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ICPD BEYOND 2014 THEMATIC CONFERENCE ON HUMAN RIGHTS

(The Netherlands, 7-10 July 2013)

BACKGROUND PAPER

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Executive Summary Recognition of the basic rights of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children, to have the information and means to do so, and to enjoy the highest attainable standard of sexual and reproductive health, free of coercion discrimination and violence, is the touchstone of the Cairo Programme of Action (PoA). The PoA also recognizes that women and adolescent girls, especially those who live in impoverished and otherwise disadvantaged communities and circumstances, disproportionately bear the gravest costs and consequences of failure to promote and protect sexual and reproductive health and reproductive rights. Since the PoA was adopted in 1994, numerous intergovernmental forums have reaffirmed and elaborated on the ICPD commitment to universal access to sexual and reproductive health and to the promotion and protection of reproductive rights. Progress on the PoA has been reported from every region of the world. Countries have devised innovative strategies and programmes to advance the sexual and reproductive health and rights agenda. This has led to real and substantial accomplishments, including reduction in rates of new infection for HIV in many countries, an overall 50 per cent reduction in maternal mortality, and increases in the use of modern contraception. Nonetheless, the ICPD agenda remains unfinished business. Sexual and reproductive health problems represent one-third of the total global burden of disease for women between the ages of 15 and 44, and violence against women and girls remains the most frequent human rights abuse worldwide. The inequalities between and within the countries and persistent disparities between women and men and between social and ethnic groups, have inhibited progress. Full implementation of the PoA, and subsequent intergovernmental agreements, is required for the realization of human rights, especially by women and by adolescents, and also for development. Nonetheless, far too often, human rights have been underplayed or ignored altogether in designing and implementing health and population policies and services. A common result of this approach has been siloed funding and vertical interventions rather than the holistic approach, with human rights at the center, which was mandated by the Programme of Action. Outright abuses of human rights have also occurred in many countries in their delivery of sexual and reproductive health services. Further, inattention to the fundamental human rights principle of equity and equality has contributed highly skewed availability of and access to sexual and reproductive health services, in most countries. The 20-year review of the implementation of the PoA offers a key opportunity both to reaffirm the centrality of human rights protections in this landmark agenda for action and to prioritize the specific actions required to achieve a comprehensive and integrated approach to sexual and reproductive health and rights. Failure to accelerate implementation of the PoA will undermine not only health and human rights but also all efforts to reduce poverty, secure equitable social, economic and environmental development, and achieve social justice. This paper elaborates how policies and actions must and can be premised on human rights, drawing on the ICPD PoA and subsequent intergovernmental agreements, and applying the lens of equity, equality

Disclaimer: This paper was commissioned by the co-organizers of the Conference to Mr. Rajat Khosla, independent consultant and researcher. The views expressed in the paper do not necessarily represent those of the co-organizers of the Conference.

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and accountability. The paper highlights the gaps and challenges in designing and implementing human rights-based strategies to protect sexual and reproductive health and rights. It also provides examples of good practices. Incorporating the human rights-based approach into programming requires a shift in thinking, from simply meeting needs to doing so in ways that fulfill human rights. A fundamental element of a human rights-based approach is the empowerment of individuals to claim their rights to information, education and services. This requires governments to take a series of measures, such as creating an enabling legal and policy environment, including removing the many barriers that individuals face to obtaining the information, education and services needed for sexual and reproductive health and rights; ensuring participation and accountability; making special efforts to reach those who are extremely disadvantaged or marginalized or living in situations of conflict and crisis; and providing resources from both national and international sources. In addition to supporting individuals’ empowerment, governments are also obliged to ensure availability of and access to the information, comprehensive sexuality education, and quality sexual and reproductive health services necessary to achieve sexual and reproductive health and enjoy human rights.

Government actions to meet both of these sets of obligations have been widely insufficient. As a result, individuals and couples commonly lack effective access to these necessary interventions.

The paper also examines in some detail just three of the many inter-connected dimensions of sexual and reproductive health and human rights, namely: gender equality and prevention of gender based violence; women’s autonomy and reproductive rights; and sexual health, wellbeing and human rights. These analyses reveal the complex interconnectedness, as well as the common invisibility, not only of these three, but also of many other, dimensions of sexual and reproductive health and its determinants.

While the review and appraisal of the Programme of Action is a time for celebration of progress, it also is a pivotal opportunity to design and advocate for priority actions that governments, their citizens and their partners need to take to promote, protect and fulfill the human rights that are at the core of the ICPD and subsequent intergovernmental agreements on sexual and reproductive health and rights.

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Table of Contents Executive Summary ...................................................................................................... 1 1. Background and context ........................................................................................... 5 2. Human rights in the ICPD Programme of Action ........................................................ 6

2.1. Human rights based approach as defined in the Programme of Action .................... 7 3. Empowering individuals to claim their rights ............................................................. 8

3.1. Protecting agency and creating an enabling environment ........................................ 8 3.1.1. The legal and policy environment .................................................................................... 8 3.1.2. Ensuring full and equal participation ............................................................................. 11 3.1.3. Enhancing accountability ............................................................................................... 11 3.1.4. International assistance and cooperation ...................................................................... 14

3.2. Addressing barriers ........................................................................................... …….14 3.2.1. Social, political and cultural barriers .............................................................................. 15 3.2.2. Financial barriers ............................................................................................................ 16 3.2.3. Physical barriers ............................................................................................................. 17 3.2.4. Legal or statutory barriers .............................................................................................. 18 3.2.5. Age related barriers ........................................................................................................ 19 3.2.6. Sexual orientation and gender identity related barriers ................................................ 20 3.2.7. Conflict and fragility ....................................................................................................... 20

3.2.8. Multiple intersecting barriers…………………………………………………………………………………….21

4. Programme of Action and Sexual and Reproductive Health and Rights: Core Entitlements 22

4.1. Access to a package of essential sexual and reproductive health services and programmes ......................................................................................................................................... 22

4.1.1. Availability and access of comprehensive and integrated services ................................ 24 4.1.2. Quality of Services .......................................................................................................... 25

4.2. Access to sexual and reproductive health education and information ................... 26 5. Key issues for further discussion ............................................................................. 28

5.1. Gender equality and prevention of gender based violence ..................................... 28 5.1.1. Gender based violence ................................................................................................... 29

5.2. Women’s autonomy and reproductive rights .......................................................... 35 5.2.1. Family planning and contraception ................................................................................ 36 5.2.2. Safe Abortion .................................................................................................................. 38 5.2.3. Maternity care ................................................................................................................ 39

5.3. Sexual health, wellbeing and human rights ............................................................. 41 5.3.1. HIV and Sexually Transmitted Infections ........................................................................ 42 5.3.2. Adolescents’ sexual health and well-being .................................................................... 43 5.3.3. Human rights and sexuality ............................................................................................ 46

6. Using human rights for advancing the Programme of Action .................................... 48

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1. Background and context 2014 marks the twentieth anniversary of the watershed agreement adopted at the International Conference on Population and Development (ICPD), adopted by consensus by 179states. In the ICPD Programme of Action (PoA), member states of the UN for the first time recognized “reproductive rights”, and affirmed that they encompass internationally recognized human rights. Governments also agreed that gender equality, equity and women’s empowerment were crucial to effective population and development strategies.1 The PoA calls for a comprehensive approach to sexual and reproductive health and reproductive rights. It recognizes that sexual and reproductive health services and programmes, including family planning, safe abortion, maternity care, and prevention of sexually transmitted infections and HIV, must be guided by the needs of, and protect the human rights, of couples and individuals, rather than be driven by demographic targets. Since this landmark agreement, numerous intergovernmental forums have reaffirmed the ICPD commitment to universal access to sexual and reproductive health and to the promotion and protection of reproductive rights. The Beijing Declaration and Platform for Action and the Millennium Declaration are two key milestones in this process.2 The most recent recognition of the ICPD vision is expressed in the Agreed Conclusions of the 2013 Commission on Status of Women, which: Urges all governments to promote and protect the human rights of all women including their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence; and adopt and accelerate the implementation of laws, policies and programmes which protect and enable the enjoyment of all human rights and fundamental freedoms, including their reproductive rights in accordance with the PoA of the ICPD, the Beijing Platform for Action, and their review outcomes;3 The last 20 years have also seen some major advances in implementation of the ICPD PoA. Increasingly, countries have started integrating human rights in policies and programmes related to different areas of sexual and reproductive health. A number of judicial bodies at the national, regional and international levels have also adjudicated on issues related to sexual and reproductive health and have examined state obligations in relation to specific aspects of sexual and reproductive health and reproductive rights. There are been fundamental advances towards the development of technical and policy guidance to assist governments and others in the use of human rights concepts and methods to improve laws, regulations and policies related to sexual and reproductive health4.

The UN conducted quinquennial reviews of the PoA in collaboration with governments and Civil Society Organizations (CSOs) in 1999, 2005 and 2009. While highlighting the importance of the agenda and recognizing progress, all of these reviews also acknowledged that the Programme of Action remained unfinished business, particularly for women, girls and marginalized groups.5

Persistent disparities in the enjoyment of the rights enshrined in the ICPD PoA exist between women and men, between adults and

1 See, ICPD Programme of Action, para 7.3.

2 Beijing Declaration and Platform of Action, 1995; Millennium Declaration, 2000.

3 UN Commission on Status of Women, 2013, Agreed Conclusions, para 34 (b) (nn).

4 Jane Cottingham et al., Using Human Rights for Sexual and Reproductive Health, Bull World Health Organ 2010;88:551–555.

5 Angela Collet, Advocating for Full Sexual and Reproductive Health and Rights: Still an Uphill Battle, DAWN, October 2009.

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adolescents and youth, and between different social and ethnic groups across the world.6

Addressing the gaps and inequities in implementation is essential to ensure that current and new generations of women, men, adolescents and young people7 can claim and realize their sexual and reproductive health and rights. The 20-year review of the implementation of the Programme of Action, and the formulation of a new international, post-2015 development framework, offer significant opportunities both to reaffirm the importance of the landmark PoA and to accelerate access to comprehensive and integrated sexual and reproductive health services, and advancement of sexual and reproductive health and rights for all in the future.8

Human rights protections provide the foundation for universal achievement of sexual and reproductive health and human rights (see box 1). This paper elaborates how all of the required policies and actions must be premised on human rights as set out in the ICPD PoA and subsequent intergovernmental agreements. It reviews and assesses policy and programme experiences in relation to different aspects of sexual and reproductive health. Looking through the lens of equity, equality and accountability, it highlights some of the gaps and challenges in the implementation of sexual and reproductive health and rights strategies. It also highlights examples of good practices in the implementation of the PoA.

BOX 1 Why is a human rights approach necessary?

• Rights protect against coercion, discrimination, and violence. Reproductive rights include the right of individuals and couples to make decisions concerning their health and reproduction free of discrimination, coercion, and violence as expressed in human rights documents. (See ICPD, Para. 7.3.)

• Human rights are legally binding obligations, which States commit to through ratification of international human rights treaties.

• Rights require access to necessary information, education and services, as well as mechanisms for redress of abuses and violations of their rights. A human rights approach recognizes that all individuals have equal rights and entitlements to access, irrespective of who they are and where they live.

• Rights require a comprehensive approach. Since the individual’s varied and changing needs are always at the center of a human rights- based approach, comprehensive inputs appropriate to the changing circumstances of individuals are required. (See ICPD, para. 7.6.)

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Adapted from IWHC, Reproductive Health and Rights are Human Rights, 1999

2. Human rights in the ICPD Programme of Action ICPD Programme of Action starts with the recognition of the core premise of the UDHR that: All human beings are born free and equal in dignity and rights. Everyone has the right to life, liberty and security of person.10 It further reaffirms several human rights, including, amongst others gender equality, the right

6 Ana Langer, Cairo after 12 Years: successes, setbacks and challenges, Lancet Vol 368, 2006.

7 This paper uses the UN definition for adolescents and young people: Those 10-19 are adolescents; and those 15-24 are young

people. 8 Sonia Correa, Adrienne Germain, Rosalind Petchesky, Thinking Beyond ICPD+10: Where should our movement be going?,

Reproductive Health Matters, 2005; 13(25): 109-119. 9 IWHC, Reproductive Health and Rights are Human Rights, 1999.

10 Programme of Action, Principle 1.

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to the highest attainable standard of physical and mental health, the right to education and the right to adequate standard of living.11 Importantly it recognises that:”… 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 right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents.”12 While the linkages between sexual and reproductive health and human rights are well recognized, their content, as well as practical means to apply them have continued to be elaborated in international, regional and national human rights instruments and other intergovernmental agreements. Considerable conceptual progress has been made in the last several areas, most notably in Human Rights Council resolutions on maternal mortality and morbidity and sexual orientation and gender identity.13 However, in general, attention to human rights has been either weak or non-existent. Competing approaches such as “population control” ( driven by demographic targets) or “maternal and child health care”, have been emphasized rather than the ICPD package of integrated sexual and reproductive health services. Alongside financing strategies these approaches continue to drive vertical programming and policy.14

The common result has been siloed funding and interventions rather than the holistic approach, with human rights at the center, which was mandated by the Programme of Action. Further, as elaborated later in this paper (see sections 3 and 4), inattention to human rights often results in neglect of and continued discrimination against certain population groups.

2.1. Human rights based approach as defined in the Programme of Action The PoA is clear in its identification of human rights as central to population and development-related programmes. The UN Commission on Population and Development, UN Treaty Monitoring Bodies, UN Agencies, CSOs and others have unpacked the scope and content of the approach specifically in regard to sexual and reproductive health, emphasizing the indivisible, interdependent and interrelated nature of human rights.15 ICPD defines a comprehensive and interdependent agenda of human rights, such as the right to education, right to health, the right to development, freedom of expression and the right to information enable women, girls and other marginalized groups to have a voice, exercise health and reproductive choices and claim their rights. Incorporating the human rights-based approach into programming requires a shift from thinking only in terms of satisfying needs to an equal concern with fulfilling rights. The ICPD PoA and other agreements and declarations, for example, call on governments to ensure interventions and strategies:

Promote and enable equality and equity between women and men of all ages (nondiscrimination)

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Programme of Action, Principles 4, 8, and 11. 12

ICPD Programme of Action, paragraph 7.3 13

See, HRC Resolutions 11/8, 18/2 and OHCHR Report A/HRC/21/22. See also resolution 17/19 and OHCHR Report A/HRC/19/41. 14

Carol Ruiz-Austria, ICPD+15 at the crossroads, in DAWN ICPD+15 Supplement 2009. 15

The most recent affirmation of this approach can be seen in: UN OHCHR, Technical Guidance on Human Rights Based Approach to Preventable Maternal Mortality and Morbidity, A/HRC/21/22.

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Enable women and men of all ages to claim their rights (empowerment)

Include women and men, including in the young ages, who represent their communities, in the design and implementation of development initiatives (participation)

Invest in building the capacity of young people to collect and validate data, ensuring youth-led and youth-friendly monitoring and evaluation mechanisms in the design, planning and implementation of national policies and programmes.16

Make services and programmes accountable to the women and men of all ages who use them (accountability)17

A human rights-based approach thus addresses the whole policy and programming environment, and entails working for legislation that complies with international standards, effective mechanisms for law implementation, and accountability and monitoring tools. A human rights-based approach to sexual and reproductive health looks also at strategies to ensure provision of affordable, acceptable and comprehensive health services for the people, with particular focus on women and girls, and other disadvantaged sectors of the population.18

3. Empowering individuals to claim their rights The PoA recognizes that: “The empowerment and autonomy of women and the improvement of their political, social, economic and health status is a highly important end in itself. In addition, it is essential for the achievement of sustainable development”.19 A key contribution of the Programme of Action was to transform women’s reproductive capacity from an object of population control to a matter of women’s empowerment.20 Empowerment is essential to enable individuals claim their rights and also to ensure a cycle of accountability that promotes and protects their human rights.

This section highlights measures, which enable individuals to claim and realize their sexual and reproductive health and rights. The first part of the section looks at the enabling factors and the second part looks at some of the barriers that individuals face in realizing their rights.

