Serra Sippel's blog

Uganda to Reintroduce Female Condoms

2009-06-29T09:00:00-04:00

"When a man comes up with excuses for not using a male condom, women have a right to introduce their own tool for protection."

-- Deusdeait Kiwanuka, Project Coordinator, Safe Homes and Respect for Everyone (SHARE)

Deusdeait's words poignantly capture a major challenge in fighting HIV/AIDS: to ensure women have access to prevention tools designed to put them in charge and give them an opportunity to initiate protection. Enter the female condom - the only safe and effective prevention tool that is designed for women to initiate and is available for use NOW. But "available for use" doesn't necessarily translate into "accessible to women" - whether in the U.S. or abroad.

Consider Uganda, where the Ministry of Health reports that 76% of the country's new infections are sexually transmitted and women make up 60% of those infected. Moreover, 42% of new infections occur in marital sex. These sobering statistics cry out for expanding prevention options that put women in the driver's seat. Despite this, women and their partners currently have no access to female condoms in the country.

Fortunately, the tide is turning for women, men and youth who could benefit from the female condom. The Ugandan government plans to reintroduce and promote the female condom this fall, and civil society leaders in Uganda see this as an opportune moment to accelerate investment and support in this initiative.

Last week, the Center for Health and Gender Equity (CHANGE) and the Global Campaign for Microbicides (GCM) - both US-based organizations advocating for the availability and accessibility of a range of prevention options for women worldwide - convened local leaders from HIV/AIDS, reproductive health, domestic violence, human rights and women's rights groups in Kampala for an advocacy training targeted at donors and national government to ensure successful reintroduction of female condoms in Uganda. As part of the training, participants met with members of the Health Development Partnership Group, which USAID heads; with UNFPA and the Ministry of Health, demonstrating civil society support for the prevention method. Participants also learned about the history of the female condom in Uganda and how to move forward with advocacy efforts beyond the training.

The training was opened by Mr. Benard Mujuni of the Ministry of Gender, Labour and Social Development, who made the case for women's access to currently existing prevention methods such as female condoms - and future products such as microbicides - as a human rights and reproductive rights issue. But in order for female condoms to succeed today, in Uganda and elsewhere, civil society must be full partners in any launch or rollout of female condom programming.

Vastha Kibirige, coordinator of the condom unit at the Ministry of Health, underscored this point by providing an overview of the Ministry's situation analysis of the female condom in Uganda that was released earlier this year. Kibirige explained how the first introduction of female condoms in Uganda in 2000 was not successful, but this was not because of the product. Civil society was not actively engaged in the first rollout of female condoms, and a lack of resources and sustained support for distribution, education and programming, made the existence of the product useless.

Accessibility issues explained by Kibirige posed very real problems for many women. For example, a participant from the Center for Domestic Violence Prevention recounted how domestic violence fuels women's requests for female condoms in situations of martial rape. Sometimes, when these women are able to negotiate condom use, men come up with excuses or resist using male condoms. Her clients say that if they had female condoms with them, they could put them on before they have sex, giving them an additional tool for negotiation and protection.

This is not to say that female condoms are a magic bullet or that access alone will ensure successful use and uptake. But the group did highlight the concept of "universal acceptability" - a different way to think about and advocate around female condoms. This frame calls for removing stigma and biases often associated with female condoms, allowing men, women and youth to freely choose female condoms as a legitimate prevention option.

Finally, against the backdrop of our discussions around women's high risk of infection from marital sex and lack of access to female condoms, it was interesting to note PEPFAR's abstinence and fidelity impact on Uganda. In our shuttle bus to meet with USAID and other donors in the Health Development Partnership Group was a bumper sticker with wedding rings, stating "Stop AIDS. Keep the Promise," "Be Faithful in Marriage." It's clear that much more work needs to be done.

Let's hope the Obama administration, especially the new global AIDS coordinator and USAID administrator will turn the tide for women and men and young people in Uganda by supporting the Ministry of Health's efforts to save lives by making female condoms accessible.

Candidates Must Address Global Reproductive Health in First Debate

2008-09-24T08:00:00-04:00

In the upcoming presidential debate on foreign policy issues, will candidates be asked to address sexual and reproductive health and human rights of women as a critical component to our nation's foreign policy? I submit that if we truly want to regain international credibility and legitimacy, the U.S. must become a collaborator with our global neighbors on a variety of issues. Why not start with the global crises women face throughout the world regarding fundamental sexual and reproductive health and rights?

