July 23, 2014 § Leave a comment
Being the editor of Reproductive Health Matters has been an incredible experience. I’ve not only been able to be a full-time editor in this job, but also a lecturer, sharing the knowledge that RHM has published, and a teacher of writing for publication. I’ve also always done this job as an active participant in the field and as an advocate for sexual and reproductive health and rights. In the 22 years since we started the journal, I’ve had the privilege of working with hundreds of the most amazing authors and peer reviewers anyone could hope to meet.
With readers in 186 countries and the support of RHM’s donors, boards and authors, RHM has become a much valued resource in the field for information, knowledge, perspectives, ideas for change on the ground, and recommendations for policy, services, research and action.
The world of journal publishing is increasingly complex and RHM faces a period of transition to online publishing and changes in relation to open access publishing that raise new and different equity-related issues from the past.
Funding will always present a challenge.
However, RHM’s unique perspective, determination to cover controversial, new and neglected issues and challenge orthodoxies is needed now more than ever. I look forward to welcoming someone with the passion and skill to meet these challenges who will take RHM into the future with
new ideas and energy.
November 6, 2013 § Leave a comment
Brussels, 24 October, 2013
Marge’s speech to an interdisciplinary workshop – empowerment: do we speak the same language? Organised by the Belgian Platform on Population and Development within the Health Working Group on Sexual and Reproductive Health and Rights
Thanks for inviting me to speak not just once but twice today! Mylène has provided a broad conceptual description of empowerment. What I will try to do is talk about the practical issue of how to achieve the empowerment of women and raise some questions about what that actually means.
Let’s start with what is most obvious. We are all subject to many kinds of control and authority in our lives – political, legal, professional and work-related, medical, cultural, social, ethnic, familial, and religious control and authority. But in almost all societies, women and girls are also subject to male authority, which is exercised through all of these other forms of authority.
The call for empowerment of women and girls, who are half the world’s population, has primarily been in response to and rejection of male authority over women, and defined primarily as a need for achieving gender equality. For example, in the UK in the 1970s, the Women’s Liberation Movement put forward seven demands:
1. Equal pay for equal work
2. Equal education and equal opportunities
3. Free contraception and abortion on demand (thus, equality in bodily autonomy)
4. Free 24 hour nurseries
5. Legal and financial independence for all women
6. The right to a self-defined sexuality and an end to discrimination against lesbians
7. Freedom for all women from intimidation by the threat or use of male violence. An end to the laws, assumptions and institutions that perpetuate male dominance and men’s aggression towards women.
It’s 40 years later, and we have still not achieved any of these demands fully, though many aspects of women’s lives have improved greatly in regard to most of them. But I believe the extent of the success has been more limited than one might have expected because there is much more getting in the way than merely gender discrimination. What is involved is access to power and the exercise of power itself, and the changes in who women are if they succeed in becoming independent, autonomous, and empowered – which is something to fear for many men and many women too.
The word “empowerment” implies that women lack power, which in turn may be taken to imply that women are helpless or victims. We are often presented that way, for example as “victims” or as “survivors”, for example of rape or violence or trafficking. And indeed, many women do indeed lack power in multiple ways.
Women Can Do It is an example of an early women’s empowerment training programme originated by Norwegian Labour Party Women, as long ago as the 1970s. Their aim was to help more women participate in society, to have half the power being half the population, and holding as many formal positions and as much authority as men. They developed a training course for women that involved building confidence, learning the rules of political and organisational work, and giving the participants the courage to speak out and take part in decision-making processes, participate in society, in NGOs, in political parties, speak up at work and in the family. They argued that women often hold back from speaking their minds, worried that they will not be as eloquent as men, or not be listened to, or be ridiculed or neglected at meetings. The training was also an opportunity for women to meet and form networks. This programme has been conducted in more than 25 countries worldwide, according to Wikipedia. It covered the following topics: democracy and women’s participation, communication, argumentation, speeches, debates, working with the media, negotiation, resolution of conflicts, networking, advocacy and campaigning, and violence against women.
On the other hand, as the iconic Chinese slogan tells us, women hold up half the sky. This wonderful slogan aimed to challenge that fact that women often held up the less valued parts of the sky, with little or no recognition or reward for doing so and little space left to participate in more highly valued activities. But, clearly, the issue is not that women have no power but that they carry many responsibilities in a disempowered condition, that is, in ways that give others control over their rights, choices, decisions, actions, and ultimately, their lives. Women’s acceptance of this condition is inculcated in them from the time they are babies, and to great effect.
