Report of the Dutch Launch of the Guttmacher – Lancet Commission report ‘Accelerate progress – sexual and reproductive health and rights for all’
Posted by Maria on August 8, 2018 at 1:29 pm
On Thursday 24th May, the Guttmacher-Lancet Commission launched their report ‘Accelerating Progress – Sexual and Reproductive Health and Rights for All’ in the Netherlands. During the first part of the meeting, Ann Starrs, Chair of the Commission, presented the key elements of the report, including the new definition of integrated SRHR and the package of services it entails.
The integrated definition of Sexual and Reproductive Rights by the Guttmacher-Lancet Commission states that ‘Sexual and reproductive health is a state of physical, emotional, mental, and social wellbeing in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction, or infirmity. Therefore, a positive approach to sexuality and reproduction should recognise the part played by pleasurable sexual relationships, trust, and communication in the promotion of self-esteem and overall wellbeing. All individuals have a right to make decisions governing their bodies and to access services that support that right. Achievement of sexual and reproductive health relies on the realisation of sexual and reproductive rights, which are based on the human rights of all individuals to:
- have their bodily integrity, privacy, and personal autonomy respected;
- freely define their own sexuality, including sexual orientation and gender identity and expression;
- decide whether and when to be sexually active;
- choose their sexual partners;
- have safe and pleasurable sexual experiences;
- decide whether, when, and whom to marry;
- decide whether, when, and by what means to have a child or children, and how many children to have;
- have access over their lifetimes to the information, resources, services, and support necessary to achieve all the above, free from discrimination, coercion, exploitation, and violence.”
In addition to that, the “Essential sexual and reproductive health services must meet public health and human rights standards, including the “Availability, Accessibility, Acceptability, and Quality”
framework of the right to health.28 The services should include:
- accurate information and counselling on sexual and reproductive health, including
- evidence-based, comprehensive sexuality education;
- information, counselling, and care related to sexual function and satisfaction;
- prevention, detection, and management of sexual and gender-based violence and
- coercion;
- a choice of safe and effective contraceptive methods;
- safe and effective antenatal, childbirth, and postnatal care;
- safe and effective abortion services and care;
- prevention, management, and treatment of infertility;
- prevention, detection, and treatment of sexually transmitted infections, including
- HIV, and of reproductive tract infections; and
- prevention, detection, and treatment of reproductive cancers.” [1]
Lambert Grijns (Dutch Ambassador for Sexual and Reproductive Health and Rights & HIV and AIDS), shared his thoughts and ideas on the report, and the importance of it.
Ann Starrs then reviewed how the report can be used to move the SRHR agenda forward.
The meeting was held at KIT and attended by 51 Share-Net members and 8 non-members.
Discussion with Share-Net members
During the second part of the meeting, attendees came together in World Café groups to discuss seven topics related to the report. The topics included: Quality of (SRH) counselling, Safe Abortion, STI’s including HIV/AIDS, Infertility & Subfertility, Sexual health and Wellbeing, SBV in humanitarian/fragile settings and how to involve men?
The questions covered during the World Café session are as follows:
- Round One: “Identify barriers for addressing this topic in your work environment”. (Problems)
- Round Two: “Define approaches to give more prominence to the topic in your work/organization/policies and programmes” (Approaches)
- Round Three: “Discuss how to make a difference, resulting in more prominence and higher impact related to the theme?” (Moving Forward)
World Café 1 – Quality of (SRH) counselling
Chair: Evert Ketting
Note taker: Tamlyn Mac Quene
Round 1: Problems
The topic of counselling is very broad and these services are delivered by different cadres, either professional or lay, and therefore come in different shapes and forms. Counsellors need to be trained and qualified. Important elements of training include the legal framework in a specific country (including anonymity and confidentiality), as well as the age of consent. The training of counsellors needs to include skills in listening and asking questions instead of just providing advice. However, most counsellors are volunteers and not always properly trained. There are many people in need of counselling services that have no access. Many people receiving counselling services still face discrimination and stigma. Finally, counselling should be rights-based and science-based, as well as linked to other services.
Round 2: Approaches
There is a need for more information about the numbers of people who use counselling services and those who are in need of these services. Also, evidence is needed about the effects of counselling. This will help in determining the size of the problem. Counselling services should be voluntary and client-centred. There is a need for guidelines for counselling and a focused communication strategy. Counsellors, be it health care workers or lay counsellors, should be trained and motivated with incentives such as a good salary and free extra services.
