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January 01, 2008

Achieving Global Sexual and Reproductive Health Rights

by Serra Sippel

“The empowerment and autonomy of women and the improvement of their political, social, economic and health status is a highly important end in itself. In addition, it is essential for the achievement of sustainable development.”
    —International Conference on Population and Development Programme of Action, 4.1

For the past eight years, the U.S. government has been losing credibility because of a “go it alone” foreign policy that does not engage with the international community. A serious instance of this non-engagement is the Bush administration’s narrow and at times obstructive approach to global sexual and reproductive health and rights and HIV/AIDS prevention.

Since 2001, the United States has deliberately impeded efforts by other governments and by non-governmental organizations (NGOs) to adopt comprehensive approaches to sexual and reproductive health. These tactics have undermined even broader foreign policy goals of security and democracy. An urgent need exists for the United States to exercise a new collaborative style of global leadership that promotes and protects sexual and reproductive health and rights worldwide, integrating those issues within its broader program of foreign assistance. Through new executive leadership and adequate congressional funding, the United States could implement effective interventions and create new modalities for advancing sexual and reproductive health and rights.

Failure to promote sexual and reproductive rights has a particularly devastating impact on women. High rates of illness and death related to sex and reproduction are rooted in gender disparity that burdens women’s lives throughout the world. Expansion of women’s access to education, income, and property is deterred by social and cultural norms that limit women’s control over sex and reproduction and that permit violence against women and girls even in the family.

The next president should take a close look at the facts. Eighty percent of HIV infections are sexually transmitted, and women bear the brunt. Women account for more than 50 percent of infections worldwide, and 61 percent of those infected in sub-Saharan Africa, where new infections are rising rapidly among women and adolescent girls. Shockingly, despite investments in sexual and reproductive health programs over the past forty years, an estimated 200 million women experience unmet needs for contraceptive services. Eighty million unintended pregnancies occur each year, 60 percent of which end in abortion. Some 500,000 women die each year from pregnancy-related complications, and 99 percent of these deaths occur in developing countries. Furthermore, policies and laws that restrict and criminalize abortion force the procedure out of the hands of trained health care providers; as a result, some 68,000 women die each year from unsafe abortions.

Comprehensive programs and services that are universally available can, with adequate funding, prevent HIV and AIDS and most pregnancy-related death and illness. Integrated programs are needed for individuals and couples to decide freely the number, spacing, and timing of their children. Immediately, the United States should provide access to safe, effective, and affordable methods of family planning, while promoting access to information, technologies, and services necessary to having a healthy and safe sexual and reproductive life. A truly comprehensive program also will improve, over time, social and economic inequalities and particularly violence against women and girls fostered by notions of masculinity, harmful traditional practices, and denial of legal and property rights to women.

The advantages of comprehensive programming are self-evident and have been proven. Yet the United States caught up in anti-abortion and anti-family planning policies, now lags far behind other nations in responding effectively to global reproductive and sexual health and rights crises.

The United States and Sexual and Reproductive Health and Rights

Since 1965 and until recent years, the United States has led the world in supporting international voluntary family planning programs that include the availability and use of safe, modern contraceptives in developing countries. For many decades, the United States has played an important role in agreements that recognize the basic human right for an individual to make decisions about family size and birth spacing free from discrimination, coercion, and violence, while having access to necessary information and technology. As we entered the twenty-first century, the U.S. government abdicated a leadership role on these issues, in large part because of its resistance to a modern international consensus that viewed reproductive health as more than family planning and a world community that adopted a rights framework for sexual and reproductive health.

The concept of reproductive rights—the right to freely make childbearing decisions—was first recognized at the 1968 World Conference on Human Rights in Tehran, Iran, and was embraced by the vast majority of nations at subsequent United Nations conferences on population and development. In 1994, at the International Conference on Population and Development (ICPD) held in Cairo, Egypt, the United States joined a clear consensus of the assembled to shift policy formulation on population and economic development from a demographic-centered approach to one of human rights, gender equality, and social and economic development in connection with sexual and reproductive health and rights. There it was agreed that policies related to voluntary family planning and population should promote informed choice, quality of care, and freedom from coercion. The ICPD’s major pronouncement was the recognition of women’s individual rights and responsibilities in reproductive decision-making, acclaimed as a key to advancing economic development.

