexuality education in her own community. “When I was a student, I was in class seven, and there was just one chapter—on menstruation,” she recalled. “The teacher also did not feel comfortable teaching that section to us.”

Without comprehensive sexuality education, young people are vulnerable to myths and misinformation. Boys and men, in particular, “have knowledge gaps, they have misconceptions,” Paul said, explaining that she has seen men forbid their wives from using contraception because of the belief that “an IUD travels anywhere around in the body… they think they can feel pain from an IUD. This is not true.”

Students who receive comprehensive sexuality education are not only empowered to make healthier sexual choices, but they are also better equipped to seek help when needed. “The information I share can significantly change a person’s life,” said Lourenço.

She recalled one girl who, while receiving sexuality education through a mentorship programme, revealed she had a chronic wound on her breast—something she regarded as an embarrassment but not an emergency. Another young woman disclosed that she was living with an uncle who had sexually abused her. “The girl locked herself up and couldn’t speak with anyone for fear of being expelled from the home and ending up on the street,” Lourenço described. Mentors were able to secure services for both girls, but Lourenço is haunted by what might have been: “If we did not intervene, what would become of these girls?”

Comprehensive sexuality education can also play a role in preventing gender-based violence. When taught to international standards, the lessons include messages about human rights, gender equality and respectful relationships (UNESCO and others, 2018). And experts are increasingly calling for this information to frame violence prevention as the responsibility of potential perpetrators, rather than the responsibility of victims and survivors (Schneider and Hirsch, 2020).

“They need to know what their rights and duties are in a society first,” Lourenço said, explaining that this is the foundation of comprehensive sexuality education as she teaches it. “Then they need to know how their bodies work so that they can make decisions for themselves and not let others make decisions for them.”

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