VIII. GENDER ISSUES IN REPRODUCTIVE HEALTH AND
PROMOTING MALE RESPONSIBILITY

Bhassorn Limanonda *

Introduction

For the five decades since the adoption of the Universal Declaration of Human Rights in 1948, many efforts have been made to advocate basic human rights, improve the status of women, empower women and promote gender equality in every possible aspect. Such efforts are clearly evident in international-level charters developed with regard to basic rights, particularly women's rights. These included the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cutural Rights, which entered into effect in 1966. The Convention on the Elimination of all Forms of Discrimination Against Women, adopted in 1979, sought to address pervasive social, cultural, and economic discrimination against women; the Vienna Declaration and Programme of Action, which emerged from the World Conference on Human Rights in 1993, emphasized the rights of women and girls, requiring special attention to eradicate all forms of discrimination on grounds of sex and all forms of gender-based violence; the International Conference on Population and Development held at Cairo in 1994 set out the context and content of reproductive rights as well as the reproductive health of individuals or couples, and gender relations. The Conference also reaffirmed the right of women as central to all aspects related to reproductive health. Women's empowerment and enhanced decision-making are considered essential to reach the goal of improving the status of women; the Fourth World Conference on Women in Beijing 1995 reaffirmed and strengthened the 1994 Cairo consensus on women's reproductive health and rights (UNFPA, 1997a).

At the regional level, the Bali Declaration on Population and Sustainable Development was adopted during the Fourth Asian and Pacific Population Conference, held in Bali, Indonesia, in 1992. It was agreed among participating countries that there was a need to improve the status and role of women and, at the same time, promote more male participation in reproductive health through various measures. In order to achieve this goal, a set of recommendations was proposed in which it was stressed that national policies and programmes that incorporated gender issues be adopted and implemented to ensure equal opportunities for females in all aspects of life, such as education, training, employment, nutrition, and reproductive health. Furthermore, all forms of discrimination against women should be eliminated. A high status of women and their involvement in roles additional to those of wife and mother would have a considerable effect on demographic behaviour, reproductive health, the practice of family planning, and children's well-being. These in turn would have an impact on the improvement of the status of women, especially their involvement and authority in decision-making, and participation in the development process (Sadik, 1991; United Nations, 1992).

A. Cairo Conference: reproductive health, reproductive rights and gender

Among the many international charters and declarations, issues of human rights and gender equality, equity and empowerment of women in relation to reproductive health have been most clearly identified in the Programme of Action adopted in Cairo in 1994. At the Cairo Conference, for the first time the universal right to sexual and reproductive health was recognized beyond the long-established right to contraception. Reproductive health and reproductive rights are defined in the Programme of Action as follows:

Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so...(paragraph 7.2).

Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their rights to make decisions concerning reproduction free of discrimination, coercion and violence (paragraph 7.3).

Based on these definitions, it is clear that reproductive health, with the centrality of family planning, is related to the new paradigm that emphasizes individual rights. Reproductive choices are placed in the broader context of reproductive health and development, in particular gender equality, equity and the empowerment of women. An additional issue incorporated in this area is the promotion of male responsibility in family life and reproductive health.

The Programme of Action recommended areas of concern in reproductive health and reproductive rights as follows:

Family planning services, information, education and communication, and counselling
Sexually transmitted diseases and human immunodeficiency virus (HIV) prevention
Human sexuality and gender relations
Adolescent sexual and reproductive health issues (such as unwanted pregnancy, unsafe abortion, STDs/HIV)

With regard to gender equality, equity and empowerment of women, the areas of concern are the following:

Empowerment of women and improved status of women
Elimination of discrimination against girls and women
Promotion of male responsibility and participation

1. Country responses in Asia to the recommendations in the Programme of Action on reproductive health, reproductive rights and gender relations

Many countries in Asia have adopted the recommendations in the Programme of Action and established policies on issues of reproductive health, reproductive rights and gender relations. However, there is a wide variation among the countries in terms of policy coverage and programme implementation. This variation is due to the diverse characteristics of countries in the region and many other factors, including the level of political commitment; the stage of demographic transition; socio-economic conditions; and. cultural norms related to gender. The following are examples of positions taken by a number of countries in the region.

Cambodia. Prior to the population census in Cambodia in March 1998, there was virtually no database for either studying the changing demographic scene or formulating population policies and programmes. Drawing on the recommendations of the Cairo Conference, the prime aim of the birth-spacing policy adopted in 1995 is to promote maternal and child health through longer birth intervals. Birth-spacing services are now integrated into the maternal and child health service under the Ministry of Health. The centrality of women in the development process is acknowledged. A gender appraisal of existing laws, particularly those that affect women, has been undertaken. Steps have also been taken to improve women's education.

China. Following the Cairo Conference, the Programme for the Promotion of Family Planning in China (1995-2000) was adopted in 1995. Family planning, population control and the education programme were identified as being among the top priorities of social development for the next 15 years. Information about reproductive health care is disseminated to the public. Counselling and quality reproductive health services are provided to women of reproductive age in order to enable them to make informed choices. Abortion of female foetuses following the use of technologies to determine foetal sex, and the abandonment of baby girls, are strictly banned by law. In order to improve the economic and social status of women in China, several large-scale projects have been implemented.

Indonesia. The Government has implemented many initiatives associated with the Programme of Action. The implementation of programmes on reproductive rights and reproductive health has been placed under the Prosperous Family Reproduction Movement. There are three fundamental programmes involved: the Healthy and Prosperous Mother Programme, the National Family Planning Programme and the Family HIV/AIDS Awareness Programme. In 1993, state policy guidelines were developed based on the principle of equality and harmonious partnership between men and women.