Round 3: Moving Forward
To move forward, participants mention that investments should be made to ensure that counsellors are trained. They both needs skills training and theoretical training. The training should include: dealing with more difficult and sensitive topics; knowledge about the social environment and context in which they are working; awareness of their own bias/morals. Furthermore, the quality of counselling services should be assessed and counsellors held responsible for the services they provide. Ethical standards should be created and implemented and a professional body of counsellors should be established. Finally, the privacy of the counselling process also needs to be improved.
World Café 2 – Safe abortion
Chair: Irene de Vries and Lisa Juanola
Note taker: Lisa Juanola and Irene de Vries
Round 1: Problems
Many countries have restrictive legal frameworks for abortion. However, civil society organisation and health providers still find ways to work on abortion. Other barriers dependent on the legal frameworks are the costs of getting an abortion. Specially for the most vulnerable groups, not only in developing countries, but also in countries like the Netherlands where abortion costs are not covered for undocumented people/migrants or non-official-residents. Social and gender norms as well as religious beliefs are also some of the main barriers for accessing abortion. In several contexts, women’s marital status influences their access to safe abortion services, making it more likely for unmarried women to want to access abortion in secret. Finally, there is the barrier of health workers calling for conscientious objection, even denying referrals, because of their personal religious and cultural beliefs and values. The group also discussed that medical abortion was not easily accessible, mifepristone is rarely available and misoprostol is sometimes not registered or its use is restricted.
Round 2: Approaches
One of the first approaches discussed was rephrasing the abortion message, specifically formulated messages in ‘positive’ ways. Positive and pragmatic messaging is important to encourage strong communication, and create a storyline which is difficult for the anti-choice groups to persecute.. This would include adding more statistics and facts to the dialogue.. Another strategy discussed was the use of personal stories of women who have had abortions, adding an emotional aspect which they hope would reach those advocating for policy change. The final strategy agreed upon was including country specific laws and regulations, as this information is not always easily accessible.
Round 3: Moving Forward
To move forward, we need to link different groups. There are different silos addressing abortion: medical doctors, women’s movements, policy makers, etc, who should coordinate their work. Synergizing approaches and letting sectors come together in order to work more efficiently and effectively towards the same goal.. Second, involving young people to take on more prominent roles. Younger generations are generally more open to the abortion topic and strong in communicating their message. It would be interesting to let them rephrase the abortion discourse and take the lead on the communication materials and messages.
World Café 3 – STIs, including HIV
Chair: Anke van Dam
Note taker: Katy Elliott
Round 1: Problems
The first problem discussed was the merging of HIV into the SRHR domain, which has been done poorly in the Netherlands. An example of this challenge is that when identifying HIV as sexually transmitted, you lose the population which transmits HIV in a different way, such as IV drug users. In order to provide services, there needs to be an integrated model. However, in doing so, there needs to be a focus on who is excluded from that model. The second issue discussed was that there is a low amount of attention given to preventing HIV (e.g. focus of AIDS2018 is on new medications). The next issue is one concerning HIV and migration. For example, if diagnosed with HIV in Russia, one will be deported. Finally, there are questions around funding streams – SRHR funding and HIV funding for prevention are separate but aren’t we actually trying to reach the same group of people? However, the ‘HIV hook’ allows you to get money for certain populations, e.g. prisoners. Overall, there are still many issues regarding HIV which need to be tackled, however a key question is how to bring everything together into an integrated package which is inclusive and has benefits for everyone.
Round 2: Approaches
The group discussed the key question ‘if we integrate STIs and HIV, what do we lose and what do we gain?’ It was suggested that an integrated approach might work for prevention, but maybe not so much for treatment and care. When discussing prevention, a key focus should be on young people. This could be through combined methods of comprehensive sex education, contraception, barrier methods, PrEP, and clean needle programs. Barrier contraceptive methods are being overlooked by donors and governments, as historically this has been left to the private market There was an agreement that all parties should be reminded that these products are critical to work on prevention successfully. .