3.1. Protecting agency and creating an enabling environment Access to education and information, to freedom of expression and assembly are intrinsic to realization of sexual and reproductive health and rights. Lack of investment in programmes to empower women and adolescents, denial of access to information and education on sexual and reproductive health, overall denial of space, particularly for young girls, to access information and express themselves remains, however, a significant barrier to the achievement of the ICPD PoA.

3.1.1. The legal and policy environment A key component of a rights based approach is a legal and policy environment that promotes and enforces reproductive rights and also gender equality in laws, practices, policies and value systems. A major gain since the Programme of Action is recognition of reproductive rights in laws and Constitutions

16

Bali Global Youth Forum Declaration, 2012. 17

Adapted from www.unfpa.org 18

See www.unfpa.org 19

Programme of Action, para 4.1. 20

http://www.un.org/womenwatch/daw/csw/shalev.htm

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(see Box 2). For example, the Constitutions of Ecuador, Nepal (interim) and Bolivia explicitly include a provision on reproductive rights. Similarly, many laws and policies, which recognize one or more aspects of reproductive rights, have been adopted since the ICPD. Another major achievement has been a series of landmark judgments at the national and international levels in relation to sexual and reproductive health, including in relation to gender discrimination and gender based violence.21

BOX 2

Key legal developments

Following the ICPD, various international and national human rights norms that protect the reproductive rights of girls and women have been adopted:

African Union adoption of the protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa (Maputo Protocol) providing broad protection for African women’s rights, including reproductive rights. (2003)

Council of Europe, Convention on preventing and combating violence against women and domestic violence (2011)

United Nations Human Rights Council adoption by consensus of the ground-breaking resolution on “Preventable Maternal Mortality, Morbidity and Human Rights.” (2009)

General Comments and concluding observations by UN Treaty Monitoring Bodies, particularly, the CEDAW Committee decisions in Alyne da Silva v. Brazil and L.C. v. Peru (2012)

CPD 45 resolution on adolescents and youth (2012) and CSW (2013) Agreed Conclusions on violence against women

National level developments

Adoption of interim constitution in Nepal that provides broad protections to women’s reproductive rights by stating that women have “the right to reproductive health and other reproductive matters.” (2007) Ground-breaking judgments by the Nepali Supreme Court in case of abortion, uterine prolapse. (2003)

Adoption of reproductive health laws in numerous countries e.g. Benin (2003), Mali (2002), and Uruguay (2009).

Colombian Constitutional Court judgment striking down the country’s total abortion ban, citing the ICPD POA to support its conclusion. (2006)

Passing of the Responsible Parenthood and Reproductive Health Act in Philippines. (2012)22

The reading down of Article 377 by the Delhi High Court resulting in decimalization of homosexuality in India. (2009)

Adoption of policy in Tamil Nadu in India, which provides free surgery for transgender people. (2010)

Liberalization of Mexico City’s abortion law. (2000)

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Nonetheless, legal and policy restrictions continue to inhibit the realization of sexual and reproductive health and rights. For instance, in a clear statement of concern, the Global Commission on HIV and Law in its report states that, “In many countries, the law (either on the books or on the streets) dehumanizes many of those at highest risk for HIV: sex workers, transgender people, men who have sex with men

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See for instance, Naz Foundation v. Govt of Delhi (Delhi High Court); Alyne da Silva v. Brazil (CEDAW Committee); L.C v. Peru (CEDAW Committee); and Ana Victoria Sánchez Villalobos and others v. Costa Rica (Inter-American Court). 22

At the time of writing this paper a case is pending in the Supreme Court in Philippines challenging the validity of the

legislation. 23

Adapted from: CRR, ICPD+15, 2009.

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(MSM), people who use drugs, prisoners and migrants. Rather than providing protection, the law renders these “key populations” all the more vulnerable to HIV.”24 In a recent report, the Office of the High Commissioner for Human Rights observes, “the criminalization of private consensual homosexual acts violates an individual’s rights to privacy and non-discrimination and constitutes a breach of international human rights law.”25 Such statements have resonance in other areas too, particularly in case of abortion services. For example, implementation of criminal laws against abortion can subject women to life-threatening situations because services are denied or unavailable or the women are imprisoned. The UN Special Rapporteur on the right to health has emphasized abortion restrictions, noting that such restrictions are often discriminatory in nature and violate the right to health by restricting access to quality goods, services and information26. The WHO Safe Abortion Guidelines (see Box 3) emphasize that laws, policies and practices that restrict access to safe abortion services can deter women from seeking care and create a “chilling effect” (suppression of actions because of fear of reprisals or penalties) for the provision of safe, legal services.27

BOX 3 Safe Abortion: Technical and Policy Guidance for Health Systems (WHO 2nd ed.) Eliminate regulatory, policy and access barriers to safe abortion services

Remove third-party authorization requirements that interfere with women’s and adolescents’ right to make decisions about reproduction and to exercise control over their bodies.

Eliminate barriers that impede women’s access to health services, such as high fees for health-care services, the requirement for preliminary authorization by spouse, parent or hospital authorities, long distances from health facilities and the absence of convenient and affordable public transport, and also ensure that the exercise of conscientious objection does not prevent women from accessing services to which they are legally entitled.

Implement a legal and/or policy framework that enables women to access abortion where the medical procedure is permitted under the law.

Another example is the final report on health in the context of the post 2015 agenda which recommends that the revision of laws that criminalize behaviors such as substance use, same-sex sexual acts among consenting adults, and sex work, and laws that criminalize or impede access to comprehensive sexuality education, modern contraceptives including emergency contraception, and safe abortion services, must be included as a matter of priority.28 However, it is not only state use of criminal laws that inhibit progress but also other measures such as third party authorization requirements, which restrict access29 These requirements violate the right to privacy and women’s access to health care on the basis of equality of men and women. Even in places

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Global Commission on HIV and Law, Risks, Rights and Health, 2012. 25

OHCHR, A/HRC/19/41, 2012. 26

Report of the UN Special Rapporteur on the right to health, 2011, A/66/254, Summary. 27

WHO, Safe Abortion: Technical and Policy Guidance for Health Systems, 2012, chapter 4. 28

The World We Want, Health in the Post-2015 Agenda: Report of the Global Thematic Consultation on Health, April 2013. See also, Bali Global Youth Forum Declaration, 2012. 29

WHO, Safe Abortion: Technical and Policy Guidance for Health Systems, 2012.

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with no formal requirements for parental or spousal consent, social and cultural norms may lead service providers to restrict young people’s access or to insist on informing parents/careers or partners.30 Access to care may also be unduly delayed by burdensome procedures of medical authorization, especially where required specialists or hospital committees are inaccessible. Laws also have a discriminatory effect on other groups, such as persons living with disabilities. Disability and related issues are often not addressed in national sexual and reproductive health policy, laws, and budgets, resulting in impediments for persons living with disabilities in realizing their human rights. Legislation and regulations affecting sexual and reproductive health must reflect the needs of persons with disabilities.

3.1.2. Ensuring full and equal participation Under international human rights law, governments have an obligation to ensure active, informed participation of individuals in decision-making that affects them, including on matters related to their health.31 The Programme of Action reaffirms this core principle in relation to sexual and reproductive health and emphasizes the need to involve those directly affected, including specifically those excluded as a result of discrimination, coercion or violence, in developing laws, policies and practices.32 The UN Committee on the Elimination of All Forms of Discrimination against Women has noted that, in general, the participation of women in government at the policy level continues to be low. Although significant progress has been made in some countries, in others women’s participation has actually declined.33 CEDAW requires state parties to ensure that women have the right to participate fully and be represented in public policy formulation in all sectors and at all levels (Article 7(b)).34

Participation of other groups in decision-making process is crucial to develop a more inclusive agenda, in particular the PoA emphasizes, adolescent participation in decision-making as essential. The recent ICPD Global Youth Forum Bali Declaration clearly outlines that young people’s participation, in particular, in all stages of decision-making and implementation of policies and programmes is a precondition of sustainable development.35 It is important to also ensure participation of persons with disabilities and ensure policies and programmes are developed with their equal and meaningful participation. Evidence shows that policies and programmes are better when persons with disabilities take part in their development, however, often that is not the case and persons with disability are not included in decision-making processes. 36

3.1.3. Enhancing accountability Establishing a cycle of accountability is intrinsic to ensuring that individuals’ agency and choice are respected, protected and fulfilled. Agency and choice are also fundamental to enable individuals to have a voice and to hold governments to account. Governments must, therefore, adopt policy, programme

30

IPPF research, to be published late 2013. 31

CEDAW, General Recommendation 24; CESCR, General Comment 14. 32

Programme of Action, principle 4. 33

UN-DESA, The World’s Women: 2010. 34

CEDAW Committee, General Recommendation 23, para. 25. 35

Commission on Population and Development, Resolution on Adolescents and Youth, CPD 45th Session, April 2012. See also Bali Global Youth Forum Declaration, 2012. 36

WHO/UNFPA, Promoting sexual and reproductive health of persons with disabilities, 2009

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and implementation frameworks based on human rights, and also monitor, review and remedy sexual and reproductive health and rights violations. Human rights accountability requires multiple forms of review and oversight, including, administrative, social, political, and legal. It also requires international accountability which requires systematic integration of information on sexual and reproductive health and rights into reports submitted to international human rights mechanisms, including regional human rights bodies, treaty monitoring bodies and for the universal periodic review of the Human Rights Council, together with implementation of recommendations from these bodies.37

The observations and interpretations made by different bodies have served the dual purpose of ensuring accountability on the one hand while also clarifying the nature and extent of States’ obligations to guarantee sexual and reproductive rights on the other. At the national level too, increased litigation and greater involvement by human rights mechanisms have contributed to promotion and protection of these rights (see Box 4).

BOX 4 Using litigation for seeking remedies Advocates in domestic courts have successfully drawn on constitutional and human rights law to argue that the State is not fulfilling its legal obligations to prevent maternal mortality and morbidity. In the 2010 decision of Laxmi Mandal v Deen Dayal Hari Nager Hospital & Ors, the Delhi High Court recognized a constitutionally protected right to maternal health care and ordered compensation for human rights violations experienced by two impoverished women who died during childbirth. Similarly, in Nepal is the first case to be decided by a national supreme court that holds a government accountable for failing to ensure the affordability of abortion services, and instructs the government to take steps to guarantee that no woman is denied an abortion solely on financial grounds The Supreme Court’s decision is monumental in its unequivocal recognition of abortion as a woman’s fundamental right and its delineation of states’ positive obligations to ensure this right. Litigation has been effectively used at the international level as well. For example in case of Alyne da Silva Pimentel Teixeira who died of postpartum hemorrhage following the stillbirth of a 27-week-old fetus on November 16, 2002 in Rio de Janeiro, Brazil. Her death led in 2011 to the first decision of an international treaty body holding a government accountable for a preventable maternal death. In the first ever decision on the issue of maternal mortality, CEDAW Committee found Brazil in violation of its human rights obligations and ordered government to take steps to improve access to maternity services and provide compensation to the family of Alyne.

For example, the Kenya National Commission on Human Rights’ inquiry into sexual and reproductive health and rights has been instrumental in enhancing monitoring and accountability. The Commission made concrete recommendations for removing barriers to the realization of women’s right to sexual and reproductive health, including improving access to contraceptive information and services, maternal healthcare, and safe and legal abortion, and protecting the sexual and reproductive health rights of

37

OHCHR, Technical Guidance on the Application of a Human Rights-based Approach to Implementation of Policies and Programmes to Reduce Preventable Maternal Mortality and Morbidity, A/HRC/21/22.

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vulnerable or marginalized groups.38 New methodologies based on a human rights-based approach, such as maternal death audits, have also been implemented in many countries (see Box 5).

BOX 5 Maternal Death Reviews (MDRs): the Application of the Human Rights Principle Accountability in Eastern and Southern Africa Since 2003 African Ministries of Health in Eastern and Southern Africa have worked towards institutionalization of MDRs

39. The development of national policies and guidelines for MDRs by countries has improved from 35 per cent

in 2007 to 65% in 2010, including Comoros, Lesotho, Malawi, Namibia, Rwanda, and Uganda. A review of the Beyond the Numbers’ methodologies in the Eastern and Southern Africa showed that maternal deaths are a notifiable condition in 65 per cent of countries in the region. By 2010, 50 per cent of countries had set up national committees to plan, coordinate and implement MDR activities. This has proved vital in improving monitoring of maternal deaths and near misses and has helped governments in the respective countries plan interventions better

40.

All victims of human rights violations have a right to an effective remedy and to reparations. To ensure the effective use of remedies, the State must systematically raise awareness about the applicability of claims relating to sexual and reproductive health and rights among lawyers, judges and the public, and provide adequate funding for accountability mechanisms. According to the UN Committee on Economic, Social and Cultural Rights, any victim of a violation of the right to health should have access to effective judicial or other appropriate remedies at both national and international levels.41 The Committee has also stated that national ombudsmen, human rights commissions, consumer forums, patients’ rights associations or similar institutions should address violations of the right to health.42 However, many countries do not have effective structures for filing complaints when sexual and reproductive health information and services are denied.

As the ICPD approaches the 20th year mark, the international community has the opportunity to address serious gaps in accountability. Establishing accountability systems, rooted in human rights principles and participatory, transparent processes is a human rights obligation. Particular attention should be paid to equity in access to services and rights protections for the poorest and most excluded sectors of society, as well as their participation in decision making.43 Monitoring and accountability in the context of sexual and reproductive health are seriously compromised by significant gaps in data, both at the national and international levels. There are particular gaps in information around issues that are considered sensitive, or that carry social stigma, or that are treated as criminal offences, such as access to abortion information and services. For young people, data that exist are skewed towards married women ages 15-49, leaving out those who are not

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Kenya National Commission On Human Rights, Realising Sexual And Reproductive Health Rights In Kenya: A Myth Or A Reality?: A Report Of The Public Inquiry Into Violations Of Sexual And Reproductive Health Rights In Kenya (2012), available at http://www.knchr.org/Portals/0/Reports/Final%20Report_%20Sexual_Reprodutcive_health.pdf. 39

WHO “Beyond the Numbers”: http://www.who.int/making_pregnancy_safer/documents/9241591838/en/index.html 40

UNFPA, Submission to the OHCHR report on technical guidance on human rights based approach to maternal mortality, 2012. 41

UN Committee on Economic, Social and Cultural Rights (CESCR) General Comment 14, para. 59. 42

CESCR General Comment 14, para. 59. 43

ICPD-HLTF, Rights, Dignity and Health for All: Policy Recommendations for ICPD Beyond 2014, 2013.

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older, younger and not married or in union. Significant gaps exist on young men and boys, on adolescent girls, and on population sub-groups, and on their access to sexuality education and SRH services.44As reaffirmed by the ICPD Global Youth Forum Bali Declaration, there is an urgent need to collect statistics and data not just on health interventions, but also on other sexual and reproductive health issues such as sexual coercion and violence, female genital mutilation/cutting, early and forced marriage, and use of safe and unsafe abortion. Such information is crucial if governments are to assess accurately the extent to which rights are being denied and target interventions accordingly. Disaggregating data by sex, ethnicity, by relevant age groups (10-14, 15-19, 20-24), wealth quintiles, and place of residence helps ensure that discrimination and exclusion are not masked by national averages.

3.1.4. International assistance and cooperation All development partners should contribute to the creation of a social and international order in which human rights, including sexual and reproductive health and rights, can be realized by everyone. Human rights obligations with regard to advancing global health, including sexual and reproductive health, call for shared approaches and systems of collective responsibility.45

The Special Rapporteur on the right to health has emphasized that: “The right to health gives rise to a responsibility of international assistance and cooperation on developed States to assist developing States to realize the right to health. Developed States should support developing States’ efforts to reduce maternal mortality. This responsibility is reflected in Millennium Development Goal 8, which is a commitment to develop a global partnership for development.”