Lao People's Democratic Republic. In 1995, a birth-spacing policy was adopted. The main goal of this programme is to reduce maternal, infant and child mortality by 25 per cent by 2000. The resolution of the Sixth Party Congress in 1996 called for active implementation of demographic policies which should support population growth at a level suitable for economic development. The need for strengthening the equal rights of both sexes in every aspect is recognized. Some traditional customs and practices remain as obstacles to the advancement of women in the Lao People's Democratic Republic.

Malaysia. The Malaysian 30-year old Population and Family Development Programme has shifted from a family planning approach to the integration of wider areas of development planning. The current thrust of population policy emphasizes population quality, human resources development and allowing couples to plan their families in the light of their own perceived well-being. The need for equity in the provision of health services has long been recognized in Malaysia, and many of the key elements of Health for All and the primary health care approach have been adopted. New programmes are being developed for menopause/andropause and adolescent groups. Since 1994, more research has been conducted on parenting patterns and adolescent behaviour. Research, including surveys, has been conducted to provide greater understanding of factors facilitating the role of women in the family and their participation in the work environment. In 1994, the Cabinet passed the Domestic Violence Act to ensure protection for women and children.

Mongolia. A population policy was approved by the Government in April 1996, the main goal of which is to maintain the average annual population growth rate at no less than 1.8 per cent, and reduce the infant and child mortality rates by 50 per cent. The national policy calls for conditions favourable to birth-spacing in the interests of maternal and child health. Equal rights for men and women is an important objective of policy in Mongolia. However, the proportion of women participating at the national decision-making level is not satisfactory.

Myanmar. The Ministry of Immigration and Population and the National Health Committee were formed in 1995. A major goal is to achieve "Health for All by the Year 2000". Current health programmes include special programmes for women, such as maternity, child welfare and birth-spacing. It was also realized that reproductive health programmes should be adopted to encourage, strengthen and intensify the action to be taken for reproductive health for all. The Government will concentrate on strategies to ensure that the gender gap evident in many areas does not widen.

The Philippines. After the Cairo 1Conference, elements of family planning and reproductive health were identified and prioritized. Areas for substantive and structural enhancement in the health programme in general were determined. A gender-sensitive population policy framework within a reproductive health perspective was developed using the life-cycle approach. The framework will unify and synchronize all policies that relate to reproductive health and reproductive rights in the country. The Philippine Development Plan for Women has become the blueprint for gender-responsive planning and implementation. There was a refocusing of the strategy of addressing women's disadvantaged position from a woman in development approach to a gender and development approach. Guidelines were formulated to ensure the integration of gender concerns into all aspects of the project development cycle.

Thailand. A national population policy was declared in March 1970 aimed at reducing the population growth rate. This has been successful, with the annual growth rate declining from more than 3 per cent when the policy was formulated to approximately 1.1 per cent by the end of the Seventh National Development Plan in 1997. Owing to the rapid decline in population growth, and to be consistent with the Programme of Action, the Government, through the Ministry of Public Health, has adjusted the direction of the national population policy towards integrating family planning policy and services into a broader reproductive health policy. Emphasis is placed on promoting family planning services in areas where fertility remains high, improving the quality of family planning and reproductive health services, continuing IEC for maternal and child care, prevention of reproductive tract infections, STDs, HIV/AIDS, and the promotion of male participation as part of a policy of improving gender relations.

Viet Nam. The country has strong policies on gender equality . This equality was enhanced during the war years when women held combat and leadership roles. A 1994 policy directive states that at all levels of the government and the Party, women should comprise at least 20 per cent of representatives. The directive also requires that gender awareness be improved, and training and retraining of women provided. Population and family planning research has been prioritized up to the year 2000.

B. Women's situation in reproductive health and health risks

Despite the attempts undertaken at both international and national levels with regard to women's status and rights in various aspects, including health, it is obvious that a large number of women in many developing countries still suffer to a great extent in regard to their general health and reproductive health conditions.

In 1997, The State of the World Population (UNFPA, 1997a) documented the effects of denying sexual and reproductive rights to both men and women worldwide. Many of these problems are related to gender-based cultures, norms and values which are embedded in each society. Some of the effects are as follows:

Approximately 585,000 women-one every minute-die each year from pregnancy- related causes, nearly all in developing countries. Many times this number are disabled as the result of childbirth.
About 200,000 maternal deaths annually result from the lack, or failure, of contraceptive services.
A total of 120-150 million women who want to limit or space their pregnancies are still without the means to do so effectively. Altogether, 350 million couples lack information about, and access to, a range of contraceptive services.
At least 75 million pregnancies each year (out of about 175 million) are unwanted; they result in 45 million abortions, 20 million of which are unsafe.
Each year, 70,000 women die as a result of unsafe abortion, and an unknown number suffer infection and other health consequences.
An estimated 3.1 million people were infected by HIV, which leads to AIDS, in 1996; 1.5 million died from HIV/AIDS- related causes in the same year; 22.6 million people are living with HIV/AIDS.
Approximately 1 million people die each year from reproductive tract infections, including STDs other than HIV/AIDS. More than half of the 333 million new cases of STDs annually are among teenagers.
About 120 million women have undergone some form of female genital mutilation; another 2 million are at risk each year.
At least 60 million girls who would otherwise be expected to be alive are "missing" from various populations as a result of sex- selective abortions or neglect.
Approximately 2 million girls under the age of 15 are introduced into the commercial sex market each year.
Rape and other forms of sexual violence are rampant, though many cases of rape are unreported because of the stigma and trauma associated with rape and the lack of sympathetic treatment from legal systems.

