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This conceptual framework serves as a theoretical basis for the training package and provides conceptual tools to critically analyze current health care practices and to promote more fruitful approaches. Interrelated aspects of these new approaches include: equitable interpersonal relationships within health care teams and between providers and users; the possibility for users to be informed and choose freely among alternative methods and treatments; recognition and respect for users' beliefs, practices and experiences in relation to their bodies, sexuality and reproduction; respect for the population's sexual and reproductive rights; technical competence; availability of essential supplies; accessibility of services for different groups of users; and administrative practices that promote equity. What are the basic concepts that support this type of approach? Here, we emphasize the need to understand and reflect on four interrelated concepts: gender, sexual and reproductive health, sexual and reproductive rights, and quality care. While we provide basic definitions for the training process, it is important to emphasize that these are relatively new and highly contested concepts for which multiple and sometimes conflicting definitions and applications coexist. Each individual and health care team needs to develop its own conceptual and philosophical position through debate, reflection and practice. Theorectical and Conceptual Evolution Sexual and Reproductive Health Sexual and Reporductive Rights
Theoretical and Conceptual Evolution Health care practices are constantly being modified and improved by the generation and introduction of new technology, including medicines, vaccines, diagnostic tools, surgical equipment and contraceptive methods. Similarly, new methods and techniques for provider-user interaction and communication are also transforming health care. The approach developed in this training package is informed by, and contributes to, changes along various philosophical and conceptual paths, among them:
We understand gender as that which identifies us as women and men within our social life based on different attitudes and forms of behavior, different roles and responsibilities, opportunities, spaces and activities. We learn gender values and behaviors as we grow up, and they influence who we become. These culturally constructed differences are symbolically associated with sex differences, which are biological characteristics that differentiate males and females, permitting sexual reproduction of the species. Teresita de Barbieri writes: "We are born with biologically sexed bodies, to which we attribute one or another social and cultural meaning. As humans we are historical beings, we are not born in nature, we are born in societies, in a world culturally construed with laws, norms, values, symbols, and collective commitments. All cultures have forms of gender training, and all institutions, governments, schools, churches, families, are pedagogical fields for gender construction. Thus, in all societies, men and women are raised with life philosophies marked by gender" (Barbieri 1991).
Marcela Lagarde (1995) explains that there are two basic concepts of gender in Latin American societies. The first is the traditional gender ideology, which says that all men and women's characteristics are natural. It assumes that gender categories and identities were created by God, or in accordance with Nature's laws, and are thus immutable. This gender ideology is implemented, guarded and sanctioned by social institutions, which establish parameters for male and female behavior (here, there are only two gender categories: masculine and feminine, as any variation is considered unnatural). In Bolivia, this traditional gender ideology foments conditions of inequality and unequal value of men and women, exemplified by educational practices in which girls are trained to be self-sacrificing mothers and obedient wives within the domestic domain, while boys are trained to be strong and brave, to lead in the public domain and be heads of the household. The other concept of gender to which Lagarde refers breaks with this traditional scheme. It defines gender as a category of critical analysis designed to consciously deconstruct the dominant gender order and to contest conventional assignations of social, psychological and cultural characteristics. This gender concept reveals that power differences between men and women are not natural and genetic, but rather historically construed and assigned. This position, in contrast to the first, facilitates efforts to move towards more equitable conditions and relations between men and women (Lagarde 1995). An important aspect of gender is the manner in which certain anatomical differences are interpreted and managed within each society. Men and women have the same capacity to produce pleasure in each others' bodies, but only a woman can "produce another body" (Torres Arias 1989). On the basis of this fact, Barbieri theorizes that every society assigns a special power to the female body, and establishes the need to keep that body under control: "To assure an effective control of reproduction, it is necessary to take actions to control sexuality…. In other words, in order to control reproduction in such a way that one or more men can claim rights over the product of women's bodies, it is necessary to control access to the female body… Control of women's bodies means to limit women's work in such a way that they can not escape" (Barbieri 1991). Sexual and gender identities and relations are not uniform, and we need to consider ways in which they intersect with other axes of social differentiation. Gender