Interview for Amnesty, 22 August 2015

04/06/2016 § Leave a comment

The following are my answers (with some additions) to questions in an interview with Saphia Crowther of Amnesty International via email, for publication by them last year:

  1.   What drives you to campaign for sexual and reproductive rights? Was there one person, incident or news story that inspired you to become an activist?

I became active in my mid-20s in the second half of the 1970s in the UK National Abortion Campaign because I had an unintended pregnancy from a relationship with someone who did not want to know, and I decided, after a long month of thinking what to do, to have an abortion. This was not long after the 1967 Abortion Act had been passed, and my GP was quite scathing about it and said she was only referring me because I wasn’t married. The ob-gyn who did the abortion came round the room and told each of us he was just going to “pop an IUD in” when he’d finished, and I had to fight not to have that. Luckily the nurse who found me sobbing when I woke up (a common side effect of anaesthesia combined with misery) patted me on the arm and told me that it was my life and I had done what I thought best, and not to feel bad about it. That experience made me an abortion rights advocate for the rest of my life.

  1.    Tell us why access to safe abortion is important. How do restrictions on safe abortion in countries like El Salvador and Ireland impact on women’s equality?

Access to safe abortion is necessary for women because they have sexual relationships with men. While the sex is hopefully wanted, pregnancy as a consequence of it may or may not be either intended, or when it happens, wanted. Moreover, sex is far too often not wanted, particularly among young women, and the data on the extent of sexual abuse of girls is shockingly high. Wanted or unwanted, however, having sex is not a good reason or qualification for having a baby and being a parent. The advent of contraception and safe abortion has allowed us to separate sex from pregnancy, and to choose to have a child(ren) at the point when we definitely want them and are best able to raise them. It has been shown that unwanted children have a more difficult time in life in many ways. It has also been shown that having children by choice is the best way to have children. This is not to say that an unintended pregnancy cannot become a wanted one, it can and sometimes does. Moreover, an initially wanted pregnancy may later become unwanted ‒ due to a serious changed life circumstance, such as illness or divorce, or the baby may be found to have a serious anomaly that the woman/couple feel they cannot cope with.

  1.     How are the situations in Ireland and El Salvador similar? And how do they differ?

They are similar in that in both countries all or almost all abortions are illegal. They are different in that women in Ireland can seek a safe abortion in Britain or another EU country nearby, while in El Salvador, there is nowhere close by to travel to. Hence, in El Salvador there are many unsafe abortions among poor women as they cannot afford to pay for a safe illegal abortion. Furthermore, in El Salvador when women present at a hospital with complications from an unsafe abortion, or even from a miscarriage or stillbirth, they are at risk of being arrested, put on trial for either illegal abortion or homicide, and sent to prison, often for many years. For several years now, there has been an internationally supported campaign to free 17 of those women (Las 17), which Amnesty has been centrally involved in supporting. In fact, we know of women in at least 26 countries who are in prison for having had an abortion.

  1.      You founded the journal Reproductive Health Matters in 1992 to put women’s voices and experiences at the centre of research into sexual and reproductive health. Two decades on, are women still marginalized in discussions and decisions about their reproductive health?

Yes, and particularly in regard to their right to a safe abortion on request.

  1.      Public pressure is crucial to getting legal restrictions on abortion overturned. How have public perceptions of abortion changed in recent decades, and how can people put pressure on those in power?

Across the world the great majority of people support access to safe abortion on at least some grounds, certainly when there is a risk to the woman’s life or health, if the pregnancy resulted from rape or sexual abuse, and in cases of serious fetal anomaly. The numbers who support access to safe abortion at a girl/woman’s request are also very high (with a rising trend) in countries where safe abortion is available, and the numbers are growing in countries that have not yet changed their laws, most of which are leftovers from colonial times. An increasingly vicious anti-abortion movement is trying to turn the clock back everywhere. This is because they believe women should be enslaved by their own fertility and denied autonomy over their own lives, not because they are interested in there being billions more babies in the world. The anti-abortion movement ignores and does nothing for living children in need. People can put pressure on those in power by taking a public stance as part of a movement, through their trades unions, NGOs they work for, and as part of human rights, family planning, maternal health, sexual and reproductive health and rights movements. Or as individuals by writing to their member of parliament and expressing opposition to any attempt to restrict or criminalise abortion.