1. Reproductive health in relation to gender

Before discussing the issue of gender and reproductive health in depth, it is essential to understand the basic concepts and their relevance to policies of reproductive health involving gender relations and the promotion of male participation.

The UNFPA thematic workshop on gender, population and development differentiated "gender" from "sex" in the following manner: sex is a distinctive biological and physiological identity of men and women largely based on their reproductive functions and characteristics. On the other hand, gender is the socially and culturally constructed roles ascribed to males and females. These roles, while based on biological differences, are learned from childhood. Gender roles change over time and vary widely within and between cultures.

Gender roles and gender relations, therefore, have to do with differences in what men and women do, and the ways in which their socially defined role benefits or harms them. They also relate to access to resources and to autonomy and control resulting from specific rights, roles, power relationships, responsibilities and expectations assigned to women and men (Long, 1984; Population Council, 1996). Gender relations have a profound impact on women's status, reproductive health and overall health. Gender relations also influence male health and behaviour, including their power and control over their female partners. Male participation in reproductive health requires that men must take responsibility for their own fertility, for their part in preventing the spread of STDs and for the well-being of their partner and children (UNFPA, 1994).

Factors influencing gender relations include demographic factors (migration/urbanization), socio-cultural factors (changing traditions, lifestyles), environmental factors (drought/floods), political events, both external and internal (new policies/change in government/war etc.), economic factors (income distribution, structural adjustment policy), legal parameters (change in membership or suffrage laws), and religion and education (changed expectations of educated girls and boys) (Thomson, 1997).

Reproductive health is a life-cycle phenomenon of girls and women. It is also, however, a lifetime concern for both women and men, often with intergenerational consequences and implications. While biologically determined factors may have their effects on the reproductive and sexual health of males and females at different stages of life, there are many other socio-cultural factors that have different influences on men and women. These factors include poverty, malnutrition, education, employment, income, access to information and services and gender-based norms and values.

In implementing policies and programmes on reproductive health in relation to gender in accordance with the Programme of Action, many countries face challenges and constraints. These constraints can include a lack of understanding of the broad concept of reproductive health; lack of efforts to identify and address factors that are to the detriment of girls and women; insufficient commitment of policy makers; problems of policy and programme implementation, such as making services and information available to all individuals and couples; quality of care; individual rights related to choice and confidentiality, integration and coordination of the services and information provided; and development of the appropriate institutional structures and human resources required to effectively implement programmes and monitor their impact. There can also be constraints arising from lack of resources.

2. Problems in reproductive health related to gender

From the policy perspective, it is usually agreed that population policies must take into account all aspects of women's needs, including reproduction. Comprehensive reproductive health programmes should serve the needs of both men and women at all stages of their lives. It is necessary for women to be integrated into the decision-making process, enabling them to make decisions, especially crucial ones, even where there are socio-cultural obstacles to ways to improve the position of women (Bangkok Post, 1996). Males should also be encouraged to take more responsibility and share in improving women's reproductive health and to protect women's rights.

From the implementation perspective, however, it is clear that despite the long-term attempts focusing on gender equality and improving women's status, much remains to be done. A large proportion of women in many countries still do not enjoy equal status with men, and many remain unaware of their reproductive rights. The development models introduced during recent decades have contributed in many ways to the growing poverty and marginalization of women. In the area of reproductive health and domestic affairs, while women carry a greater burden by far than men, particularly in the practice of contraception, their needs are often totally neglected. At the same time, women's reproductive health problems have been greatly compounded by men's sexual behaviour, their power and control over their female partners and their lack of responsibility in many respects (Nichter, 1997; Pensri, 1997).

The following is a list of the areas of the pervasive neglect of women's health that occur over their life cycle (report of the Workshop on Gender and Women's Health, Resource Center for Primary Health Care, Nepal, 1994, cited in Pensri, 1997). Many of these general health problems and reproductive health risks clearly reflect a bias in norms and values attached to gender relations, particularly a lower status of women in many societies.

Infant and girl child (0-12 years)

Infections such as acute respiratory infections, gastroenteritis etc.
Discrimination in food and education
Household domestic workload
Child abuse and violence
Adolescent girls (12-18 years)
Early marriage
Lack of sex education
Lack of food/health services
Abuse and violence
Reproductive/gynaecological health
Adult women (18-45 years)
Maternal/reproductive health
Gynaecological health
Occupational health
Psychological health
Ageing women (above 45 years)
Menopause
Desertion/loneliness
Nutritional problems
Ageing problems

3. Gender-based discrimination and sex-selective abortion

A form of sex discrimination that starts early in life in many societies is sex-selective abortion of girl foetuses, made possible through modern medical technology. This practice of sex selection has become a matter of public concern since it has many implications for the future demographic composition of populations and socio-economic development.