All development partners should ensure that their development policies are rights-based, which includes refraining from doing harm to individual’s sexual and reproductive health. Also, donor countries are obligated to protect women’s sexual and reproductive health rights by effectively regulating private actors over which they exercise control.46 Human Rights obligations require development partners to make their development assistance predictable, harmonized and to provide transparent economic assistance.47 Agreement should be reached with national Governments on consolidated budget support as well as reporting of “externally funded expenditures”.48

3.2. Addressing barriers The Programme of Action recognized that governments should: “make it easier for couples and individuals to take responsibility for their own reproductive health by removing unnecessary legal, medical, clinical and regulatory barriers”.49 This has also been reaffirmed in various other documents, most recently in the UN Secretary-General’s Global Strategy on Women’s and Children’s Health. However, women, adolescents and marginalized groups continue to face multiple barriers to realizing their rights. These barriers are examined below.

44

Guttmacher Institute and IPPF, Demystifying Data: A Guide to Using Evidence to Improve Young People’s Sexual Health and Rights, 2013 45

OHCHR, Technical Guidance on the Application of a Human Rights-based Approach to Implementation of Policies and Programmes to Reduce Preventable Maternal Mortality and Morbidity, A/HRC/21/22. 46

E/C.12/2000/4, para. 39; A/60/348, para. 62. 47

OECD, the Paris Agreement and Accra Agenda. See also the Busan Partnership for Effective Development Cooperation, outcome of the Fourth High-level Forum on Aid Effectiveness, 2011. Available from www.aideffectiveness.org/busanhlf4/images/stories/hlf4/OUTCOME_DOCUMENT_- _FINAL_EN.pdf. 48

WHO, Keeping Promises, Measuring Results, p. 2. 49

Programme of Action, para 7.20

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3.2.1. Social, political and cultural barriers Social norms and cultural factors often act as a barrier in individuals’ realisation of their human rights in relation to sexual and reproductive health. Individuals and groups are also denied access to programmes and services on grounds of political belief or membership. Notions of religion and morality and personal convictions of health care providers have been shown to inhibit utilization and sometimes provision of essential, even life-saving, interventions. Providers in Uganda and Argentina reported ideological constraints to the provision of certain contraceptive methods.50 Providers in South Africa also reported struggling with ethical dilemmas related to the provision of reproductive health services and information to people living with HIV, and, in a separate study, the provision of safe and legal services for induced abortion.51 In this regard, human rights law provide clear guidance according to which providers’ exercise of their rights to freedom of thought, conscience, and religion must not jeopardise their patients’ health.52 The European Court of Human Rights elaborated this standard in a case in which two pharmacists in France were found liable for refusing to provide doctor- prescribed contraceptives to several women on religious grounds.53 The court explained that as long as the sale of contraceptives is legal and occurs by medical prescription only in pharmacies, pharmacists “cannot impose their religious beliefs on others as a justification for their refusal to sell such products, ... [They] can manifest those beliefs in many ways outside the professional sphere”.54 These decisions are consistent with the Ethical Guidelines of the International Federation of Gynaecology and Obstetrics.55 Individuals who object on grounds of conscience to providing contraceptives must refer patients to willing providers, and provide services where they have a monopoly and in emergency situations.56 Certain groups are especially stigmatized and fearful of the judgment and treatment they might receive. This includes amongst others adolescents, unmarried young women and mothers, migrants, minorities, as well as sex workers, people living with HIV, and men who have sex with men. Specific efforts are needed to reach these groups if services are to be truly inclusive and effective.57 Another group that faces severe social and cultural barriers in their access to health care generally including sexual and reproductive health are indigenous peoples. Indicators of poverty as well as maternal and infant mortality are systematically higher amid indigenous peoples than non-indigenous populations.58 Recent studies have shown the multifaceted nature of violence faced by indigenous

50

Mugisha JF, Reynolds H. Provider perspectives on barriers to family planning quality in Uganda: a qualitative study. Journal of Family Planning and Reproductive Health Care, 2008, 34:37–41. 51

Harries J, Cooper D, Myer L et al. Policy maker and health care provider perspectives on reproductive decision-making amongst HIV-infected individuals in South Africa. BMC Public Health, 2007, 7:282. 52

Jane Cottingham, Adrienne Germain, Paul Hunt, Use of Human Rights to Meet the Unmet Need for Family Planning, Lancet 2012, July 14 ; 380(9837): 172-180. 53

Pichon and Sajous vs France. European Court of Human Rights, application no. 49853/99. Admissibility decision. Oct 2, 2001. 54

Pichon and Sajous vs France. European Court of Human Rights, application no. 49853/99. Admissibility decision. Oct 2, 2001. 55

FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health. Ethical guidelines on conscientious objection. Int J Gynaecol Obstet 2006; 92: 333–34. 56

Jane Cottingham, Adrienne Germain, Paul Hunt, Use of Human Rights to Meet the Unmet Need for Family Planning, Lancet 2012, July 14 ; 380(9837): 172-180. 57

ICPD-HLTF, Rights, Dignity and Health for All: Policy Recommendations for ICPD Beyond 2014, 2013. 58

UNFPA, Promoting Equality, Respecting Diversity, 2010.

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women’s and girls’ and the impact it has on the realization of their sexual and reproductive health and right.59 Among indigenous peoples, women face triple discrimination linked to gender, ethnic and socio-economic factors.

In the last years this situation has started to change and empowered indigenous women leaders, organizations and networks are playing an influential role. Policies that support indigenous women's reproductive health rights lead to the development of "intercultural" approaches and reproductive health programmes and services that avert maternal and newborn deaths and morbidities (see Box 6).

BOX 6

Bolivia: SAFCI Model

The family, community and intercultural healthcare model (SAFCI) created by Supreme Decree No. 29601 of July 11th 2008, currently in effect, places great emphasis on health promotion in the community and considers access to institutional care to be an urgent need. The four key principles of SAFCI are community participation; intersectionality; interculturality and integrated and holistic health services.

As a result of this process, culturally pertinent health-care procedures regarding sexually transmitted infections, uterine cervical cancer and family planning were developed for the SAFCI. These procedures are being implemented throughout the country, leading to positive health outcomes.

60

3.2.2. Financial barriers Poverty acts as one of the major barriers that curtail access to sexual and reproductive health services. The Committee on Economic, Social and Cultural Rights has commented generally on the need for affordable access to health services, goods and facilities, including affordable sexual and reproductive health services.61 Where governments have taken steps to ensure affordability of services the demand for services has increased, leading to better health outcomes. (see Box 7)

BOX 7

Ecuador: Free maternity law

Ecuador’s Free Maternity Law guarantees the right to free, high-quality care for pregnant women during pregnancy, birth and the post-partum period. A total of 54 services related to maternity, childcare and reproductive and sexual health are covered. The National Council on Women, a government agency, is working to establish User Committees throughout the country. These groups, whose members are elected by their communities, monitor public health facilities’ compliance with the Law and also educate providers and community members about what the Law encompasses. Eleven User Committees were known to exist in 2001. In 2008, 89 User Committees in 43 cantons in 13 provinces are registered with the National Council on Women. Understanding and internalizing the human rights vision into their thinking, behavior and thus programmes has been a lengthy but vital process, as it serves as the foundation that motivates and guides their actions.

59

UNICEF et al., Breaking the Silence on Violence Against Indigenous Girls, Adolescents and Young Women, 2013. 60

UNFPA, Promoting equality, recognizing diversity, 2010. 61

See, e.g., Armenia, 08/12/1999, U.N. Doc. E/C.12/1/Add.39, 15; Poland, 19/12/2002, U.N. Doc. E/C.12/1/Add.82, 28; Poland, 16/06/1998, U.N. Doc. E/C.12/1/Add.26, 12.

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A key element in the inequities and inequalities protecting sexual and reproductive rights are States’ decisions to either fund, or to restrict funding, for sexual and reproductive health services. For example, the exclusion of funding for modern contraceptives in Manila City under the pre-2012 legislation disproportionately affected poor women who rely on the public health system. Similarly, the lack of insurance coverage for hormonal contraceptives in Slovakia meant that women who cannot afford to pay the out-of-pocket costs have been unable to access hormonal contraceptives. Conversely, in Mexico City, the availability of abortion services at no cost has positively enhanced equity in access to such services.62 Art 2.1. of the ICESCR requires states parties to take steps to the maximum of their available resources including those available through international cooperation and assistance. In recent years, the requirement to use “maximum available resources” has reemerged. The recent financial crisis and push for budget cuts and austerity measures that came in its aftermath have had multiple impacts on the provision of health services in general, and sexual and reproductive health services in particular. This has a direct impact on out-of-pocket spending by households and has gendered effects, especially in regions such as South Asia, where household spending for health is biased against girls and women. 63

Another barrier affecting availability of many sexual and reproductive health commodities is market failures, where return on investment is not sufficiently high to create incentives for manufacturers to enter the market or sustain sufficient levels of production. For example, several studies have identified magnesium sulfate as the most effective medicine for preventing and treating the deadly seizures caused by high blood pressure during pregnancy (pre-eclampsia and eclampsia); yet, according to a study, “magnesium sulfate is rarely globally manufactured because its low cost leaves little profit-based incentive for pharmaceutical companies to produce it”.64 The lack of global supply in turn limits distribution and availability.65

3.2.2. Physical barriers Studies have identified two main geographical barriers to access: the poorer health infrastructure in rural areas compared to urban ones and the lack of health care providers in these areas. For those living in remote areas, health facilities are often not available and transportation to health services outside the settlements is either too expensive for many people, or simply unavailable. Geographical inequalities in access to health care are common barriers for many in different countries. Addressing these barriers helps to ensure equal and timely access for individuals and groups. (see Box 8)

The Committee on Economic, Social and Cultural Rights, requires states to ensure that health facilities, goods and services are within safe physical reach for all sections of the population.66 Critically, CEDAW’s Article 14 recognizes that special and prioritized efforts must be made to reach the disadvantaged such as rural women.67

62

See Guttmacher Institute, Abortion Worldwide a Decade of Practice, 2009. See also, UNFPA, By Choice and Not by Chance, 2012. 63

Gita Sen, SRHR and Global Finance: Crisis or Opportunity, ICPD+15 Supplement DAWN, 2009. 64

Every Women Every Child, UN Commission on Life Saving Commodities for Women and Children, Final Report 2012. 65

Every Women Every Child, UN Commission on Life Saving Commodities for Women and Children, Final Report 2012. 66

CESCR, General Comment 14, para 12. 67

Mariana Durano, Politicise CEDAW Article 14(a), DAWN, 2012.

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BOX 8 Opening doors to family planning in remote, ethnic households of Laos PDR: Community-based distribution agents

The Government of Laos in 2006, along with partners, launched an initiative to provide client-friendly family planning services in culturally appropriate ways to remote communities, working through community-based distribution agents. In Laos, 80 per cent of the population lives in rural areas, mostly dispersed in small villages that are often difficult to access. Indigenous ethnic communities comprise 40 per cent of the population. These communities have limited knowledge about family planning and access to reproductive health services is almost non-existent. The initiative clearly shows that, when client-friendly and free-of-charge family planning services are provided to communities that cannot afford to access such services, remote and ethnic populations become more receptive to using them. When community agents are involved in implementing and monitoring of services, in-built accountability systems are developed. Overall, the family planning uptake in delivery areas has gone up from 12 per cent in 2007 to 45.42 per cent in 2011. Contraceptive prevalence rate has increased sharply in many of these remote areas. It reached 60 per cent in March 2012 from a baseline of 13.2 per cent in 2006 in the Ah Gnor catchment area, Taoi District, Saravan Province.

68

Slum dwellers' living in urban areas also face similar challenges. Their access to sexual and reproductive health is affected by the social and economic conditions that manifest in different forms of deprivation, including inaccessible or poor quality sexual and reproductive health services in the areas where they live.69

Certain groups of individual, such as those with physical or mental disabilities face particular challenges in their attempts to access health care services in general and sexual and reproductive health services in particular. In fact, persons with disabilities may actually have greater needs for sexual and reproductive health education and care than persons without disabilities due to their increased vulnerability to abuse.70 However, because of the lack of physical access, the lack of disability-related technical and human support, stigma and discrimination, sexual and reproductive health services and information are

often inaccessible to them.71

3.2.3. Legal or statutory barriers A key barrier to sexual and reproductive health services faced by many takes the form of legal or statutory requirements, which inhibit access. One area where such restrictions have devastating impact is on access to safe abortion.72 The World Health Organization has noted that: “the more restrictive legislation on abortion [is], the more likely abortion [is] to be unsafe and to result in death.”73 In spite of

68

UNFPA, Global Programme to Enhance Reproductive Health Commodity Security, 2011. 69

See: Safe and Friendly Cities for All: A joint UNICEF, UN-Women and UN-Habitat initiative 70

WHO/UNFPA, Promoting sexual and reproductive health of persons with disabilities, 2009 71

UNFPA, Emerging Issues: Sexual and Reproductive Health of Persons With Disabilities, 2007. 72

WHO, Safe Abortion Guidelines, 2012. 73

UN Committee on Economic Social and Cultural Rights, Day of General Discussion on the Right to Sexual and Reproductive Health, 26 November 2010, comments by WHO, para. 55.

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this clear warning, a few governments ban all abortions in all circumstances. The vast majority of governments allow abortion on request, or to save the life of the women and for at least one other condition such as fetal anomaly, or to safeguard the woman’s health. As recognized in the 1999 Key Actions for Further Implementation, in all cases where abortion is not against the law it must be safe.74 The fundamental human rights to life and to security of the person, as well as freedom from cruel and inhumane treatment, and from discrimination, among others, means that unnecessary restrictions on abortion should be removed and governments should provide access to abortion services, both as a public health imperative and as a matter of human rights protection.75

Laws that criminalize same sex consensual activity and that require service providers to report known offenders have the effect of barring LGBT individuals from health services, and, in many countries, are a serious barrier for transgender and intersex people to access services.76 In different regions around the world, particularly in Africa and Asia and the Middle East numerous countries have laws criminalizing homosexuality.77 Studies have shown that this has resulted in a range of human rights violations, from denial of health services and freedom of association to harassment, violence against and murder of LGBTI individuals.78 Numerous instances of threats and harassment against human rights defenders working on sexual and reproductive health and rights have been reported from all around the world. Organizations and individuals working on LGBTI issues, abortion, family planning services and other are

often attacked and face reprisals for their efforts to promote and protect these rights.79

3.2.5. Age related barriers The ICPD PoA, UN Treaty Monitoring Bodies, the Commission on Population and Development and others have clearly recognised that, unequal access by adolescents to sexual and reproductive health information and services amounts to discrimination. Adolescents often avoid seeking health care for fear of being chastised, stigmatized, or punished for sexual involvement.80 Adolescents can also face barriers to sexual and reproductive health services because laws and policies which restrict access on the basis of age, or subject such access to third party authorization. Unmarried young women and adolescent girls in particular face significant obstacles.

Also pregnant adolescents are often deprived of their right to education. In that regard, the ICPD Global Survey has found that 82% of countries report commitments to “ensuring equal access of girls to education at all levels”, and 80.5% of countries are committed to “keeping more girls and adolescents in secondary school”. However, there is a notable fall off in government commitments to girls education when the topic is “facilitating school completion for pregnant girls”, with only 39.7% of all countries committed to such a policy. By region, it is only in the Americas that commitment to this issue is

74

Key Actions for Further Implementation (1999), Para 63 (iii). 75

CRR, Whose Right to Life, 2012; Committee Against Torture, CAT/C/NIC/CO/1; Report of UN Special Rapporteur on Right to Health, A/66/254. 76

OHCHR Report, A/HRC/19/41, 2012. 77

LP Taborahy (2012). State-sponsored Homophobia: A world survey of laws criminalising same-sex sexual acts between consenting adults. Brussels, Belgium: The International Lesbian, Gay, Bisexual, Trans and Intersex Association. Retrieved from (http:// old.ilga.org/Statehomophobia/ILGA_State_ Sponsored_Homophobia_2012.pdf). 78

(Homophobia and punitive laws continue to threaten HIV responses and human rights 2012) http://www.unaids.org/en/resources/presscentre/featurestories/2012/august/20120828punitivelaws/ 79

http://hrbrief.org/2013/03/situation-of-defenders-of-sexual-and-reproductive-rights-in-colombia/ ; Report of the Special Rapporteur on Human Rights Defenders, A/HRC/15/24, 2012. 80

L. Bearinger et al. Global Perspectives on Sexual and Reproductive Health of Adolescents, Lancet 2007; 369: 1220–31.

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substantial, with 66.7% of governments reporting policies, budgets and programs; in Europe and Asia only 29.2% and 21.1% of countries, respectively, report commitments to this issue.81 A systematic review of interventions to increase access to sexual and reproductive health services by adolescents in developing countries indicates that training service providers; making changes to the facilities and informing adolescents and community ‘gatekeepers’ enhances access.82 These issues are elaborated chapters 4 and 5 of this paper.