Let me illustrate another perspective with a 19th century response to myths about women’s helpless, female condition, through excerpts from a statement made by Sojourner Truth, an African woman in the US who had been a slave, at a Women’s Convention in 1851, entitled:
Ain’t I a Woman?
“Well, children, where there is so much racket there must be something out of kilter. I think that ‘twixt the negroes of the South and the women at the North, all talking about rights, the white men will be in a fix pretty soon…
That man over there says that women need to be helped into carriages, and lifted over ditches, and to have the best place everywhere. Nobody ever helps me into carriages, or over mud-puddles, or gives me any best place! And ain’t I a woman? Look at me! Look at my arm! I have ploughed and planted, and gathered into barns, and no man could head me! And ain’t I a woman? I could work as much and eat as much as a man – when I could get it – and bear the lash as well! And ain’t I a woman?…
If the first woman God ever made was strong enough to turn the world upside down all alone, these women together ought to be able to turn it back , and get it right side up again! And now they is asking to do it, the men better let them…” http://www.sojust.net/speeches/truth_a_woman.html
The men better let them, she said! Ponder that in relation to the term “empowerment”; I’ll come back to it. This speech was 162 years ago and the white men are still in charge, even though the pressure outside the door to get in has become much greater. So let me draw what I think are some important conclusions so far:
1) Although women not having power is about gender discrimination, it is also about many other structural violations of rights and other forms of discrimination as well, race and class being two of them, wrapped up together.
2) While men are often one of the sources, they are not the only source of women’s disempowerment.
For example, given the group session this afternoon on empowerment in health institutions made me recall a study in South Africa where the aim was to reduce the hierarchical distance between health professionals and women patients by asking the health professionals, who called patients by their names, to wear name tags so that the patients would know the name of the health professionals. It later emerged that because a lot of the patients could not read, the effort failed in its intention. Indeed seeing the doctor is often an extremely disempowering experience if the doctor completely controls the conversation about your health problem, whether and how to investigate it, can decide whether it is a real problem or not, and what will be done about it. And when I say the doctor, I mean women doctors too. The unequal relationship with patients – in social and economic class, in level of education and medical knowledge, and in control of the resources of the health system, is a bigger problem than just the sex of the persons involved. The rigid hierarchies within the health profession are also a source of disempowerment for nurses and midwives compared to doctors, to name just one example.
3) Most men are also disempowered in multiple ways, even though they may contribute to the disempowerment of women as well.
This makes any effort to empower girls and women as a matter of public policy a far more complex issue than it is perceived to be in most public policies today.
Next month’s edition of RHM has a paper by Theresa McGovern which looks at what gender equality advocates call the “gender equality machinery” in place both in UN conventions, other international policies, and at country level through case studies of Bangladesh and South Africa. Her paper shows that all these policies and the endless advocacy efforts and discussions that have led to them have indeed improved matters for women to a certain extent and in certain ways, but that many of the barriers are as strong as ever. Let me list the global policies because the number alone is instructive:
• Convention on the Elimination of All Forms of Discrimination Against Women (1979)
• Fourth World Conference on Women in Beijing Platform for Action (1995),
• 23rd Special Session of the UN General Assembly (2000)
• Millennium Summit (2000) and MDG 3 on gender equality
• Monterrey Consensus (2002) which recognized the importance of a holistic approach to development financing and stressed the need to reinforce national capacity-building efforts for gender budgeting
• Commission on the Status of Women (2006)
• Accra Agenda for Action (2008) which proclaimed gender equality as a cornerstone of development , adopted and extended at the Busan Partnership for Effective Development Co-operation (2011)
• Gender Equality Survey which was added to the Paris Declaration’s monitoring and evaluation activities, also in 2011, and
• Gender Equality Architecture Reform Campaign in 2008 of over 300 women’s organizations which led to setting up of the UN Entity for Gender Equality and the Empowerment of Women (usually called UN Women) in 2010.