identities vary with the stages of the life cycle, and the meaning of sex and age varies with socioeconomic and ethnic factors in the construction of identities and relations. We must also take into account family structure, economic organization, division of labor, religious beliefs and practices, and other cultural aspects. Gender Relations Gender is a part of all human experience and all social relations, and as such continually influences the value, power and identity of each participant. In general, Latin American societies assign certain political and economic values to men and applaud their roles in public leadership, whereas they assign certain moral values to women and venerate their maternal roles and their functions as transmitters of cultural and religious traditions in the home. These relations are part of social fabrics in which men, in general, have more power for decision-making and action than do women. Nevertheless, is it crucial to remember that this is not a simple dual hierarchy. Each individual's class, ethnic group and generation influence his or her experience within the gender structure. In Bolivia, white adult women in the middle and upper classes have much more power for decision-making and action than do adolescent men who are indigenous peasants. While powerful government, church and economic institutions are dominated by men, it is by an elite group of men. The majority of Bolivian men (who are poor, indigenous and poorly educated) do not in any sense "dominate" the society and enjoy very few privileges, even relative to their wives and sisters. Because we know that gender systems and relationships change, that they have evolved through time and differ across societies, we know that the current situation can change. But since relations of superior power for some and disadvantage for others cross all spheres of life - personal, public, private, practical, symbolic - change must be sought in all of these spheres. How do we affect such change? Jeanine Anderson (1997) suggests that conflict is inherent in human life. Within a family, conflict between generations is as inevitable as conflict between men and women, due to positions that individuals occupy in the family and society, division of labor and necessary interdependence. Anderson adds, however, that cooperation is also present, as gender systems both channel and regulate relations of conflict and cooperation. Individuals and organizations can make a positive impact on these relations by ensuring that gender conflicts and negotiations are carried out through the democratic processes of dialogue and by refusing to acquiesce to unjust conventions and situations, thus becoming silent accomplices of oppression. Gender and Health Working with sexual and reproductive health from a gender perspective allows us to go beyond a biological focus on women's bodies to a better understanding of men and women's socially construed identities and needs, in order to address the social relations that influence each person's sexual and reproductive health. Services and providers can better respond to user populations if they recognize that women and men live and perceive sexuality and reproduction in different ways, and that all of our visions are conditioned by our cultural environments, ethnicity, age and class position, and our sexual identities. Cultural symbols and values associated with gender identities influence each person's choice, use or abandonment of contraceptive methods. In Latin America, many men seek validation of their masculinity through conquest, the exercise of power and the demonstration of their capacity to father children. Thus, it is difficult for them to use or collaborate in the use of contraceptives. For their part, women who see maternity as a principal form of social recognition and value (because church and family have educated them to believe this; because the gender balance in education, labor and political and public spaces limit their opportunities; and because they see little other possibility for personal and professional growth) may choose to prioritize childbearing at a high cost to their own health and well-being. In addition, we must consider that using contraceptives implies negotiation between a couple, and that many times gender relations are such that a woman does not have the power to influence the terms of the discussion, or a man is denied participation in the decision. These identities and relations are not the only reasons why many men and women - including those who do not want more children - do not use contraceptive methods, but they are factors that should always be taken into account. Gender also plays a role in relations between providers and users. Numerous studies have determined that in Bolivia STDs are treated differently in men than in women (Crisosto 1997). When a woman seeks treatment for gonorrhea, for example, often she will be given a course of antibiotics and told to refrain from sexual relations for a certain time period. When a man is treated for the same disease, he is told that his sexual partners probably also have it, and that they should be treated at the same time. Although he is married, it is not assumed that a man's relations are limited to his wife, and providers often indicate that he should contact all partners. Many of the women who are treated alone will become infected again by a partner who was not included in the cure. This unequal clinical practice only serves to reinforce an unspoken social norm that says: "Men have a right to multiple sexual partners, and women should only have relations with their husbands. If women become infected with sexually transmitted diseases, they must suffer the consequences alone."