  1.      What’s been your greatest challenge as an activist? And your greatest success?

Challenge: Finding ways to overcome the differences in views and reach consensus on how to act and what to support among those who are part of the “movement” I am part of, and how to get governmental and inter-governmental support for putting a stop to the violent behaviour and expose the lies of the anti-abortion movement. Success: Publishing a large body of peer-reviewed work and first-class political thinking on the issue of abortion (as well as many other aspects of sexual and reproductive health) through Reproductive Health Matters up to 2015 and being able to promote and share that knowledge as an activist for the right to safe abortion.

  1.      Finally, women’s empowerment and education are vital to upholding their sexual and reproductive rights. Does men’s education also have a role in promoting women’s equality?

Men have 50% of the responsibility for causing unintended pregnancies in wanted sex, and 100% of the responsibility when they force sex on a girl or woman. This is as true among those who sit at the top of governments as among those who use the priesthood to sexually abuse children as among those at every level of the social ladder. There is therefore an ethical imperative on men and boys not to force sex on anyone, to protect themselves as well as their partners against unintended pregnancy, and to support women’s right to safe abortion upon request. This should be a central part of sex and relationships education.

IN MEMORIAM Rosa Tunberg

29/05/2016 § Leave a comment

300

It is with great sadness that I wish to inform everyone who knew her that Rosa Tunberg, who worked for Reproductive Health Matters from  October 1999 to August 2007, died from cancer on 10 January 2015 in California.

Rosa was born on 5 February 1939, in Santiago, Chile, the middle of three sisters. Her father died when she was young. When she was 18, she left Chile with her mother and younger sister to move to Los Angeles CA in the USA. Her older sister stayed in Chile. Rosa studied comparative literature at UCLA and worked at Twentieth Century Fox, where she met Karl Tunberg, a Hollywood screenwriter, whom she married in 1968. She also became a stepmother to her husband’s two children, Terence and Thomas Tunberg. While raising her own two children (Carlos and Victoria) she earned her Montessori Primary Diploma in 1976 and began teaching. In 1978, the family moved to England. Rosa worked at Richmond College outside London for some years. She was widowed in 1992.

In around 1999, Peter Hall, who had been a scientist at the World Health Organization in Geneva, retired, moved to London and started an NGO called the Reproductive Health Alliance Europe. He opened an office for RHAE next door to Reproductive Health Matters in Kentish Town and advertised for a part-time secretary/administrator to manage the office. Peter showed me her CV and before he was even able to interview her, I jumped in and asked if I might interview her as well. Rosa agreed and was duly hired by us both immediately afterwards. Rosa was a bright, cheerful, highly skilled and exceedingly warm-hearted person with a sharp and thoughtful mind. She was able to do everything you might ask for and then some. She helped to promote and publicise the journal, and increase the readership, and worked closely with Paula Hajnal-Konyi, finance manager, and with me. She always had a twinkle in her eye and at the right moments, a witty retort on her lips. She worked unstintingly, expected a lot from others and gave a lot in return.

In 2007, she decided to retire, and she and Carlos moved back to Los Angeles to join Victoria, who had returned to the USA in 2004. Rosa remained active and inquisitive about everything and reconnected with old friends in Los Angeles. The three of them travelled when they could – to Hawaii, Italy, Northern California, Florida. Rosa fought the cancer for three years, and died peacefully and quietly. She remained strong, never showing suffering.

by Victoria Tunberg, her daughter, and Marge Berer

“Just because abortion is easy doesn’t mean it’s right” : do you agree?

26/03/2016 § Leave a comment

During a day of excellent presentations on the question of “How can a state control swallowing?” on medical abortion and the law, organised by Prof Sally Sheldon of Kent University Law School, an unexpected question was asked from the floor, during the session I chaired: “Just because it [abortion] is easy doesn’t mean it’s right: do you agree?”

