B Explanatory memorandum
by Ms Petra Stienen, rapporteur
1 Introduction
1. Imagine if we had to choose
one thing that would improve everyone’s life quality. I believe
that for many people, that would be ensuring the ability to make
free, autonomous and well-informed choices about their sexuality
and their family life. Sexual and reproductive health and rights
(SRHR) are the human rights related precisely to that: planning
one’s own family, the ability to have a satisfying and safe sex
life, and the freedom to decide if, when, and how often to have
children. These rights are particularly linked to gender equality
issues and are often dealt with from the perspective of women’s
empowerment. They nevertheless concern every individual, irrespective
of their age, gender, sexual orientation or gender identity.
2. Current SRHR national legal frameworks lead to health outcomes
which disproportionally affect women who are young, poor, living
in rural areas or in vulnerable situations and who, for diverse
reasons, suffer discrimination in access to contraception, safe
and legal abortion, cervical cancer prevention, protection from gender-based
violence and access to comprehensive sexuality education. All these
factors prevent women’s full enjoyment of their rights, dignity
and integrity.
3. Sexual and reproductive health and rights are relevant to
everyone. However, up to now women have been the first concerned
by the shortcomings of policies and legislation in this area: the
consequences of the lack of access to SRHR, including unwanted pregnancies
and health risks when abortion is denied, are largely borne by them.
I believe that there should be a change in attitudes and mentalities,
both concerning upholding SRHR and assuming responsibilities. Taking
the example of contraception alone, the management of planned contraception
has been seen solely as a woman’s responsibility for far too long.
Recently, this state of affairs has been challenged in some forums
and male contraception methods have been discussed. Further research on
these methods should be strongly encouraged.
4. Several developments at international level make this report
timely and relevant. In 2019, the global community reaffirmed the
1994 International Conference on Population and Development Programme
of Action, adopted at the Nairobi Summit. At European level, the
ten-year anniversary of the Istanbul Convention on preventing and
combating violence against women and domestic violence (CETS No.
210, “Istanbul Convention”) is being celebrated. At national level,
while there has been an improvement in the enforcement of SRHR,
this area has become more controversial and polarising, making it
difficult to consolidate the progress achieved and increasing the
risk of setbacks in legislation and policies.
5. The Covid-19 pandemic has had an impact on this area. In particular,
it has highlighted the need to address shortcomings in access to
SRHR and to identify good and innovative practices which successfully guarantee
access to relevant services.
6. This report covers several areas of SRHR where innovation
is taking place, such as design and technology, medicine (with a
focus on pharmacology and the promising developments in male contraception), “ehealth”
(healthcare services provided electronically via internet) and communication.
7. I believe that the concept of sexual and reproductive health
and rights should be interpreted in wide terms and not limited to
long established issues such as contraception, interruption of pregnancy,
sexually transmitted diseases and sexuality education. An intersectional
approach to this matter helps us identify additional aspects, such
as the challenges that transgender people face and, in addition
to the right to self-determination in sexuality and reproduction,
should lead us to include in this area, the right to self-determination in
gender identity and bodily autonomy.
8. I personally believe that a shift in culture and attitudes,
rather than merely in legislation and policies, is needed. We should
not forget that sexuality is an important and ubiquitous aspect
of human life and one that is linked to physical and mental well-being,
pleasure, communication, and interpersonal connection. It is in
this positive light that we should assess and improve the regulations
on sexual and reproductive health and rights. Patriarchal values
perpetuate rules and boundaries that have been set a long time ago
to target first and foremost women. It is important to underline
that these rules and boundaries ultimately affected the entire population.
Such arbitrary rules have progressively fallen and have been replaced
by the recognition of personal freedom and a right to self-determination
in many places. This freedom is too often threatened by “reproductive
coercion”, a relatively new term that is currently used to refer
to any behaviour that interferes with the autonomous decision making
of a person, with regards to reproductive health. Guaranteeing and
further expanding freedom, rights and care for all, without discrimination,
should be our top priority as a way to respect human rights for
all.
2 Time for a change: innovative approaches
to SRHR
9. Remarkable progress has been
achieved in gender equality in the last decades, with an increase
in women’s participation in the economy, in public and political
life, and stronger action to prevent and combat violence against
women. It is now time to step up our efforts and improve substantially
the access to sexual and reproductive rights. This requires an innovative
approach and increased attention to innovation in various areas.
These include communication, information and awareness raising,
education and, crucially, science, technology and design.
2.1 “Together
for yes”: the Irish example on campaigning for abortion
10. Using accurate, precise language
is important when dealing with sexual and reproductive health and rights,
an area too often plagued by insufficient or incorrect information.
A remarkable example of innovative communication in this area is
the campaign “Together For Yes”, which contributed substantially
to repealing the 8th Amendment and the consequent legalisation of
abortion in Ireland by referendum in May 2018. The unequivocal result
of the vote (66% for Yes) was, in the words of the organisers of
the campaign, “a seismic shift in the struggle between the forces
of religious, moral and cultural conservatism and those of social liberalism
in public policy”.
11. Aware of the important achievements of their work, the co-directors
of the initiative commissioned a review of the campaign in order
to share their strategy and working methods.
Note Crucially,
one of the goals of the campaign as presented in the review was
to “put forward robust fact and evidence-based arguments to counter scaremongering
and misinformation”. Setting up an evidence-based campaign meant
relying mainly on case studies demonstrating the harms of the criminalisation
of abortion, and on technical, medical and legal expertise. Communication
was based on three main axes: “Firstly, setting the tone as informative,
reasoned, calm, and non-confrontational to assure a cautious public
that the campaign would not engage in the kind of bitter and divisive
debate the public was used to. Secondly, to centre abortion as a
necessary part of women’s healthcare. Lastly, to shift the traditional
emphasis of the debate from ‘choice’ to ‘needs’; from ‘rights’ to ‘healthcare’,
and from ‘judgement’ to ‘empathy and compassion’”.
12. On 1 June 2022, while in Dublin for the meeting of the Standing
Committee of the Parliamentary Assembly, I met with Ailbhe Smyth.