However, what about the money to fund all this? McGovern finds that UN Women’s budget is only US $235 million per year compared to UNFPA with $934 million and UNDP with $4.8 billion… Moreover, she says, the commitment to investing in women and girls has not been matched by investment in women’s rights or advocacy work. In spite of verbal support for the empowerment of women and girls, with women acknowledged as essential to economic development and societal advancement, women’s rights work is still grossly underfunded. An Association for Women’s Rights in Development (AWID) survey in 2011 of over 1,000 women’s organizations found that only 7% had budgets in 2010 of over half a million US$, 48% had not received core funding, and 52% did not receive multi-year funding. An exception that deserves mention is the Netherlands Ministry of Development Cooperation’s MDG 3 fund that awarded €82 million to 45 gender equality projects over four years, which focused on political involvement, preventing violence against women, and economic empowerment.
Indicators of disempowerment of women
Two of the most important indicators of disempowerment of women are, in my opinion:
1) violence against women and girls, including sexual violence and abuse, which remain almost unchecked all over the world. Violence is grossly disempowering at many levels. In my opinion, as long as girls and women are not safe from violence, their lives can never be considered to be in their own hands.
2) lack of access to safe, legal abortion, which is a form of state violence that prevents women having autonomy over their ability to reproduce and therefore over their own bodies. In the 1970s, we talked about the right to have an abortion as the cornerstone of women’s liberation.
Even violence is not merely a women’s problem, however, because in fact more men suffer from violence than women do. The difference is that men are not just violent towards each other individually, as they are towards women, which one might put down to higher testosterone levels, but also through the structural promotion of and use of violence by states and other organised groups, in war and other forms of armed conflict, in assassinations, mass murder, and so on. In many of these forms of violence, most of the men involved may themselves be disempowered, foot soldiers sent to kill and be killed by leaders who use them to obtain power.
As far as I am aware, those working on violence against women rarely connect this more structural form of violence with gender-based violence. Yet I believe they are connected, just as the practice and experience of violence are connected and handed down from one generation to the next, and until violence can be stopped between and against men, especially young men involved in conflict, and individual violence which brutalises and abuses men as both children and adults, as much as women, in my opinion women and girls haven’t got a chance of seeing an end to gender-based violence.
The terminology of empowerment
Let me talk about the terminology of empowerment now, and being an editor and linguistically particular, examine the verb “to empower”. This verb means “giving power to” which implies someone giving women power. Someone else? If so, who? Men? Families? Male partners? The state? Or can and do women empower themselves, let’s say to the point where being a woman isn’t a barrier any longer – or not? What makes change happen?
This is an important political problem because the answer should influence the content and form of programmes whose aim is empowerment of women and girls.
Let me add still another facet to the problem: The word “empowerment” in relation to women is used in such a way that the true nature of power (as in the “will to power”) is somehow veiled, or made more feminine and benign, and given only a positive connotation, i.e. increased self-confidence, or knowledge as power for doing good, or to be able to work and be independent, because it is for women. And women are always good and doing good, right? Except Margaret Thatcher, of course.
However, by its very nature, power is rarely shared or handed over willingly, or in fact without a fight, often a fight to the death. Sometimes that fight can last hundreds of years, or perhaps as in this case, as I see it, probably forever. No matter how far back in history you go, you will find women who are powerless over the events of their lives, and who are fighting against that power being exercised over them because they are women. You will also find misogyny – hatred of women – then as now. Misogyny is frightening. It is also an under-studied phenomenon, which deserves far more attention with regard to gender equality and women’s empowerment, because it explains a lot.
Coming back to linguistics, in the 1970s, we talked about women’s liberation, not women’s empowerment. This notion was, first and foremost, about women’s liberation from oppression. It wasn’t about obtaining power but about obtaining freedom. “Empowerment” does not carry the same sense as seeking freedom. I never use it. On balance, I prefer “women’s liberation” but it is impossible to use those words or words like “oppression” today. They sound very old-fashioned, as they have a whiff of socialism, and nobody is a socialist these days. Even so, they remain absolutely relevant concepts.
Finally, if “women’s empowerment” remains the order of the day, it is important to ask:
• whether all women want power, or to be empowered,
• whether there is a difference between these two,
• what kind of power – or empowerment – women want, and
• for what ends?
Women in the UK stood for Parliament under Tony Blair and there was a joyous photo of them all, with him standing in the middle, at the beginning of his term as PM. However, many were subjected to ridicule and sexist remarks when they tried to speak, especially on topics of concern to them which the men in the Parliament looked down on.