3.2.6. Sexual orientation and gender identity related barriers Gender stereotypes, prejudices and expected roles, often create obstacles to the equal fulfillment of sexual and reproductive health and rights. Governments are required to ensure that a person’s gender identity or sexual orientation is not a barrier to realizing human rights. However, individuals are often denied access to services, or face barriers based on sexual orientation and gender identity.

The impact on the health and rights of people marginalized on the basis of their sexuality and gender identity, particularly transgender people is severe. 83 Male and female doctors refuse to examine them. Transgender patients can be mocked and ridiculed by hospital staff, or kept waiting longer than other patients. Some seeking treatment for an STI in hospitals have been advised to stop or change their sexual behavior rather than just receiving treatment for their infection.84 UN Treaty Bodies and special procedures have expressed concern about abuse and mistreatment of lesbian, gay, bisexual, transgender and intersex individuals by health service providers.85 Homophobic, sexist and transphobic practices and attitudes on the part of health care institutions and personnel in some cases deter lesbian, gay, bisexual, transgender and intersex people from seeking services. This, in

turn, has a negative impact on efforts to tackle health concerns, including HIV/AIDS.86

3.2.7. Conflict and fragility Armed conflict and displacement have a profound negative impact on the sexual and reproductive health of women, men and adolescents and often act as barriers to individuals’ realization of their human rights. Poverty, loss of livelihood, disruption of services, breakdown of social support systems

81

The UNFPA, ICPD beyond 2014 Global Survey (Hereinafter ‘ICPD Global Survey) was conducted amongst member States in

2012 as part of the ICPD beyond 2014 Global Review process. The survey was completed by 176 member States, representing all regions. ICPD Global Survey findings presented in this paper are to be considered preliminary, as the analysis of the Global Survey data is ongoing. 82

Amy J Kesterton and Meena Cabral de Mello, Generating Demand and Community Support for Sexual and Reproductive Health Services for Young People: A Review of Literature and Programmes, Reproductive Health 2010, 7:25. 83

Neha Sood, “Transgender People’s Access to Sexual Health and Rights: A Study of Law and Policy in 12 Asian Countries.” 2010. http://arrow.org.my/images/publications/ICPD+15/CaseStudies/Transgender%20People%E2%80%99s%20Access%20to%20Sexual%20Health%20and%20Rights.pdf 84

OHCHR, Born Free and Equal, 2012. 85

Report of UN Special Rapporteur on torture and other cruel, inhuman and degrading treatment, A/HRC/22/53, 2013; see also Concluding observations of the Committee on the Elimination of Discrimination against Women on Panama (CEDAW/C/PAN/CO/7), at para. 22; see also, Germany (CEDAW/C/DEU/CO/6), at paras. 61-62; Argentina (CEDAW/C/ARG/CO/6), at paras. 43-44; South Africa (CEDAW/C/ZAF/CO/4), at paras. 39-40; Kyrgyzstan (A/54/38, 20), at para. 128; Concluding observations of the Human Rights Committee on Kuwait (CCPR/C/KWT/CO/2), at para. 30; Concluding observations of the Committee on Economic, Social and Cultural Rights on Germany (E/C.12/ DEU/CO/5), at para. 26. 86

Amnesty International, Realizing Sexual and Reproductive Rights, 2012.

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and acts of violence combine to destroy health.87 Human rights require for comprehensive sexual and reproductive health care to be made available to refugees, displaced persons and populations affected by conflict. However, the response available is often inappropriate.

Sexual and reproductive health care should be available in emergency situations and be based on the needs and expressed demands of refugees, particularly women. Care should be provided with full respect for the various religious and ethical values and cultural backgrounds of the refugees, while also conforming with universally recognized international human rights. The often-inadequate response to these needs, in situations of conflict and fragility, acts as barrier in individuals’ realization of their sexual and reproductive health and rights.

3.2.8. Multiple-intersecting barriers Often many of these barriers overlap each other and some individuals or groups of individuals face a multitude of barriers, for example women belonging to an ethnic or religious indigenous groups, sex workers or transgender individuals. Such multiple and intersecting barriers have a unique and specific impact on individuals’ relations of their human rights. Some groups of women, in addition to suffering from discrimination directed against them as women, also experience multiple forms of discrimination based on race, ethnic or religious identity, disability, age, class, caste or other factors. However, many countries fail to recognize the existence and impact of intersecting discrimination. As a result, the experiences and needs of women with multiple disadvantages are not integrated into national strategies to combat gender inequality and racial discrimination, further entrenching the discrimination and disadvantage they face.88

By way of illustration the ICPD Global Survey found that, despite 8 out of every 10 countries are committed “to increasing access to comprehensive sexual and reproductive health services for women” (81.6%) and “adolescents” (78.3%), however, this percentage decreases in the case of “persons with disabilities” (55.3%) and “indigenous people and cultural minorities” (61.5%). These intersecting and mutually reinforcing inequalities are often rooted in historical relationships, and continue to be reproduced in different areas. For instance, in many parts of the world indigenous peoples are invisible, either because national statistics systems do not disaggregate information, or simply because their indigenous identity is not recognized. Where data is available, indigenous peoples usually lag behind in most economic and social indicators whether income, poverty, nutrition, education, health including sexual and reproductive health and other health challenges. Indigenous women are highly vulnerable to HIV/AIDS with economic, social and sex exploitation as contributing factors, although here too there is a serious gap in reliable data on sexually transmitted infections and

HIV/AIDS.89

87

Inter-Agency Manual on Reproductive Health in Humanitarian Settings, 2010. 88

CEDAW, General Recommendation 25; CESCR General Comment, 16. 89

UNFPA, Twelfth session permanent forum on indigenous issues, May 2013.

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4. Programme of Action and Sexual and Reproductive Health and Rights: Core Entitlements While the previous section highlighted the key requirements for empowering individuals to claim their sexual and reproductive health and rights, this section identifies the entitlements at the core of the PoA.

UN Treaty Bodies, Commission on Population and Development and others highlight the imperative to incorporate a human rights based approach in making sexual and reproductive health services available, accessible, acceptable, affordable and of good quality. The CEDAW Committee further reinforces states parties’ obligations to protect women’s rights relating to health, and their obligation to “refrain from obstructing action taken by women in pursuit of their health goals.” Key components of this guarantee, discussed in this section, include access to a package of essential sexual and reproductive health services and programmes and comprehensive sexuality education.

4.1. Access to a package of essential sexual and reproductive health services and programmes Considerable progress has been made over the last twenty years, in every region of the world, which is evident from an overall fifty percent reduction in maternal mortality rates in many regions, overall reduction of new HIV infection rates and increases in antenatal coverage in many regions. Nonetheless, persistent challenges remain to improve the quality and integration of sexual and reproductive health services, counseling, and information for women and adolescent girls, in ways that respect human rights, and emphasize equity and respect for diversity. 90

Sexual and reproductive health services are defined by the Programme of Action to include the following: gynecological care, all forms of safe and effective contraception; safe abortion where legal; post abortion care; maternity care, and prevention; timely diagnosis and treatment of sexually transmitted infections, including HIV breast and reproductive cancers, and infertility. It also includes discouragement of harmful practices. The PoA recommends that these services should be integrated, including through effective referral, and tailored to women’s needs throughout the life cycle. They must be provided without coercion and at a level of quality that meets human rights standards. Accountability for these must be built into programmes and their monitoring and evaluation. 91 Recent guidance developed by the OHCHR in relation to maternal mortality and morbidity provides an indication of what is required (see Box 9).

BOX 9

OHCHR technical guidance on application of a human rights based approach to maternal mortality and morbidity

The Technical Guidance developed in response to request from the UN Human Rights Council in resolution 18/2 is aimed at assisting policymakers in improving women’s health and rights by providing guidance on implementing policies and programmes to reduce maternal mortality and morbidity in accordance with human rights standards. It highlights the human rights implications for multiple actors in the policymaking, implementation and review cycle, as well as the need for robust enforcement mechanisms and international assistance and cooperation.

90

Prof Gita Sen, Special Panel Presentation: Status of the ICPD Agenda: the Present, 5th

IPC on ICPD, 2012. 91

Prof Gita Sen, Special Panel Presentation: Status of the ICPD Agenda: the Present, 5th

IPC on ICPD, 2012.

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The Guidance provides policy makers with a step-by-step guide for planning and budgeting. Based on a human rights-based approach guidance develops a multi-sectoral approach to economic and social planning and budgeting, including, at a minimum, coordination among a variety of Government ministries and departments, as well as with other key actors, such as the private sector, development partners and civil society. The Guidance also makes specific recommendations in relation to assessing accountability gaps within and beyond the health sector through a situational analysis and how to address them.

Source: OHCHR, Report of the High Commissioner on Human Rights, A/HRC/21/22, 2012.

Integrated sexual and reproductive health services through the primary health care system remain a distant reality. 92 Sexual and reproductive health services are commonly fragmented, delivered in ‘silos’ for family planning, maternal health, or HIV care. This adversely affects individuals and couples who need holistic, convenient ‘one stop’ access for their basic information and health needs. It also undermines health system effectiveness and efficiencies: Research shows that integrated services—in addition to improving health outcomes--can introduce cost-saving measures and encourage better use

of health services93 (see box 10) BOX 10

Providing integrated services to sex workers in Kenya

Sex workers in Kenya often do not use mainstream health care services because of stigma and the criminalization of sex work in Kenya. To address this situation, Alliance Linking Organization KANCO has set up a centre to provide health services to sex workers. The services offered include: information; condom education and provision; family planning; HIV testing and counseling; STI screening and management; opportunistic infection management; referral for ART; tuberculosis screening and referral; PAP smears for cervical cancer; breast examination; and group empowerment activities.

Up to 300 sex workers now access services. Support group have been established for people living with HIV and self-help groups have been set up to develop income-generating activities. Sex workers report that they have reduced their risk practices and there is greater uptake of HIV testing and other health services. Sex workers also refer their regular clients and partners for STI and HIV services at the centre.

A key piece of learning from the programme has been that service delivery has to be flexible and adaptable as sex workers are very mobile and have unpredictable working hours. Programmes must also have medical, psychosocial and behavioral components, and friendly, non-judgmental attitudes among staff are essential.

Source: International HIV/AIDS Alliance: Integration of HIV and Sexual and Reproductive health and Rights

One critical area of gap exists around access to critical services by women and girls who are victims of gender based violence. In many countries provision for psychosocial support and mental health counseling, and treatment of physical injuries; post-rape care, including post-exposure prophylactic for HIV prevention, emergency contraception does not exist despite global prevalence of violence towards women and girls.

92

ICPD-HLTF, Rights, Dignity and Health for All: Policy Recommendations for ICPD Beyond 2014, 2013. 93

See IWHC (2012), Pathways to the Integration of Sexual and Reproductive Health Services: Policies, Programs, Practices and Sexual & Reproductive Health & Rights: What does an essential package of policies and programs look like? (International Women’s Health Coalition: New York) available at: http://www.iwhc.org/. See also: WHO, UNFPA, UNAIDS, IPPF and UCSF (2009). Sexual & Reproductive Health and HIV Linkages: Evidence Review and Recommendations. Available at: http://www.unfpa.org/public/publications/pid/1341

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UN Treaty Bodies, Commission on Population and Development and others highlight the imperative to incorporate a human rights based approach in making sexual and reproductive health services available, accessible, acceptable, affordable and of good quality. The CEDAW Committee further reinforces states parties’ obligations to protect women’s rights relating to health, and their obligation to “refrain from obstructing action taken by women in pursuit of their health goals.” Key components of this guarantee include:

4.1.1. Availability and access of comprehensive and integrated services CEDAW Committee calls on governments to take action to address all aspects of health care for women and girls, including access to contraception, family planning resources, and treatment for HIV/AIDS.94 The design, organization and coordination of the components of the health system should be guided by fundamental human rights principles, including non-discrimination/equality, transparency, participation and accountability.95 This has been emphasized by other Treaty Bodies as well, and they have underscored the need for states parties to provide the full range of high-quality and affordable health care, including sexual and reproductive services.96 For numerous reasons, sexual and reproductive health services desperately needed by women and girls are often not available or accessible, especially as an integrated package. They may not be seen as a priority by governments. Experience shows that, even where governments have developed programmes and allocated resources to reproductive health, the impact has often been limited because they have not addressed the structural barriers that prevent women getting access to these services, including underlying discrimination and inequality. For example, health services are often concentrated in more affluent communities or in urban areas and women living in others areas have significantly different health outcomes. Human rights violations, such as gender-based violence, which includes early or forced marriage, and women’s lack of control over decisions to use sexual and reproductive health services, are also critical obstacles to women’s and girls’ health.97

The limited availability and/or affordability of the basic underpinnings of quality sexual and reproductive health services are still a major challenge in many countries. Among many examples, contraceptives can be out of stock for months at a time, especially in rural and remote areas, or only limited contraceptive choices may be available. Emergency contraception, a low-cost measure to prevent unwanted pregnancy and unsafe abortion, is still far from being universally available or accessible.98

Selective approaches –for instance, those that include prevention of unwanted pregnancy but do not support safe abortions– violate human rights and lead to detrimental outcomes in terms of an individual’s health and decision-making power and autonomy. Equally, approaches that exclude access by some groups –for instance, girls and young women who have not yet had a child, adolescents, those who are unmarried or lesbian, gay, bisexual or transgender people– violate human rights.99

A related requirement, which is often ignored, is acceptability of services. Human rights require “All

94

CRR, Family Planning is a Human Right, Briefing Paper, 2008. 95

OHCHR, Technical Guidance on Human Rights Based Approach to Maternal Mortality and Morbidity, 2012. 96

CESCR, General Comment 14, 2000. 97

Amnesty International, Realizing Sexual and Reproductive Rights: A Human Rights Framework, 2012. 98

ICPD-HLTF, Rights, Dignity and Health for All: Policy Recommendations for ICPD Beyond 2014, 2013. 99

Amnesty International, Realizing Sexual and Reproductive Rights: A Human Rights Framework, 2012.

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health facilities, goods and services must be respectful of medical ethics and culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoples and communities, sensitive to gender and life-cycle requirements, as well as being designed to respect confidentiality and improve the health status of those concerned.”100 As discussed earlier social and cultural factors and gender and life-cycle requirements often not only affect individual sexual and reproductive health needs but also determine their ability to access the service.

4.1.2. Quality of Services Sexual and reproductive health services should be, but often are not, provided at a level of quality that meets human rights standards. In addition to medical ethics and the public health imperative, the right to the highest attainable standard of health obligates governments to ensure that health facilities, goods, and services, including SRH services, are of good quality.

Quality of the interventions should go side-by-side with the increase of coverage, since the latter alone doesn’t guarantee the health results.101 Strengthening health networks and referral systems is still an unfinished agenda in many countries. Upgrading of second and first level facilities with appropriate infrastructure and equipment, and providing adequate numbers of skilled and motivated human resources are necessary to increase coverage and facilitate access.

Quality of care has long been recognized as essential for family planning programmes, but often not implemented as required by human rights.102 The core elements of quality of care in family planning can be broadly applied to other sexual and reproductive health services. For instance, quality care cannot be provided to women unless they consider the implications of violence. Quality care to women therefore requires that health professionals recognize the health consequences of violence and take basic precautions to protect women’s safety and dignity.103 In this regard, it is important for governments to train health care workers on how to discuss the issue of violence with clients in an informed, compassionate and respectful manner. In addition to training, health managers need to ensure that providers receive support from other departments and that required infrastructure, policies, and services exist.