Ms Smyth was one of the founders of “Together For Yes”, and therefore the
best person to tell me more about the campaign and the reasons of
its success. It is now clear to me that a series of factors contributed
to it, one of which was time: the process leading to the referendum
started in 2012, after the death of a 31-year-old woman, Savita
Halappanavar, who had been denied medical care due to the lack of
clear guidelines on abortion, and it lasted for 6 years until the
referendum was actually held in 2018. Meanwhile, the referendum
on equal marriage had marked a radical change in Irish society and
politics.
13. When in 2017 it became clear that the government would call
a referendum, a broadly based coalition was formed, which included
not only feminist movements but also left-wing and other socially
progressive political forces. Anti-choice forces, on the contrary,
were fragmented and worked separately. The Catholic Church, which
had unsuccessfully opposed marriage equality in 2015, failed again
to have an impact on the outcome of the referendum. In the wake
of several scandals, particularly on child abuse cases and on the Magdalene
laundries, the credibility of the Church had waned.
14. “Together for Yes” chose to engage as little as possible with
their opponents, and rather to talk directly to the electorate.
They gave voices to those that people trusted the most: doctors
and women who had had an abortion. Real stories of women, who had
often had to travel abroad to obtain abortion care, were an important part
of the campaign, as they helped to persuade the electorate. Telling
their story was the beginning of healing for their entire country.
The experience of the campaign confirmed that story telling matters.
At the same time, it requires protection for those who share their
story: it is crucial to prevent secondary victimisation.
15. To sum up, crucial elements of the successful 2018 campaign
in Ireland were a long-term strategy, clear messages based on real-life
experience and on scientific knowledge, and broad coalition building.
These elements, and particularly the evidence-based approach and
the priority given to scientific and technical knowledge remain
an important legacy of this campaign and a lesson to learn for all
those who intend to promote the access to sexual and reproductive
health and rights.
2.2 The
right to sexual well-being and pleasure
16. Promoting sexual and reproductive
health requires a positive approach, free from patriarchal values dictating
the role of women and men within family and in society. It also
means acknowledging that every individual has a right to self-determination,
sexual well-being, and pleasure. As the World Health Organisation states,
“sexual health, when viewed affirmatively, 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”.
Note
17. I had an insightful meeting with Lisa de Pagter, an advocacy
officer at Dutch foundation Rutgers and a board member of Seksueel
Welzijn Nederland (Sexual Well-being the Netherlands), an organisation
founded by the late Ellen Laan, a highly respected figure in this
area in the Netherlands. Rutgers has worked with young people on
sexuality for more than 50 years. In their own words, “sexual and
reproductive health and rights encompasses both physical, mental
and social well-being. It is about the individual, their relationships
and wider society. It is about pleasurable sexual relationships,
self-esteem, trust and communication.” I can only subscribe to this
understanding of the concept of SRHR. This organisation carries
out programmes in different regions of the world in areas including
contraception and safe abortion, sexual and gender-based violence,
as well as sexuality education. Among their programmes I would like
to mention is “Dance4Life”, which works with young people worldwide
on unsafe sex (“the fastest growing health risk”), using the power
of dance and music to enable young people to empower themselves
by discussing openly and learning about sexual health.
18. Together with Lisa de Pagter, I met Nienke Helder, a young
designer who works on sexual well-being. She is the creator of “Sexual
Healing”, a research project aiming at innovating the approach to
overcoming “sexual dysfunctions” faced by women as a consequence
of traumatic experiences. She observed that “while sex life is a
highly personal thing, the treatment of trauma-induced female sexual
problems such as pelvic muscle blockage is often clinical, focuses
on physical issues, and takes penetration as its ultimate goal”. Nienke
Helder’s project, developed in co-operation with medical and paramedical
experts and women who have experienced traumas, focuses on designing
a therapy from the point of view of finding pleasure. The project
is based on a set of sensory objects to be used by women “to explore
what feels good to help relieve fear and pain and (re)gain a sense
of security about what their bodies enjoy”.
Note
2.3 A
new term for an age-old threat: “reproductive coercion”
19. I consider it important, particularly
for all those who support human rights and fundamental freedoms,
to apply the notion of “reproductive coercion” to behaviour that
interferes with the autonomous decision making of a person with
regards to reproductive health, whether in the form of contraception
sabotage (for instance removing or damaging a condom, or a contraceptive
patch), coercion or pressure to become pregnant, or controlling
the outcome of a pregnancy (for instance, pressure to continue or
to terminate a pregnancy).
Note Reproductive
coercion was first defined and analysed around a decade ago and
is closely related to gender-based violence, as “one of many forms
of power and control exercised by an abusive partner”.
Note It
is far from a marginal problem: a study published in 2019 in the
BMJ Sexual and Reproductive Health journal revealed that one in
four women at sexual health clinics reported coercion over their
reproductive lives, including “contraceptive sabotage”.
Note
20. This type of coercion may be exercised at many levels: by
individuals, often within an intimate partner relationship, by family
members or religious leaders but also at medical level and at State
level, through legislation and policies unduly limiting the enjoyment
of sexual and reproductive rights and thus the individuals’ reproductive
freedom. I wonder if we should not draw a parallel between the concept
of reproductive coercion perpetrated by individuals, particularly
in the setting of an intimate relationship, and the undue limitations
on people’s reproductive freedom deriving from legislation and policies
that hinder the access to sexual and reproductive healthcare, thus
limiting the enjoyment of relevant rights. The behaviour may be
different, but the ultimate impact on individual freedom is similar.
21. Preventing and sanctioning reproductive coercion should be
part of legislation and policies on gender-based violence. Whether
it manifests itself as physical violence or in other forms, such
coercion is a limitation of personal freedom, mainly targeting women,
that may have a seriously harmful impact and must not be ignored
or underestimated.