In this Friday's debate, the candidates should be pressured to talk about stands they would take involving women and sexual and reproductive health. Let moderator Jim Lehrer ask for responses to the facts:

80% of HIV infections are sexually transmitted and women account for more than half of those infected worldwide
Women are 61% of those infected with HIV and AIDS in sub-Saharan Africa, the region most heavily hit by the HIV/AIDS pandemic
200 million women experience yearly an unmet need for contraceptive services
80 million unintended pregnancies occur each year, 60% of which end in abortion
500,000 women die each year from pregnancy-related complications
68,000 women die each year from unsafe abortions

The U.S. led the world for decades in supporting voluntary family planning programs. Prior to 2000, the U.S. joined other governments in signing international agreements that recognized the rights of individuals--including adolescents--to have access to accurate information and services to prevent unintended pregnancies and HIV infections. Yet for the past eight years, a very different U.S. government waged a narrow, moralistic crusade against sex and reproduction--at times alone, and sometimes in the eclectic company of the Vatican.

Will the candidates continue the U.S.'s so-called "balanced" approach to global HIV prevention that promotes abstinence and fidelity within marriage as the best ways to prevent HIV infection, even where marital sex represents the greatest risk for women? Or would candidates commit to promoting HIV prevention interventions that are based on evidence and are proven effective? Ask whether as president they will ensure that U.S. foreign policy advances the right to obtain information and to assure that individuals have access to comprehensive information, tools and skills so that they can decide freely what prevention method makes sense for their realities, whether they are young, old, man, woman, married, single, gay, straight, rich, poor.

Will the candidates be asked to commit to funding the United Nations Population Fund (UNFPA), the UN agency effectively supporting a range of critical sexual and reproductive health programs and services? Are they aware that the U.S. has withheld funding from UNFPA based on a falsehood that UNFPA supports coercive family planning in China? Do the candidates understand the facts, which were delineated to the current Administration by assessment teams--including delegations from the State Department and faith-based leaders--which found that UNFPA does not support or participate in managing coercive family planning programs in China, and in fact has been a catalyst for change in China?

Will the candidates address the crisis of maternal deaths due to unsafe abortions by supporting public health best practices to ensuring that abortions are safe? I would like to hear the candidates commit respect for all people to exercise free speech and assembly and standard ethical practices. Where groups are honest and open with patients about abortion or decide to legalize abortion in their countries because women and girls are dying, they should not be punished with denial of U.S. foreign assistance (read: rescind the Global Gag Rule). And I'd like to see candidates decide that it is time that federal funds be used to provide safe, legal and voluntary abortions to those who cannot afford the procedure-overseas and at home (read: ask Congress to repeal the Helms and Hyde Amendments).

And what about sex workers? Would the candidates declare that sex workers deserve dignity and respect and have rights to U.S. assistance and HIV prevention? This question should be posed because these Senators both supported legislation to reauthorize PEPFAR with the condition that organizations have a policy explicitly opposing prostitution, and further requiring that funds cannot be used to promote or advocate legalization of prostitution. Such puritanical policies undermine public health and human rights, while exacerbating stigma and isolation of marginalized persons, and putting at risk the lives of sex workers, their clients and partners.

There is much talk these days about U.S. foreign assistance reform. Much of this talk concerns global humanitarian organizations--many who are recipients of U.S. assistance. But not much is being said about sexual and reproductive health and rights. And I doubt the presidential candidates will volunteer answers and therefore must be rigorously asked.

In a recent article for the ABA Human Rights magazine, I make recommendations for U.S. foreign assistance reforms that advance sexual and reproductive health and rights, which is expanded here:

Institute greater transparency for foreign policy goals related to sexual and reproductive health and rights, delineating what the United States is trying to accomplish through its funding.
Align U.S. foreign assistance with the ICPD Programme of Action and the Millenium Development Goals. Build on the successes of European donor nations, and pool resources where creative partnerships are happening.
Create two new cabinet-level posts: one for global development and the other for women, making women's equality and sexual and reproductive health and rights a priority of U.S. foreign policy.
Adopt modalities to ensure that U.S. funding goes directly to innovative, smaller grassroots organizations that promote sexual and reproductive health and rights and gender equality, and make sure U.S. money gets in the hands of women.
Eliminate restrictions and unnecessary reporting requirements, and fund comprehensive sexual and reproductive health programs that integrate HIV prevention based on public health best practices and human rights standards.