The questioner did not at that stage state his views but the question sounded, even on the surface, anti-abortion. I decided to respond myself. Of course not, I said. But no matter what aspect of reproductive health we look at, tradition as developed by the law and the medical profession has been to make things as difficult for women as possible. When doing surgical abortions, pain relief is often not offered at all, or too little is offered or too late. When pain relief during labour and delivery was finally developed in the 20th century, many were against it because the Old Testament talks about Eve being punished for her sin by having to suffer pain during labour and delivery. And although contemporary abortion methods, both manual vacuum aspiration and medical abortion, are extremely easy to provide, are very safe, take very little time and are very low tech, they are fenced in with a huge range of barriers and regulations. Gynaecologists in many countries still insist on using D&C, which takes much more time and skills, requires general anaesthetic and an overnight stay in hospital, as well as carrying a higher risk of complications. The fact that WHO has not recommended using D&C for something like two decades makes no difference. In short, things are often made as difficult for women as possible when it comes to pregnancy, and especially when it comes to abortion.

This is the same kind of myth as the one which says: if you make abortion easily available, everyone will want to have one. Thus confusing abortion with ice cream or sweets.

What I should have said, in order to keep the exchange as succinct as possible, was: “It doesn’t make it wrong either…”.

In fact, it’s wonderful for women that abortion has become so easy. Now all we need to do is liberate it from those who will use any means they can find ‒ out-of-date laws, punitive morality, clinically unjustified regulations, and even bald-faced lies ‒ to keep it difficult.

 

Opposing the criminalisation of self-use of abortion pills

14/03/2016 § Leave a comment

More officials in European governments seem to have discovered that women are buying MA pills over the internet and are having abortions outside their health systems. The immediate response to this is that these abortions are or should be “illegal”; indeed, they are illegal under the law in Ireland, the UK and Italy, if not also elsewhere. Two women were charged last year in Northern Ireland and are awaiting trial, three women are in prison in England (two for self-use of MA pills for very late abortions, one for selling them). Italy has just increased the fine for these abortions from €51 to €5,000-10,000. In Ireland the punishment is up to 14 years in prison. Women in the US have also faced criminal charges for this, and a case was heard in Australia as well, though in that instance the couple involved were let off.

Is the abortion rights movement ready for this new form of criminalisation of abortion to spread? I don’t think so, and I think we need to be talking about it quite urgently, especially in Europe.

A recent Guardian article about the extent of conscientious objection to abortion in Italy(http://www.theguardian.com/world/2016/mar/11/italian-gynaecologists-refuse-abortions-miscarriages), misses the point that for more than 90% of abortions, i.e. those in the first trimester, and indeed uncomplicated abortions up to 18-20 weeks, women don’t need a gynaecologist. Care from a trained nurse or midwife or other mid-level provider, with home use in the first trimester and in a day clinic in the second trimester are fine for uncomplicated abortions; WHO recommendations support this. It is primarily women with fetal anomalies and other later and complicated cases who need hospital-based abortion services under a gynaecologist, as these are understood today, and while it is crucial to provide and protect these services, they are not the model for all abortions.

Based on the evidence, we can push this a step further and say that for most women, abortion “services” should be offered mainly by pharmacies, and for the rest the health professionals who become abortion “providers” and the education and training they receive needs to change a lot. Pro-choice gynaecologists should be among those to take the lead in arguing this as they have the standing to be listened to.

We need to start arguing that medical abortion pills are safe enough that they should be as readily available for early abortions as emergency contraception is for the morning after. And we need to be informing women of this because most women probably don’t know it. Not the way we know it.

Do we even have a consensus on these points among ourselves? I’m not sure. But what I hope we all do agree on is that criminalising the self-use of MA pills is happening and must be opposed, and I believe urgently.

Most of the mainstream media articles on women self-inducing abortions quote one official or other that the pills are dangerous if used without the supervision of a health professional. The article about Italy is an example. There is a lot of evidence to the contrary that needs to be shared as widely as possible.

Quinacrine: the non-surgical sterilisation method that refuses to die

16/01/2016 § Leave a comment

A response to all the articles on so-called “permanent contraception” in Contraception 2015;92(2):89-176)

It is with a deep sigh, after more than 10 years, that I sit down to respond to your articles on “permanent contraception”, particularly the one by Jack Lippes pushing quinacrine sterilisation, that dead letter, to the fore once again, in your August journal issue (Contraception 2015;92(2):89-176).