Gender practices and meanings manifest themselves in the religion, science, education, environment, social and economic conditions of each society. They influence sexuality and sexual and reproductive health, together with our perceptions and interpretations of what constitutes health and who is entitled to it. Thus, gender systems may legitimize certain values, practices and beliefs surrounding the sexual and reproductive lives of different actors in such a way as to impair the health of specific groups. In order to promote sustainable improvements in the sexual and reproductive health of the population, policies and services need to consider these social conditions and issues. A gender perspective helps us to analyze and promote changes in organizations, institutions and communities by moving towards goals of more inclusive, equitable and effective health services. We must also consider the dynamics of power, knowledge and decision-making in the relations within each family, between providers and users and within governments and other institutions and the populations they serve. Health services that have addressed these relations and have extended their coverage to include comprehensive sexual and reproductive health needs of women and men, have improved quality care and increased impact on user populations. Processes of positive change also require analysis of relations of power and knowledge within health institutions, in order to transform unequal and stereotyped professional relations that interfere with the provision of equitable quality care. Sexual and Reproductive Health
Current ideas of sexual and reproductive health express a change from earlier biomedical definitions of health and illness toward a more ample concept, which encompasses social science and ethical considerations and promotes men and women's sexual and reproductive rights, together with respect for cultural contexts and individual decisions. Traditionally, health policies and programs have focused on physical functions of the reproductive system, and especially on fertility control. In recent decades, however, we have begun to understand that personal and cultural experiences of sexuality are intimately linked to the biological health of the reproductive system: that these are two inseparable dimensions of what is experienced as a single phenomenon in human life. Reproductive and sexual health develop interdependently during the life cycle, and affect each person on multiple levels. For example, the physical and psychosocial stress of multiple and closely spaced births may impair a woman's sexual expression, and negatively affect her sexual health (Bassu 1997). In the same way, certain sexual practices and choices can make individuals vulnerable to diseases that cause harm, and even infertility, in the reproductive system. As early as 1974, a committee of experts from WHO defined sexual health as the integration of physical, emotional and intellectual elements in ways that positively enrich and strengthen personal identity, communication and love. The comprehensive vision expressed here surpasses reproductive and pathological aspects to encompass affection, pleasure and communication, which are important in people's lives (Cerruti Basso 1993) and contribute to improved life and personal relationships (ICPD 1994; Alcalá 1995). Different definitions and interpretations of sexual and reproductive health coexist. Medical sciences tend to express them in biological terms, while some NGOs and international organizations tend to emphasize men and women's rights or the provision of information and services (WHO 1997). The training guide presented here develops an understanding of sexual and reproductive health that encompasses these different concerns and takes into account possible tensions between them. Although the concept of sexual and reproductive health should definitely include biological factors, it is also fundamental to consider psychosocial and cultural factors, as well as sexual and reproductive rights. Health is a process that influences and is influenced by many life factors (WHO 1997). The International Conference on Population and Development (ICPD) held in Cairo 1994, established a new vision of reproductive health that explicitly incorporates sexual health:
This definition of reproductive health includes a number of points worth considering. First, when we talk of "a state of complete physical, mental and social well-being", we must ask how many people do not have good reproductive health because they do not enjoy mental or social well-being? The phrase "to have a satisfying and safe sex life" should be noted as the first time that an international document, signed by approximately 180 nations, touched on the theme of sexual satisfaction. Finally, the "right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice" makes reference to the quality of health care. Continuous efforts of NGOs and women's movements have been important forces behind the broadening of the concept of sexual and reproductive health, especially in the Third World (Correa and Petchesky 1994). These movements have questioned academic, analytical and institutional divisions that arbitrarily separate what is lived as an integral experience. While most services still focus on reproduction, and deal only marginally with sexuality and rights, at the ICPD, world consensus was generated around the need to forge more comprehensive and user-focused reproductive health programs. According to this vision, sexual and reproductive health services may include, but are not limited to: voluntary fertility regulation; prenatal, birth and postpartum care; tetanus vaccines; support for breastfeeding; infertility treatment; prevention, screening and treatment of STDs, including HIV-AIDS; gynecological examinations; prevention and treatment of breast