2.4 ehealth:
making access to SRHR easier and safer thanks to internet
22. Technological innovation in
the area of sexual and reproductive healthcare is making sexual
and reproductive healthcare more easily accessible and safer through
eHealth, which is the use of information technology tools, such
as computers, communication satellites and patients’ monitors for
healthcare. Mobile health or mHealth is part of eHealth and refers
more specifically to the use of portable devices, particularly mobile
phones, in this area.
23. The World Health Organization (WHO) fully supports eHealth.
In 2005, the World Health Assembly urged member States to consider
developing and implementing eHealth to promote equitable and affordable healthcare
access for their citizens
Note and
in 2013 it adopted a resolution on eHealth standardisation encouraging
member States to establish a national eHealth strategy. In 2019,
WHO released its first guidelines on eHealth interventions. More
precisely, it made recommendations on 10 ways countries can use
digital health technology, accessible via mobile phones, tablets,
and computers, to improve people’s health and essential services.
The guidelines included, among others, using mobile devices to send
notifications of births and deaths, and telemedicine to allow people
living in remote areas to access health services by using new technology
tools (mobile phones, web portals etc). It also stressed the importance
of training healthcare providers to adapt to digital technology
tools and to use them efficiently.
Note In its resolution
of 26 May 2018 on digital health, the World Health Assembly urged
member States to “assess their use of digital technologies for health
at the national and subnational levels”, and “to consider how digital
technologies could be integrated into existing health systems infrastructure.”
It also proposed “to strengthen public health resilience, to improve
the digital skills of all citizens and to develop legislation and/or
data protection policies around issues such as data access, sharing
etc. and to communicate these on a voluntary basis to the WHO.”
Note
24. In addition, WHO, in collaboration with the International
Telecommunications Union and the Regional Ministry of Health of
Andalucia (Spain), created the European mHealth Innovation Hub,
Note a mechanism which aims to help countries
to integrate the use of mHealth in national healthcare services.
25. The tools provided by eHealth include:
- public platforms with reliable information and resources
regarding sexual and reproductive health issues to counteract misinformation
and disinformation such as the “foetal heartbeat at 6 weeks” myth;
- online consultation and counselling that would ensure
confidentiality on sexual and reproductive health related issues;
- online and at-home testing for sexually transmitted infections
for people that cannot or do not want to visit clinics for testing;
- the potential use of artificial intelligence to screen
for sexually transmitted infections and to provide anonymous medical
advice to help overcome the barrier of embarrassment;
- at-home testing of fertility for women and men to increase
their reproductive autonomy;Note
- the promotion of new technologies (online prescription)
that allow early medical abortions.Note
26. As concerns public information platforms, according to the
findings of civil society organisation European Parliamentarian
Forum for Sexual and Reproductive Rights (EPF), several European
governments provide online information on SRHR. EPF has listed these
countries and rated the quality and accessibility of such information
in the Contraception Policy Atlas Europe, which is updated yearly.
The 2022 edition of the Atlas shows that only 18 European countries
(39%) provide governmental websites, of which 16 may be considered of
good quality.
Note These include Austria, Belgium and
Norway. As EPF representative Marina Davidashvili explained to me,
“we believe that in the era of fake news and young people looking
out for information online, governments have the responsibility
to provide high quality and evidence-based information to the people
on their SRHR”. It is therefore important that every government
responds to its role and ensures that citizens are properly informed
regarding SRHR.
27. Applications in the area of sexual and reproductive healthcare
are beneficial for several reasons: first of all, they contain a
wealth of information that is easily accessible to anyone, not only
via computer but in most cases also via a smartphone. Information
is generally presented clearly and structured in categories, which makes
it easier for users to find the answers to their queries. Some users
find books and other traditional forms of publication overwhelming,
especially when they need to solve a specific doubt. “The smartphone
approach is particularly promising given the many challenges of
providing a quality sexual health education for young people of
either gender in many countries and regions. About half of the world’s
population now has a smartphone and those numbers continue to grow”.
Note In addition, many of the available
apps can be used free of charge and function also without an internet
connection. Lastly, and particularly important, users access the applications
anonymously.
Note This creates a less intimidating environment,
as most young people are hesitant to refer to a family member or
even a doctor to solve their questions on sexuality.
28. Applications cannot substitute a doctor’s appointment, but
they can provide information that may both help users to address
a specific situation and, more generally, educate them about their
body, their sexual health and reproduction. In this context, it
is useful to present some of these applications and explain their functioning:
- Ovia
Fertility and Cycle TrackerNote is a fertility tracker application.
It allows women to narrow down their ovulation day and figure out
their cycles, as it includes an ovulation calendar and another calendar
to track the different events during the cycle. The app also provides
thematic articles on fertility and conception. Users can save data
for offline use and export it to an Excel file too. Users can introduce information
on their period, mood, intercourse, basal temperature, blood pressure,
and so on. The information is processed by the app and presented
in multiple ways, providing for a personalised navigation.
- My Sex Doctor is
a sexual health and information app which was created “for people
who didn’t get the sex education they could have used.”Note It provides information on a
range of issues such as puberty (a category “what’s happening to
my body” refers to changes happening at puberty age), abortion, menstruation,
relationships and more. The app can be used without an internet
connection, which makes it even more accessible. Users’ reviews
praise among other things the app’s structure, as its various sections
such as “Topics”, “Dictionary” or “Symptom checker” clearly categorise
the content helping users to find their way to the information they
need.
- Girl Talk is an
American application designed specifically for younger users. It
was originally created by gynaecologist Lynae Brayboy to help prevent
unwanted pregnancies. Its four guiding principles are: trusted sexual
health information, visually appealing graphics, compatibility with
iPhones, and age-appropriate, straightforward content. The content
was adapted from various sources, including the Department of Health
and Human Services’ Office of Adolescent Health and Planned Parenthood.