Round 3: Moving Forward
Moving forward, we should focus on key populations within the HIV field. The report talks about general approaches, but different approaches are needed for specific groups who have specific needs. Furthermore, discussion should happen with the UN as a whole, not just WHO, in order to ensure the language of all UN bodies is aligned. The report is very comprehensive, so could be useful when tackling this. Finally, y a holistic approach is advised which would include working with service providers, educators etc. to properly address the issues discussed above.
World Café 4 – Infertility & subfertility
Chair: Hilde Kroes
Note taker:
Round 1: Problems
Infertility is often overlooked because it is not a life-threatening health condition, or one that has an easy answer. Even when there are treatments available, these are often very expensive (especially assisted reproductive technologies). Next to that, people’s health can suffer because of infertility, especially when regarding mental health, as this is highly stigmatized in different areas and can be troubling to those going through it. At the moment, there is not enough accurate information or care to help individuals and health care systems focussing on this issue. Another topic that was discussed was reproductive tourism and the ethical dilemmas this brings to infertility debates. This is about the equity of fertility: these technologies and the possibility to go abroad making fertility something for the rich. The people of lower socioeconomic status are the ones providing services for assisted reproductive technologies (such as selling their eggs or being a surrogate), but not the ones being able to access them. Lastly, because there are many who are worried about the growing world population, there has been hesitation to invest in fertility treatments especially in lower- or middle-income countries, making reproductive rights difficult to address.
Round 2: Approaches
One solution proposed for increasing awareness and getting more people involved is to include students in the discussion, through experts (guest) lecturing at universities. When discussing infertility, it is important to shift the discussion towards human values and cultural importance, instead of only focussing on health and population. Also discussed was the need for (in)fertility to be a part of sexual education, and how this process looks different for each country or culture. For example, in some contexts where fertility is very important, people test their fertility at a young age or before they marry, and get pregnant at a time where they might not actually be ready. Moreover, it is important to educate people on how fertility works, and to address the fears people have and the myths that exist when it comes to infertility. An important aspect to this would be addressing the rumour that contraceptives cause infertility. Causing young people to avoid using contraceptives and in turn at risk for unwanted pregnancies or STIs. . It is also important to address secondary infertility (infertility after having a child), as this currently does not receive enough attention. Lastly, there needs to be focus on the cultural repercussions of infertility, what this means for gender roles, how it affects women and their places within the community.
Round 3: Moving Forward
The existing working group on infertility at Share-Net is the first opportunity to move forward. They are trying to not only raise awareness about infertility, but also putting into place strategic plans and linking it to other SRHR issues such as gender-based violence and STIs. One thing that is necessary is better estimates about the numbers of infertility cases. A proposed action is to educate people about identifying fertility signs (fertility/body awareness), to become aware of (in)fertility and possible issues earlier in life, instead of solely focusing on prevention of pregnancy. It is essential that the fear of contraceptives causing infertility is addressed. It is important to have accurate information about how each form of contraception works, and what happens to the body after it is finished, i.e. how long does it take for a body to become fertile again. Another critical point is that infertility and family planning be addressed and discussed openly with the LGBTQ+, HIV+, and disability communities in order to fight stigma and work on community specific issues.
World Café 5 – Sexual Health & Wellbeing
Chair: Denise van Dijk
Note taker: Kimberley Meijers
Round 1: Problems
Topical standpoints:
Governments and donors often chose to focus on avoiding death rather than improving life, because of this there a topics that are left off the table when addressing sexual health and wellbeing. This includes infertility, sexual pleasure and intimacy. Pleasure and intimacy are especially being ignored when discussing target groups like young women and LGBTQ+.. Civil society is more open to addressing this topic but they are usually dependent on funding from donors, and in turn must follow the donor’s focus and flexibility. The SRHR field is used to working on a project basis which can be difficult to incorporate sexual pleasure and wellbeing, as it is more about lifestyle. It is also a logistical problem, as we need an integrative system to be able to address sexual health, pleasure and wellbeing holistically.
Target group issues:
Young people/unmarried people don’t have access to information and counselling, because it is not acknowledged that they are sexually active. The lack of focus on sexual pleasure leads to lack of dialogue and the neglect of dialogue leads to inadequate tailor-made counselling. Coercion to use certain services, treatment and counselling because it is the only option that is available. Furthermore, service providers do not counsel or provide options to their clients/patient because of their own norms, values and beliefs. We need to remember that sexual rights include topics such as sexual pleasure and wellbeing in addition to rights for LGBTQ+ & abortion.