It is often argued that quality improvements stimulate cost savings and increase cost-effectiveness within health systems.104

In the 1990s, Judith Bruce developed a framework105 for quality care in family planning services, emphasizing that services should be “client- oriented”. The Bruce framework focuses on clinical provision of family planning, and defines six elements of quality: provision of choice; information and counseling for clients; technical competence; good interpersonal relations; continuity of care; and appropriate constellation of services. Recent efforts have applied the concept to other health services, examined empowerment of individuals and communities who use the services, focused additional

100

CESCR, General Comment 14, para 12 (c). 101

The World We Want, Health in the Post-2015 Agenda: Report of the Global Thematic Consultation on Health, April 2013. 102

Jane Cottingham, Adrienne Germain, Paul Hunt, Use of Human Rights to Meet the Unmet Need for Family Planning, Lancet 2012, July 14 ; 380(9837): 172-180. 103

IPPF, Improving Health Sector Response to Gender Based Violence, 2010. 104

WHO, Quality of Care in the Provision of Sexual and Reproductive Health Services, 2011. 105

Judith Bruce, Fundamental Elements of Quality of Care: a Simple Framework, Studies in Family Planning, Population Council, March/April 1990.

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attention on the health infrastructure, examined social and material incentives and disincentives for the use of reproductive health services and products, considered the effect of sex of provider/client on provision and utilization of services, and examined how the provider’s attitudes influence access to services.106

4.2. Access to sexual and reproductive health education and information The ICPD and the UN Commission on Population and Development, among others, have repeatedly recognized the responsibility of governments to: “provide young people with comprehensive education on human sexuality, on sexual and reproductive health, on gender equality and on how to deal positively and responsibly with their sexuality.” At the 45th Session of the UN Commission on Population and Development in 2012, elaborating on commitments made in the ICPD and the Key Actions for Further Implementation, UN member states agreed to a set of actions to promote young people’s sexual and reproductive health and rights. They agreed, among other things, to “give full attention to meeting the reproductive health service, information and education needs of young people with full respect for their privacy and confidentiality, free of discrimination, and to provide them with evidence- based comprehensive education on human sexuality, on sexual and reproductive health, human rights and gender equality, to enable them to deal in a positive and responsible way with their sexuality”.107

This has been reaffirmed in the ICPD Global Youth Forum Bali Declaration (2012), which calls on governments to create enabling environments and policies to ensure that young people have access to comprehensive sexuality education, in formal and non-formal settings, through reducing barriers and allocating adequate budgets. Moreover, the Declaration calls upon governments to implement and monitor sustainable gender sensitive and transformative educational programs, by establishing gender-sensitive indicators and quality education systems and infrastructure, which should include qualified staff, appropriate facilities, tools (including technology), teaching materials and methods. As the ICPD Global Survey indicates, three-quarters (75.8%) of countries are committed to “age-appropriate sexuality education and counseling within schools”, 69.2% to incorporating life planning skills into young people’s formal education, and 70.4% committed to “revising the contents of curricula to make them more gender-sensitive.” However, only 59.3% were committed to “incorporating comprehensive sexuality education into formal education”, or “incorporating population and sexual and reproductive health information into the teacher’s training curricula” (59.6%). And only 49.3% were committed to “reaching out-of-school youth with sexual and reproductive health information and services”. When countries are grouped according to income, few major differences in these proportions are observed, but commitments to out-of-school SRH education were higher in poorer countries than in wealthier countries. Providing young people with scientifically accurate and rights-based information about sexuality and reproductive health appropriate to their age has proven effective in improving their health. The report of the Special Rapporteur on the right to education noted that, in order to achieve the highest attainable standard of physical and mental health and well-being, “we must be able to look after our health, deal positively, responsibly and respectfully with our sexuality and must be aware of our needs and rights,” which the Special Rapporteur emphasizes is only possible through comprehensive sexuality education.108

106

WHO, Quality of Care in the Provision of Sexual and Reproductive Health Services, 2011. 107

Commission on Population and Development, Resolution on Adolescents and Youth, CPD 45th Session, April 2012, para. 26. 108

Report of the UN Special Rapporteur on Right to Education, A/65/162, 2009.

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CRC has on numerous occasions underscored the need for states parties to ensure that all adolescents, both in and out of school, have access to information on how to protect their sexual and reproductive health.109 The Committee has urged state parties to initiate and support measures, attitudes, and activities that promote healthy behavior by including relevant topics in school curricula.110 The Committee has at numerous occasions called on states to “provide adolescents with access to sexual and reproductive information, including on family planning and contraceptives, the dangers of early pregnancy, the prevention of HIV/AIDS and the prevention and treatment of sexually transmitted diseases.”111

This has been reaffirmed by other Treaty Bodies as well. The CESCR has emphasized states parties should remove “… all barriers interfering with access to health services, education and information, including in the area of sexual and reproductive health.”112 CEDAW Committee too has made sexual and reproductive health education a priority in a number of its concluding observations and has frequently asked states parties to implement sexuality education programs.113 The Committee has also addressed the content of sexuality education programs, recommending that they include information on reproductive rights, responsible sexual behavior, sexual and reproductive health, prevention of STIs including HIV/AIDS, prevention of teenage pregnancies, and family planning. The Committee also has recommended that sexuality education programs target both adolescent girls and boys.114

Failure to provide this information and education these bodies recognize is a violation of human right. It leaves young people vulnerable to coercion, abuse, exploitation, unintended pregnancy and sexually transmitted infections, including HIV. For example, the UNAIDS Report on the Global AIDS Epidemic reported that among young people aged between 15 and 24 –a group that accounts for 45 per cent of all new HIV infections– only 40 per cent had accurate knowledge about HIV transmission.115 According to UN estimates, the vast majority of adolescents and young people still do not have access to the comprehensive sexual and reproductive health services and education on sexuality that they need for a healthy life. 116 National programmes that empower women, particularly adolescent girls and young women, by encouraging them to know their bodies and to exercise their rights, however, remain rare. In some countries, governments use criminal laws and other punitive measures to control access to education and information about sexuality.117

One of the most common and erroneous misconceptions about comprehensive sexuality education is that it `promotes promiscuity’.118 Multiple studies have shown that comprehensive sexuality education

109

CRC, General Comment 15, 2013. 110

See Mauritius, 31, U.N. Doc. CEDAW/C/MAR/CO/5 (2006); Mexico, 33, U.N. Doc. CEDAW/C/MEX/CO/6 (2006); Philippines, 28, U.N. Doc. CEDAW/C/PHI/CO/6 (2006); Togo, 32, U.N. Doc. CEDAW/C/TOG/CO/5 (2006). 111

CRC, General Comment 4. 112

CESCR, General Comment 14, para 21. 113

CRR, Human Right to Information and Education on Sexual and Reproductive Health, Briefing Paper, 2008. 114

See Turkmenistan, CEDAW/C/TKM/CO/2 (2006). 30–31; Estonia, 77, U.N. Doc. A/57/38, Part I (2002); Uruguay, 170, U.N. Doc. A/57/38 (2002); Belize, 56–57, U.N. Doc. A/54/38 (1999); Greece, 207–208, U.N. Doc. A/55/38 (1999). 115

UNAIDS Report on the Global AIDS Epidemic 2012; UNESCO, International Technical Guidance on Sexuality Education: An evidence-informed approach for schools, teachers and health educators, Paris, UNESCO, 2009; see also UNFPA, Comprehensive Sexuality Education: advancing human rights, gender equality and improved sexual and reproductive health, UNFPA, 2010. 116

UNESCO, International Technical Guidance on Sexuality Education, 2009. 117

Amnesty International, Realizing Sexual and Reproductive Rights, 2012. 118

ICPD-HLTF, Rights, Dignity and Health for All: Policy Recommendations for ICPD Beyond 2014, 2013.

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does not ‘promote promiscuity’ nor ‘increase levels of sexual activity’. Rather, through information and skills development, it empowers young people to make decisions about if and when to become sexually active and how to protect themselves against unwanted pregnancies and sexually transmitted infections, including HIV.119 In addition, parents often prefer an educational institution or programme (rather than themselves) to impart the information and skills they know their children require being safe and staying healthy.120 Studies show that if programmes encourage critical reflection on gender norms as a component of CSE, this has a positive impact on health outcomes.121

In a review of the effect of 83 evaluated sex education programmes, including 18 in developing countries, data were generally reported for one or more of five sexual behaviors: sexual initiation, frequency of sexual intercourse, number of sexual partners, condom use, and contraceptive use. A few studies reported pregnancy and STI rates. This review showed substantial evidence that curriculum-based programmes can have positive effects on sexual behaviors in young people. 65% of the studies found a significant positive effect on one or more reproductive health outcomes; only 7% found a significant negative effect. 33% of the programmes had a positive effect on two or more outcomes. Findings were similar across developing and developed countries. The findings showed that effective programmes shared certain common characteristics. These characteristics relate to the development, implementation, and content of the curriculum. Programmes that incorporated these characteristics were much more likely to reduce risky sexual behaviors than were programmes that did not incorporate many of these characteristics.122

5. Key issues for further discussion This section looks at the intersection of context and entitlements, through analysis three inter-connected issues namely: gender equality and prevention of gender based violence; women’s autonomy and reproductive rights; and sexual health, well-being and human rights. These issues are identified based on their interconnectedness, their neglect in relation to sexual and reproductive health, and the human rights imperative to address them.

5.1. Gender equality and prevention of gender based violence Under international human rights law, all states are required to ensure non- discrimination and equality. In order to fulfill these obligations, states must address and eliminate discrimination in laws, policies and in practices, including the actions not only of agents of the state, but also of private organizations and individuals. They also need to take broader measures to address factors that cause or perpetuate discrimination, and ensure that men and women, boys and girls, are truly able to enjoy their human rights equally. States, therefore, need to identify and address the reasons that certain groups are not able to exercise choice and control in their lives, or get the information and sexual and reproductive health services they need.123

119

UNESCO, UNFPA, UNICEF, UNAIDS, WHO (2009) International Technical Guidance on Sexuality Education, Vol. 1. (United Nations Educational, Scientific and Cultural Organization: Paris) 120

UN HRC (2010). Report of the United Nations Special Rapporteur on the Right to Education (United Nations Human Rights Council: Geneva). Available at: http://www.right-to education.org/sites/r2e.gn.apc.org/files/SR%20Education%20ReportHuman%20Right%20to%20Sexual%20Education.pdf p.14 121

UNFPA (2010) Comprehensive sexuality education: advancing human rights, gender equality and improved sexual and reproductive health. Bogota: UNFPA. 122

Mahmoud Fathalla et al., Sexual and Reproductive Health for All: A Call for Action, Lancet 2006, 368:2095-100. 123

UN Convention on the Elimination of All Forms of Discrimination against Women, 18 December 1979.

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The final report of the post 2015 thematic consultation on education observes that gender inequality remains a challenge. Although gender gaps in education have narrowed in many places, many African and Asian countries have not yet provided equal access to education for girls. Some 39 million girls are not enrolled in either primary or secondary education, while two thirds of the world’s 755 million illiterate adults are women. Only about one third of countries have achieved gender parity at secondary level. In developing regions, there are only 83 women per 100 men in tertiary education. Ineffective sexual and reproductive health education inhibits adolescent girls’ access to information on sexual and reproductive health, “thereby contributing to school drop outs especially amongst those girls at the age of puberty”.124 Further, the report, Growing Up Global indicates that girls drop out as a result of sexual harassment, violence and coercion in educational settings including by adult teachers and staff.125 Harmful gender norms and violence continue to impact women’s autonomy and access to services and support.126 This coercion takes many forms, for instance forcing women and girls who become pregnant as a result of rape to carry the pregnancy to term.127 Another example of such coercion is not permitting girls and women to make decisions about when and with whom they will have sex or whether, when and whom they will marry. Consensual sexual relationships between men and women, if one or both is married to another, are criminalized in national law.128

The lack of priority given to services that are needed by women, such as maternal health services, is in itself a form of discrimination. Even where governments have prioritized some of these services, the programmes do not look at those factors that make it difficult or impossible for women to get access to the services available. Even the best designed and resourced population or development programme will not succeed in improving people’s lives if the legal and political commitments made by governments to ensure gender equality are not at the heart of the programme.129

The achievement of gender equality, the protection of women’s human rights including sexual and reproductive rights and support for women’s empowerment are essential for the success of post 2015 development agenda.130 Some ongoing challenges include:

5.1.1. Gender based violence Despite the ongoing global consensus to ensure gender equality and eliminate gender based violence, women’s and girls’ right to autonomy over their sexuality and reproduction continues to be vehemently challenged and violated all around the world. The CEDAW Committee has emphasized that violence against women exists in all countries and its consequences are exacerbated by the woman’s characteristics and life circumstances such as race, ethnicity, disability, and economic status.131 One reason is that actions to achieve gender equality are often perceived to undermine the longstanding social order built on control by men and families over women’s sexuality and reproduction.

124

The World We Want, Education in the Post 2015 Development Agenda, Report on Global Thematic Consultation on Education, 2013. 125

Cynthia B Lloyd, Growing Up Global: The Changing Transition to Adulthood in Developing Countries, NAP, 2005. 126

UNW, Background paper CSW 2013. 127

Amnesty International, The total abortion ban in Nicaragua: Women’s lives and health endangered, medical professionals criminalized (Index: AMR 43/001/2009). 128

Amnesty International, Left without a choice: Barriers to reproductive health in Indonesia (Index: ASA 21/013/2010). 129

Amnesty International, Realizing Sexual and Reproductive Rights, 2012. 130

CSO outcome document Monrovia, 2013, DAWN 2013 Newsletter. 131

See Netherlands, 205–206, U.N. Doc. A/56/38 (2001); Norway, 494, U.N. Doc. A/50/38 (1995); Philippines, 29-30, U.N. Doc. CEDAW/C/PHI/CO/6 (2006); Sweden, 353, 356–357, U.N. Doc. A/56/38 (2001).

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Gender-based violence is one of the most pervasive human rights violations in the world and the consequences for sexual and reproductive health and rights are severe. Forms and manifestations of violence against women and girls include, amongst others, domestic violence; sexual assault and incest; sexual abuse and coercion of girls; date rape and gang rape; trafficking and femicide; harmful practices such as early and forced marriage, female genital mutilation, crimes committed in the name of honor, dowry-related violence, acid attacks, son preference, and the sale and abduction of girls; sexual harassment in public spaces, health and educational institutions, programs and places of work. These manifestations often represent only the tip of the iceberg. In many contexts, much less visible forms of control of women’s and girls’ sexuality, such as the restriction of their mobility, education or participation in economic and public life, typically in the name of protecting their chastity and family honor, lie at the heart of the disempowerment of women and girls.132

Sexual coercion and violence, usually by partners or others known to the person who is assaulted, are the most common form of violence against women worldwide. Gender inequality is also expressed in many other forms of violence such as trafficking in women and girls most often for purposes of sexual exploitation.133 Another manifestation of gender inequality is seen with respect to high levels of sexual violence during armed conflicts, military interventions and protracted humanitarian interventions. Sexual violence is often used as a direct weapon of war and can be used as a form of ethnic cleansing and to displace communities.

Although women and girls are predominantly affected by sexual violence, men and boys too are victims of such violence. Sexual violence has been perpetrated against men and boys as a tactic of war or in the context of detention or interrogation. The social consequences of this violence are acute and they further perpetuate and reinforce gender disparities.134

Certain groups such as persons with disabilities are particularly vulnerable. Persons with disabilities are up to three times more likely to be victims of physical and sexual abuse and rape. However, most persons with disabilities have little or no access to police, lawyers and courts for protection. They also have less access to medical interventions, including psychological and prophylactic care. Forced sterilization, forced abortion and forced marriage are common.135 They are more likely to become infected with HIV and other sexually transmitted infections than the general population and in crisis situations these risks are multiplied.136

The former UN Special Rapporteur on Violence against Women, Radhika Coomaraswamy has analyzed the link between the control of female sexuality and violence against women in her last report to the UN Commission on Human Rights. As she points out, “in recognizing women’s sexual and reproductive autonomy rather than protecting women’s sexual purity, one can tackle the roots of gender-based violence”.137

Violence and the threat of violence affect many aspects of women’s health and further perpetuate and reinforce gender inequalities. Women living in violent relationships are often unable to make sexual and

132

ICPD-HLTF, Rights, Dignity and Health for All: Policy Recommendations for ICPD Beyond 2014, 2013. 133

Claudia Moreno, Heidi Stockl, Protection of Sexual and Reproductive Rights: Addressing Violence Against Women, International Journal of Gynecology and Obstetrics 106 (2009) 144–147. 134

UNSG, Sexual Violence in Conflict, 2013. 135

World Bank, 2004. HIV/AIDS and Disability: Capturing Hidden Voices: Report of World Bank and Yale University Global Survey HIV/AIDS and Disability, World Bank. 136

Groce N. HIV/AIDS and people with disability. Lancet, 2003, 361:1401–1402. 137

Report of Special Rapporteur to the Commission on Human Rights, E/CN.4/2001/73.