Dr Lippes whitewashes the history of why quinacrine was rejected as a female sterilisation method,[1] rejected not only because of concerns about its carcinogenic potential but for many other reasons as well. Dr Jaime Zipper from Chile, who invented the method, would never be allowed today to get away with the “research” he carried out on women with quinacrine for tubal sterilisation in the absence of any pre-testing of the drug for safety, dosage or efficiacy ‒ before it was ever injected into a single woman. Women were treated like guinea pigs in his and other “research”, and no proper long-term work on safety or optimal dosage was ever completed. Not was the method in fact ever properly approved or registered in any country. There were only a handful of countries where quinacrine sterilisation was ever used, and even in those cases, it was always individual doctors who used it, while others carried suitcases full of quinacrine pellets across borders to share with them, e.g. in a remote rural area of India.

The early high failure rates Dr Lippes reports of 9-12% were indicative of the absence of proper research, since they should have led to a rejection of the method early on. The far lower failure rates shown in the studies in his Table 1 were all from very small studies except for one; most had too short follow-up periods and the findings were never confirmed in larger randomised, controlled studies. The very large study by Dr Do Trong Hieu of Viet Nam, published in the Lancet, in which over 30,000 women were subjected to the procedure, led to the closure of the programme in Viet Nam following a critical analysis of its findings. I was personally involved in creating an outcry about it at that time. (I will return to this below.)

The dismissal by Dr Lippes of the data on cancer risk arising from inflammation in rats, and indeed his whole article, is an example of how the proponents of quinacrine did then and continue to minimise the negative evidence and exaggerate the positive evidence to claim the method is safe.

Dr Lippes’s review of the literature ignores several articles I published in the early days of Reproductive Health Matters (RHM) and one in the BMJ almost ten years later. In 1993 in RHM, Amy Pollack and Charles Carignan[2] examined the same evidence examined in Contraception by Lippes. They noted, for example, that in the Viet Nam paper, 20,000 of the 31,000 women in the total study sample were excluded from follow-up for pregnancy rates, and the finding in one province of 91 pregnancies out of 937 women was also excluded. A year after their article was published, concern was expressed by Ralph Heywood, consultant toxicologist to WHO in 1994,[3] that more research needed to be done to exclude toxicological effects related to mutagenicity, teratology and persistence of the compound in tissues. He recommended that toxicological testing of quinacrine in animals should be done prior to any further clinical trials or any other provision of the method to women.3 Dr Lisa Rarick, the then Medical Officer at USFDA, also raised concerns, given the uncertain failure rate, that a quinacrine failure might increase the risk of ectopic pregnancy.3 Yet despite this published concern, a number of individual doctors continued to promote and perform quinacrine sterilisations ‒ e.g. in rural India and Pakistan. I asked what should be done when consensus views are ignored or rejected by individual providers. The question still holds. A year later, and following a further statement on toxicity and quinacrine by Ralph Heywood,[4] quinacrine sterilisations were still being done in Chile too, led by Dr Jaime Zipper, but challenged by the Foro Abierto de Salud y Derechos Reproductivos (Open Forum for Reproductive Health and Rights).[5] It was this and other feminist activism that led to the decision by WHO not to recommend quinacrine sterilisation of women to be continued, until far more rigorous examination of safety and efficacy was carried out.

But the problem of promotion of untested methods remains with us. In 2004, the BMJ published an article about a “clinical trial” in India evaluating the antibiotic erythromycin as a female sterilisation method,[6] following the ban by India on the use of quinacrine for that use, due to safety and efficacy doubts. Quinacrine’s dwindling supporters were looking for an alternative. They tried erythromycin tablets, which were placed in the upper part of the uterine cavity in 790 women “volunteers”. The failure rate was unacceptably high at 28–35% after 12 months. This “trial” was criticised as illegal and unethical, and highlighted the ease with which unethical clinical trials could still be conducted in India on vulnerable populations by errant doctors.