A number of international consensus documents and treaties from the Cairo conference and a subsequent women’s conference in Beijing, China, as well as the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW, which the United States. has not yet ratified), codify the ideals sought for decades by women’s organizations worldwide. These ideals are now set as principles, policies, and practices that are needed to ensure sexual and reproductive health and rights. In its report to the UN secretary-general, the Millennium Project, led by Jeffrey Sachs and informed by women’s health experts, advanced sexual and reproductive health as essential for achieving the Millennium Development Goals (MDGs) that address extreme poverty. The MDGs were agreed to by 189 countries, including the United States, in 2000.

As a world “superpower,” the United States plays a critical role in reaching the MDGs and improving sexual and reproductive health and rights. Yet after decades of leading the world in expanding access to desperately needed contraceptives in low-income countries, the United States now is reversing course because of ideological blinders. Conversely, U.S. financial aid for the global AIDS pandemic has increased dramatically. Even this response to AIDS, however, is greatly weakened by inflexible funding structures and ideologically driven restrictions, meaning less than optimal protections reaching those with the greatest needs.

Consider that HIV prevention, family planning, and child and maternal health programs are each funded separately, thereby creating a vertical approach that interferes with the delivery of services to those at greatest risk of illness and death—women and girls. Also, highly verticalized funding streams needlessly force critically linked services to compete for money, a serious problem that adds redundant layers of infrastructure and administration. Finally, a U.S.–imposed restriction such as the Mexico City Policy (also called the Global Gag Rule), abstinence-until-marriage funding directives, and obstructionist tactics taken against prominent international organizations further exacerbate the problems.

U.S. Attempts to Curtail Sexual and Reproductive Health and Rights Globally

Through ideologically driven policies and funding restrictions, the current administration—with congressional participation or acquiescence—has demonstrated its contempt for established rights by imposing its conservative, so-called “moral” views on its programs and policies.

Consider policy “guidance” given to field staff and implementing partners from the Office of the U.S. Global AIDS Coordinator (OGAC), an agency that oversees the President’s Emergency Plan for AIDS Relief (PEPFAR) with a stated mission that includes preventing sexual transmission of HIV. OGAC stresses the “ABC” approach (Abstain, Be faithful, use Condoms) as the nation’s “balanced” prevention strategy. Yet, under each component, “A” and “B” are presented as optimal, while “C” is reserved for “high-risk” groups. By positioning condoms as a technology for a marginalized segment of society, OGAC’s policy deliberately stigmatizes a highly effective tool used to fight the spread of HIV. In 2003, the prior, more conservative Congress, as willing collaborators, mandated that starting in 2006, 33 percent of prevention funds were to be “earmarked” for abstinence-until-marriage programs. In legislation to reauthorize PEPFAR in 2008, a less conservative Congress replaced the earmark with an equally onerous funding directive and reporting requirement for abstinence-until-marriage programs.

Abstinence-until-marriage programs ignore basic civil rights to obtain information, to make informed choices about sex and reproduction, and to live free from discrimination. Such policies undercut the ultimate goal of preventing the greatest number of sexually transmitted infections possible. The policy, and its PR messages, perpetuate a false picture that sex within marriage is safe, when it is a real risk for many women. U.S. global AIDS policy even denies sexually active youth, and those likely to become sexually active, the knowledge, skills, and tools they need to protect their health. In the Dominican Republic, where clinic records show an increase in pregnancies and sexually transmitted infections prior to age fifteen, this policy can be deadly. Groups funded by the U.S. government are faced with a Sophie’s Choice of providing lifesaving information, supplies, and services, or obeying U.S. rules to keep their funding.

The current U.S. administration has denied funding to the United Nations Population Fund (UNFPA), the UN agency responsible for supporting a range of sexual and reproductive health programs and technical assistance (including family planning, HIV and AIDS, gender equality, and safe motherhood) in developing countries. But UNFPA also works in China, a country with a harsh one-child population policy and a history of state-sponsored forced abortion and sterilization. The U.S. administration falsely charges that UNFPA participates in China’s coercive practices. Even though several assessment teams—including delegations from the U.S. State Department, UK members of Parliament, and U.S. faith-based leaders—found that this charge is not true and recommended that the U.S. resume funding of UNFPA, U.S. funds are still being withheld from the UN agency.