and cervical cancer; treatment of complications from abortion; nutrition programs; production and dissemination of educational and informational materials; education and counseling about sexuality; protection against violence; training of extension workers; personal and couple counseling; and diverse activities that empower users to take greater control and responsibilities for their own health (Dixon-Mueller 1993; Hardee and Yount 1995). All men and women, whether or not they have experience with sexual and reproductive health services, may have their own interpretations of what those terms mean, interpretations informed by their culture, age, religion, education and personal health experiences. The health of each population, in turn, is influenced by the quality of care and education available, by the level of recognition of social sexual and reproductive rights, and by gender meanings and roles within society. In many parts of Latin America, the characteristic called machismo emphasizes the sexual prowess of men, measured by the quantity and daringness of their sexual conquests (Barker and Lowenstein 1996). This stereotype pushes men to take serious health risks and leads to unwanted pregnancies, unsafe abortions and STDs (Zeidenstein and Moore 1996). In Bolivia, women seek health services with much more frequency than do men, due to their reproductive biology as well as cultural roles that determine women's greater responsibility for the health of children, parents and sick relatives. There is a growing consensus, however, that a more balanced participation on the part of men would contribute to health improvements for the whole population. The ICPD Programme of Action emphasizes the importance of involving men more fully in spheres from which they have been excluded or marginalized:
Thus, working with a gender perspective implies increasing emphasis on men, getting men involved and recognizing that sexual and reproductive health pertains to men as well as women. In spite of the above recommendation, services are still predominantly oriented toward women's needs and the fulfillment of women's rights, and many health centers have not fully accepted that men also have sexual and reproductive rights. The failure to explicitly include men in sexual and reproductive health programs clearly limits the chances of achieving greater well-being for men and women. Services overburden women by reinforcing the idea that women are responsible for the health of the whole family and for the regulation of fertility and by not promoting involvement of men. Ormel and Pérez (1997) observe that, although we should continue to respond to the needs and rights of women and to recognize the inequalities that they suffer, men also need information, education and access to services in order to participate more actively in the care of their own health, that of their partners and of their children. Sexual and Reproductive Rights
The concept of sexual and reproductive rights, together with the declarations that promote respect for these rights, has a long history. After the Second World War, the Charter of the United Nations (1945), affirmed faith in fundamental human rights, the dignity and value of human life, and equality of rights between men and women. In 1948, the Universal Declaration of Human Rights included Article II, which proclaims the right of all persons to the established rights and liberties without any distinction based on race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or any other condition. Throughout the years, rights were defined with increasing specificity, and the idea of sexual and reproductive rights was addressed explicitly in the Declaration of the World Conference on Human Rights in Tehran in 1968, which proclaimed that parents have the basic right to freely determine the number and spacing of their children, as well as the right to education and information concerning this issue. Later, at the World Conferences on Population held in Bucharest (1974) and Mexico (1984), this paragraph was adopted and adjusted so that the term "parents" be replaced by "couples and individuals." Other conferences and declarations reinforced the notion that the right to decide about reproduction, as well as the right to access health services, were basic human rights. In 1979, the General Assembly of the United Nations approved the Convention on the Elimination of All Forms of Discrimination against Women, and signing countries committed to take measures to ensure the full development and advancement of women. One of these measures is a commitment to ensure equal access to health services, including those related to family planning, and to promote the same rights for men and women to decide the number and spacing of their children. This measure also highlighted the need to access information, education and the resources necessary to exercise this right. Ten years later, the Convention on the Rights of the Child established a set of basic rights for minors, which affirmed the right of all persons to access services for voluntary regulation of fertility. The 1993 World Conference on Human Rights in Vienna reiterated the importance of eliminating all forms of sexual discrimination, together with the need to work to eradicate gender-based violence. At the International Conference on Population and Development in Cairo, certain sexual and reproductive rights were explicitly recognized as basic human rights.
The United Nations Fourth World Conference on Women in Beijing reaffirmed earlier consensus on the need to eradicate all forms of discrimination and violence against women and to guarantee the right to decide freely and responsibly about matters of sexuality and reproduction. The Beijing Platform for Action mentions factors that influence women's health, which are often overlooked as circumstantial.