An early study of why women joined the anti-abortion movement in the US in the 1970s-80s, by Kristin Luker, in a book called Abortion and the Politics of Motherhood, was that the women did not want women as a group (or themselves personally) to have the possibility of going beyond the roles of wife, mother and homemaker. Luker shows from these interviews clearly how and why women sought to disempower other women, just as men did. Yet the irony she also discovered was that by becoming active in that movement, anti-abortion women made themselves into more than wives, mothers and homemakers, and didn’t even see it. This is true regarding far more than abortion.
I will conclude by saying that as long as empowerment is linked only or mainly to gender equality, it is reduced to an issue of women’s relationships to men, both individually and at a familial and societal level. I have tried to argue that as important as gender equality is, it is not the only issue involved, but is about many more structural issues and aspects of power and oppression to which most men, as well as most women, are subjected.
Empowerment and inclusion of all
Let me close with a paragraph from the Montevideo consensus from the Latin America & the Caribbean regional meeting on population and development, August 2013:
Affirming that freedom, capacities and the right to take informed decisions, empower persons to develop their potential and participate fully in the economic and social spheres; that the realization of human potential and innovation depend on guaranteed human rights, physical integrity and protection against violence and that the right to health, education, housing and a livelihood ensures full empowerment and inclusion of all…
This is a description of empowerment that I can support.
Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes
September 24, 2013 § 1 Comment
A blog by Marge Berer, Editor Reproductive Health Matters. Originally posted on the blog of JALI - the Joint Action and Learning Initiative on National and Global Responsibilities for Health
I asked JALI if I could write a blog after I had read the minutes of the May 18 meeting in Geneva on the way forward for an FCGH, to raise some issues that I’ve been confronting in the seemingly endless consultations and statements circulating on the internet on the post-2015 world – to do with what an MDG replacement would look like, whether or not universal health coverage as currently conceived is the answer to how to address health, and whether and where my issues of sexual and reproductive health and rights might fit into the “Sustainable Development Goals”, the most likely successor to the MDGs, when they have had such short shrift in the MDGs.
I was particularly struck by the paragraph on the two animating principles of a Framework Convention on Global Health mentioned in the minutes, that is, ‘global health equity (within and between countries) – “global health with justice,” as offered by Larry Gostin – and the right to health… setting clear standards to make it more concrete, measurable, and enforceable… addressing global governance for health… shifting international law towards health. It would ensure for all people the conditions required for health, including health care, public health, and social determinants of health, setting standards and establishing a national and global financing framework to enable universal access to and coverage of health care and public health measures (e.g., clean water, sufficient nutritious food)… directly address domestic inequities…[and] promoting Health in All Policies.’ (pp.2-3)
Just as people in the meeting raised the fact that some participants in the FCGH process required more explicit attention, e.g. health workers and health worker unions, as did some issues, e.g. mental health, I would like to raise three aspects that I think need to be part of the FCGH discussions:
i. Gender issues – that is, the differences between men and women in their health needs, their access to health and health care, and the inequities in that differential access. Gender issues in relation to health are crucial to any convention. There has been a lot of work by women’s health advocates on gender issues in relation to women’s health but far less work by either men or women on gender issues in relation to men’s health. In the same ways as girls’ and women’s health issues were at one time almost invisible in the previous century, attention to boys’ and men’s health issues has not been developed in the past 30 years, in spite of the growing attention to women’s health issues and wide-ranging work on gender, both in academia, by the women’s health movement and even in WHO. In a recent paper I was considering for publication, for example, it was said that gender-based violence against women was the most common form of violence, when in fact men experience far more violence globally overall, but between each other, whereas women experience violence mostly from men. Thus, work is needed on how to address gender issues within an FCGH in relation to the right to health, the social determinants of health, health financing, etc, and how this might be approached needs much more thought and consideration.
ii. Religious, political and “cultural” opposition to what an FCGH would stand for, being used most vocally today to justify why access to crucial aspects of health and health care related to sexuality and reproduction are being withheld and denied, and many sexual and reproductive rights condemned and criminalised. Underlying this opposition are two forms of hate: misogyny and hatred of any form of sexuality that is not heterosexual and heteronormative.