Evidence from surveys undertaken in various Asian societies indicates considerable variation in the degree of preference for the sex of children. Such variation is clearly inherent in people's values and attitudes towards gender and is strongly determined by socio-cultural factors. Unusual patterns of child deaths and distorted sex ratios at birth reflect a constellation of cultural attitudes about sex roles and values, especially the low status accorded to girls. At present, under the situation of rapidly declining fertility occurring in many Asian countries and areas (such as Hong Kong, China, the Republic of Korea and Taiwan Province of China), gender bias, especially discrimination against female children, has become more focused. When couples limit the number of their children, selection of the sex of a child becomes more crucial for them. Sex-selective abortion favouring boys has been carried out through the use of modern technologies such as female foeticide, chorionic villi sampling, amniocentesis, and ultrasound tests (Kim, 1995). Discrimination towards young girls and women takes various forms, ranging from female infanticide, abandonment of female children, and poor quality of life for girls, to maltreatment of women, such as domestic violence, sexual abuse or rape. Singh (1996), in a speech at the International Symposium on Issues Related to Sex Preference for Children in the Rapidly Changing Demographic Dynamics in Asia, held at Seoul in 1994, said as follows:

Since the mid-1980s, more and more evidence has come to light of increased discrimination against girls. Female sex-selective abortion following parental foetal sex-detection tests, female infanticide, abandonment, and wilful neglect of female babies in the provision of nutrition, medical attention and general care have been observed in several Asian countries. In some situations, these phenomena have led to distortions in the sex ratio at birth, as well as a reversal of the biologically determined infant and child mortality differential that normally favours females. Thus, in the same way as the new medical technology appears to be modifying natural sex ratios at birth on account of son preference, discriminatory treatment of boys and girls, particularly with respect to nutrition and health care, is continuing to reverse the natural differential in survival chances in infancy and childhood in particular settings.

A preference for a particular sex of children also influences the reproductive behaviour of couples and the mortality of children (for instance, infanticide, abortion, and abandonment of female babies). The desire among couples in many societies to have at least one or two sons is considered to be an important barrier to fertility reduction since it can stop or delay couples adopting family planning. While information is sparse, reports suggested that at least 60 million girl foetuses are aborted in various Asian populations after sex detection has been performed, particularly after the first birth (UNPFA, 1997a:42).

4. Women and nutrition

The State of World Population, 1997 report by UNFPA indicated that worldwide, malnutrition contributed more than any other factor to disease and injury. It was reported that malnutrition contributed to 5.9 million deaths in 1990 and accounted for 15.9 per cent of all morbidity. Poverty was the main underlying cause, but a disproportionate number of those affected were female. In many families, girls and women were the last to obtain the limited amount of food available to families. Malnutrition and associated health problems among young girls were far more common than they needed to be, even in poor families. Malnutrition for girls in early life resulted in health problems later on in life; it contributed to anaemia, a risk which intensified after the start of menstruation. Malnutrition and anaemia contributed to many of the problems found in pregnancy and delivery. It also played a part in many maternal deaths (UNFPA, 1997a).

5. Maternal health

It was reported in 1997 that in developing countries, maternal health, STDs and HIV accounted for more than 50 per cent of the treatable or preventable diseases in women aged between 15 and 44. Women were at risk from complications during pregnancy, childbirth, abortion and unsafe abortion and reproductive tract infections, particularly STDs. Many of them also suffered from gynaecological disorders such as menstrual complaints, vaginal discharge and urinary tract complaints (ibid.).

6. Family planning and contraceptive use

There are four major problems commonly encountered by women in family planning and contraceptive use: accessibility to family planning information and services, quality of services, gender responsibilities, and spousal communication. These problems become major obstacles preventing women from regulating fertility or exercising their reproductive rights.

(a) Accessibility to family planning information and services

Over the past three decades, more acceptable and safer contraceptive methods have been developed to provide more choices for individuals and couples in childbearing. The contraceptive prevalence rates among women in developing countries have increased steadily and are at a satisfactory level. However, contraceptive methods remain unavailable to many, both men and women, who need them. It is estimated that at least 350 million couples lack access to the full range of safe and effective modern contraceptive methods (UNFPA, 1997c). In addition, there still exist variations in the levels of contraceptive prevalence rate among women who live in different geographic areas and among different socio-economic classes. A problem of unmet need for family planning services is particularly evident among the large number of women who are less privileged in many respects and who are often left behind in the modernization process. They are women who live in remote rural areas, the urban poor who live in marginal areas, those who lack access to education, and those who cannot find work or who work under adverse conditions. These women usually lack knowledge about family planning, have less access to contraceptive services, or have little or no power to make decisions regarding reproduction, all of which results in high fertility among them. In addition, these women often lack basic knowledge of maternal and child health, health care for young children, child-rearing and nutrition (Bhassorn, 1994).

(b) Quality of care in family planning

The importance of quality of care for the success of family planning programmes is not less than the accessibility and availability of supplies. Service quality, including interpersonal relations between service providers and recipients, has a great impact on the continuation of contraceptive use. However, this aspect of service quality has been largely neglected or is often ignored. Some practices undertaken during the service process have violated women's rights and limited their choices in fertility regulation. For example, in India and Nepal, though the standard of care established suggests no more than 40 procedures a day for sterilization, some physicians work on up to 80 to 100 cases per day (Bruce, 1990)

(c) Gender responsibilities in family planning

Research findings since the 1960s confirm that females are the major target of family planning programmes. Well over 95 per cent of acceptors of contraception are females. In addition, the ratio of male to female sterilization acceptors has been strikingly unbalanced. The reason for placing responsibility largely on women is probably based on the idea that home-making, pregnancy and childbirth are the sole duties of women. Therefore, men currently play a minor role in family planning and in determining contraceptive use. The other explanation is that there are various temporary and easy-to-use contraceptive methods available for females, while only condoms and male sterilization are available for men. However, it is argued that women may benefit from practising family planning since they are relieved from the burden of childbearing and it decreases the risk of death. At the same time, women would be freer to participate in other productive activities (Bhassorn, 1991). While it is evident that men play only a small role in family planning, it is surprising to find that little research has been carried out on male attitudes toward family planning, the need for contraceptive use, their motivation to participate, barriers against participating in the programme, and the like (Bhassorn, 1992).

(d) Spousal communication.