The FHI360 article was a real eye-opener for me, as it seems they were responsible for the erythromicin study in India, which I do not recall. It is not surprising, however, as FHI was a driving force in this whole history. The history revealed in this article is indicative of the determination not to let this idea go, and even to bring unnamed advocates on board to try and legitimise what could not be justified.[7]

Turning to the other articles on the subject of non-surgical sterilisation in your August edition, I was interested to see how the article by Elizabeth K Harrington et al[8] quietly denigrated the whole idea of surgical sterilisation because it is surgical, in that it requires training and a decent service delivery setting. Is training and a decent service delivery setting still not a reasonable expectation for women in the global South? She is right, not everyone prefers a surgical method. Yet she admits that surgical female sterilisation has not only been shown to be very safe but is also the most widely used fertility control method globally.

Interestingly, none of these articles takes up the alternative of vasectomy ‒ an unfinished job if ever there was one ‒ let alone the idea of a permanent non-surgical male method. Odd that no one has tried inserting quinacrine in men’s nether parts, or is it? The biases may not seem obvious in the absence of a thorough review of the issues, but bias there is indeed among the cluster of authors who populate this whole journal edition.

The comparison I felt was most relevant and most missing in these papers, however, was that between surgical vs. medical abortion, the only existing surgical and non-surgical methods of fertility control. Both these abortion methods are easy to provide in the first trimester of pregnancy, and both have been shown by WHO to be safe for mid-level providers to offer at primary care level, with simple training.[9] Both have advantages as well as disadvantages, but the real value is that women have a choice between them.

My generation put the notion of “choice” in fertility control on the global map and showed that the more and varied methods there were to choose from, the more people were likely to find at least one method that was acceptable and met their needs. Your authors in this edition have quite a different perspective. They want something that will end fertility, and the less likely it is to “fail” or “fail to be used” the better. From this position, Elizabeth Harrington et al3 and Jeffrey Jensen[10] seem to assume that a long-acting method of contraception is always preferable to the others. This has not been shown, nor is it likely to be true ‒ if one asks a large enough number of women and their partners, and especially young people. And in spite of the still rising numbers of people with HIV and other sexually transmitted infections, the importance of condoms seems to have passed these authors by altogether. In fact, both qualitative studies by Elizabeth Harrington et al3,[11] find the demand for safety to be uppermost as a value among study participants. Moreover the preference expressed for a non-surgical sterilisation method is hypothetical and with caveats ‒ and not based on the experience of surgical sterilisation or an actual non-surgical method.

I would also question these authors’ preference for the term “permanent contraception” rather than “sterilisation” and “vasectomy”. Both these surgical methods can be reversed, and although Jeffrey Jensen likes to think women’s fertility intentions fall rigidly into only three categories, there are quite a few people who have opted for sterilisation or vasectomy who have later changed their minds, and for whom reversal methods were consequently developed. To use the term “permanent” belies that availability, and might even put people off. It would certainly mislead them into thinking there is no going back. Perhaps that is what the supporters of quinacrine sterilisation are aiming for. They seem not to have considered that the lack of potential for reversal with quinacrine might greatly decrease its appeal, even among those for whom “something non-surgical” may be preferable. Of course, no one has attempted to reverse a quinacrine sterilisation. Once the fallopian tissue is thus scarred, it is presumably very permanent indeed.

Lastly, I must say that for a journal that publishes first class research on abortion, I was very disappointed to see you allowing remarks about the need for abortion as a sign of failure ‒ whether of contraceptive methods themselves or of the women who choose them. Can we not finally acknowledge contraception as a fallible form of prevention and abortion as a solution when prevention fails? The belief that contraception which never fails is possible is, in my view, a chimera. Moreover, if women were given proper information and unrestricted access to safe abortion methods, most abortions would take place well before 8 weeks LMP, and even (with medical abortion) as early as 35 days of pregnancy (Beverly Winikoff, personal communication, July 2015). Let’s try developing new non-surgical post-fertilisation methods of birth control, for example.[12]

However, whether or not one thinks a non-surgical method of sterilisation would be preferable to a surgical method, quinacrine is not the answer. Let’s re-bury it and keep it buried.