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reproductive choices, putting them at great risk of early and unwanted pregnancy and sexually transmitted infections, including HIV.138

What is often missing is a multi-pronged strategy which promotes gender equality to eliminate GBV, including: building capacity at national and sub-national levels for collecting, analyzing and using GBV data; educating men and boys about gender equality and their responsibilities to respect and support women’s and girls’ human rights and empowerment; promoting grass roots and community-based participation in the implementation and monitoring of policies/programmes; undertaking evidence-based advocacy and media campaigns; and devising strategies for prevention of GBV, including in conflict and post-conflict situations.139 A key part of the response strategy has to be training and equipping the officials in the justice system to effectively respond to the incidents of gender based

violence (see Box 11).

BOX 11

Training Police to prevent Gender Based Violence

Since 2009, Afghanistan Ministry of Interiors and the National Police Academy with support from partners have developed the capacity of Afghan National Police recruits to recognize and prevent violence against women. The Ministry and the Police Academy developed a comprehensive course and manual for integration into police training programmes. The project is of crucial importance in light of the ongoing transition period in the country and the deteriorating security situation in the provinces, which has increased the vulnerability of women and girls.

140

Women and girls who are subjected to gender-based violence often do not have access to essential services. It is vital to ensure provision of full range of services including access to free 24-hour hotlines, psychosocial support and mental health counseling, and treatment of physical injuries; post-rape care, including post-exposure prophylactic for HIV prevention, emergency contraception for pregnancy prevention and diagnosis and treatment of sexually transmitted infections and other.141 Recognizing the harm caused by gender based violence, some countries have developed innovative approaches to provide a holistic response to the problem. (see box 12).

BOX 12

Addressing GBV in Tanzania

The Jijenge! Programme in Tanzania recognized the harm gender inequality was causing to women, including to their sexual and reproductive health. Going beyond a typically biomedical approach to sexual and reproductive health, the programme developed a women friendly approach to sexual and reproductive health via three strategies:

Providing information and clinical services for women, information, services and counseling that helped women identify the root causes of the sexual health problems in their communities;

Training community workers to create more women friendly service agencies and providers, including teachers, police, judges, church groups , among others, to adopt woman-friendly practices;

138

Anna Glasier et al., Sexual and Reproductive Health: A Matter of Life and Death, in Lancet Vol 368, 2006. 139

UNFPA, Investing in people: ICPD+10, 2004. 140

UNFPA, CSW 2013 Briefing, 2013. 141

ICPD-HLTF, Rights, Dignity and Health for All: Policy Recommendations for ICPD Beyond 2014, 2013.

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Changing attitudes in communities by stimulating public debate on the situation of women through brochures, street theatre, community meetings and other ways of disseminating information.

The programme found that a specific focus on gender-based violence (particularly when messages were delivered via a number of routes) turned out to be more effective than a broader approach to gender inequality. Men’s involvement in discussions was key, as was the endorsement of influential members of the community.

142

Violence against women and girls has multiple consequences for sexual and reproductive health and rights. It has fueled the feminization of the HIV/AIDS pandemic and has contributed to unwanted and early pregnancy; higher risks of sexually transmitted infections; poor maternal-child health outcomes, including premature labor, low birth weight, miscarriage and stillbirth resulting from abuse during pregnancy; and obstetric fistulae than can result from brutal sexual violence. Moreover, women who are sexually assaulted or in abusive and violent relationships and situations commonly cannot control basic decisions about contraceptive use, or insist on condom use to prevent STIs. Other violations of sexual and reproductive rights have been recognized internationally as forms of violence, including forced sterilization, forced abortion and forced pregnancy.

Early and forced marriage One in three girls in developing countries will be married without their consent before they are 18 years old. Despite near-universal commitments to end child marriage, over 67 million women 20-24 year olds in 2010 had been married as girls. Half were in Asia, one-fifth in Africa. In the next decade 14.2 million girls under 18 will be married every year, rising to an average of 15.1 million girls a year in 2021 until 2030, if present trends continue.143

An analysis of 78 developing countries has shown that girls who are poor, have little or no education and who live in rural areas are most likely to marry or enter into union before age 18. Girls living in rural areas of the developing world tend to marry or enter into union at twice the rate of their urban counterparts (44 per cent and 22 per cent, respectively). Those with no education are three times more likely to marry or enter into union before age 18 as those with a secondary or higher education. Furthermore, more than half (54 per cent) of girls in the poorest 20 per cent of households are child brides, compared to only 16 per cent of girls in the richest 20 per cent of households.144 Early marriage stands in the way of ensuring that girls have healthy and productive lives and are able to make autonomous decisions about their sexual and reproductive lives. Girls married early face complications from pregnancy, the main cause of death among adolescent girls 15-19 in developing countries, except some in Sub-Saharan Africa where HIV and AIDS are highly prevalent.145 Girls who are married young are also more vulnerable to sexually transmitted infections (STIs), including HIV/AIDS.146

For millions of girls, marriage is anything but safe and or consistent with their best interests. Data shows young girls are often forced into marriage without any free, prior and informed consent. Early and forced marriage violates girls’ rights in numerous ways. It commonly involves rape, exploitation in the household, and an early end to the girl’s education. Girls who are married at a very young age

142

UNFPA, By Choice not By Chance, 2012. 143

UNFPA, Marrying too young, 2012. 144

UNFPA, Marrying too Young: End Child Marriage, 2012 145

UNFPA, Marrying too young, 2012. 146

IWHC, adolescents factsheet.

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experience related educational, social, and personal disadvantages compared with those who marry later.147

Interventions are needed to prevent and eliminate the forced marriage of girls and boys aged 18 and younger; to help ensure a safe passage to marriage and adulthood for all girls; and to support girls who are already married. However, the overall response of governments has been very slow in this regard.

Female Genital Mutilation The Programme of Action states that “In a number of countries, harmful practices meant to control women's sexuality have led to great suffering. Among them is the practice of female genital mutilation, which is a violation of basic rights and a major lifelong risk to women's health.”148 It requires Governments to take active measures to “…prohibit female genital mutilation wherever it exists and to give vigorous support to efforts among non-governmental and community organizations and religious institutions to eliminate such practices.”149

The CEDAW Committee has equated the practice of FGM with violence against women and characterizes it as a threat to women’s rights to life and physical integrity. The Committee has consistently underscored states parties’ responsibility for violence against women, whether committed by private or state actors.150 It has further called on states to take steps to eliminate FGM. This has been supported by CESCR which has emphasized the need to “shield women from the impact of harmful traditional cultural practices and norms that deny them their full reproductive rights.”151

Female genital mutilation has been reported to occur in all parts of the world, but it is most prevalent in: the western, eastern, and north-eastern regions of Africa, some countries in Asia and the Middle East and among certain immigrant communities in North America and Europe.152 About 140 million girls and women worldwide are currently living with the consequences of FGM. In Africa an estimated 101 million girls aged 10 years old and above have undergone FGM.153

Several governments have passed laws against the practice, and where these laws have been complemented by effective education and public awareness-raising activities, the practice has declined. National and international organizations have played a key role in advocating against the practice and generating data that confirm its harmful consequences.154 Despite some successes, the overall rate of decline in the prevalence of female genital mutilation has, nevertheless, been slow.155

147

IWHC, adolescents factsheet. 148

Programme of Action, para 7.35. 149

Programme of Action, para 4.22. 150

CRR, Female Genital Mutilation and Other Harmful Practices, Briefing Paper, 2008. 151

CESCR, General Comment 14. 152

UN Inter-Agency Statement on FGM, 2012. 153

http://www.who.int/mediacentre/factsheets/fs241/en/ 154

UN Inter-Agency Statement on FGM, 2012. 155

UN Inter-Agency Statement on FGM, 2012.

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BOX 13

Medicalization a threat to abandonment The term “medicalization” was adopted to describe when FGM/C was performed by medical providers, irrespective of location, in the first WHO/UNICEF/UNFPA Joint Statement in 1997 and reaffirmed in 2008 by the Interagency Statement (UNFPA, UNHCR, UNICEF, UNIFEM, WHO, FIGO, ICN, MWIA, WCPA, WMA, 2010). Despite contradicting the World Medical Association’s Declaration of Helsinki, 1964 stating that it is the, in many countries medicalization is one of the greatest threats to abandonment. To combat this alarming trend, the UNFPA and UNICEF in collaboration with WHO and International Medical Councils issued “The Global strategy to stop health-care providers from performing female genital mutilation” in 2010, clearly stating that health providers that perform FGM/C are not only violating girls’ and women’s human rights but one of the fundamental ethical principle: “do no harm”. Nevertheless, in Egypt, a 2012 survey of health professionals revealed that medicalization still poses a major threat to abandonment. The study found that health providers appeared to still be susceptible to the traditional mythology surrounding the practice rather than current scientific evidence. As demand persists, health care providers are also tempted by additional income.

Forced sterilization States, medical practitioners, and others have practiced forced sterilization of both men and women for decades. The CEDAW Committee has considered forced sterilization a violation of a woman’s right to informed consent, and a violation of her right to human dignity and physical and mental integrity.156 The Committee has clarified that, except where there is a serious threat to life or health, the practice of sterilization of girls, regardless of whether they have a disability, and of adult women with disabilities in the absence of their fully informed and free consent, should be prohibited by law.157 CEDAW Committee has called on states to adopt legislative changes regarding forced sterilization, provide mandatory trainings on patients’ rights, and compensate victims of coercive sterilization.158 In June 2011, the International Federation of Gynecology and Obstetrics (FIGO) issued new guidelines on female contraceptive sterilization and informed consent. These Guidelines explicitly state that ‘only women themselves can give ethically valid consent to their own sterilization. Family members including husbands, parents, legal guardians, medical practitioners and, for instance, government or other public officers, cannot consent on any woman’s or girl’s behalf.’

Violence based on sexual orientation and gender identity Homophobic, sexist and transphobic practices and attitudes on the part of health care institutions and personnel in some cases deter lesbian, gay, bisexual, transgender and intersex people from seeking services, despite the negative impact on efforts to tackle public health concerns, including HIV/AIDS.159 UN Treaty Monitoring Bodies have expressed concern about lesbian, gay, bisexual, transgender and

156

CEDAW, General Recommendation 24, para 22. 157

CEDAW Concluding Observations: Australia CEDAW/C/AUS/CO/7. See http://www2.ohchr.org/english/bodies/cedaw/cedaws46.htm 158 See, e.g., Japan, CCPR/C/79/Add.102 (1998); Slovakia, 12, CCPR/CO/78/SVK (2003). See also, AS v. Hungary, Communication no.4/2004. 159

UN Office of the High Commissioner on Human Rights, Discriminatory laws and practices and acts of violence against individuals based on their sexual orientation and gender identity, A/HRC/19/41, 2012, para. 54.

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intersex people as “victims of abuses and mistreatment by health service providers.”160

Studies have documented police brutality against lesbian, bisexual and transgender women in many countries. Discrimination on the basis of sexual orientation and gender identity means that lesbian, bisexual and transgender women are often blamed for the violence targeted at them. The violence is seen by perpetrators and many law enforcement officials as a “punishment” for their failure to conform to social conventions.161

Such violence has multifaceted effects. For instance, access to education may also be affected when boys and girls are denied the right to freely determine their gender identity or sexual orientation. Further, sexual and reproductive health information and services continue to be geared towards the experience and needs of those conforming to heterosexual gender roles. Harassment, exclusion, discrimination and other abuse of patients by health personnel because of their real or perceived sexual orientation or identity remain a serious concern in many countries. This type of discrimination highlights a failure to recognize diverse sexual orientations and gender identities in the sexual and reproductive health information and services provided.

5.2. Women’s autonomy and reproductive rights The Programme of Action sets out reproductive rights that arise from a number of other human rights, such as the rights to health and non-discrimination.162 It recognizes the right of couples and individuals to decide on the number, timing and spacing of children, their right to the information and means to do so, and their right to sexual and reproductive health, free of discrimination, violence and coercion. The Programme of Action therefore places women’s autonomy and choice as the foundations of sexual and reproductive health and rights.

Women’s autonomy in context of reproductive rights means the right of a woman to make decisions concerning her fertility and sexuality free of coercion and violence. This is an absolute right. Women must be in-charge of decisions concerning their own sexuality and reproductive lives. Informed consent and confidentiality are instrumental to ensuring free decision-making by women and girls. Autonomy also means that a woman seeking health care in relation to her fertility and sexuality is entitled to be treated as an individual in her own right, fully competent to make decisions concerning her own health, without any third party approval or authorization.163 This is a matter, among other things, of the woman's right to equality before the law as well as her legal capacity. The last two decades have seen a surge in development of normative standards and jurisprudence in this regard as discussed later in this

160

UN Office of the High Commissioner for Human Rights, Discriminatory laws and practices and acts of violence against individuals based on their sexual orientation and gender identity, A/HRC/19/41, 2012, para. 54; See the concluding observations of the Human Rights Committee on Cameroon (CCPR/C/CMR/CO/4), para. 12. Concluding observations on Costa Rica (CEDAW/C/CRI/CO/5-6), para. 40.See also A/HRC/14/20, paras. 22-23; Aggleton, P., HIV and AIDS- related stigmatization, discrimination and denial: research studies from Uganda and India (Geneva, UNAIDS, 2000), pp. 17-18; African Commission on Human and Peoples‟ Rights resolution, 26 May 2010 (ACHPR/Res163(XLVII)2010); “Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people: recommendations for a public health approach”, WHO, 2011, pp. 10- 11; Committee on the Rights of the Child, general comment No. 4 (CRC/GC/2003/4), para. 6. 161

Amnesty International, Realizing Sexual and Reproductive Rights, 2012. 162

Programme of Action para .7.3 163

CEDAW, General Recommendation 24.

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paper. Importantly, the right to autonomy in making health decisions in general, and sexual and reproductive decisions in particular, derives from the fundamental human rights to liberty and bodily integrity.

Nonetheless, the implementation of these guarantees has been slow and in some cases non-existent. This is evident in many areas, discussed below which include, early and forced marriage; family planning and contraception; safe abortion and maternity care.

5.2.1. Family planning and contraception The ICPD replaced a demographically driven approach to family planning with one that is based on human rights and the health needs, aspirations, and circumstances of each woman. Since the ICPD, millions more women have had fewer children and started their families later in life, giving them an opportunity to complete their education or earn income.164 Still, many are unable to exercise their right to family planning and end up having more children than they intend, burdening them economically, harming their health, and undermining opportunities for a better life for themselves and their families.165 Clearly this right has not yet been extended to all, especially in the poorest countries.166

Women’s autonomy in context of family planning means the right of women to choose whether or not to reproduce, the right to access full and accurate information and to choose their preferred method of family planning and contraception, and when to use it. However, coercive practices against women in family planning, such as, restricted choices among contraceptive methods, or denial of services, forced pregnancies, forced abortions, and forced sterilization, violate this right. Measures needed to ensure that women are treated as active agents, not as passive beneficiaries, are often missing.

According to recent estimates, around 222 million sexually active women of reproductive age, who do not wish to become pregnant, are not using modern contraception. 167 In the 69 poorest countries —where 73% of all women with unmet need for modern contraceptives reside— the number actually increased, from 153 to 162 million women.168 Serious challenges restrict their access to family planning and contraception. Countries that have developed innovative approaches to address these concerns are improving access to contraceptive by communities. (see Box 14) While efforts made by countries have resulted in a significant increase in contraceptive use in developing countries over the last twenty years, there remains a serious unmet need for family planning, whether for spacing or for prevention of unwanted pregnancy.