Communication between spouses, and among family/household members, regarding family planning and contraceptive use is considered crucial to the adoption of contraception, and is found to be positively correlated with fertility behaviour. Chai (1997) suggested that issues of spousal communication across societies and its variations might be understood in terms of the different structural and cultural factors within which the couples live, that is, religious ideology and cultural norms concerning gender roles and status which impinge upon women's autonomy. Levels of spousal communication on contraceptive use are also governed by family structure (patriarchal or highly authoritarian versus nuclear), wife's education, the perceived status of women in the family and in the community, and women's role in decision-making (Hollerbach, 1980; Chai, 1997). In some settings, kin or non-kin (peers, neighbours, community leaders, health professionals) also play important roles in the decision-making process of the couples. More importantly, decision-making (that is, passive, unilateral or joint) on fertility or contraceptive use very much depends upon the gender and power relations predominating in the family. In developing countries, the husband's attitudes, preference, intention and decisions are more important. Most often, it is the husbands who exert the greater influence in couple communication and fertility decision-making (Bhassorn, 1992; Chai, 1997). However, under certain conditions the wife's influence can also prevail. The success of family planning programmes depends a great deal on women's power in this regard and on whether they can decide themselves to use or not to use contraception-and if they decide to use contraception, what methods they should use and when should they use them. Therefore, service providers should devote much more effort to providing women with information, ideas, knowledge and awareness related to family planning and fertility regulations (Hollerbach, 1980; Bhassorn, 1992).

7. Women's general health risks

The relationships between gender and health are not confined to reproductive health. Because of cultural expectations related to gender roles, women may face a number of health risks that are not faced by men. Gender-based health problems may also be related to access to services or to health policy. For example, a study in Thailand found that misuse and over-consumption of drugs by healthy Thai women reflect Thailand's health policy problems. Some of the problem could also be traced to a cultural emphasis on women's modesty, which deprives them of necessary knowledge about their own bodies.

For many Thai women, self-care means self-medication. Modern medicines are used excessively and unnecessarily because they are thought to be safe, effective and convenient. Therefore, women need to be educated about taking medicine. The research revealed that among the more common medicines used by women are those that are designed to help them delay the menstrual cycle and deal with menstrual cramps, avoid pregnancy or cope with morning sickness and excess milk flow if they do fall pregnant, and even to treat acne and vaginal discharge.

The study recommended that a comprehensive list of drugs hazardous to women should be distributed nationwide and that health authorities should fight for women's interests rather than yielding to the pharmaceutical companies. Most importantly, women themselves should learn to take care of their own health without relying solely on modern medicine. These issues need to be addressed seriously by the countries of the ESCAP region.

8. Sexual health risks

The issues of human sexuality and sexual health risks are receiving much greater attention and are among the important components of reproductive health in relation to gender. These issues were clearly addressed in the Cairo Conference in 1994.

Sexual health refers to a satisfying sex life, free of violence, fear and unnecessary pain and including mutually caring sexual relations. Sexual health is an integration of the somatic, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love (United Nations, 1994).

At present, in the midst of the AIDS epidemic there are increasing concerns about the sexual behaviour of men and women that exposes them to the risk of contracting diseases. Some of these diseases are fatal and have a serious impact on public health. Special attention has been given to women because they are particularly vulnerable to STDs, including HIV/AIDS. They are much more likely to be infected through sexual intercourse than men, and their partners' high-risk behaviour can endanger them. Many are powerless to protect themselves (UNFPA, 1994).

WHO estimates that the HIV virus is currently spreading faster in Asia than in any other part of the world. Recent estimates are that by the year 2000, about 42 per cent of all HIV infections at the global level will be in Asia, and a steep rise in infection levels is expected among women.

An important co-factor in the spread of HIV is STDs. In many developing countries, STDs are among the five most common problems for which people seek medical treatment. The major types most frequently found and reported are: gonorrhoea, syphilis, haemophilus ducreyi, non-gonococcal urethritis and lymphogranuloma venereum. Among women in developing countries, syphilis prevalence rates may be 10 to 100 times higher than those in developed countries, and gonorrhoea prevalence rates may be 10 to 15 times higher. Many infected women are completely asymptomatic and may suffer permanent and painful damage to their health and fertility and to the health of their newborn because they do not know that they need treatment (AIDS Analysis Asia, 1995 and Dadian, M.J. 1996, cited in Bhassorn, 1997).

Studies in many countries have highlighted the increasing rates of reproductive tract infections among adolescents. This is associated with increased sexual activity among adolescents who, quite often, engage in unsafe sex. In women, such infections, notably that caused by chlamydia trachomatis , have received little attention. Female adolescents with these infections are more likely than older women to develop pelvic inflammatory disease, along with its long-term complications of infertility, ectopic pregnancy, chronic pelvic pain, cervical cancer, pre-term delivery and low birthweight and infant blindness (Pimpawun, 1997).

With the increasing threat to women's reproductive health posed by reproductive tract infections and STDs, it is important to gain a better understanding of the level of knowledge of women on reproductive tract infections/STDs; how much they know about the severity of symptoms that warrant medical consultation; and what women are doing to treat reproductive tract infections/STDs and prevent themselves from being exposed to sexual health risks. In many countries, no systematic information is provided to instruct youth about sexual behaviour, sexual health care and contraceptive practice. Because of gender-based cultural attitudes and norms regarding this issue, there is little provision of knowledge or information for young women to create awareness regarding STD prevention, treatment and consequences. Accessibility to family planning services and clinics for the treatment of STDs is also limited. Efforts should be made to raise awareness about the dangers of improperly treated reproductive tract infections to serve as an entry point to discussing AIDS in countries where women have been reluctant to attend AIDS educational activities (Nichter, 1997; Bhassorn, 1997).

