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Background and Resources for Module 2 Session Objectives:
Specific Objectives:
Key Concept: Sexual and reproductive rights Activities:
Time: 4 hours, 30 minutes Activity 1: Defining Our Sexual and Reproductive Rights Objective: Reflect on the exercise of sexual and reproductive rights in our own professional and personal experience. Procedures:
Discussion guide:
Time: 1 hour Materials: - Index cards Discussion: All people have sexual and reproductive rights. The specific details of these rights and the exercise of them are expressed differently in different cultural groups, genders, generations and religions. Yet for all people, sexual and reproductive rights are based on the principles of human dignity, liberty and equality. The promotion and full exercise of sexual and reproductive rights contribute to the improvement of health services and the quality of health care, thereby, causing a positive impact on the health of user populations. It is not possible to isolate sexual health rights from reproductive health rights, i.e., the kind of quality care that improves a population's health depends on addressing both these rights in a comprehensive way. Expected results for participants:
Activity 2: Constructing the Concept: Sexual and Reproductive Rights Objectives:
Procedures:
Activity guide:
Time: 30 minutes Materials: - Concept card: Sexual and reproductive rights Discussion: In order for women and men to take responsibility for their sexual and reproductive health, and to make decisions favorable to their own health and that of their families, both users and providers must know, respect and exercise basic sexual and reproductive health rights. Activity 3: Promoting and Exercising Sexual and Reproductive Rights Objective: Identify ways to promote sexual and reproductive rights in the daily work of health services and commit to these practices. Procedures: Part 1 Form four groups, with each receiving a story that represents different experiences of health care (the complete texts of these stories are included in the support resources at the end of this section). After taking five minutes to prepare, assign roles and read through the scripts, each group presents its story, reading and/or performing the interactions in front of the other groups. The stories include:
Time: 25 minutes Part 2 After all the stories are presented, distribute to each group a discussion guide which will guide reflection and analysis of the stories just performed. Discussion guide: In the story we just enacted, in what way do the providers:
Time: 20 minutes Part 3
Time: 30 minutes Part 4
Time: 45 minutes Total time for four-part activity: 2 hours Materials: - Copies of the scripts Expected results for participants:
Activity 4: Developing Messages to Promote Sexual and Reproductive Rights in the Workplace Objective: Help participants to formulate communication strategies to promote the respect for and guarantee of sexual and reproductive rights in their own institutions and activities. Procedures:
Background and Resources for Module 2 Discussion Guide for Group Reflection
Concept Card: Sexual and Reproductive Rights Sexual and reproductive rights are inalienable human rights, inseparable from other basic rights such as the right to food, housing, health, security, education and political participation. Sexual and reproductive rights can be defined in terms of power and resources: the power to make informed decisions over one's own fertility, procreation and child care, gynecological health and sexual activity, as well as the resources to carry out those decisions safely and effectively (Correa and Petchesky 1994). History of sexual and reproductive rights The concept of sexual and reproductive rights, together with the declarations that promote respect for these rights, have 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 persons, 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. Other conferences and declarations reinforced the notion that the right to decide about reproduction, as well as the right to access to health services, were basic human rights. In 1979, the General Assembly of the United Nations approved a Convention on the Elimination of All Forms of Discrimination against Women, and countries that signed the treaty 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 right for men and women to decide the number and spacing of their children. This measure also highlights the need to access the information, education and resources necessary to exercise this right. The International Conference on Population and Development in Cairo recognized certain sexual and reproductive rights as basic human rights. "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 right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents" (ICPD, Programme of Action, Paragraph 7.3, 1994). The 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 promotion of sexual and reproductive rights in health care services Today, the exercise of sexual and reproductive rights by men and women is considered a fundamental basis for a better quality of life (UNFPA 1997). Generally, sexual rights are not distinguished from reproductive rights; they are treated as dimensions of a set of basic human rights, the exercise of which constitutes a fundamental strategy for human survival and quality of life. Increasing emphasis on sexual and reproductive rights 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" (1996). Quality of care 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 intimate matters and sexual decisions of men and women. List of Sexual and Reproductive Rights These rights include but are not limited to:
This list of rights is compiled 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). Story #1: "I Don't Understand about Methods" Rosalía is a 21-year old indigenous woman who met Pedro a year ago. They fell in love and decided to move in together. Pedro works as a mason, and Rosalía left her job as a maid and began to sell food in the marketplace, which gives her more time and freedom to build a relationship with Pedro. In the house where Rosalía worked, her employer and her friends would say that "a woman should take care to not have children too soon" and "men just make babies and disappear." Remembering these warnings, she decided to visit a health center. When Rosalía arrives at the center, she is impressed by the number of women in the waiting room with babies and toddlers. She timidly approaches the receptionist and asks for a visit with the doctor. She thinks to herself that she would be less frightened if the doctor were a woman but is afraid to say this to the receptionist, who is busy asking her a series of questions about her personal life and noting the answers on a chart. Rosalía answers in a low voice, not wanting other patients to hear. When the questions are finished, she receives a number and is told to wait her turn. After an hour and a half, her number is called. Rosalía walks quickly to the consulting room, where she is relieved to find a woman doctor. Her brave "Good morning, doctor" is answered by a kind "How are you, child? Take a seat." The doctor reads the chart that the receptionist filled out and says, "So this is your first visit? How can I help you?" Rosalía explains that she has recently moved in with her boyfriend and does not want to have children yet because they are saving to buy a house. The doctor answers "Very well, child, it's good that you think ahead, but you must remember that children are always welcome, and that you are young and can care for them well now — when you are older it will be more difficult. Tell me what method you have been using." Rosalía explains that she is using the rhythm method, but is afraid it will fail. The doctor explains to her that there are several ways of protecting herself, and rapidly lists IUDs, condoms, pills and injections before asking her which one she wants. Rosalía is confused, and has not understood many of the words the doctor has used, but is afraid to tell her so. "Which one do you suggest, Doctor?" she asks, and the doctor says she would like to examine her before making a suggestion. Rosalía takes off some of her clothing, and when the doctor moves to check her heart, she says, "So much clothing, child. Skirt on top of skirt on top of skirt. Why don't you use western clothing? That way you can save money — your traditional clothing must be very expensive and uncomfortable." Rosalía does not answer but feels increasingly uncomfortable and eager to leave. Upon completing the examination, the doctor says that Rosalía can use any method and asks her which she prefers. At that point she is nervous and confused and only says, "I'll talk to Pedro. Perhaps he will get mad at what I choose. Then I'll come back." "Very good," answers the doctor, "I'll be waiting for you to come back, and it would be good if you bring Pedro along so that we can discuss this with him." Rosalía leaves quickly, feeling that she never wants to come back. She has a bad feeling about the visit. It seemed to her as if the doctor mistreated her and ridiculed her about her clothes, and she didn't understand a thing the doctor said about methods. When she gets home she doesn't share her experience with anyone, nor does she return to the doctor. Three months later Rosalía is pregnant, and plans to travel back to the countryside to have her baby where her mother and sisters can attend to her. Story #2: "I'm Paralyzed with Anguish" Ana is in a difficult situation: Her period is a month late, and she is worried that she is pregnant. Last week she went to the pharmacy to get an injection to "regulate her menstruation," but nothing happened. She then followed the advice of a friend, whose aunt had given her some pills to take, together with strong, very hot oregano tea. Ana also made great efforts to carry heavy things, and run up and down the stairs of their apartment building. Six days after taking the pills and oregano, and after several days of intense physical effort, Ana wakes up feeling terrible. Her mother, seeing that she is pale, depressed and overcome with anguish, sits on the bed and asks Ana what is the matter. Ana explodes in tears, and finally tells her what happened, and admits that she is pregnant. Her mother also starts to cry, and asks why Ana didn't trust her enough to confide in her. "The thing to do now, Ana, is get you to the doctor. I'll help you get dressed and take you to the clinic where I go each year for my Pap test." The wait is not long, but Ana can barely walk when she is called into the consulting room. Ana hardly answers when the doctor asks what is troubling her, but he grasps the situation quickly and has her lie on the table so that he can examine her. When the doctor announces that she is suffering from an incomplete abortion, Ana starts crying again, and her mother tries to calm her while the doctor prepares the anesthesia and equipment for a D&C. When the procedure is finished and Ana is resting, the doctor invites Ana's mother to sit down and talk. He explains that the methods used by Ana are very dangerous, and that it is important for her to overcome this frightening experience, understand what happened, and to be better prepared in the future. He makes a date for an appointment with Ana the following week. Ana's mother agrees that the doctor should explain "everything" to Ana. When the girl wakes up crying, the doctor takes her hand and assures her that she will be fine, that she must go home and rest, and that he looks forward to meeting with her the following week. Story #3: "How Can I Tell Them What I Have?" In his 34 years, Martin has almost never been in a clinic. His work as a mason did not leave him much free time. His wife has always gone with her sister to prenatal visits and the births of their three children, and it was she who took the children to get vaccinated. When he enters the health center, Martin sees a series of doors marked with signs: Vaccines, Laboratory, Administration, Maternity, etc. He decides to ask at administration, although he is very worried about what exactly to ask for. Martin greets the woman behind the administration desk and asks her where he can find