The information provided covers topics including anatomy and physiology,
sexuality and relationships, contraception, sexually transmitted
infections, and body image. Researchers praised this app as beneficial:
“the reported usefulness of Girl Talk as a sexual health application
increased significantly and knowledge improved most in topics such
as anatomy and physiology and STI prevention. Although most participants
(76.5%) stated that they had been previously exposed to sexual health
information, 94.1% of participants stated that Girl Talk provided
new information than outlined in health class.”Note
- BedsiderNote is a birth control reminder
application. In other words, this application reminds users through notifications
to take the contraceptive pill, to switch the ring monthly, to replace
the patch weekly, or to take the Depo Provera injection (progesterone,
a hormone used to prevent ovulation) depending on which contraceptive
method each user has chosen. There is an option to snooze the reminder
for up to six hours. If this period is exceeded, the application
sends a message mentioning the use of a backup birth control method.
The notifications sent are humorous, making the procedure appealing
to the user. The application can also be set to remind of medical
appointments or help to find emergency contraception.
- an example of an application created in Africa is InfoAdoJeunes,Note made available
in 2020 by the Association Togolaise pour le Bien Être Familial
(ATBEF), a member association of the International Planned Parenthood
Federation (IPPF) in Togo, to provide information on sexual and
reproductive health to young people. In the early times of the Covid-19
pandemic, the application proved popular with its target public,
as young people are accustomed to using mobile phones to obtain
information. The application is evidence-based and accurate, uses
simple language and has a colourful layout, making navigation easy
and amusing. It contains eight navigation options, namely: comprehensive
sexual education, menstrual cycle, contraception, teleconsultation,
web TV, games and quizzes, a chat forum, and a tab where users can
ask an expert a question. Conceived in the pandemic era, the app
provides services such as teleconsultation, for people who have
no access to hospitals and healthcare services.
29. It is worth noting that sexual and reproductive applications,
while beneficial at many levels, may expose their users to some
danger in connection with the highly personal information they collect.
In the United States, in the wake of the overturning of the Supreme
Court’s
Roe v. Wade decision
which may lead to banning or severely restricting access to abortion
in much of the country, some experts and activists invited women
to delete all menstrual apps, as the information they contain may
be incriminating.
Note Even applications tracing people’s
movements could be used by investigators if States pass legislation
forbidding women to travel where abortion is legal.
Note While the alert was triggered with
regard to recent developments in the United States, we should remain
vigilant to the situation in Europe as well. Public authorities
should refrain from using personal and medical information for purposes
of reproductive coercion, and prevent and sanction any such misuse, perpetrated
by any individual or organisation.
30. Besides mobile apps, I would like to mention a website named
Pussypedia
Note whose aim is to combat misinformation
on key issues of women’s life and to provide accurate and coherent
information. In addition to women’s anatomy and sexual and reproductive
health, Pussypedia includes articles on social issues, covering among
other things trans, intersex and nonbinary bodies and stereotypes
connected to patriarchy. The articles are written by a community
of people all over the world in a simple and appealing language.
The website is full of illustrations and colours and is linked to
a book, which it aims to constantly update. While it differs from mobile
apps, this website is part of the more general phenomenon that sees
online technology used to grant easy access to information on sexual
and reproductive health and rights, combined with multi-theme analysis.
3 Male
contraception: state of play
31. Traditionally, the burden of
contraception has always fallen on women. Some women spend several decades
of their life trying to avoid pregnancy. This “fertility work” may
be viewed as one of the many aspects of women’s unpaid work. In
this sense, it eventually contributes to gender inequality.
Note Fertility
work encompasses not only the physical burdens of contraception,
including a long list of side effects, but also the financial and
mental burden of it.
Note Overall,
female contraceptive methods tend to be more expensive than male
methods mainly because most require at least one visit to a doctor
while some require a renewable prescription.
Note Additionally, due to the hormonal nature
of various female contraceptive methods, they produce more serious
side effects than male methods. As a result, almost 50% of women
discontinue the use of hormonal contraception after 1 year because
of adverse side effects.
Note
32. The development of new male contraceptive methods would not
only alleviate the burden of contraception on women but would also
give men reproductive autonomy. At present, effective male contraceptive
options are limited to condoms and vasectomy. Worldwide, none of
these methods account for more than 7% of contraceptive use as most
men rely on female compliance with contraceptives.
Note The
reason men bear so little responsibility for birth control lies
heavily in outdated gender norms such as the idea that women should
be the primary caretakers of children.
Note The
feminisation of contraceptive use began well before the invention
of the female birth control pill, but the rapid popularity of the
pill led to a real shift and men were essentially absolved from
contraceptive decisions.
Note Nevertheless,
a shared responsibility model would be much more effective in preventing
unwanted pregnancies as one woman can only get pregnant once within nine
months while a man can cause a much higher number of pregnancies
in a year.
33. Even though the research to develop hormonal male contraception
started at the same time as the development of female hormonal contraceptive
methods, the availability of a long-acting and reversible method of
hormonal male contraception remains an unfulfilled need.
Note An important
number of studies on hormonal male contraception have been terminated
early due to the appearance of side effects such as mood disorders and
decreased libido, while women on hormonal birth control have been
enduring such side effects for decades.
Note
34. On the bright side, hormonal male contraceptive pills exist
that have been proven to be highly effective and safe to use in
recent years.
Note.Studies
show that an experimental male oral contraceptive is successful
in decreasing sperm production with the help of a modified testosterone
that has the combined actions of androgen and progesterone, while
preserving libido.
Note Although
there are some concerns around the acceptability of a hormonal male
contraceptive, surveys suggest that a hormonal contraceptive method
would be welcomed by a large percentage of men and most women in
stable relationships would trust their partner to use it.
Note However, women in casual relationships
had less trust that their male partners would use the male pill
effectively.
Note Studies also show that even
under conservative assumptions, the introduction of a hormonal male
contraception could contribute to averting unwanted pregnancies
and the impact would be especially great in settings where current
use of contraception is low.
Note
35. As regards the current development of non-hormonal methods
of male contraception, these could potentially be more appealing
to men as they do not impact levels of testosterone or sexual function.
Note The non-hormonal
methods in development are promising but extensive testing is required
before human safety studies can be performed to determine their
efficacy for the prevention of unintended pregnancies.