BOX 14

Providing subsidies to enhance contraceptive access: Romania

In 2001, in an attempt to implement WHO recommendation to provide contraceptives either free or at a subsidized rate, Romania’s Ministry of Health and Family earmarked budget to provide free contraceptives to eligible women. The Ministry continues to provide free contraceptives to eligible groups. The Government also launched the Romanian Family Health Initiative, a six-year partnership with the goal of expanding and improving equitable access to family planning and other reproductive health services, particularly in rural areas. One of the

164

UNFPA, By Choice not By Chance, 2012. 165

UNFPA, By Choice not By Chance, 2012. 166

UNFPA, By Choice not By Chance, 2012. 167

UNFPA, By Choice not By Chance, 2012. 168

AGI and UNFPA: Adding It Up: Costs and Benefits of Contraceptive Services—Estimates for 2012

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program’s central pillars was to provide free contraceptives to low-income communities. The provision of free contraceptives contributed to a significant increase in contraceptive prevalence, which rose from 29.5% in 1999 to 38.2% in 2004.

Source: CRR Contraceptive Briefing, 2010

According to the ICPD Global Survey conducted by UNFPA social, economic and cultural factors act as barriers in access to contraceptives for many women; poverty, distance and lack of good information still prevent people, especially in rural areas, from reaching services. Moreover, in general, disparities in unmet need for family planning have widened since 2005, particularly for wealth disparity and residence disparity.169

While the proportion of demand satisfied for contraception increased significantly for all regions/sub-regions during the period 1990-2000, the rate of increase has slowedsince then. At the global level, the proportion of demand satisfied increased 5.6 percent between 1990 and 2000, compared to only 1.5 percent between 2000 and 2012. 170

Analysis based on data for 87 UNFPA programme countries shows that women living in urban areas, with secondary or higher education and living in the wealthier households continue demonstrating higher level of proportion of demand satisfied. 171 West and Central Africa and Eastern and Southern Africa had the largest disparities. In West and Central Africa, women living in the richest 20 percent of households were 2.4 times more likely to have their demand satisfied than their counterparts living in the poorest 20 percent of households. 172

The CEDAW Committee has frequently expressed concern over women’s lack of access to contraceptive and family planning services and information. The Committee has identified several obstacles to accessing contraception and has urged member states to address them, including cost; lack of medical insurance coverage; legal obstacles; discrimination on the basis of marital status; and coercion, which prevents women from being able to choose freely a form of contraception.173

It is also important that Family Planning is provided as part of a comprehensive health care package through primary health care services, using a life-cycle approach (i.e. addressing changing needs of a girls and women as they pass through different biological, social and psychological stages of their lives, not as a vertical programme, an approach used by policy makers concerned about population growth and less about women’s health.

Civil society organizations have called for a holistic response and have frequently urged governments and regional and international agencies to work together to urgently address the unmet need for

169

Source: UNFPA, “How Universal is Access to Reproductive Health?: A review of the evidence in 2013” (FORTHCOMING) 170

Source: UNFPA, “How Universal is Access to Reproductive Health?: A review of the evidence in 2013” (FORTHCOMING) 171

Source: UNFPA, “How Universal is Access to Reproductive Health?: A review of the evidence in 2013” (FORTHCOMING) 172

Source: UNFPA, “How Universal is Access to Reproductive Health?: A review of the evidence in 2013” (FORTHCOMING) 173

See e.g. Bangladesh, A/52/38/Rev.1, (1997); Belize, A/54/38 (1999); Burkina Faso, A/55/38, (2000) Colombia, A/54/38 (1999); Democratic Republic of the Congo, A/55/38 (2000); Ghana, CEDAW/C/GHA/CO/5 (2006), Philippines, CEDAW/C/PHI/CO/6 (2006)

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comprehensive and integrated SRH services, including for the most marginalized and disadvantaged groups, such as women and girls at risk of or living with HIV/AIDS, women with disabilities, sex workers, women using drugs, and migrant women, among others. Financing for the comprehensive SRHR agenda is urgently needed.174

5.2.2. Safe abortion …In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counseling, education and family-planning services should be offered promptly, which will also help to avoid repeat abortions.

175

This was further elaborated in 1999, in Key Actions for Further Implementation, which emphasized:

…in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women's health.

176

Access to safe abortion has been increasingly recognized as a matter of both human rights and public health, because unsafe abortion is a leading cause of maternal mortality and morbidity, and forced pregnancy is a form of gender-based violence. In his Global Strategy for Women’s and Children’s Health, the Secretary-General pointed out that unsafe abortion accounts for one out of every eight maternal deaths; in a statement made on 14 June 2010, the High Commissioner declared that States had obligations to address unsafe abortion. Unsafe abortion is one of the five major causes of maternal deaths.177 Each year, there are around 47,000 deaths and between 5 and 8.5 million women with temporary or permanent disability or injury due to complications.

Only four countries of the world prohibit abortion entirely, even when a woman’s life is in danger. In 102 countries, abortion is legal not only to save the life of the woman but also in cases of rape, incest, or fetal impairment. In 58 countries, abortion is permitted without restriction as to the reason. In all these places, providers should be trained and equipped to ensure that services are safe and readily accessible.

Human rights bodies have declared restrictive abortion laws and failure to ensure access to abortion when it is legal incompatible with international human rights law and amounting to violations of, inter alia, the rights to life and health and of the principle of non-discrimination arising with a discriminatory, disproportionate impact of on poor and rural women.178 The denial of safe abortion or the penalization of abortion has also been deemed to, in certain circumstances, constitute a violation of the right to be free from torture and cruel, inhuman and degrading treatment.179

174

ASIA Pacific women demands on post 2015 Agenda, 2013 DAWN Newsletter. 175

Programme of Action, para 8.25. 176

Key Actions for Further Implementation, 1999, para 63 (iii) 177

WHO, “Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008”, sixth ed., pp. 1 and 5. Available from http://whqlibdoc.who.int/publications/2011/9789241501118_eng.pdf. 178

See CCPR/CO/70/ARG. 179

See CCPR/C/79/Add.72, para. 15; CCPR/CO/70/PER, para. 20; and CCPR/CO/82/MAR, para. 29. See also CCPR/CO/79/LKA, para. 12 and CAT/C/CR/32/5, para. 6 (j). See also K.L. v. Peru, Communication No. 1153/2003, Human Rights Committee, para. 6.3, U.N. Doc. CCPR/C/85/D/1153/2003 (2005). L.C. V. Peru, Communication No.22/2009, CEDAW/C/50/D/22/2009, 2011. P and S v. Poland, Application No. 57375/08, Judgment of the European Court of Human Rights, 2013.

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Despite this, thousands of women around the world continue to suffer from death and disability resulting from unsafe abortions. It is estimated that globally, women average one abortion during their reproductive years.180 Almost half of all abortions are unsafe and cause a serious risk to a woman’s life or health.181 In low-income countries, women have an average of one unsafe abortion during their reproductive years; close to 70,000 women die annually as a result of these unsafe procedures.182 In many developing countries around the world, in Sub-Saharan Africa, MENA, and Asia, unsafe abortions are a leading cause of death among women and girls.183

The legal status of abortion in the country as well as the quality of abortion services both affect the availability and accessibility of abortion. Legal obstacles to provision of safe abortion services force women to resort to unsafe abortion when faced with an unwanted pregnancy.184 As country experiences show, legislation that expands access to abortion does not increase the recourse to abortion—but it can save lives.

UN Special Rapporteur on right to health has argued that laws criminalizing health services that only women need - whether such laws are aimed at the persons who provide such services or at the women who receive them - are discriminatory as such.185 The criminalization of abortion is particularly problematic, because it not only impairs women's right to reproductive choice - to make free and responsible decisions concerning matters that are key to control of their lives - but also exposes them to the serious health risks of unsafe abortion, violates their right to bodily integrity and to life itself.

Women and girls who face punishment for having an abortion are not less likely to attempt abortion—they are less likely to have access to safe services.186 When abortion is restricted by law, trained providers are generally reluctant to perform abortions, even when legally permissible, because they do not know the law, fear censure from the community, or hold personal beliefs against abortion. This can force women to seek unsafe abortions.187 Nearly twenty years since Cairo, effective measures needed to ensure availability and accessibility of safe and legal abortion services are often missing.

To the full extent of the law, safe abortion services should be readily available and affordable to all women. This means services should be available at primary-care level, with referral systems in place for all required higher-level care.

Actions to strengthen policies and services related to abortion should be based on the health needs and human rights of women and a thorough understanding of the service-delivery system and the broader social, political and economic context.188

5.2.3. Maternity care Countries should strive to effect significant reductions in maternal mortality by the year 2015: a reduction in maternal mortality by one half of the 1990 levels by the year 2000 and a further one half by 2015. The realization

180

Guttmacher Institute, 2012. 181

David A Grimes et. al, Unsafe Abortion: the preventable epidemic, WHO, 2006. 182

CRR, Forsaken Lives, 2012. 183

WHO, Safe Abortion Guidelines, 2012. 184

Anna Glasier et al., Sexual and Reproductive Health: A Matter of Life and Death, in Lancet Vol 368, 2006. 185

Report of the UN Special Rapporteur on the right to health, 2011, A/66/254. 186

WHO, Safe Abortion Guidelines, 2012. 187

WHO, Safe abortion guidelines, 2012. 188

Safe abortion guidelines

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of these goals will have different implications for countries with different 1990 levels of maternal mortality… However, all countries should reduce maternal morbidity and mortality to levels where they no longer constitute a public health problem. Disparities in maternal mortality within countries and between geographical regions, socio-economic and ethnic groups should be narrowed.

189

These commitments were reiterated in Millennium Development Goal 5, which called for a reduction of maternal mortality by 75% by 2015. Of all SRH indicators, the greatest gains since 1994 have been made in relation to reducing the maternal mortality ratio. In 1994, more than half a million women died each year from largely preventable causes related to pregnancy and childbirth, and by 2010 the maternal mortality ratio had declined by 47%. Even with this progress MDG5 is still the one most off-track of all MDGs and targets will not be met by many countries.

One of the clear manifestations of intersecting discrimination is the large number of women around the world who die in pregnancy and childbirth – some 800 women a day. Every year, 16 million adolescent girls become pregnant. Maternal mortality is the leading cause of death for this age group in low and middle-income countries. For every woman who dies, another 20 endure lifelong suffering because of injury, infection, disease or disabilities due to pregnancy, childbirth or unsafe abortion. An estimated 10 million women worldwide who survive their pregnancies annually experience injuries.190

Most maternal deaths and injuries are preventable – the health care interventions needed to save women’s lives are well known. However, governments are not always providing women with the information and services they need. For instance, although 79.2% of countries reporting in the ICPD Global Survey that they have committed to “providing referrals to essential and emergency obstetric care”, the percentage of countries that reports having an adequate geographic distribution of emergency obstetric care (EmOC) facilities ranges from 40.4% in Africa to 96.7% in Europe. Hence, commitments fall short where health systems are most fragile, and where the numbers of skilled personnel are inadequate and mal-distributed in countries. Distribution of health care services is strongly associated with maternal mortality ratios, in that 96% of countries with the lowest maternal mortality ratios report having an adequate geographic distribution of EmOC facilities in the ICPD Global Survey, but this percentage drops to 29% in the case of countries with the highest maternal mortality ratios.

As the above information suggests, health care systems in many countries are often inaccessible to women and girls living in poverty, or from rural or indigenous communities, who do not have the money or transport to travel to health facilities. When facilities are available, the types of services provided are usually of poor quality. This is driven in part by a profound health worker shortage in the 58 countries in which 91% of maternal deaths occur. Indeed, little progress has been seen in skilled birth attendance in sub-Saharan Africa, where fewer than half of all births are attended by skilled personnel. Some countries have taken innovative measures to address this (see Box 15). But access to health care services, though vital, is only part of the solution to reducing maternal mortality and morbidity. Any real solution has to address the root causes that stop women from making decisions about their own health and prevent them from choosing whether or not they wish to get pregnant, carry a pregnancy to term, and ultimately how many children they want.

189

Programme of Action, para 8.21. 190

Amnesty International, Realizing Sexual and Reproductive Rights, 2012.

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BOX 15

DJIBOUTI: Community-based approach to increase utilization of maternal health services Djibouti has one of the highest maternal mortality ratios in the Arab States region, estimated at 300 maternal deaths per 100,000 live births in 2008. Health centres are not well distributed and are far from many women. Emergency transferring of woman from health centres to tertiary or Emergency Obstetric Care (EmOC) services may take up to ten hours. Additionally, women may not be able to afford the transport costs. To improve the responsiveness of the health system and improve quality of care, UNFPA supported a community-based initiative to increase the utilization of maternal health services. The pilot programme targeted rural communities that were either nomadic or semi-nomadic (with populations not exceeding 30,000 inhabitants; approximately 7,000 inhabitants who are women in reproductive age; and 2,700 under-five children). The initiative generated strong adhesion among community members. The programme started in 16 communities and has now reached more than 42 communities. These results have contributed to increasing delivery at facilities. Health facility births that used to range from 10-15 per cent in 2008 have now reached 48-100 per cent in 2012.

191

The CEDAW Committee has repeatedly expressed concern over high rates of maternal mortality and has framed the issue of maternal mortality as a violation of women’s right to life.192 These concerns have also been reiterated by other Treaty Bodies, which have framed women’s lack of access to reproductive health services, including emergency obstetric care, as contributing to maternal mortality and as violating women’s rights to equality and life.193 The HR Committee has asked states parties to remove barriers to access, such as treatment costs, lack of reproductive health information, and restrictive abortion laws.194 It has also recommended the implementation of legal and policy measures to ensure equal access to a full range of reproductive health-care services and information. This includes not only maternity care, but also contraceptives, family planning counseling, sex education, and safe abortion services.

5.3. Sexual health, wellbeing and human rights Sexual health, is defined as “a state of physical, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.”195

Protecting sexual health requires enabling people of all ages, including adolescents, to have access to the necessary information and health services. The PoA further recognizes that a safe and satisfying sexual life also requires removing obstacles such as gender discrimination, inequalities in access to health services, restrictive laws, sexual coercion, exploitation, and gender-based violence.196

191

Report of UNFPA ED, 2012, Annex 8. 192

See, e.g., Belize, A/54/38 (1999); Colombia, A/54/38 (1999); Dominican RepublicA/53/38 (1998); Madagascar, A/49/38, (1994). See also Alyne da Silva v. Brazil, Communication No.17/2008. 193

Mali, CCPR/Co/77/mli (2003); Kuwait, CCPr/Co/69/KWT (2000); Peru, CCPR/Co/70/PEr (2000). 194

E.g. Poland, CCPR/C/79/add.110 (1999); Viet Nam, CCPR/ Co/75/VNm (2002). 195

www.who.int 196

Anna Glasier et al., Sexual and Reproductive Health: A Matter of Life and Death, in Lancet Vol 368, 2006.

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Sexual health is influenced by a number of factors, including sexual behavior and attitudes, societal factors, biological risk and genetic predisposition. It encompasses the problems of HIV and STIs/RTIs, and cancer resulting from STIs, and sexual dysfunction. Addressing sexual health at the individual, family, community or health system level requires integrated interventions, including reproductive health services as relevant, delivered by trained health providers in the context of a functioning referral system. It also requires a legal, policy and regulatory environment where the sexual rights of all people are upheld. Special protections are required for groups particularly at risk such as women and adolescents.

Human rights obligate governments to take steps to enable individuals to express their sexuality without fear, discrimination or violence. This requires a series of measures to address, HIV and Sexually Transmitted Infections; adolescent sexual health and well-being and human rights and sexuality.

5.3.1. HIV and Sexually Transmitted Infections The global AIDS response has succeeded in achieving health and development gains in all countries around the world.197 However, challenges remain. Globally, HIV remains the fifth leading cause of death among adults.198 In 2011, 34 million people were living with HIV, with 2,400 young people infected every day. Despite the overall decline in the number of people newly infected with HIV, 2.5 million people acquired HIV in 2011, including 890, 000 young people.199

Human rights violations contribute to the spread of HIV/AIDS and other STIs. Government duties, grounded in international guarantees of the rights to life, health, privacy, and non-discrimination, include increasing public awareness, particularly among women and adolescents, about the risks and effects of HIV infection and must give special attention to the rights and needs of women and adolescents, including their particular vulnerability to HIV infection.200

Although 8 million people living with HIV are now receiving treatment, nearly 8 million more people are eligible for treatment but unable to access it. People living with HIV face many barriers that interfere with their ability to initiate and adhere to their treatment regimens.201 Fear, stigma and discrimination, health system failings as well as poverty and gender inequality have been cited as obstacles.202 While male and female condoms are highly effective not only for disease prevention but also for contraception condom use and access to female condoms remains minimal in many countries..