9. Abortion

Approximately 25 million legal abortions were performed worldwide around 1990 — or one legal abortion for every six births. This estimate must be considered the minimum number, as no attempts have been made to estimate the magnitude of unreported legal abortions (WHO, 1994, cited in United Nations, 1996). Based on information available for 193 countries, the majority of countries (98 per cent) have laws that permit abortion to save the life of a woman. However, a significant fraction of the abortions carried out are performed under unsafe conditions and result in the woman's death or permanent injury. It has been estimated that one in five maternal deaths stems from unsafe abortions. A mother's death or illness has a tragic effect on her family, and can reduce the survival chances of any young children she may have (UNFPA, 1994; United Nations, 1996). Where legal abortion is seriously restricted, an underground system usually operates. One important measure of the number of illegal abortions is the number of women admitted to hospital with complications following pregnancy termination. Complications include excessive bleeding, perforation of the uterus and pelvic infection. Severe infection or perforation of the uterus can result in a hysterectomy. Renal failure, blood clots and tetanus are rare, but can be fatal, even with prompt treatment. Illegal abortion is more dangerous because women are usually sent away soon after the procedure and there is no check on medical procedure, method or equipment. Complications can occur even with the best medical care and most up-to-date technology. The shame associated with illegal abortion means that a woman is usually reticent to talk about her unwanted pregnancy, or her uncertainty about what to do, or to seek help from friends and family in reaching a decision (Simmons, 1996).

10. Violations against women's reproductive rights

Violence against women is widespread. Most violence against women occurs in the context of sexuality and reproduction. Gender-based abuse is broad-based and includes physical, sexual and psychological abuse of female children, dowry-related violence, marital rape, female genital mutilation, sexual harassment, sexual assault, trafficking in women, forced prostitution, female infanticide and selective malnourishment of female children. In this section, only two examples of violations against women's rights will be presented and discussed.

The processes of modernization and globalization have resulted in a number of problems that affect women. Industrialization, in combination with more open and more relaxed regulations on cross-border travel, has contributed to growth of the sex service business. Because of its often illegal status, there are no accurate reports available on the number of commercial sex workers, but it is believed that the numbers are increasing. In many countries, a large number of young women and under-age girls (under 18) enter the sex industry voluntarily or involuntarily. Young girls may be sexually abused or physically tortured. In many cases, the growth of prostitution is related to the rapid spread of HIV/AIDS. Without social and economic remedies, legal solutions to commercial sex have proved to be unsuccessful because of the complex networks involved in the business. Problems connected with prostitution, especially child and women trafficking, have become both social and health problems (Bhassorn, 1993). Solutions need to be sought quickly.

One of the most persistent risks to the health of women is the physical or emotional abuse of women by their male partners. Between 20 and 60 per cent of women worldwide report having been beaten by their male partners. A large percentage of women are beaten while they are pregnant, often causing miscarriage, premature birth and low birthweight babies. The children of the victims may also be battered. Violence in the family is clearly common and affects women of all classes. Cases are under-reported because of the stigmatization of the victims. However, the increasing rates of suicide and suicide attempts among women are the response to the intolerable situation that many of them face. The underlying causes of domestic violence stem from the socialization of women to be submissive while accepting a "male-dominating" culture that places men in a superior position. It is important that campaigns be undertaken to raise public awareness of domestic violence. Men should play a key role in eliminating coercion and violence against women. Deep-rooted cultural norms should be changed to help men develop a self-image as nurturing people who care for their partners (UNFPA, 1997a).

C. Male responsibilities and participation in reproductive health

In previous sections, women's problems in reproductive health and reproductive rights in relation to gender were discussed extensively. These problems in many ways reflect deep-rooted cultural beliefs about gender relations. Women's poor health (malnutrition, anaemia), higher burden in family planning, greater exposure to sexual health risks (reproductive tract infections, STDs, HIV/AIDS), gender-based maltreatment (sex selection, domestic violence, rape, forced prostitution) and powerlessness to protect themselves, reflect a lower status of women. There are numerous examples of the limited involvement of males in reproductive health and family life. For instance, in most societies only a small percentage of males use contraception for fertility control, and an even smaller percentage use condoms within and outside marriage for preventing STDs and HIV. Violence is overwhelmingly male violence directed towards women, and there is little sharing of household responsibilities or child care by males.

Nichter (1997) provides an example of sexual behaviour of males that can have a negative impact on their female partners. Many men place their partner at risk of STDs when they engage in sexual exchanges outside their primary relationship. An important issue to consider is whether these men think that they are exposing their partner to such risk. Although many men engage in what they consider to be preventive health practices before and after sex as a means of protecting their own health and that of their primary partner, many of these health practices operate under a misguided set of assumptions and cultural beliefs. Educational interventions are needed to correct such popular health practices while supporting acts of male responsibility. Once such educational programmes are in place it may be appropriate to point out to men that exposing their primary partners to the risk of STDs/AIDS through ineffective prevention proactively constitutes an act of violence against women.

In the Programme of Action, reproductive health approaches stressed women's empowerment at the centre of health and development, while recognizing that to empower women without taking men into account would mean that the objectives could not be reached successfully. Therefore, it is essential that gender equality be promoted. Men should be encouraged to take more responsibility for their sexual and reproductive behaviour as well as their social and family roles since they exercise preponderant power in nearly every sphere of life (United Nations, 1994). Under this concept, a number of responsible interventions for male participation in reproductive health and family life were recommended. For instance, encouraging men to use contraception, supporting their partner's contraceptive use, preventing STDs/HIV, eliminating gender-based violence, and encouraging men to share more of the household responsibilities.