The U.S. must abandon its self-absorbed role as Decider-in-Chief of morality and personal decisions on sex and reproduction. The U.S. must become a collaborator in the global arena, leading by example-leading by serving those who suffer most from ideological restrictions on sexual and reproductive health assistance.

I look forward to watching the Friday debate to see if any candidate has chosen his path--Decider or Collaborator for women and sexual and reproductive health and rights.

World Bank Reproductive Health Strategy

2007-05-08T08:45:00-04:00

The Bush administration has gained notoriety for using women's health as a pawn in catering to its ultra-conservative political base. Particularly noticeable is its attempts to narrow the scope in which international agreements and agencies address sexual and reproductive health and rights, such as attempting to remove references to reproductive rights and access to reproductive health services in UN documents, cutting off U.S. funding for UNFPA, and trying to restrict WHO positions on abortion and generic drugs. To this administration, women are always dispensable.

Most recently, the Bush Administration has used its appointees to the World Bank—Bank president Paul Wolfowitz and U.S. Executive Director to the Bank's board, E. Whitney Debevoise—as conduits to impose its ideology on Bank policy

At the same time Wolfowitz came under fire for the Riza pay-raise affair, the Government Accountability Project exposed a leaked draft of the Bank's Health, Nutrition and Population Strategy (HNP Strategy) with virtually no references to family planning or sexual and reproductive health and rights (SRHR). The draft was reportedly "censored" by Juan José Daboub, who was appointed by Wolfowitz as managing director of the Bank. Daboub, former finance minister of El Salvador and said to be a member of Opus Dei, is a strong supporter of the Bush administration's anti-family planning policies. In separate but related incidents, Daboub sought to remove references to family planning from the country assistance strategy for Madagascar and attempted to water down references to "climate change" in the Bank's key strategy paper on the environment.

News traveled quickly and the International Planned Parenthood Federation and Center for Health and Gender Equity organized letter-writing campaigns to foreign affairs, health and finance ministers, asking them to pressure Bank Executive Directors (EDs) to include references to SRHR in the new HNP Strategy.

Bank officials responded that the leaked draft had been revised, and language referencing SRHR was restored. This revision was thanks to Heidi Marie Wieczorek-Zeul the German development minister who is an expert on Cairo and Beijing and a gender champion for the Bank. She successfully garnered support from the Norwegians and the British to re-insert SRHR references into the document.

Understandably, the Bank reached out to groups to try to calm the storm that was brewing, sharing excerpts from the revised document that mentioned SRHR. Bank officials met with some groups to hear their concerns, and in turn, groups got to hear Wolfowitz's rhetorical support for family planning and Daboub's recitation of his dubious memo denying allegations of tampering with text.

The new language that was inserted, however, was extraordinarily weak and unacceptable to SRHR advocates. Organizations sent letters to the EDs calling attention to the weak language and urged them to reject any document without strong language and a clear Bank endorsement for SRHR. A few groups worked quietly behind the scenes with Bank staff to influence the language.

As a result of the continuous advocacy inside and outside the Bank, and especially the pressure from European advocacy groups and European parliamentarians, a group of European EDs sent an office memorandum (PDF) to the vice president and sponsor of the Strategy document, rejecting the document and threatened postponing the April 24 board meeting if language was not revised. Consequently, the Bank produced another draft, this time with clear endorsement for SRHR.

Mission accomplished? Not likely. Now that Daboub's efforts were foiled, in came the U.S. ED, Debevoise, with further attempts to role back Bank policy on SRHR. Debevoise sought to insert the phrase "age-appropriate reproductive health care," which the Europeans rejected immediately because of the implications for the health and lives of young women and adolescents in developing countries. Debevoise also sought to replace reproductive health "services" with "care" and reproductive "rights" with "health."

Advocacy groups made a final attempt to save SRHR language by sending another round of letters to the EDs.

In the end, the U.S. ED was defeated and on April 30, the World Bank's 10-year Health, Nutrition and Population Strategy (PDF), was approved by the Bank's Executive Board, reaffirming the Bank's longstanding endorsement of the Cairo consensus and ensuring that the Bank would continue to devote financial and technical resources to sexual and reproductive health.

There is no doubt this was a victory. However, it is the kind of victory that is far too common under this U.S. administration—one where we simply hold our ground rather than actually make progress. Given the short time frame and the level of crisis, we needed a coordinated advocacy effort that was focused. In this instance, it was to ensure not only that the Strategy included references to SRHR, but that those references would have serious and effectual implications in the Bank and the field.