Today, the exercise of sexual and reproductive rights by men and women is considered a fundamental basis for a better quality of life. Generally, sexual rights are not distinguished from reproductive rights, rather they are treated as dimensions of basic human rights, the exercise of which constitutes a fundamental strategy for human survival and quality of life. The acceptance of sexual and reproductive health rights has philosophical, ethical and political implications, as it becomes clear that a large proportion of health problems can be avoided by respecting basic human rights. A confluence of discourse and emphasis on sexual and reproductive rights and on gender is contributing to changes in health care values and paradigms. "Within this framework" writes Ladi Londoño, "a gender perspective helps us identify great shortcomings, unnecessary medical interventions, as well as the importance of emotional and affective aspects" (Londoño 1996). Quality of life does not only lie in improved infrastructure, reduced rates of maternal mortality and better resources for health care, it is also based on the exercise of and respect for individual autonomy in the intimate matters and sexual decisions of men and women. Different local and international organizations, as well as individuals, have also created lists of the sexual and reproductive rights. Here, we present a list of rights taken from IPPF's Declaration of Sexual and Reproductive Rights (1996), from Mari Ladi Londoño's book, Sexual and Reproductive Rights (1996), and from the Open Forum for Sexual and Reproductive Rights in Chile (1996). These rights include but are not limited to:
Many of these rights have been recognized internationally and may take different forms of expressions within varying national and cultural contexts. In Bolivia, one important universal right recognized by the Constitution is the right to health. The official document, which Bolivia's delegation presented at ICPD in 1994, affirms the necessity to "improve coverage and quality of services in primary health, with special emphasis on reproductive health" (Ministry of Human Development 1994). The document also emphasizes the importance of respecting women's decisions about sexuality and fertility, together with the democratization of roles within family and society.
The term "quality care" is frequently used in health services, where it conveys multiple meanings because the concept is neither universal nor homogenous. Quality is different not only for men and women, but for persons of different cultures, ethnic groups, social classes and ages. In other words, everyone has his or her own definition of quality. Recognizing that the meaning of quality care can vary from one person to another, it is still possible to talk of certain principles that help us to achieve quality care. These include: a focus on the comprehensive well-being and satisfaction of diverse users; the active and equitable participation of all persons involved in the provision of care; the practice of offering options from which users may select, such as different contraceptive methods or birthing positions (Finger and Hardee 1993); the empowerment of users to make free and informed decisions about their own health; and the equitable treatment of women and men, people of different ages, social classes and ethnic backgrounds. Quality care has three interrelated dimensions: quality in administration and management, quality in human interactions, and technical quality. Quality in Administration and Management This first aspect is directly related to an institution's philosophy, which transmits ideas, values and attitudes to employees as well as to users (Araujo and Matamala 1995). Quality management encourages a work and health care environment free from discrimination and abuse of power. Key here is the existence or absence of mechanisms that promote the participation of personnel and users in the improvement of services provided. These might include posted policies promoting users' rights or prohibiting discrimination; the use of suggestion boxes; and the organization of participatory and democratic meetings between administration and staff, and between these groups and representatives of the user population. Therefore, who evaluates quality care? Since the philosophy is oriented toward the satisfaction of users, it is users themselves who should evaluate the quality of services. To improve quality care, we must begin with a philosophy that places priority on user satisfaction (Finger and Hardee 1993). An institutional philosophy grounded in user satisfaction will be manifested in a facility's infrastructure, menu of information and services offered, labor practices and relations, staff treatment and labor policies, the guarantee of confidentiality and privacy during provider-user visit and even in the hours of service. If the institution does not take quality care into account as a matter of policy, it is improbable that staff will be able to provide the kind of services that satisfy users. Structural characteristics of a program can promote or prohibit respect for sexual and reproductive rights and the full exercise of these rights on the part of users. For example, every institution needs to consider ways to provide access to targeted groups by taking into account users who need to travel long distances or work long hours, and by adjusting the clinic hours accordingly. Quality in administration and management also means analyzing the different needs of men, women, married, single, and adolescents, and building programs in order to respond to these different expectations and needs. Each institution expresses its gender perspective in the relations it establishes with the public, from the assignation of resources among different groups of users and providers, to the distribution of tasks and responsibilities within the institution. A gender perspective is key to understanding different groups, to ensuring that services do not favor some and discriminate against others and making sure that programs do not reinforce existing inequalities. For example, many maternal-child health and family planning programs could be improved by questioning and changing their practices of orienting services and information exclusively to women; reinforcing stereotypes that give women sole responsibility for their families' health; and denying the fundamental importance of men's participation. Quality in Human Relationships This second aspect encompasses the empathy expressed by providers, time dedicated to each user, sharing of knowledge and respect for each user's opinions and decisions. It also implies respect for differences between people, e.g., a woman in native dress deserves the same understanding and respect as a woman in modern dress; a disheveled adolescent boy deserves the same service as a professional man.