After the Cairo Conference, many countries directed considerable efforts towards the delivery of a broad range of reproductive health services designed to meet women's needs more effectively. At the same time, there have been attempts to raise awareness among men of issues related to gender and associated impacts on women's health. Countries have tried different ways to motivate men to become more involved in family planning. Mass media IEC campaigns and the provision of services and various group activities for men have been used. In the Philippines, a new reproductive health centre for men is experimenting with innovative ways to involve men in reproductive health programmes. Indonesia expanded its counselling programme to include training materials on male participation in family planning and reproductive health (UNFPA, 1997a). In the Islamic Republic of Iran, a range of activities have been developed to encourage male participation in reproductive health. These include orientation of policy makers and top-level managers about male participation in reproductive health/family planning activities; compulsory attendance in pre-marriage counselling courses of young men planning to marry; educating male workers in factories about the importance of male participation in reproductive health/family planning; conducting in-service training courses for soldiers about the importance of male participation in the above; and, sending family planning surgical teams to factories to perform vasectomies free of charge.

However, doubts have been raised by Sciortino (1997) about the effectiveness of interventions aimed at diminishing gender disparities and promoting male participation and responsibility in reproductive health and family life. According to Sciortino, the first obstacle is that there are no clear-cut, comprehensive strategies (programmes, plans and interventions) available on how to transform conceptual frameworks into practice. Second, the ideal in translating concepts of male participation in reproductive health into practice is far from the reality. There are many obstacles to obtaining cooperation among sectors in changing the social roles of men and women in order to improve their health status. Third, the concept of women's empowerment in sexual and reproductive matters is still questionable without other fundamental societal changes. In situations where women are subordinate and powerless in the family and society, it is not at all easy to encourage impoverished women who are in a dependent position to assert their reproductive and sexual rights or to bargain with their partners for their reproductive needs. It appears that in many ways women-centred awareness-raising programmes make women feel more frustrated about their inability to share their fear or to show their doubts on their reproductive needs with their husbands. Fourth, programmes proposing to give more responsibility to men and empower women, while indeed a worthy ideal, require a long period of implementation because it is a long and difficult process to empower women. Therefore, from a pragmatic point of view, reproductive health intervention should focus on men who are in the powerful position and convince them to protect the health of their partners. However, this should not be allowed to reinforce existing power relations by placing men in the primary position of protecting reproductive health. Making men responsible can leave women powerless (Nichter, 1997). Responsible interventions require careful consideration of different types of relationships and need to target both partners in a sexual relationship (Sciortino, 1997).

D. Conclusions and recommendations

The present paper has reviewed country responses to the 1992 Bali Declaration and the 1994 Programme of Action. Based on the documents reviewed, the paper highlights critical issues on women's reproductive health in relation to gender issues. Issues on the role and participation of males in reproductive health and family life are also assessed and discussed. The paper uses research findings and policy initiatives from a variety of countries, especially Thailand, to highlight the issues. While it is recognized that the diverse nature of countries in the Asian region means that not all specific issues are relevant to all countries, the examples provided in the paper provide a general framework for analysing gender issues in reproductive health.

From a policy perspective, it has been recognized by most countries that there is a need to take into account women's needs in all aspects, including reproductive health and reproductive rights. In looking after women's well-being, there is also a need to take men into account. Men should be encouraged to take more responsibility and play more vital roles in sharing women's burdens. These concepts have been implicitly or explicitly specified in a series of international and national laws, declarations and charters over the last five decades. The issues of reproductive health, reproductive rights, gender issues and promotion of male participation are emphasized in the Programme of Action of the 1994 Conference. However, in an attempt to meet the guidelines set out in the Programme of Action, countries have faced obstacles and challenges at both micro (individual and family) and macro (policies and implementation) levels.

The review of women's situation in reproductive health and reproductive rights in relation to gender indicates that much remains to be done in these areas. Women in many societies still do not enjoy equal status with their male counterparts. Many women remain unaware of their reproductive rights, including the right to make decisions about their own reproduction. Women's rights are often violated by their male partners in many respects. The pervasive neglect of women's general health and reproductive health is common and often ignored in many cultures.

Problems of women in reproductive health start early in childhood (some problems start before birth) and last long into the later years of life. These problems include sex-selective abortion; sex discrimination in access to food, education and employment; a greater domestic burden on girls and women; girl child abuse and violence; little or no access to sex education, reproductive health information and services; higher exposure to gynaecological and sexual health risks (reproductive tract infections, STDs, HIV/AIDS); high rates of maternal morbidity and mortality resulting from pregnancy and childbirth; sexual abuse; domestic violence; and menopause and ageing-related problems.

Although it is accepted that the reproductive health problems faced by women at different stages of life are largely determined by biological factors, gender-based norms and values and gender biases that are embedded in each culture also play their part. The problems of women, to a large extent, result from inequality in gender relations and unbalanced gender roles which place men and women in different positions. At the micro level, men are normally expected to lead the family: they are the household heads and family breadwinners. With these main functions, men are put in a superior position. Women's main roles are those of wife and mother, looking after what is often considered to be the less important area of domestic affairs. In addition, women bear most of the burden of reproduction and child care. These "less important tasks" put women in a much lower place than their male counterparts. The clearly defined responsibilities of men and women prevent men from becoming involved in what are considered women's affairs, including reproductive health and family life. Moreover, in many societies a "male dominance" culture is widely accepted and practised. Therefore, the reproductive rights of women are violated in many aspects.