One of the reasons I support a Convention is that it would give greater weight to all these issues by requiring not only non-discrimination and equality, but also regular examination, analysis and critique of country programmes, along with official recommendations for policy and programmes, and demands for accountability and action through interpretation of the implementation of the convention. We are beginning to see such a framework making a difference in relation to sexual and reproductive rights issues, particularly via the work of CEDAW. So I recommend studying CEDAW’s history, functions, and procedures particularly and how they might be applied more broadly across health. I would be interested in being involved in this in the future.
iii. The process of developing the successor to the MDGs may cut out the few specific aspects of health and health care that were allowed into MDG 5, where they were mostly reduced to their lowest common denominator and stripped of their complexity, e.g. universal access to reproductive health was a late add-in to MDG 5, which never moved beyond superficial attention to a few aspects of reducing maternal mortality, diluted heavily by tacking newborns, infants and children onto “maternal” health, and omitting the great majority of interlinked sexual and reproductive health problems.
Universal health coverage in my opinion may also succeed in shortcutting and eliminating the “controversial issues” in whatever is included under a “unified health goal” post-2015, and it may also make support for addressing specific aspects of health equally or even more difficult. Having devoted two recent issues of Reproductive Health Matters to privatisation in sexual and reproductive health services, where articles provided evidence of a resulting increase in inequity of access to health care among the 4th and 5th socioeconomic quintiles of many African and Asian countries, I am worried that the health goal that is eventually agreed is likely to be biased one way or another towards consumerism, commercialisation and privatisation of health and health services, and their financial underpinnings such as health insurance. I am very uncertain of the value of what has emerged so far as regards universal coverage from WHO, given the pressure on the agency from the World Bank, big pharma, world trade policies, and the influence of private/foundation donors, when measured against what we would like to see as the basis for the Framework Convention on Global Health.
June 5, 2013 § Leave a comment
Marge Berer, Editor, Reproductive Health Matters
The announcement regarding the decision to allow Beatriz in El Salvador to have a “premature delivery” requires a continuing response from the abortion rights community.
The article states: “The medical team at the Maternity Hospital is ready to act immediately at the slightest sign of danger.” In fact, the opposite is true. Danger signs have existed in Beatriz’s pregnancy from the beginning. Instead of acting on them and terminating the pregnancy as soon as it was known that the embryo had no chance of survival, if not sooner, the medical team of the hospital has put her life at constant risk. Like Savita Halappanavar in Ireland, Beatriz’s condition could suddenly worsen, e.g. her blood pressure could go out of control, her kidneys could fail, and she could die in a short space of time.
No one in the hospital or the Ministry of Health of El Salvador should be allowed to get away with the falsehood that her care is in good hands. Her care is in the hands of people who have been prepared to let her die for the sake of a fetus with no brain, but with only a heartbeat and without the chance of a life.
She will be “allowed” to have a caesarean section, described as a “premature delivery”. Why a c-section, why surgery? Is this justified because it is the safest possible form of delivery for her? Can someone explain this please? What is wrong with either a dilatation & evacuation, or induction with mifepristone and misoprostol? Both surely carry fewer risks?
Please recall the case of “Aurora” in Costa Rica, at the end of 2012, who was also carrying a fetus with no chance of life, a fetus whose heartbeat stopped only at 29 weeks of pregnancy. She also was then given a c-section. Some of us asked why that was necessary at the time, but no one raised the question or challenged it publicly. It is time to ask publicly: why is a c-section the delivery method of choice? Is it only because it is the only form of termination of the pregnancy that they think cannot be labelled abortion?
Are these two cases representative of a new “Catholic health policy” for pregnant women with an emergency obstetric situation involving a non-viable embryo/fetus – that they are imprisoned in a hospital, in some cases for months, denied a life-preserving abortion until the fetal heartbeat stops, and then delivered of the dead baby by the highest risk procedure possible for the woman, a caesarean section?
Beatriz’s treatment should be considered cruel and degrading treatment and a violation of the Hippocratic oath to do no harm. The protest here is not finished; it is only beginning because cases like Beatriz’s and Aurora’s are only just coming to light through the vigilance and action of human rights and women’s abortion rights groups. What we need to challenge is not just the abortion laws of El Salvador, Costa Rica, Ireland and other countries where even abortion to save the life of the woman is not permitted. We need to challenge the Ministers of Health, parliaments, Supreme Courts, hospitals and clinicians in every country whose clinical decisions and actions are subservient to the dictates of the Roman Catholic Church’s “health policy” on abortion, which blatantly and cruelly disregards the right to life and health of pregnant women. Whose bottom line is that even with a non-viable embryo/fetus with a heartbeat but no chance of survival a termination is never permissible.