As a consequence of this narrow focus, we were limited in our victory. Instead of moving the Bank forward to include progressive language—like explicit support for access to safe abortion services and reference to the role of gender-based violence in the spread of HIV—we held the line—a line established 13 years ago. While we embrace the principles of the ICPD Programme of Action, it did not go far enough in 1994, and in 2007, we should be demanding so much more than what we achieved in Cairo.

The challenge now is twofold. As an advocacy community, we must monitor application of Bank agreements at the country and regional level and ensure that at the core of each country strategy is an effort to promote SRHR and women's fundamental human rights. We also need to continue to build and expand advocacy for SRHR so that we can move away from defending SRHR to advancing SRHR.

An Overdue Conversation: Meeting the Sexual and Reproductive Health Needs of Orphans, Vulnerable Children and Youth

2007-01-29T08:00:00-05:00

Serra Sippel is the Deputy Director at the Center for Health and Gender Equity (CHANGE).

Attention to the lives of orphans and vulnerable children has increased with celebrity adoptions of African children by Madonna and Angelina Jolie and Brad Pitt, and the opening of an elite school for girls in South Africa by Oprah Whinfrey. For decades children (defined as children under the age of 18) have been targets for acts of charity by celebrities, focusing on their special needs: food, education, vaccinations, and health care. But rarely addressed, if at all, are the very real sexual and reproductive health needs of orphans and vulnerable children (OVCs).

Throughout the world, children and youth are living without the support, protection and care of parents. They are also often abandoned by the state, making them susceptible to violence, exploitation and disease. Many of these youngsters are condemned to live on city streets, in conflict and war zones, and in refugee camps where there is no protection from violence, coercion and exploitation. Many are caring for siblings and dying parents—often selling sex to support them—and are at risk of exploitation and HIV infection. Some are already infected with HIV and often lack the skills and knowledge to prevent sexual transmission of the virus to others and re-infection for themselves.

Studies confirm this. One recent study in Zimbabwe found a greater number of HIV infections among female OVCs ages 15-18 than among their non-OVC peers. In addition, the female OVCs experienced higher rates of STI symptoms and teenage pregnancy. A study in Rwanda and Zambia examining sexual behaviors of 10-19 year-olds found that those who were orphaned experienced earlier sexual debuts than non-orphans.

These young people live as best they can without protection from HIV infection, other sexually transmitted infections (STIs) and unintended pregnancies, and they suffer—young women and girls in particular—when their sexual and reproductive rights are not upheld.

Sexuality is basic and fundamental to our humanity. Yet many today have difficulty—some actually experience discomfort—addressing issues of sex and sexuality. This is especially true of young people's sexuality. In fact, one could rightly assert that the global community has been remiss in addressing sexual and reproductive health and rights of children and youth.

This negligence is found at both the national and international levels and much of it is driven by ideological and extreme religious perspectives on both sexual and reproductive health and rights and the rights of children. At the 2002 United Nations Children's Summit, the United States (one of only two countries—the other Somalia—that has not ratified the Convention on the Rights of the Child) joined the Holy See and a block of conservative Islamic states to obstruct consensus on issues related to the sexual and reproductive health and rights of youth, objecting to comprehensive sexuality education for youth and insisting upon abstinence-only education. They sought to uphold the rights of parents to control information communicated to their children, which meant they also opposed confidential counseling for youth.

Although "children" has been defined as individuals below the age of 18 (Convention on the Rights of the Child), most people hear "children" and envision a five-year-old rather than an adolescent or teenager. I propose that we change our language so that instead of OVCs we say OVCYs (orphans, vulnerable children and youth); this will enable policy makers and advocates to better understand the diverse needs (including, but not limited to, sexual and reproductive health) of this population.

Some fear that giving children and youth too much information about sexuality, reproduction and methods to avoid unintended pregnancies and STIs will encourage sexual promiscuity. But evidence shows that access to comprehensive sexuality information delays debut of sexual intercourse and protects those youth who are or will be sexually active from STIs and unintended pregnancies. And in light of the HIV and AIDS epidemic, information and services about safer sex—including condom use—as well as confidentiality and informed consent are critical to meeting the health needs of children and youth, especially those who are orphaned and vulnerable.

We cannot ignore reality. And the reality is that ignoring the sexual and reproductive health and rights of orphans and vulnerable children leaves them vulnerable.

If we are serious about providing real support to them, programs for OVCYs must integrate age appropriate, gender sensitive, comprehensive sexual and reproductive health services and education in order to meet the basic needs of this growing and vulnerable population.