NoteIn
the last few decades, the pharmaceutical industry has abandoned
most of its investments in the field of male contraception, leaving
only non-profit organisations and public entities to work on the
subject.
Note While the work of these organisations
and entities is promising, interest from big pharmaceutical companies
could ensure that a new male contraceptive is available on the market
sooner. However, these companies will only become interested in
the development of a new male contraceptive once it has been proved
that a wide market for the product exists.
36. Several studies indicate that men show significant interest
in using new methods of male contraception in order to share the
responsibility of birth control and to gain reproductive autonomy.
Note However, an initial positive
attitude towards male contraceptive methods is not enough. Once
these new methods are available on the market, there should be promotional
campaigns targeting not only men but also their female partners
in order to gain trust in efficiency.
Note Moreover,
to prepare for the release of a new male contraceptive method, public
policy is needed. Not only the health care system but also the educational
system and local communities should be involved in the introduction
of a new male contraception, especially within marginalised populations.
Note Health
care facilities should include male contraception in primary care
so that health care providers can educate their male patients about
these options.
Note Governments
should also generate policies requiring public insurance programs
to expand their coverage to include contraception for men in order
to make it more accessible.
Note
4 Sexual
and reproductive health and rights for all: overcoming gender, gender
identity and age limits
37. An innovative approach to sexual
and reproductive health and rights that I deem important to adopt
is an inclusive one that is not limited to girls and women in reproductive
age, but rather extends to everyone, irrespective of their age,
gender, gender identity and gender expression.
38. Experts and activists are increasingly aware that traditional
policies on sexual and reproductive health and rights are too limited
in scope, and that large shares of the population face exclusion
from this area. Too few legislators and policy makers are familiar
with such approach, as I often notice when meeting with them. Therefore,
I consider it as part of my mission, as rapporteur for this report
and in my professional and political work, to advocate for access
to sexual and reproductive health and rights to be guaranteed to
everyone.
39. A sign of the gradually increasing awareness of and support
to this principle is the “Statement on sexual and reproductive health
and rights of the ageing population”
Note approved in November 2017 by the
International Medical Advisory Panel. The statement aims to provide
sexual and reproductive rights organisations with the latest evidence
and it underlines the importance of addressing the SRHR needs of
the ageing population. This includes ensuring access to appropriate,
rights‑based, stigma‑free sexual and reproductive health information and
services, and other health services. The statement also provides
practical guidance on how to offer services without compromising
the needs of the ageing population.
40. Among civil society organisations, Canada-based GRAN, or Grandmothers
Advocacy Network, is a good example of inclusive activism. While
focusing on “grandmothers, vulnerable children and youth in sub-Saharan
Africa”, their work and recommendations may inspire European actors
as well. “SRHR is not only a health issue but also a human rights
issue, a gender equality issue, and an age discrimination issue”,
reads GRAN’s background paper “Older Women: Sexual and Reproductive
Health and Rights (SRHR)”.
Note Their analysis is clear: “the sexual
health of women beyond reproductive age in sub-Saharan Africa and
around the world is almost always overlooked in policies and programs,
healthcare, research, academic discourse, and in the media. Older
women are absent from official records and are invisible to policy-makers
and organizations providing development assistance. As a result,
older women are often denied basic services and protection of their
sexual and reproductive health and rights”. They explain that the
sexual health of women aged over fifty is disregarded for reasons
including ageism (prejudice and discrimination based on age, with
the misconception that sexual health is irrelevant because older
people do not engage in sex after the end of reproductive life)
and the traditional focus on maternal and child health.
41. It is unreasonable to neglect the health needs and rights
of women after the age of fertility, as they face specific health
challenges, including a higher risk to developing non-infectious
diseases, such as breast and cervical cancer, which can affect sexual
functioning both physically and psychologically. The stereotypical thinking,
widespread among healthcare professionals and policy makers, and
the misconception that ageing women do not have sexual health needs,
makes tackling the issues I mentioned more difficult.
42. A 2020 editorial of the
Reproductive
Health review entitled “Leaving no one behind” also includes
taking the elderly along concerning their sexual and reproductive
health and rights”
.Note I can only but
agree with this stance, given that the article refers not only to
women but also to men. It explains that when older people engage
with the health systems to discuss and seek help regarding SRHR,
it becomes clear that these health systems are not designed to meet
their needs or address their issues. It confirms that health workers
are often described as holding stereotypical, prejudiced and discriminatory
attitudes against older people based on their age. Changing this
situation should be a priority for policy makers. The same article
adds that “in the World report on ageing and health published in
2015, healthy ageing is defined as “the process of developing and maintaining
the functional ability that enables well-being in older age” … However,
to realise true healthy ageing, SRH and rights issues cannot be
ignored”. I would like to highlight that the current decade (2020–2030) was
declared as the decade of healthy ageing.
43. Everyone should be able to count on age-friendly healthcare,
affordable medicines and long-term care that acknowledges the importance
of sexual health throughout life. Attention should be paid to ensuring
that everyone, irrespective of their age, and particularly people
that are more vulnerable to discrimination, including persons with
disabilities and LGBTI people, may enjoy their sexual and reproductive
rights. The specific issues of women past the age of reproduction
and of older men should be given greater visibility and attention,
and they should be addressed in compliance with relevant human rights
standards and obligations. An additional recommendation is inspired
by the 2014 article “Sexual and reproductive health and rights of
older men and women: addressing a policy blind spot” published by
Isabella Aboderin of Bristol University. Professor Aboderin writes
that growing attention has been paid to older persons since the
turn of the century, fuelled by increasing awareness of the rapid
ageing of populations, but only in relation to health issues in
general, not to sexual and reproductive health. She also finds that
this policy lacuna is the result of a lack of data and scientific
evidence in this area. A few years later, the situation has only
partly improved. Therefore, further research is still needed to
prepare adequate policy responses to the challenges we are discussing.
44. As an article published on the October 2021 issue of
Frontiers in Reproductive Health explains,
“Sexual and reproductive healthcare is often conceptualized as ‘women's’
or ‘men's’ health services, which may be excluding many people from
seeking care […]. Health care professionals should be sensitive
and understand how gender, as opposed to sex assigned at birth,
can directly affect clinical practice”.