Treatment remains inadequate for key populations at higher risk, such as sex workers, men who have sex with men, people who use drugs and transgender people, and especially for young people in these and other affected groups. Female sex workers are 14 times more likely to be living with HIV and men who have sex with men are estimated to be more than 19 times more likely to be living with HIV than

197

UNAIDS, AIDS, Health and Human Rights: Towards the End of AIDS in the Post 2015 Development Era, 2013. 198

Lozano R et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 2012, 380:2095–2128. 199

Together we will end AIDS. Geneva, UNAIDS, 2012 (http://www.unaids.org/en/resources/campaigns/togetherwewillendaids, accessed 24 January 2013). 200

CEDAW, General Recommendation 16. 201

WHO, UNICEF and UNAIDS. Progress report 2011: global HIV/AIDS response – epidemic update and health sector progress towards universal access. Geneva, World Health Organization, 2011 (http://www.who.int/hiv/pub/progress_report2011/en/index.html, accessed 24 January 2013). 202

UNAIDS, AIDS, Health and Human Rights: Towards the End of AIDS in the Post 2015 Development Era, 2013.

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the general population, with people who inject drugs being up to 22 times more likely. However, according to recent estimates, domestic funding on HIV programmes for sex workers, men who have sex with men and people who inject drugs remains very low, representing a lack of political will to provide services. Information on HIV risk and HIV services for transgender people, for sexual partners of people who inject drugs, for people with disabilities, and other vulnerable groups is rarely collected

systematically, but depending on the region, can be extremely high.203

Sexually transmitted infections and women An estimated 499 million new cases of curable sexually transmitted infections occur annually. Girls and women disproportionately bear the long-term consequences of these diseases. For example, each year untreated STIs cause infertility in thousands of women of women around the world, and untreated syphilis in pregnant women results in infant death. Testing and treatment are key, but millions don’t have access to information and services to deal with these infections.

A variety of biological and social factors make women more susceptible to STDs than men. Women are physiologically more vulnerable than are men to contracting STIs when they have unprotected sex (i.e., without using a condom) with an infected partner. Additionally, STIs in women are more likely to be asymptomatic; if women are unaware of their infection, they cannot seek timely care and hence may experience serious complications.204 When STIs are not treated, they can result in pelvic inflammatory disease, which leads to infertility and ectopic pregnancy. Chlamydia (one of the most common STIs) can result in serious permanent damage to women’s reproductive organs and can result in a few complications in men. Genital herpes, syphilis and HIV can be passed to babies during pregnancy and at delivery and can result in stillbirth (a baby that is born dead), low birth weight (less than five pounds), brain damage, blindness and deafness.205

Human papillomavirus (HPV) is the most common sexually transmitted infection in women, and is the main cause of cervical cancer which causes about 279,000 deaths annually, equal to the number of maternal deaths. While HPV is also very common in men, most do not develop any serious health problems. Some positive gains have been made in this regard with respect to vaccination for certain strains of HPV. However, the vaccination remains inaccessible to most due to high costs.

5.3.2. Adolescents’ Sexual Health and well-being The Programme of Action emphasizes:

The reproductive health needs of adolescents as a group have been largely ignored to date by existing reproductive health services. The response of societies to the reproductive health needs of adolescents should be based on information that helps them attain a level of maturity required to make responsible decisions. In particular, information and services should be made available to adolescents to help them understand their sexuality and protect them from unwanted pregnancies, sexually transmitted diseases and subsequent risk of infertility.

206

203

UNAIDS, AIDS, Health and Human Rights: Towards the End of AIDS in the Post 2015 Development Era, 2013. 204

Guttmacher, Sexually Transmitted Diseases Hamper Development Efforts, 1997. 205

CDC, Factsheet on STDs, 2011. 206

Programme of Action, para 7.40

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It further urges:

Governments, in collaboration with non-governmental organizations, are urged to meet the special needs of adolescents and to establish appropriate programmes to respond to those needs. Such programmes should include support mechanisms for the education and counseling of adolescents in the areas of gender relations and equality, violence against adolescents, responsible sexual behavior, responsible family-planning practice, family life, reproductive health, sexually transmitted diseases, HIV infection and AIDS prevention.

207

Implementation of this agenda has barely begun and adolescents around the world continue to face numerous barriers to accessing education and services required to realize their sexual and reproductive health. Access to comprehensive sexuality education and services, for both the 10-14 age group and those 15-19, is very limited. To address this, the Commission on Population and Development in 2012, urged:

“…Governments to protect and promote human rights and fundamental freedoms regardless of age and marital status, including, inter alia, by eliminating all forms of discrimination against girls and women, working more effectively to achieve equality between women and men in all areas of family responsibility, in sexual and reproductive life, in education at all levels, and by protecting the human rights of adolescents and youth to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health.”

208

Today’s world has the largest generation of young people under 25 in history, totaling 3 billion, or 44% of the world’s population.209 Almost half (1.2 billion) of these are adolescents (10-19 years)210 who already are, or will be, entering the sexual and reproductive stages of their lives. Young people’s urgent needs for sexuality education and related services are all too obvious. Only 34% of young women and 36% of young men know how to prevent HIV globally and 1 million girls in the ages 10 to14 give birth every year.211 Many live in developing countries with restricted opportunities and choices.They lack adequate rights protections, education and services for their informed sexual and reproductive health decision-making and safe passage into adulthood. Some countries, however, have developed strategies to reach boys and girls in schools with positive effects (see Box 16).

BOX 16

Vietnam: Providing Outreach at Schools

The Vietnam Family Planning Association operates an outreach project in more than 100 secondary schools, delivering youth-friendly services to all students who want them. They provide information about sex, sexual and reproductive health, counselling, contraception, testing for sexually transmitted infections, and referrals. The Association also trains young people to deliver education to their peers. By having access to services, and as peer educators, young people are empowered and their knowledge improved. The Association’s experiences were

207

Programme of Action, para 7.47 208

CPD 45, 2012, OP 7. 209

UNFPA (2011). State of the World Population 2011: People and Possibilities in a World of 7 Billion. (United Nations Population Fund: New York). Accessed at: http://www.unfpa.org/public/home/publications/pid/12511 on February 20,2013. p.47 210

UNICEF (2012). Progress for Children: A Report Card on Adolescents. (United Nations Children’s Fund: New York) Accessed at: http://www.unicef.org/publications/index_62280.html on February 20,2013. p.3. 211

ICPD-HLTF, Rights, Dignity and Health for All: Policy Recommendations for ICPD Beyond 2014, 2013.

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shared with other co-organizations, helping others to refine their youth-friendly services and outreach initiatives.

212

As reflected in the ICPD Programme of Action and subsequent international agreements, all young people should have access to comprehensive sexuality education and related services in order to enable them to exercise their rights, understand their bodies, make informed decisions about their sexuality and better plan their lives.213

Many factors contribute to adolescent risk for STIs, HIV, or negative health outcomes of early pregnancy, with even greater vulnerability for some subgroups.214 Many societal issues also contribute to risks for adolescents. The very common age differences between sexual partners, gender differences in norms for sexual behavior and early and forced marriage for girls, all heighten the possibility of sexual coercion, unwanted pregnancy and STIs as well as HIV.215

It is essential to address the unique sexual health needs of adolescents. These needs are distinct from children and adults in terms of physical maturity, cognitive capacity and social skills. However, health services for adolescents are rarely differentiated. SRH services are commonly denied to unmarried adolescent boys and girls. Services for married adolescent girls are delivered through reproductive care for adult women and do not take into account their special needs.216

While data on the sexual and reproductive behavior of adolescents and young people are limited often due to under-reporting, global estimates by the Guttmacher Institute show that 52 million never-married women, mostly adolescents and young women aged 15-24 in the developing world, were sexually active and in need of contraceptives in 2012. The study shows that a steady long-term trend toward increased levels of sexual activity among this group, due to reasons such as the declining age of menarche, the rising age at marriage and changing societal values.217 This trend emphasizes the growing need to ensure that all adolescents and young women have access to sexual and reproductive health services, including contraception suitable to their needs, as envisaged in the ICPD PoA.218 Some countries have adopted progressive measures to address this need (see Box 17).

BOX 17

Youth-friendly services in Malawi

Malawian Ministry of Health has partnered with the Family Planning Association of Malawi and UNFPA to provide integrated youth-friendly sexual and reproductive health services through multi-purpose Youth Life Centres as well as via community-based and mobile services; they have strengthened their infrastructure as part of improving quality of care for young people. Services include contraception, including emergency contraception, pregnancy

212

Report of the High Commissioner for Human Rights on Practices in Adopting a Human Rights-based Approach to Eliminate Preventable Maternal Mortality, A/HRC/18/27. 213

UNESCO (2011). School Based Sexuality Education Programmes: A Cost and Cost-Efectiveness Analysis in Six Countries. (United Nations Educational, Scientific and Cultural Organization: Paris) Available at: unesdoc.unesco.org/images/0020/002070/207055E.pdf 214

L. Bearinger et al. Global Perspectives on Sexual and Reproductive Health of Adolescents, Lancet 2007; 369: 1220–31 215

L. Bearinger et al. Global Perspectives on Sexual and Reproductive Health of Adolescents, Lancet 2007; 369: 1220–31 216

L. Bearinger et al. Global Perspectives on Sexual and Reproductive Health of Adolescents, Lancet 2007; 369: 1220–31 217

Adding it up, Guttmacher 2012. 218

http://www.savethechildren.org.uk/sites/default/files/docs/Charting_the_Future.pdf

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testing, treatment of sexually transmitted infections, HIV counseling and testing, antiretroviral therapy, treatment of opportunistic infections, cervical cancer screening and treatment, general sexual and reproductive health counseling, post-abortion care, and prenatal and postnatal care for teen mothers. The services are promoted through newspapers, advertisements and by word of mouth. Improvements in service infrastructure, the participation of young people in service provision, the integration of sexual and reproductive health and HIV services, and the frequent solicitation of input from young clients—all of these investments have improved the

quality of the sexual and reproductive health services and have significantly increased their use.219

Never-married adolescent girls have a great disadvantage in obtaining contraceptives, largely due to stigma attached to being sexually active before marriage in many societies.220 Young people also face many barriers accessing modern contraception in the all the regions.221 Even married adolescents face difficulties in contraceptive access, when compared to married adults. In regions where contraceptives are available, married adolescents are less likely to use contraception in comparison to adults. In Latin America, Europe and Asia only 42-68% of adolescents who are married or in partnerships use contraceptives. In Africa the rate ranges from 3-49%.222 In countries with higher contraceptive prevalence rates such as Bangladesh and Colombia, married teens do use contraception; however, when these rates are compared with all married women respectively, the contraceptive rates are significantly below those of adult married women. In India, however, where the primary form of contraception is sterilization, adolescents and young married women have a higher unmet need to contraception, because alternatives to sterilization are often not easily available and accessible. 223 The CRC has recommended that states parties undertake comprehensive studies of the nature and extent of adolescent health problems. Such studies would involve the full participation of adolescents,

and be used as a basis to formulate adolescent health policies and programs with particular attention to

reproductive and/or sexual health.224

5.3.3. Human rights and sexuality The last twenty years have seen some fundamental developments in dialogue and intergovernmental agreements about human rights and sexuality, partly because of the HIV epidemic. Recognition is increasing that it is vital to provide individuals access to comprehensive information about sexuality, their vulnerability to the risks and adverse consequences of sexual activity; good-quality sexual health care; skills development for relationships based on gender equality and mutual respect for human rights; and an environment that affirms and promotes sexual health. However as discussed in previous sections (see sections 3 and 4), state response has often been limited and many continue to impose criminal sanctions in relation to sexual and reproductive health. The Programme of Action includes important references to sexuality and gender and their relationship

219

UNFPA, By Choice and By Chance, 2012. 220

Adding it Up, Guttmacher, 2012. 221

Szostak, M; Pabijenek, K. (2012).Reclaiming & Redefining Rights-ICDP+20: Central and Eastern Europe region SRHR youth fact sheet (draft, unpublished). Kuala Lumpur, Malaysia: The Asian-Pacific Resource & Research Centre for Women (ARROW). 222

http://www.who.int/mediacentre/factsheets/fs364/en/index.html 223

http://www.savethechildren.org.uk/sites/default/files/docs/Charting_the_Future.pdf 224

CRC, General Comment 15, 2013.

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to each other. It also recognizes that gender- based sexual violence and efforts to control women’s sexuality affect both women’s health and their status in society.225 Another important feature of the Programme of Action is its recognition that reproductive health includes a satisfying and safe sex life and that sexual health involves “the enhancement of life and personal relations, and not merely disease prevention”.226

Tremendous changes in the engagement of human rights with sexuality have been made over the last twenty years. The issue today is no longer whether human rights will engage with sexuality, but rather involves very particular practical questions: on what terms, for whom, for what purposes, about which aspects of sexuality, and with what limits.227

Initiatives are putting this new thinking into practice, such as organizing to support single women ‘outside the safety net of marriage’ in India, tackling female genital mutilation through pleasure promotion in Kenya, human rights trainings in Turkey which take sexuality as an integral component of women’s empowerment and include a module on ‘sexual pleasure as a women’s human right’. Creative work is also taking place with men as partners of women, as well as explorations of the sexual and reproductive health rights of men themselves. Transgender people are increasingly mobilizing to claim their rights.

New alliances are being forged which take an integrated approach to sexuality, such as the Coalition for Sexual and Bodily Rights in Muslim Societies, and regional Sexuality Resource Centres established in each continent. Such initiatives have enabled people to look beyond their own issue and see the interconnections with other themes, and move towards building a common movement for sexual rights.228

There have been some major advancements in identifying links between human rights and sexuality, ranging from health and rights-oriented declaration of sexual rights by the International Planned Parenthood Federation to the Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity (see Box 18), elaborates principles applicable to sexual orientation and gender identity, an important subset of sexual rights. These are key developments, which already have had a significant local and global political impact.

BOX 18

Yogyakarta Principles

The “Yogyakarta Principles on the Application of International Law in Relation to Issues of Sexual Orientation and Gender Identity” were adopted by a meeting of experts in international law in Yogyakarta, Indonesia, in November 2006. They confirm legal standards for how governments and other actors should end violence, abuse, and discrimination against lesbian, gay, bisexual, and transgender people, and ensure full equality.

The principles address:

rape and other forms of gender-based violence;

extrajudicial executions;

225

Programme of Action para 7.35 226

Programme of Action para 7.2 227

Alice Miller, Sexuality and Human Rights, ICHRP. 228

Pinar IIkkaracan and Susan Jolly, Gender and Sexuality, 2007.

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torture and other forms of cruel, inhuman, and degrading treatment;

medical abuses;

repression of free speech and assembly; and

discrimination in work, health, education, housing, access to justice, and immigration.

6. Using human rights to advance the Programme of Action The progress and achievements of the last twenty years have reinforced the imperative of a further advancement of the sexual and reproductive health and rights agenda as a human rights imperative. Sexual and reproductive health policies, programmes and strategies must be based on gender equality and human rights. They must ensure that everyone can exercise their rights to sexual and reproductive health, free from discrimination, violence and coercion.

The review and appraisal of the Programme of Action is as much a time for celebration as it is an opportunity for introspection. It is an opportunity to assess past achievements, address continuing challenges and develop a credible framework for tracking future progress. As governments meet to assess performance it is important to remind ourselves of the human rights obligation to respect, protect and fulfill sexual and reproductive health and rights. It is also important to examine the gaps and challenges that inhibit performance. This is essential not only for advancing the ICPD agenda but also ensuring that the post 2015 agenda and the new international framework speak to the needs and aspirations of people around the world.