The Global Gag Rule bars any foreign organization that receives U.S. assistance from using its own funds or funds from other sources to perform abortions; advocate for liberalization of abortion policies; or provide information, referrals, or counsel to women on abortion procedures. It even prohibits these groups from receiving U.S. contraceptive supplies, such as condoms, birth control pills, or intrauterine devices. Tragically, the Global Gag Rule violates fundamental rights that Americans merely take for granted. By barring doctors and health care workers from even telling women about the range of pregnancy options, U.S. policy eradicates a woman’s basic civil right to make informed decisions about her health. And by unilaterally prohibiting international organizations from working with their governments to advocate for less restrictive abortion laws, and to enact laws that ensure safer medical practices, the Global Gag Rule tramples freedom of speech and assembly.

In Ethiopia, the Ministry of Health estimates that 32 percent of maternal death is caused by unsafe abortion. In 2005, the government revised its law to permit abortion in certain circumstances, including rape and incest. Ethiopian reproductive health service providers and advocates reported that the Global Gag Rule not only prevented them from participating in their country’s legislative and democratic pro­cess, but it prevented groups and programs from helping the government educate and implement the changes to the law, leaving the majority of the nation’s women at continued risk of death and morbidity due to illegal and unsafe abortions.

As a counterpart to the Global Gag Rule, the U.S. Global AIDS Act bars the use of funds to promote, support, or advocate the legalization of prostitution, and requires organizations receiving U.S. assistance to adopt policies opposing prostitution. Research documents this policy’s chilling effect. The policy keeps international organizations from providing health services and information to sex workers out of fear of losing U.S. funding. In addition, intimidating service organizations to withhold public health care and services from sex workers blocks societal efforts to stem HIV infection among marginalized populations, while negating the very fundamental civil rights that Western democracies such as the United States advocate as a political solution. For example, in Botswana, two major national HIV/AIDS organizations that receive U.S. funding for HIV prevention do not include among their services outreach to sex workers—a population at high risk of HIV infection—because they feel that would mean they “support” sex workers. Both organizations reported that the U.S. anti-prostitution pledge should be lifted so they can provide desperately needed health services and interventions to sex workers.

In 2007, the U.S. government proposed a Partner Vetting System (PVS) intended to prevent U.S. Agency for International Development (USAID) funds from reaching terrorist organizations through NGOs that provide assistance in developing countries. A PVS would require recipients of U.S. foreign assistance to report employees, volunteers, and board members to the U.S. government. Reported information would be maintained in a federal database. InterAction, an umbrella organization of NGOs, has advised USAID that any PVS would violate the Privacy Act’s prohibition against maintaining files on persons not suspected of a crime. USAID was told that the PVS actually would threaten the lives of workers who are perceived as U.S. intelligence agents. A PVS also would expose workers who might not agree with current administration policies and chill the political thinking of humanitarian aid workers providing sexual and reproductive health services.

These concerns are genuine and in no way illusory. Former World Bank president Paul Wolfowitz and the U.S. representative to the bank’s executive board, E. Whitney Debevoise, acted as conduits for the administration’s restrictions on sexual and reproductive health and rights within World Bank policy. When Wolfowitz was exposed in a pay-raise scandal, a draft of the bank’s Health, Nutrition, and Population Strategy was circulated that virtually made no reference to family planning or sexual and reproductive health and rights. The draft was reportedly “censored” by a Wolfowitz appointee serving as managing director of the bank, a former finance minister of El Salvador who belongs to the conservative Opus Dei and is known to be a supporter of White House anti–family planning policies. After the European executive board representatives reinstated the references into the final draft, Debevoise sought to erase reproductive health “rights” and “services” from the strategy, but failed.

While these problems create a consistent undercurrent in U.S. foreign policy today, other concerns further complicate the picture. A planned restructuring of U.S. international development assistance is under way. Health-related programs receive a lower priority than “political” and “security” concerns. Funding has become increasingly tight, and support for health priorities such as sexual and reproductive health programs is losing ground. These are serious policy problems that will be left for a new administration.

The Bush Administration’s Foreign Aid Reform

In 2006, Secretary of State Condoleezza Rice introduced the administration’s plan to reorganize U.S. foreign assistance to bring greater coherence to the country’s aid structure. The goal of the new foreign assistance framework is, “Helping to build and sustain democratic, well-governed states that will respond to the needs of their people and conduct themselves responsibly in the international system.” Objectives include Peace and Security, Governing Justly and Democratically, Investing in People, Economic Growth, and Humanitarian Assistance.