RHM has just published my paper analysing Catholic health policy on emergency obstetric care involving termination of pregnancy which discusses all the cases I could find that have come to light up to several months ago:
Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women: An analysis of the death of Savita Halappanavar in Ireland and similar cases
It seems this is not an uncommon problem. If health professionals systematically put the lives of their patients at risk for any other ideological non-clinically justifiable reason, it would not be tolerated. I believe any Catholic health professionals and/or hospitals refusing to terminate a pregnancy as emergency obstetric care should be stripped of their right to provide maternity services. In some countries these are the main or only existing maternity services. Even so, governments should refuse to fund these services, and either replace them with non-religious services or require that non-religious staff are available at all times specifically to take charge of such cases to prevent unnecessary deaths. At issue is whether a woman’s life comes first or not at all.
Previously posted in RH Reality Check – June 1st 2013
March 12, 2013 § Leave a comment
Bererblog readers might be interested in the new RHM BLOG which includes comment and analysis from Reproductive Health Matters staff and guest bloggers on topical SRHR issues. Since launching we have added these posts:
Rape the stereotyping of Indian culture and moving from ‘protection’ to ‘freedom‘ – a guest blog by Pooja Badarinath
It’s also a place where you can find Reproductive Health Matters’ responses to current consultations:
Marge is going to continue blogging here so watch this space…
February 19, 2013 § Leave a comment
Marge Berer, Editor, Reproductive Health Matters
The news that broke earlier this year from Israel, that Ethiopian Jewish women had been given the injectable contraceptive Depo Provera without their knowledge or consent, awakened a strong feeling of déjà vu for me. This is where I came into this field, 35 years ago. Depo Provera had recently come onto the market for the first time. There were far fewer contraceptive methods available at the time and therefore far less choice. A method that a woman need only renew once every three months was a gift, from one perspective. One injection four times a year and no fear of unwanted pregnancy, no need to insert anything, wear condoms, remember to take a pill every day, get your partner’s agreement if he was opposed to using something. It was heralded as the solution to high levels of unwanted pregnancy.
At the same time, the potential for abuse of this method was obvious from the beginning, and abuse there was from paternalistic family planning providers. The “irresponsible woman”, who kept coming back for abortions, women who were poor, uneducated or with learning difficulties, who didn’t understand contraception or the importance of limiting births, were seen as the ideal candidates for Depo Provera. Middle class, more educated women stayed with the pill or got a copper IUD. HIV hadn’t appeared yet and condoms had become a thing of the past with the advent of the pill in the 60s. Diaphragms were what our mothers had had to use, with or without condoms, when there was nothing else. You had to be over 30 to be sterilised. Modern contraception was barely 20 years old and it was truly liberation for my generation, as it still is.
At the same time, however, the Dalkon Shield IUD, an IUD which was thought to increase the risk of upper reproductive tract infection because of the nature of its string (extending into the vagina for removal purposes), believed to facilitate the conduction of infection upwards, caused a hue and cry. Due to action by US feminist women’s health activists at the time, the method was withdrawn from the market and the reputation of all IUDs suffered for many years. Young women, who with hindsight and greater knowledge we can guess were getting sexually transmitted infections in large numbers as they experimented with sex, were not allowed to have IUDs because of this risk, when in fact, it was probably the sexual networking that was unsafe, as we learned when HIV hit the globe.
Even so, as part of a small but very vocal international feminist women’s health movement who supported women’s reproductive rights and opposed “population control”, I wrote a pamphlet called “Who needs Depo Provera?” in 1983, which was distributed pre-computer very widely both in the UK and other countries. Reading it again now, I am embarrassed to find how completely negative it was. It not only expressed fears of the potential for abuse of informed consent with the method, which remains justified. It was also so negative about the known side effects that anyone reading it would be completely put off, even if the method might have suited them. And it expressed exaggerated fears about the long-term safety of the method, which at the time was unknown because studies of long-term safety had not been conducted. We conflated the existence of negative side effects (to do with effects on menstrual bleeding, weight gain and mood changes) which do exist and may affect women, with an assumption that long-term safety was a problem. There was just enough evidence of possible issues to create this concern, but instead of expressing it with caution and uncertainty, in a scientifically justified manner, we used it to condemn the method.