Round 2: Approaches
Collaboration with the target population; young people, LGBTQ+, people with disabilities etc. is proposed. Furthermore, we should raise the importance of sexual health by having the evidence available and showing how the impacts on social & economic growth and development. A case could be built around this evidence which is presented to governments to assist with advocacy and policy change. SRHR has to become a powerful tool to invest in. We should focus on creating an evidence based research on the positive effects of focusing on SRHR:
- Can decrease abortion rates, decrease GBV, STIs and teenage pregnancy.
- Messaging should be phrased positively on how sexual health, pleasure and wellbeing contributes to other goals like the SDGs.
- We should not only work from a risk perspective but also from an opportunity perspective.
Finally, more freedom in donor financing is needed to focus on sexual wellbeing and governments like the Netherlands have to push the agenda and fund alliances, research and initiatives etc.
Round 3: Moving Forward
Stewardship by doing research, setting up alliances and then organizing strategic joint actions. WHO Reproductive Health research department could provide this stewardship. We should also integrate sexual health, pleasure and wellbeing within already existing frameworks and search for platforms, events and conferences to put them on the agenda.
World Café 6 – GBV in humanitarian/ fragile settings
Chair: Bianca Tolboom
Note taker: Meike Stieglis
Round 1: Problems
Not all the causes of GBV are known, however some include infertility, power relations, gender identity, and more. GBV also does not have one face, there are several instances of violence that fall under this umbrella such as rape, domestic violence, and FGM. Each instance of violence has their own issues for example in cases of rape, the victim may be blamed and it may be difficult to identify perpetrators. FGM is an incredibly complex issue which is accepted by the community and also defended by the girls themselves. Furthermore, domestic violence is often not claimed as GBV and there is no legal ground for people to do so. There is a large amount of stigma and discrimination surrounding GBV. There is also a lack of understanding of what constitutes GBV and many people may not know they are victims, including men and boys, who experience GBV as well as women and girls, however are not recognized as so. With regards to services provided, the question of integration poses a problem because there are interlinkages between GBV and other SRHR issues, which means that health workers are not the only actors required to tackle the problem.
Round 2: Approaches
A clear definition of GBV is needed, which encompasses an awareness of power relations. We also need to conduct research, translate and share the resulting evidence. We should provide education to specific age groups, including children in and out of school. An enabling environment can be created by providing CSE and challenging norms. We should not only provide information, but also engage in dialogue. Finally, we should have the skills and tools to recognize GBV and act accordingly.
Round 3: Moving Forward
Moving forward, we should unpack what is meant by integration, stop making a divide between developing and developed countries and make sure there is always an assessment of the need in each context. We should learn from successful programmes and not try to reinvent the wheel – Share-Net could help with this.
World Café 7 – How to involve men?
Chair: Jan Reynders
Note taker: Tara Asgari Laleh
Round 1: Problems
In the first round, the problems with regards to the issue of male involvement were discussed by the participants. For instance, sex education for boys and men often starts very late and also SRHR services are primarily not men-friendly. The participants also highlighted how difficult it is for men to recognize that patriarchy affects them too. Finally, there is a considerable gap between what is in policy documents and what appears in everyday health practices.
Round 2: Approaches
One of the main problems is that programs and policies are focused on women more than men which creates difficulties with their involvement in SRHR programmes. Thus, the role of men is often overlooked in those programs. Also, another problem that was discussed is that in involving men in SRHR programs some important groups such as undocumented migrants are still missing.
Round 3: Moving Forward
An opportunity to moving forward is developing men-friendly SRHR services. Another important issue that was discussed is the significance of developing a comprehensive sexuality education. It is particularly important to engage men as young as possible with programs on gender-based violence. Moreover, the need for conducting research on men’s needs was highlighted. In conducting research we should keep in mind that each and every research contextualize its project in its specific region since there are always many differences within a single community. Related to this issue is also the importance of recognition of diversity in men’s needs. Providing men and boys with awareness of their rights was also discussed in the last part. Here, the importance of providing violent men with counselling services was further discussed.
[1] Ann M Starrs, Alex C Ezeh, Gary Barker et Al. Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30293-9/fulltext