Note Transgender and non-binary
people, with their specific sexual and reproductive health needs,
“are often excluded from gynaecological and reproductive practices,
as current guidelines and recommendations in this area exist within a
gender binary, heteronormative system, catering care to those who
identify as heterosexual and cisgender”. The article adds that one
of the main barriers to quality care for transgender people is the
lack of adequate clinician training. Addressing this shortcoming
should be an absolute priority.
45. On a separate but closely related note, I would like to add
that even the concept of bodily autonomy, which is a crucial aspect
of sexual and reproductive health and rights, should be interpreted
in a wider, inclusive sense. Generation Equality Forum, co-hosted
by France and Mexico in 2021, promoted bodily autonomy as a central
element of gender equality policies. I can only welcome this progress
and the increasing political support for this right. I would like
to add that the concept of bodily autonomy is also relevant to the
rights of transgender people. It should be made clear that bodily
autonomy includes the power and agency to self-determine one’s gender
identity.
5 Design:
an agent of change and a tool to promote gender equality
46. Design is an important part
of our everyday life and, as emerged from the hearing held by the
Committee on Equality and Non-Discrimination on 10 October 2022
with experts Alice Rawsthorn and Jimena Acosta, it is not only a
matter of appearance, of making our living environment more aesthetically
pleasing. In fact, it is an agent of change, intertwined with social,
economic, scientific and cultural developments, and may be used
as a powerful tool to alleviate inequalities, including those based
on gender, and to improve healthcare. In spite of such positive
potential, until now design has often aggravated gender inequality,
mainly due the dominance of cisgender men in its ranks. As Caroline
Criado-Perez writes in the important book Invisible
women, we live in “a world designed by men”, and for
men: most smartphones are too big for the average woman’s hand (and pockets),
voice recognition is 70% more likely to understand a male voice
and, crucially, women are misdiagnosed more often than men due to
the impact of a supposedly gender-neutral approach to designing medical
instruments, which is actually based on men’s characteristics and
functioning. Gender inequality has an impact not only on medicine
but also on technology and even on venture capital funding.
47. In the realm of sexual and reproductive healthcare, the negative
impact is particularly clear. However, there are positive changes:
egregious cases of discrimination are now more likely to be called
out, and books, art exhibitions and cultural projects have raised
awareness of this issue. The influence of senior women and non-binary
people in hi-tech and other industries is leading to increasingly
successful and inclusive design, and financial investors are becoming
aware of the commercial potential of sexual healthcare innovation.
Positive developments include telemedicine tools that were first
used during the early phases of the Covid pandemic. New products
have been launched, such as the Elvie breast pump that is more discreet
than traditional ones and allows women to express milk while carrying
out their normal activity. Menstrual cups developed in Malaysia
are an example of innovative tools created to tackle period poverty
by replacing tampons.
48. As Ms Rawsthorn highlighted, design’s contribution to addressing
complex challenges includes not only pursuing good design, but also
avoiding bad design, by anticipating the negative impact of badly
designed tools. Artificial intelligence has a role to play in this
respect and is being used, among other things, in diagnosing sexually
transmitted diseases.
49. Women’s contribution to design has increased in recent decades,
although, as Ms Acosta underlined, many of the tools they designed
(props for menstruation, contraceptives, breastmilk devices) are
still not mentioned in most design books. Innovation never stopped:
pregnancy tests, for instance, would take two hours to deliver a
result in the 1960s, 30 minutes since 1985 with the introduction
of Clear Blue, and now only three minutes with the latest digital
version of the test. Women’s health apps such as Flo and Ovia collect various
types of data on fertility, ovulation and even predict menopause.
50. I can only agree with Ms Acosta, who points out that while
innovation increasingly hacks the system towards equality, the system
itself remains based on women’s oppression. This is why in Latin
America gender equality movements such as La Marea Verde often refer
to the need to innovate in the area of sexual and reproductive health
and rights. Existing power structures need to be redesigned, they
say, to reach reproductive justice and “co-liberation”, a concept
based on the idea that “none of us is free if some of us are not”.
6 Spain:
where there’s political will, there’s a way
51. The fact-finding visit I conducted
to Spain on 28 and 29 September 2022 proved timely and fruitful.
I chose Spain mainly due to the considerable progress the country
has achieved in gender equality legislation and policies in the
last decades. In the 2000s, awareness of outstanding gender inequalities
and a strong political will to address them led Spanish governments
to initiate and implement ambitious legislation, including the Organic
law on gender-based violence (2004) and the Organic law on real
equality between women and men (2007). I believe that this is an
important example for other Council of Europe member States, including those
in the Mediterranean region and other countries of Catholic tradition,
where the usual examples from Northern Europe may feel less relevant
or less applicable to the local context.
52. On a different but related note, the 2005 reform introducing
same-sex marriage was another sign that Spanish legislators and
policy makers did not hesitate to challenge traditional patriarchal
values, their priority being promoting equality across the board.
The current Spanish Government, especially the Minister of Equality,
Ms Irene Montero, whom it was a real pleasure to meet, shows the
same determination in pushing forward a gender equality and LGBTI-inclusive
agenda. A few days before I went to Spain, Minister Montero stated
that the new legislation on abortion and the “Trans Law” reforming
gender recognition were top priorities and she “demanded” they be
adopted before the end of 2022.
53. Ms Gloria Lopez, an journalist from AMECO-Press (the Spanish
Association of Women Media Professionals) with whom I met in Madrid,
confirmed that the draft bill to reform the legislation on sexual
and reproductive health and rights and abortion was important news,
in view of the challenges faced today including regulations varying
across autonomous regions, the impact of years of budget cuts, and
widespread conscientious objection. In addition, the draft provided
for sexuality education in schools, which was currently lacking
or insufficient. Progress in this area has triggered a backlash
from conservative forces including the Catholic Church, which has
some influence on education, and the most conservative politicians.