Our action against Depo Provera, which included a protest outside the Committee on Safety of Medicines (because we were not allowed to give evidence or raise questions in their hearings on approval of the method) had many consequences. A good consequence was that long-term safety studies were initiated and became a standard part of contraceptive research and development. Another was that we contributed to the recognition of the importance of the concept of informed choice as regards using contraception, in place of “doctor knows best”. Informed choice, which the movement was demanding all over the world, became accepted in mainstream family planning and something that women expected. (I’m simplifying a very complex set of events over many years here, in order to be brief.)
On the negative side, however, there have been two lasting ill-effects. The first was exemplified in Zimbabwe at the time, where Depo Provera was pretty much the only available contraceptive. The government took the decision to focus its family planning programme around this method, whether due to the cost implications of a choice of methods, or because primary level family planning providers could most easily deliver it, or out of awareness that men did not understand the value of contraception and were widely opposed to it, and this method could not be removed by them, or because women were having more children than they wanted and the method is highly effective – most probably for all these reasons. Women in Zimbabwe accepted Depo Provera for its benefits and had begun to use it widely. That programme was very negatively affected by our actions in the UK and elsewhere. This was not a victory, as we believed at the time. On the contrary, it was a costly and terrible mistake.
Secondly, to this day, some feminist women’s health activists remain negative about Depo Provera and other longer-acting hormonal contraceptive methods, even though their benefits are clear, their side effects are no longer a secret and are explained to women more often, and their long-term safety has been studied and confirmed. Their opposition has been carried over to implants, IUDs, and medical abortion pills, in effect splitting the feminist women’s health movement into conflicting camps, and continues to have the very negative effect of limiting the still limited choices women have for preventing and terminating pregnancy.
On the other hand, the potential for abuse of injectables – because they are easy to administer in the context of other services without necessarily explaining what it is, and of implants because they require surgical removal, and of sterilisation because it is permanent and difficult or impossible to reverse – remains. Such abuses are not a thing of the past. They emerge regularly, as Lisa Hallgarten has shown in a recent blog, citing a number of RHM articles, whether due to pressure to meet targets, racist efforts to reduce births among ethnic minority populations, or discriminatory efforts such as to stop women with HIV from having children.
But there are some big differences between what was happening in the 20th century and what is happening now. The most important is that there is widespread recognition that these are abuses so that, when they emerge into the light of day, something is more often done (and sometimes done quickly) to stop them, including through public investigation, the courts and the UN human rights system – as has happened in Israel with Depo Provera and with sterilisation of HIV-positive women in southern Africa. (Though not quickly enough in Eastern Europe for Romany women, who got little support for a long time.) Mass abuse such as the sterilisation camps in India under Indira Gandhi in the 1970s, is hopefully far less likely. Still, the need for vigilance remains.
Secondly, the new “family planning initiative” in seeking to greatly increase access to contraceptives, which is a very good thing, knows it cannot afford to be tarred with the brush of failing to deliver informed choice. It is being very cautious about targets, even though it is calling for them. It says it supports informed choice and a rights-based approach, even though these are inconsistent with targets in the hands of a system that punishes health workers for failure to reach targets. This is an ongoing discussion; it may not be unalloyed progress, but it is definitely progress of a kind.
February 13, 2013 § Leave a comment
Marge Berer, Editor, Reproductive Health Matters
We all have to decide when it’s time to step down as we age, and now we can say “even the Pope”. I’m a few decades younger than him but I can already see that decision waiting in my future too. Maybe he is too frail in mind and body. At his age, he has a right to be. Maybe he’s had one too many scandals related to sexual abuse to deal with, and he doesn’t want to cope with any more, or know what to do about them, or how to prevent more of them taking place without compromising what he stands for. I’m sorry he is unwell, but I’m glad to see the back of his policies.
My hope is that his virulent misogyny, dressed in sheep’s clothing, his support for women’s deaths through unsafe abortion, his unswerving opposition to condoms and contraception, his condemnation of so many aspects of sexuality, are all stepping down with him, never to return.