References

[1] Lippes J. Quinacrine sterilization (QS): time for reconsideration. Contraception 2015;92(2):91-95. http://www.sciencedirect.com/science/article/pii/S0010782415002322.

[2] Pollack AE, Carignan C. The use of quinacrine pellets for non-surgical female sterilisation. Reproductive Health Matters 1993;1(2):119-22. http://www.rhm-elsevier.com/article/0968-8080(93)90018-O/pdf

[3] Berer M. The quinacrine controversy one year on. Reproductive Health Matters 1994;2(4):99-106. http://www.rhm-elsevier.com/article/0968-8080(94)90016-7/pdf.

[4] Berer M. The quinacrine controversy continues. Reproductive Health Matters 1995;3(6):142-44. http://www.rhm-elsevier.com/article/0968-8080(95)90169-8/pdf.

[5] Shallat L. Business as usual for quinacrine sterilisation in Chile. Reproductive Health Matters 1995;3(6):144-46. http://www.rhm-elsevier.com/article/0968-8080(95)90170-1/pdf.

[6] Mudur G. Use of antibiotic in contraceptive trial sparks controversy. BMJ 2004;328(7433):188.

Summarised in: Law and Policy Round Up. Reproductive Health Matters 2004;12(24):2111. http://www.rhm-elsevier.com/article/S0968-8080(04)24153-2/pdf.

[7] Katz KR, Nanda K. A nonsurgical permanent contraception stakeholder advisory committee: FHI 360’s experience. Contraception 2015;92(2):139-42. http://www.sciencedirect.com/science/article/pii/S0010782415000384.

[8] Harrington EK et al. Conceptualizing risk and effectiveness: a qualitative study of women’s and providers’ perceptions of nonsurgical female permanent contraception. Contraception 2015;92(2):128-34. http://www.sciencedirect.com/science/article/pii/S0010782415000955.

[9] Health worker roles in providing safe abortion care and post-abortion contraception. Geneva: WHO Department of Reproductive Health and Research; July 2015. http://www.who.int/reproductivehealth/topics/unsafe_abortion/abortion-task-shifting/en/.

[10] Jensen JT. Nonsurgical permanent contraception for women: let’s complete the job. Contraception 2015;92(2):89-90. http://www.sciencedirect.com/science/article/pii/S0010782415002486.

[11] Harrington EK et al. Interest in nonsurgical female permanent contraception among men in Portland, Oregon and eastern Maharashtra, India. Contraception 2015;92(2):135-38. http://www.sciencedirect.com/science/article/pii/S0010782415001006.

[12] Berer M. Compelling arguments for developing new post-fertilisation methods of birth control. Berer Blog. 11 July 2015. https://bererblog.wordpress.com/2015/07/11/compelling-arguments-for-developing-new-post-fertilisation-methods-of-birth-control/.

The history and role of the criminal law in anti-FGM campaigns: Is the criminal law what is needed, at least in countries like Great Britain?

24/12/2015 Comments Off on The history and role of the criminal law in anti-FGM campaigns: Is the criminal law what is needed, at least in countries like Great Britain?

This article was published online in Reproductive Health Matters 2015;23(46):145-57. DOI: http://dx.doi.org/10.1016/j.rhm.2015.10.001. Here is the abstract in English, French and Spanish:

Abstract

The history of campaigns against female genital mutilation (FGM) began in the 1920s. From the beginning, it was recognised that FGM was considered an important rite of passage between childhood and adulthood for girls, based on the importance of controlling female sexuality to maintain chastity and family honour, and to make girls marriageable. How to separate the “cut” from these deeply held norms is a question not yet adequately answered, yet I believe the answer is key to stopping the practice. Since the 1994 ICPD, national and international action against FGM has grown and resolutions have been passed in global forums which define FGM as a form of violence and a violation of children’s human rights. These resolutions have contributed to building consensus against FGM and developing national legislation criminalising FGM. Prosecutions or arrests involving FGM have been reported in several African countries and Great Britain, but apart from France, there have been very few. This paper summarises this history and how FGM has been criminalised. It argues that criminalisation may not be the best means of stopping FGM, but can have serious harmful effects itself. It calls for community-led educational information and more support for dialogue within FGM-practising communities, and argues that what is important is addressing the sexual and reproductive health consequences of FGM and gaining the understanding of women who have experienced it and their families as to why they should not make their daughters and grand-daughters go through it too.