The far-right Vox party, in particular, has an agenda of promoting
the traditional patriarchal values that Spanish society has to a
large extent abandoned. An example of the criticism that feminists
face includes the reaction to a march they held on 8 March, International
Women Day, in 2020. Those were the early days of the Covid-19 pandemic, and
the event was harshly criticised by many ultraconservatives as being
a “super spreader”. Around the same date, Vox held another large
public event, which however raised no criticism.
54. The start of my visit coincided with International Safe Abortion
Day, a commemoration that is widely marked in Spain. I could feel
the effect of this special day on the spirit and motivation of many
of my interlocutors, both among civil society representatives and
the authorities. I was honoured to have the opportunity to speak
at the annual event organised in Madrid by the Ministry of Equality
to mark this day, together with Spanish women’s rights activists,
experts and media personalities.
55. I held a meeting with Ms Carmen Calvo Poyato, Chairperson,
and other members of the Committee on Equality of the Congreso de
los Diputados. I am grateful to our Spanish colleagues as a large
number of them joined the meeting, representing all political groups.
This of course is also a sign of their interest in sexual and reproductive
health and rights issues. Our conversation confirmed that gender
equality enjoys wide support across the political spectrum (with
the exception of the far-right) and politicians from all the main
parties share a pride in the progress achieved by their country
in this area. They underlined that Spain had pioneered areas including
the fight against gender-based violence, precisely thanks to such
consensual support. The 2004 Organic law against gender violence
was voted by all political parties, and in 2017 a “State Pact against gender-based
violence”
Note renewed the shared commitment to
preventing and combating violence against women.
56. The meeting with Minister of Equality Irene Montero also proved
very fruitful. A smart politician with an ambitious agenda, whom
I consider a powerful ally, Ms Montero clarified that progress in
gender equality does not happen in a void – the cultural landscape
and the values generally accepted by the population largely contribute
to defining it. That is why men have an important role to play.
Ms Montero used the term “co-responsibility” in this context, a
term I find very inclusive and useful. The same applies to media,
which have a profound influence on people’s mindsets. For the same
reason, Ms Montero also highlighted the importance of comprehensive
sexuality education in schools, which was often opposed not only
by far-right forces but also by mainstream conservative politicians.
57. A vibrant civil society active in promoting gender equality
and countering gender-based violence is another feature of today’s
Spain and its close co-operation with public authorities is a major
pre-condition for achieving real progress in these areas. In Madrid
I met with SEDRA (Federación de planificación familial: Family Planning
Federation) in their youth counselling centre in the heart of Madrid.
This organisation carries out a multitude of activities, including
advocacy to impact public policies and legislation on sexual and reproductive
health and rights, and providing assistance to the population to
complement the services provided by the public sector. Youth is
the main target of such work, with a focus on providing information
on issues ranging from contraception to sexually transmitted diseases
but also sexuality and relationships. In Spain, like in many other
countries, sexuality education is lacking or insufficient, and young
people seek information on sexuality from internet sources that
are not necessarily reliable and through pornography, which is not
meant to be educational or even accurate, and is often misleading.
My interlocutors at SEDRA found that sexuality education was often
too limited, as schools were hesitant to tackle subjects other than
contraception and infections, and that it started too late, with
students being 14 years old and older. While the youth counselling centre
endeavoured to help by providing accurate information, they were
unable to reach the entire youth population in the way that public
education could. Moreover, a majority of their users were girls,
as boys and young men seemed to find it more embarrassing to seek
information or believed they did not need it. The outcome of this
conversation confirmed once again the importance of comprehensive
sexuality education, which can be complemented but no replaced by
other services. I also had the opportunity to meet the management
of Madrid Salud (Madrid Health) a programme of the Municipality
of Madrid that provides assistance and counselling in the area of
sexual and reproductive rights to all residents, irrespective of
their age, gender and status. I was impressed by their motivation
and commitment, buoyed by the awareness of how much their services
are needed by the population and by the respect their work gained.
It appears that, irrespective of which political group is in power
at local level, Madrid Salud manages to continue its activities. The
gender perspective and feminist approach Madrid Salud follows also
struck me positively. I can only admire their commitment to equality
and their positive vision of sexuality and support their ambition
to safeguard access to sexuality healthcare and information and
remove the barriers that certain individuals and groups face. They
explained that their goal was to promote a healthy, enjoyable sexuality
for the citizens of Madrid in all their diversity. Programmes like
this are extremely valuable as they develop a perfect knowledge of
the population they serve, with its needs and the challenges it
faces.
58. While my fact-finding visit to Spain was held entirely in
Madrid, I had the opportunity to exchange in writing with representatives
of the Generalitat de Catalunya (Government of the autonomous community
of Catalonia). Sexual and reproductive health and rights seem to
be very high in the priorities of this government, which identified
gender equality among the core elements of its plans, established
a Ministry of Equality and Feminisms (Departament
d’Igualtat i Feminismes) and adopted a National Strategy
for Sexual and Reproductive Rights.
59. According to the information the Catalonian authorities provided
to me, voluntary termination of pregnancy is considered as a right
and is covered by the Catalan public health system, both in the
medical and the surgical form. It is interesting to note that the
number of clinics and hospitals that practice abortions has increased
in the past year. This sounds like an extremely positive development,
against a backdrop of declining abortion care infrastructure in
most European countries.
60. It is also positive that in December 2022 the Ministry of
Equality and Feminisms adopted an Action plan to support human rights
defenders, which covers anti-abortion harassment and violence among
other things. More generally, the Government of Catalonia is currently
taking (pro)active action against “anti-gender” groups attempting
to unduly limit women’s rights. In this context, criminal proceedings
were brought against an anti-abortion campaign instigated by an
international anti-choice platform (40 days for life) that gathered
around three abortion centres in the city of Barcelona. Also, in
November 2022, a bus that had been riding in various Spanish cities
displaying transphobic messages was stopped at the initiative of
the Ministry of Equality and escorted out of Catalonia. The organisation
behind this bus (Hazte Oír) is now facing administrative sanctions.