the office that deals with "infections." Without greeting him, the administrator says, "The visit is twelve dollars." Without having received any clarification, Martin pays the fee, receives a number and sits on a nearby bench. The whole time he is thinking frantically about how he can explain what is wrong with him, and hoping that he will be doing the explaining to a man, and not a woman nurse or doctor. A woman in native dress leaves the consulting room and nods to Martin who, like herself, is Aymara. Soon his number is called and he enters the room, where a doctor and nurse, both women, are talking about the prior patient, commenting on her poor hygiene and ignorance and expressing their doubts that she will follow through with the treatment they prescribed. They finish their conversation, and the doctor invites Martin to sit down and she asks, "What is your problem?" Martin fights his embarrassment and starts describing his symptoms, when he sees the doctor and nurse exchange a knowing look. When he has finished talking, the doctor explains that in order to know exactly what kind of infection he has, he must leave a urine sample at the laboratory for analysis. She writes out a lab order, explains that he must give the sample before eating the following morning, and makes an appointment for Martin to return a few days later for the results. Martin doesn't dare say anything — he simply nods and leaves. When he returns with his lab results, Martin must wait over an hour for his turn, and suffers an increasingly urgent need to urinate. He looks around the whole clinic, but only sees doors that say "Women," and is embarrassed to ask for the men's rest room. When he finally gets called into the consulting room, the doctor studies the lab results and writes out a prescription, explaining that Martin, as well as all his sexual partners, must take an entire course of this medicine. She also explains that he must not engage in sexual relationships for the next 15 days. When he arrives home, Martin tells his wife that the doctor has said that they both might be infected and that they both need to take the medicine. She gets very angry, accusing him of ruining the family with his infidelity and complaining about the high cost of the doctor visit and the medicine. Story #4: "Playing with Fire" Stella and Marcos are university students. A couple of months ago, Stella had a clandestine abortion and, luckily, recovered without complications. After this frightening experience, they both want to prevent another pregnancy, but are not sure what method is right for them. On a friend's advice, they go to a health center that offers numerous types of methods. When the young couple arrives at the clinic, Stella and Marcos approach the receptionist, who smiles, greets them and asks them to fill out the medical chart. When they finish, she apologizes for lack of space: two women and another couple are occupying all the chairs. The clinic is in an old house, and the reception area hardly has space for a desk in the corner. Several old magazines lie on an end table, but the lighting is too poor to read them. After a 50-minute wait, they call Stella's name. When Stella and Marcos enter the consulting room, the doctor is talking on the phone and gestures for them to take a seat. The consulting room is bigger and nicer than the waiting room; it has its own bathroom and several posters about AIDS. After a couple minutes the doctor hangs up and, smiling at them both, asks the motive of their visit. Stella takes the initiative and explains in a low voice that she recently had an abortion and does not wish to repeat it, so they want to get a sure method of birth control. She explains that they want to finish their studies and get married before having children. The smile disappears from the doctor's face and he responds intensely, "I am glad that you have come to the clinic, because a clandestine abortion is gambling with a woman's life, especially when it is poorly done. But it is even worse to play at being married and have relations when you know what can happen. You two, who seem like well-bred individuals, make mistakes as if you were uneducated. Young people today dedicate themselves to pleasure and don't think about tomorrow, or about the parents who have invested their trust in you. Returning to the point of your visit, I suggest that you choose a very secure and popular method, the Copper-T IUD. Of course there are other methods, but this is the best one for you. Stella, when was your last period?" Stella answers that she just began that day, and the doctor responds enthusiastically, "Perfect, that is the best day to introduce the IUD, because we are sure that you are not pregnant. Good, are you decided?" Stella and Marcos do not reply and the doctor suggests that they take five minutes to talk it over in the waiting room while he makes a call. The young couple walks silently to the waiting room, where Stella whispers, "It seems right that today is the day to put in the IUD, but doesn't it have side effects?" Marcos suggests, "Let's go to another doctor. This one made me feel bad -- but you decide." "He made me feel bad, too," answers Stella, "but another doctor will just be the same. We've already been through the worst here, let's just get the IUD inserted." While they are whispering, the nurse walks into the small room and overhears part of the conversation. "It's a difficult decision," she whispers to them, "but I would advise the Copper-T. I've had one in for four years with no problems." Stella asks her "what problems might I have with the Copper-T?" and she answers "None at all, dear, it's totally safe as long as you get a checkup every six months." Stella turns to Marcos with a more assured tone and says, "She's right, I will get it inserted today." The receptionist indicates that the doctor is waiting for them, and when they enter the consulting room he announces with a smile, "You've come to a decision, have you? Well let's get to it." Discussion Guide: In the story just enacted, in what way do the providers:
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