Résumé

Les campagnes contre les mutilations sexuelles féminines (MSF) ont commencé dans les années 20. Dès le début, il a été admis que les MSF représentaient pour les filles un important rite de passage entre l’enfance et l’âge adulte, fondé sur l’importance du contrôle de la sexualité féminine afin de préserver la chasteté et l’honneur familial, et de permettre aux filles de se marier. Comment séparer la mutilation de ces normes profondément ancrées est une question encore sans réponse ; ce serait pourtant, à mon sens, une démarche essentielle pour mettre un terme à cette pratique. Depuis la CIPD, en 1994, l’action nationale et internationale contre les MSF s’est étendue et des forums internationaux ont adopté des résolutions qui définissent les MSF comme une forme de violence et une violation des droits fondamentaux de l’enfant. Ces résolutions ont contribué à dégager un consensus contre les MSF et à élaborer des législations nationales qui répriment cette pratique. Des poursuites ou des arrestations liées aux MSF ont été signalées dans plusieurs pays d’Afrique et en Grande-Bretagne, mais, à part en France, elles ont été très rares. L’article résume cette histoire et montre comment les MSF ont été sanctionnées par la loi. Il avance que cette pénalisation n’est peut-être pas le meilleur moyen de faire cesser les MSF et qu’elle peut avoir elle-même de graves conséquences. Il préconise une information éducative collective et davantage de soutien au dialogue au sein des communautés qui pratiquent les MSF. Il fait valoir qu’il est important de traiter les conséquences des MSF pour la santé sexuelle et génésique et de faire comprendre aux femmes qui les ont subies et à leur famille les raisons pour lesquelles elles ne devraient pas obliger leur fille ou leur petite-fille à en passer aussi par là.

Resumen

La historia de las campañas contra la mutilación genital femenina (MGF) comenzó en la década de 1920. Desde el principio, se reconoció que la MGF era considerada un importante rito de paso entre la niñez y la adultez para las niñas, basado en la importancia de controlar la sexualidad femenina para mantener castidad y el honor de la familia, y para preparar a las niñas para el matrimonio. Cómo separar el “corte” de estas normas tan arraigadas es una interrogante que aún no ha sido contestada adecuadamente; sin embargo, creo que la respuesta es clave para eliminar la práctica. Desde la CIPD de 1994, la acción nacional e internacional contra la MGF ha incrementado y se han aprobado resoluciones en foros mundiales que definen la MGF como una forma de violencia y una violación de los derechos humanos de las niñas. Estas resoluciones han contribuido a fomentar consenso contra la MGF y a formular leyes nacionales que penalizan la MGF. En varios países africanos y en Gran Bretaña se han reportado enjuiciamientos o arrestos relacionados con la MGF, pero aparte de Francia, ha habido muy pocos. En este artículo se resume esta historia y cómo la MGF ha sido penalizada. Se argumenta que la penalización quizás no sea el mejor medio para eliminar la MGF, ya que puede tener graves efectos dañinos. Se hace un llamado a la información educativa dirigida por la comunidad y a brindar más apoyo para el diálogo con las comunidades que practican la MGF. Se argumenta que lo importante es tratar las consecuencias de la MGF en la salud sexual y reproductiva y lograr que las mujeres que han pasado por esta experiencia y sus familias entiendan por qué no deben obligar a sus hijas y a sus nietas a hacer lo mismo.

What kind of research is needed for abortion advocacy?

24/12/2015 § Leave a comment

At the 5th Research Meeting on Unwanted Pregnancy and Unsafe Abortion, Mexico City, 28-30 September 2015, Silvina Ramos presented an excellent new CLACAI publication (in Spanish) on a renewed agenda for abortion research in the LAC region: “Investigacion sobre aborto en America Latina y el Caribe: una agenda renovada para informar politicas publicas e incidencias”. I was asked to comment in the session:

DATA FOR ADVOCACY

-We need to know more about what post-abortion care involves in order to showcase the failure of post-abortion care to resolve the serious public health problem of unsafe abortion. In 2012 an estimated 6.9 million women globally were treated for complications of unsafe abortion. In Latin America, new estimates of the rate of complications show a 31% decline between 2005 and 2012, from 7.7 per 1,000 women to 5.3 women per 1,000. (Singh et al, 2015) But this is still far too high and there is no excuse for it.