At the macro level, it is recognized that obstacles in implementing programmes of reproductive health and improving gender relations result from many conditions. These include a lack of understanding of broad concepts of reproductive health; lack of effort to identify factors detrimental to girls and women; insufficient commitment of policy makers; and lack of human and financial resources to implement the programmes effectively and successfully.

In order to alleviate the problems described above, it may not be productive to focus all efforts on improving women's status or empowering women, as these changes involve many individuals and organizations. They also involve a long and difficult process of education and socialization for both men and women. Therefore, it has been suggested that male involvement should be promoted and integrated into programmes by all possible means.

Many of the proposed policies and programmes developed to address gender issues in reproductive health share common objectives, that is, to meet women's needs in reproductive health fully and to create an environment in which men could be better integrated into reproductive health programmes. The intention of providing the information here is to disseminate the experiences of various countries so that they can be used as examples that can be adapted to suit country-specific situations. It would unwise to develop "single-track" policies in dealing with these issues since countries are culturally diverse. Practical approaches are selected for consideration since they can possibly be applied in many different situations.

1. Recommendations targeting improvement in the provision of information and services on reproductive health and reproductive rights

As mentioned earlier, common problems of women in the area of reproductive health in many countries are related to lack of adequate accessibility and availability of information and services. Such lack, in combination with the lower status of women, has hindered women's ability to make decisions about their own health and reproduction. It was therefore proposed during the 1994 Conference that, in order to improve women's situation in these areas, health-care services should be more comprehensive in nature and coverage. The comprehensive services should be expanded beyond family planning and maternal health/child care programmes to cover programmes directed towards both men and women in the following areas:

Improving IEC on family planning services
Counselling and services on reproductive health, STDs and HIV/AIDS
Education and services for parental care
Prevention and treatment of infertility
Treatment of reproductive tract infections and STDs
IEC on human sexuality
Promotion of responsible parenthood

At the initial stage of launching this comprehensive service, with the aim of reducing women's problems, service needs may have to be prioritized in terms of needs and target groups. The provision of comprehensive services could be better integrated into existing organizations such as health centres where services are already provided to women in reproductive ages and who at present are at the greatest risk of HIV/AIDS infection. This new kind of service provision will be a big challenge in the years to come. It may involve the reorganization of services, providing additional training for health workers, adding more health-care facilities, and will require more effective supervisory and monitoring systems in order to make the services available for a greater number of recipients.

More attention should be paid to unmarried and sexually active male and female youth, who tend to engage in sexual activities that expose them to high reproductive health risks. They need to be educated at early ages on knowledge and responsible behaviour with regard to reproductive health. They should also be socialized to create new attitudes towards gender relations and gender equity and equality. Effective provision of information about human sexuality, as well as services in this area (i.e. counselling or distribution of condom supplies), should be encouraged.

2. Recommendations targeting improving women's reproductive rights and promoting male participation in reproductive health

The recommendations provided in this section are directed towards women's problems in the area of reproductive rights. It is clear that women in many societies are in a vulnerable position with regard to their reproductive rights. They have little choice in making decisions on their reproductive behaviour; they are unable to protect themselves from sexual health risks brought about by their male partners; and they suffer physically and mentally from domestic violence etc. To alleviate these unfavourable situations, it was recommended in the Programme of Action that programmes providing IEC on human sexuality and gender relations should be emphasized and continuously implemented in order to:

Promote adequate development of responsible sexuality that permits relations of equity and mutual respect between genders
Ensure that women and men have access to information, education, and the services needed to achieve good sexual health and exercise their reproductive rights and responsibilities (United Nations,1994).

It is important that young people, especially males, be educated or socialized about responsible sexual relations and the meaning and responsibilities of marriage and other adult relationships as well as other obligations entailed in parenthood. All these lessons and training programmes could be carried out through the education system and community-based programmes, and through the media (UNFPA, 1997a). More interesting, it has been suggested that a "woman-centred" approach in dealing with reproductive rights be replaced by the new concept of "male participation". In addition, sustained efforts should be made through various interventions to increase the involvement of males in the reproductive process, and create full respect for the physical integrity of the human body. It is essential to find ways to educate men to understand the risks women face from pregnancy, childbirth, the multiple sexual partners of their spouses, harmful traditional practices and sexual initiation too early in life.

Generally, males are characterized as household heads and primary wage earners, while the role of fathers tends to be vague, since responsibilities for child-rearing and care are still seen as belonging to mothers. It is believed that men's commitment to their children is the key to the quality of family life (UNFPA, 1997a) To promote male involvement in the family successfully, it is important to remove cultural barriers, such as young women being trained in home-making but not in income-generating skills, and young men being ill-prepared for fatherhood because they are discouraged from caring for children. Young men and those who are fathers must be involved in all programmes that deal with the family, including those that address pregnancy support, post-partum care and child welfare (ibid.)

3. Recommendation targeting creating better understanding about male participation and responsibilities

Research at the aggregate level focusing on the role and participation of males in reproductive health and male responsibilities in sharing family burdens has been rare. In order to plan or initiate more effective interventions in this area, it is necessary that policy makers have a deep understanding on these aspects. Edmonson (1995) suggested that there was an urgent need to conduct more qualitative research to identify male perspectives on a range of issues. There is a need for deeper understanding of male behaviour and attitudes towards sexual relations and responsibilities. According to Edmonson, the identification of potential parts of programme intervention that will be culturally acceptable and effective is a major priority.

End Notes

* Associate Professor, Institute of Population Studies, Chulalongkorn University, Bangkok.

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