In addition to changes in attitude on the part of workers, quality care requires that users themselves exercise more responsibility and initiative. Providers can facilitate this change by sharing knowledge about health, offering options for treatments and methods, and supporting users in their decision-making process. Services should offer complete information that permits users to care for their own sexual and reproductive health and to take preventive actions that help achieve a state of physical, mental and emotional well-being. Technical Quality This third aspect concerns adequate equipment and supplies, as well as technical competence on the part of providers. Technical competence requires that health workers apply current and appropriate knowledge, skills and technology using a humane scientific perspective. Indicators for this type of quality include the existence of clear operational norms and procedures, as well as the skill and accuracy necessary in diagnosis, treatment and follow-up of users. Technical quality includes having the necessary equipment, supplies and medicines needed to fulfill standards (Güezmes 1997), together with maintenance of conditions, the fulfillment of protocols and the availability of competent personnel (Finger and Hardee 1993). Quality equipment and supplies also refer to the general infrastructure of the center (water, plumbing, lighting, garbage disposal) and the conditions, comfort and cleanliness of the waiting and consulting rooms. A crucial aspect of technical quality is the existence of educational programs, covering medical techniques as well as techniques for patient care and communication, for continuous professional improvement for male and female workers.
The three dimensions of quality care outlined above are not independent, but rather they intersect and interrelate in the provision of sexual and reproductive health care. Advances in all three areas contribute to a change from a unilateral practice in which health professionals monopolize knowledge, information and decision-making toward a more conversational approach in which users participate with their own ideas, doubts and preferences. This new interaction occurs within an atmosphere of mutual respect, in which knowledge and responsibility are valued and strengthened in efforts toward sustainable improvement in the users' health. Quality Care and Gender Health providers often reproduce and reinforce gender inequities in their relationships with users and with co-workers. The provider-patient relationship does not take place in a cultural vacuum; providers act on their own gender beliefs and assumptions and within institutional frameworks. In many cases, health professionals tend to overvalue medical knowledge, give privilege to masculine-scientific discourse and reject other ways of knowing, thinking and talking expressed by patients. Often the sexual prejudices and values of providers and institutions are expressed through doubt, criticism, rejection and even sarcasm toward the way patients understand things, especially female patients, those who come from lower socioeconomic classes, and marginalized ethnic groups. The Beijing Platform for Action identifies numerous ways to promote women's access to health care throughout their lives, which will have to be complemented with ways to promote men's health care in order to build a balanced gender approach:
In social environments in which women assume subordinate positions in most relationships, they react to providers in the same way, thus, undermining their potential power as health care clients. In their relationships with health providers, many Bolivian women feel constrained by their fears, shame and timidity; by guilt and moralistic norms; by insecurities about their own knowledge; and by their experiences of physical, psychological and sexual violence. These constraints are coupled by gender related economic and operational difficulties that must be overcome in order to seek health care. All of these conditions limit women's capacity to take greater responsibility for their well-being, take actions that favor their health and exercise their rights. Men also approach health care from their own gender experiences and are restricted by normative models of masculinity. In Bolivian contexts, these can include pressure for "real men" to resist pain, refuse to seek or accept help and appear strong and physically and emotionally invulnerable. These aspects of "being a man" in Bolivian society impede access to health care. Pressure to demonstrate stereotyped masculine behaviors is especially strong for young men, many of whom do not seek medical care until they are extremely ill. In considering quality care, providers should recognize these gender norms and stereotypes, their impact on users' health and their influence both on provider-patient interaction and on user follow-up. Providers must understand that they are capable of forging new gender visions and possibilities, of changing their own behaviors and attitudes through their professional action. They can, for example, encourage and support women users to make strong decisions in favor of their own well-being and to assume new responsibilities for their health and sexuality. They can encourage men to admit that they hurt, seek and accept help and advice and participate in the health care of their children and partners. Better understanding and respect for others, together with improved communication among people from different backgrounds, cannot help but improve relations and processes of diagnosis, treatment and education, and thereby contribute to improvements in the entire population's health. |
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