-As regards the incidence of abortion, we need to know more about pregnancy among girls aged 8-14 resulting from sexual abuse and whether or not they have access to safe abortion, including as a form of emergency obstetric care given how small they are. This emerged as an issue in Paraguay this year. There is little information on this subject though some research has been done (see http://conta.cc/1NNx4FD, http://conta.cc/1NN3sIn and http://conta.cc/1NMS9zS).

HEALTH PROFESSIONALS

-It is important to underscore the importance of the attitudes towards abortion of health professionals, and the importance of promoting training in abortion provision only for those who support women’s right to safe abortion. The current deficit in training should be a major advocacy issue. Why nurses should be less supportive to women needs to be better understood because abortion no longer requires doctors except in emergencies. Abortion care should be in hands of nurses and/or midwives at primary care and community level today.

-The prevalence of abortions among nurses/midwives and how they themselves are treated as patients might help to explain their views and bring them on board as a profession (http://www.rhm-elsevier.com/article/S0968-8080(07)30314-5/pdf).

-Attitudes towards 2nd trimester abortion are a particular problem. Can the number/proportion of second trimester abortions be reduced with better laws and services? Evidence from Sweden and Norway, particularly with good access to medical abortion, shows this can be done. If we knew why women have abortions after 12 weeks of pregnancy in more countries, it would contribute to change. However, this is not an issue of “women’s fault” but of systemic failures on the part of health and sexuality education, laws and policies, and health systems.

CONSCIENTIOUS OBJECTION

-Many who support abortion rights call for restrictions on conscientious objection but few oppose it altogether. Joyce Arthur of Canada and Christian Fiala of Austria have written several articles together and separately on this subject, opposing the whole concept.

-Sweden does not permit conscientious objection. This policy was challenged earlier this year at European level and their law was upheld.

-I agree with these views. I believe anyone who is unwilling to carry out an essential task in their job description should find another job. Abortion services are almost unique in allowing conscientious objection. It is a leftover of anti-abortion hegemony and should be removed.

PUBLIC HEALTH vs. HUMAN RIGHTS POSITIONS TO SUPPORT ABORTION

-I would like to disagree with one of the book’s authors that the public health arguments for safe abortion are less radical than those related to women’s bodily autonomy and rights.

-Public health arguments are not only relevant but also extremely powerful. I don’t think we use them enough anymore. Yet they are likely to have more resonance with health professionals.

-How to get past the huge, irreconcilable differences in thinking? Especially in the face of growing anti-abortion fanaticism?

RESEARCH FOR LAW AND POLICY ADVOCACY

-Campaigns for safe abortion often focus on calling for specific grounds for abortion to be decriminalised. For example, health grounds, rape, serious fetal abnormality, and in some countries in Latin America even for risk to the woman’s life to be permitted.

-I recently looked at the history of how abortion laws in several countries have changed over time, from almost complete criminalisation to allowing abortion at a woman’s request. This showed that a step-by-step process has taken place in some countries over a period of years, but often over decades. The current, limited law reform bill in Chile and recent examples in Africa show this has resonance as a way forward. But is it the only or best way forward?

-It would be good for this history to be studied in depth in many more countries, across both the 19th and 20th centuries and today.

RESEARCH ON ABORTION LAWS & GOALS

-For me, one of the biggest unresolved advocacy issues is whether we are seeking legalisation of abortion or decriminalisation of abortion.

-There a difference between these legal categories and we need to study it more.

-What reforms should we propose to our current laws on abortion that will lead to health system changes that will meets women’s needs and protect and fulfill their right to a safe abortion as part of their sexual and reproductive health and rights?

-In different countries, the answers may be different, depending on the origins of the laws, and more research and critical thought and analysis are needed.