61. The Government of Catalonia appears to tackle different forms
of discrimination with strong determination and a particularly advanced
and inclusive approach. In addition to the priority attached to
sexual and reproductive healthcare and the particular focus on the
“rights”, I would like to highlight that attention is paid to the
situation of transgender people. I also found it interesting that
forthcoming activities of the Ministry of Equality and Feminisms
include an Action Plan to Combat Aesthetic Pressure, which seeks
to tackle the growing impact of aesthetic pressure on women, particularly
on girls and teenagers.
7 Communicating
on gender equality. How to tell an inclusive story in times of an
ultra-conservative backlash?
62. The promotion of innovative
approaches to sexual and reproductive rights and improving everyone’s access
to them faces an insidious challenge, namely the backlash against
women’s rights from ultraconservative forces at global level. These
movements, often of extremist religious inspiration, refer to a supposed
“gender ideology” that allegedly threatens the “natural order” –
“natural” meaning “traditional and patriarchal” – and oppose progressive
stances both on gender equality and on equal rights for LGBTI people. Anti-gender
tendencies increasingly infiltrate politics and institutions, with
far-right parties and movements embracing the misrepresentation
and disinformation on gender equality for political gain. Research
carried out by civil society organisations and individual experts
has shown that the ultraconservative campaign against human rights
in the area of sexuality and reproduction is based on a precise
strategy. According to the publication “Restoring the natural order”,
published in 2018 by the European Parliamentary Forum for Sexual and
Reproductive Rights, the first visible targets of this campaign
were abortion and same-sex marriage (leading to actual bans in several
Central and Eastern European countries), but the strategy secretly
aimed to target also contraception, in-vitro fertilisation and divorce.
63. During the preparation of this report I met with fellow parliamentarians
who used an anti-gender rhetoric, which led me to wonder how to
best react to it with a view to neutralising it. The arguments used
by ultraconservative politicians are repetitive and almost predictable.
One has the impression that a practical handbook is circulated to
provide them with a limited set of speaking points. Typical features
of this rhetoric are the use of pseudo-scientific arguments and
of a legal language echoing that used in human rights. The “foetal heartbeat”
at six weeks of pregnancy used by anti-choice campaigners is a good
example of a pseudo-scientific argument. Science says that there
is no actual heart at that stage, and no audible beat. Moreover,
before the eighth week of pregnancy the correct term is not foetus,
but rather embryo. The same applies to the concept that “life begins
at fertilisation”, with the alleged creation of a unique DNA at
that stage. “This statement is commonly offered by religious organizations
and is often cited as the basis for so-called personhood amendments,
but the assertion that it is scientifically sound is incorrect”,
writes fertility doctor Richard J. Paulson.
Note Both
pseudo-legal and pseudo-scientific arguments are intended to confuse
and convince the less educated or more malleable sections of the
public. The temptation to just disengage, not listen and not reply
is strong. Indeed, there is no point in trying to convince anti-gender
campaigners that the arguments they use are fallacious: they probably
know already. However, it is important not to leave their stances unchallenged.
As politicians supporting human rights and gender equality, we have
an obligation to dispel those myths and misrepresentations since
our audience, our electorate and the public in general, may believe them
and in good faith make their political choices accordingly. Communicating
wisely, with a view to achieving progress in access to sexual and
reproductive health and rights, implies targeting the “movable middle”,
those who are not bound to an ideological choice and are ready to
accept the more convincing option in a political debate.
64. It is also important to adapt the style of communication used
to its target. Some audiences may be used to a feminist perspective,
some other may have an approach based on human rights and fundamental
freedom more broadly. Some concepts, such as the need to respect
everyone’s right to self-determination, are non-negotiable and should
be understood by any audience. I discussed this topic with several
interlocutors, both to seek new ideas and to share my views on it.
In Spain, civil society representatives pointed out that the far
right has unduly appropriated the idea of family. Indeed, why should
the love and support and all the positive things we associate with
family belong exclusively to a political group? However, in this
case, as in others, it is not useful to follow the anti-gender tendency
into their territory. It is more useful to prioritise the concept
of individual rights and freedoms, the freedom to make choices on
one’s own life, including when and how to start a family.
8 Conclusions
65. Gender equality is far from
achieved, in Europe and beyond, and progress in women’s rights –
like human rights in general – can never be taken for granted. In
fact, today more than ever, the achievements of the last few decades
are threatened by a global backlash. We observe, in the political
debate of most Council of Europe member States and in the legislation
and policies of some of them, insidious attempts to control people’s
self-determination in sexuality and reproduction. Women’s bodies,
in particular, have become the object of a cultural and political
dispute, in a global political landscape characterised by an upsurge
of populist and ultraconservative forces that promote a revival
of patriarchy.
66. The patriarchal attempts to control people’s sexuality and
reproductive choices should be countered effectively. Women’s self-determination
in matters of reproduction has been increasingly threatened by legislation
and policies in Council of Europe member States and beyond. The
same applies to self-determination of one’s gender identity, a power
that should be recognised in the perspective of preventing and combating
discrimination against transgender people. Our societies feature
a diversity of ideas, aspirations and lifestyles which should be
recognised and embraced. Rather than erasing differences, we should
embrace and celebrate them.
67. Throughout the preparation of this report, the exchanges I
had with experts, civil society organisations, fellow politicians
in parliament and government positions, not to mention the exchanges
within the Committee on Equality and Non-Discrimination, confirmed
my opinion that much can and should be done to improve everyone’s
access to sexual and reproductive health and rights.
68. Close co-operation with civil society organisations is crucial
in achieving progress in this area. It is also of the utmost importance
to inform, raise awareness and educate the public, as many of the
issues at stake are not adequately known, and traditional misconceptions
are today combined with deliberate disinformation spread by some.
The most important condition for rapid and substantial progress,
however, is political will. Legislators and policy makers who are
committed to upholding human rights and equality should place a
high priority on sexual and reproductive health and rights. Progress
is needed and is possible, thanks to a variety of tools and innovations,
as presented in this report.