International family planning assistance is a mere sub-subset, hidden within these objectives—falling under the “Health” category of “Investing in People”—and represents just a sliver of U.S. foreign aid. And yet it is treated as though it is as controversial as allocations for war. Discourse on funding levels, and the policies attached to funding, tend to be reactionary and defensive. Consequently, there are missed opportunities for addressing family planning and reproductive health within U.S. foreign assistance objectives. Instead, the health and well-being of women in developing countries have been assigned secondary status for the favored earmarks.

Presently, the United States has lost touch with the social and economic development and sexual and reproductive health goals set out at Cairo and Beijing, which should be incorporated within U.S. foreign policy. National security and diplomatic goals of the framework for U.S. foreign assistance cannot be achieved without a serious commitment, reflected in sound policies and backed by evidence, that promotes sexual and reproductive health and rights and gender equality. Sexual and reproductive health and rights and gender equality are indispensable to effective economic development. Universal access to sexual and reproductive health and rights is the key to achieving the broader goals of security and democracy, and, therefore, should be integrated into all levels of U.S. foreign assistance.

Reforming U.S. Foreign Assistance in 2009 and Beyond

Looking ahead to the upcoming U.S. presidential election, it is important to consider what kind of change will move the United States forward on sexual and reproductive health and rights. Sexual and reproductive health and rights advocates know that with a friendlier administration, we will be able to correct and eliminate restrictions on U.S. funding such as the Mexico City Policy and abstinence-until-marriage directives on global AIDS funding. There must also be automatic refunding of the UNFPA.

In a broader context of advancing global partnerships and regaining U.S. credibility in the international community, U.S. policies should become ever more consistent with European strategies. One important task for advocates and policymakers should be to examine what European donor countries are doing in the area of economic development, gender equality, and sexual and reproductive health and rights, and identify where they are succeeding. The United States should align with and build on these successes, and pool resources where creative partnerships are happening.

In a new administration, opportunities for change within offices and structures will open. It has been suggested among some development and women’s rights advocates that we seriously explore cabinet-level posts on women and on global development. The Secretary of Women and Secretary of Global Development would raise these issues at the highest level of government. The two new posts would collaborate to improve foreign assistance and would represent real change.

Moreover, we need to develop new ways for U.S. money to go directly to women’s groups operating in the field. Some agencies have been receiving U.S. funding for a long time and continue to do so, not because of the strength of their programs, but because of their expertise in writing proposals to the government. A form of petrifaction sets in that may be trumping the public interest. Inauguration of a new administration will be the time to push the U.S. government to be innovative and creative by adopting new modalities that ensure that women truly benefit from U.S. funding.

U.S. foreign aid can be better spent by doing the following:

  1. Instituting greater transparency of foreign policy goals related to sexual and reproductive health and rights, delineating what it is that the United States is trying to accomplish through its funding.
  2. Eliminating restrictions, funding directives, and earmarks on U.S. foreign assistance for sexual and reproductive health and rights. The United States should fund comprehensive sexual and reproductive health programs that integrate HIV prevention and that promote rights and adhere to public health best practices.
  3. Allocating significant resources directly to innovative, smaller, grassroots groups with high effectiveness and achievement levels who are working on sexual and reproductive health and rights and women’s equality.
  4. Rewarding organizations that combine funding from different U.S. government sources to support comprehensive approaches that integrate HIV prevention, family planning, and maternal health.

The time for the United States to be a “superpower” is over. Europe has stepped in to fill the decency gap the United States has created, and countries such as Brazil have adopted policies more progressive than ours. Future U.S. leadership should be tempered by collaboration. The United States might give the most money in dollar amounts, but we must give up being the unilateral decider of “morality.”

Ensuring that gender equality and sexual and reproductive health and rights are truly integrated into the broader goal and objectives of U.S. foreign policy is a significant step that can result in stronger positioning of the United States as global collaborator and will ensure that U.S. funding abroad yields the greatest results.

Serra Sippel

Serra Sippel is executive director of the Center for Health and Gender Equity (CHANGE), a U.S.–based non-governmental organization that seeks to ensure that U.S. international policies and programs promote sexual and reproductive health and rights for women and girls worldwide.