Contributions debate Bush unlimited: the other American War

Now we are in 2004, exactly halfway to 2015. A renewed commitment is urgently needed. Financial promises have not been fulfilled and there is a growing pressure on the international consensus.

For example the abstinence only campaign, embraced by the United States, the Vatican and a number of Islamic countries. The Global Gag Rule: a policy, reinstated by the Bush administration in 2001 in the US, which imposes restrictions on international planning, by making US funding for foreign NGOs conditional on their acceptance of this policy. In theory, this policy means that foreign NGOs are not allowed to perform abortions or lobby to make abortions legal if they want to keep receiving the generous US funds - in practice, the policy's restrictive implementations means that foreign NGOs are not allowed to have any connection with abortion whatsoever. Since many, if not most family-planning clinics worldwide are run by NGOs refusing to sign up the Global Gag Rule. And since these NGOs have not been able to make up the shortfall of funs by other means. The aim of the Mexico City Policy is pro-life: it is meant to save the lives of unborn children as well as those of their mothers, by discouraging the use of abortion of as a method of family planning.

This aim is laudable: In no case should abortion be promoted as a method of family planning. But, unfortunately, the Mexico City Policy is having the opposite effect in practice: As clinics close and access to reproductive services becomes more difficult for lack of funding, less poor women in Europe and worldwide can afford contraception, leading to an increase in unwanted pregnancies, and consequently an increase in abortions. Since many of these abortions are unsafe, more women die as a consequence, too. The result of the Mexico City Policy is, ironically, thus not pro-life, but anti-life.

Let me take the example of an European country, Romania. Romania is among the least affluent countries in Europe, with a per capita GDP of about 1700 US$ and an annual health care spending of $71 per person. Romania suffers from a relatively high infant mortality rate, a high maternal mortality rate, and a weak health care system. During the Ceaucescu era more than 10.000 women had died of illegal abortions. Even now, Romania has the second highest maternal mortality rate in Europe. When abortions were legalised in the country after the fall of the Ceaucescu regime, 1 million abortions were performed in the 1990s, the highest abortion rate in the world. Currently, about 200.000 abortions are performed in Romania each year, most of them legally. NGOs are trying to re-orient Romanian women from abortion to contraception; but those NGOs which do not deal with abortion at all are not financially sustainable, and those who do receive no more funds from the USA.
Unfortunately, because the approach in Romania is not integrated (there are weak or no links between abortion and contraceptive services), abortion remains the most accepted contraceptive method in Romania: traditional and cheap. Except in the cost of lives: as the NGO Population Action International has pointed out in its most recent report on the impact of the Mexico City Policy, called access denied, current abortion techniques in Romania are outdated and consequently less safe. However, abortion is perceived by Romanian women as having a cleansing effect, whereas mistrust of hormonal methods of contraception is widespread. In addition, abortion costs less for women than contraception; and, although abortion is a relatively brief procedure, hospitals can bill the social insurance for an entire day of hospitalization. As a consequence of the Mexico City Policy, NGOs cannot integrate family planning with abortion services and cannot lobby for safer equipment, training and medical procedures for abortion. In other words, more women and unborn children die.

Why do we have an evening like this?

This debate is meant to keep the benefits of the Cairo agenda, the Program of Action high on the international agenda. Reproductive health and rights issues affect the lives of each and every individual in the world. The implementation of the Program of Action can and will save the lives of a vast majority of the 500.000 women dying from the complications of childbirth every year. Therefore the implementation can no longer wait nor be hampered by a lack of funds. It is time for action. Time for the Campaign Called to Account, were governments are called to account for the promises they made regarding the Cairo Program of Action. I ask everybody gathered here to support this campaign. The Netherlands should take the lead in this debate. Let's give our politicians, gathered here, new munitions for the coming months.

Introduction to 'Access Denied', Joke van Kampen

Apart from the gag rule, the second pillar of sexual politics of the current US presidency is the famous abstinence only approach with regards to the sexual education of young people. Abstinence only means no sex outside the context of marriage and thus abstaining from sex till marriage. This government channels increasing amounts of money to the abstinence only programs all over the US at the costs of more comprehensive sex education programs.

But abstinence only is not an invention of this government, it was developed by the Heritage foundation, a right wing think tank, in the eighties, interesting enough as an answer to the high rate of teenage pregnancy in the US. Conservative politicians have tried to introduce abstinence only programs within the educational system ever since but constantly failed to do so, due to limited federal influence in school curricula. Abstinence only was widely introduced when it was brought under a health umbrella. Abstinence only is supposed to be health information.

The official guidelines are, compared to what is happening in practice, pretty modest. There are 8 guidelines: the programs should teach the health, social and psychological gains of abstinence, teach that abstinence outside marriage is the standard, teach that abstinence is the only certain way to avoid out of wedlock pregnancy and sexually transmitted diseases, teach that a mutual monogamous relationship is the standard, and that sex outside the context of marriage has harmful physical and psychological effects. It teaches young people how to reject sexual advances and the importance of gaining self sufficiency before engaging in sexuality.

The first problem with the abstinence only approach is of course the enormous gap with reality . The average age of marriage in the US is 27. It is hard to believe that young people are going to hold hands and practice light kissing till their wedding night anytime near. The abstinence only guidelines do not give a definition of what sexuality is but most programs talk about light kissing and holding hands as the only permitted activity for unmarried people to physically express their affection. The reality is that more than half of America's teenagers have had sexual intercourse. 74 million adult Americans are single, it is also hard to believe that they can be convinced to abstain from sex.

From what we know the conclusion must be that abstinence only programs do not work, it is a universal fact that well informed young people tend to delay their first sexual activity, but not till their wedding night. The only difference between abstinence only educated teenagers and the lucky ones that got less rigid information, is that the abstinence only teens tend to use less contraceptives and condoms.

Because, and that is the second and very serious problem with abstinence only programs, within these programs it is not permitted to give information on contraceptives or condoms other than pointing at the failure rate. In a health context this is misleading information and in the context of booming STI rates and HIV Aids, it is irresponsible. How this is shaped into classroom programs can be seen in one of the most wide spread manuals:

"Unmarried couples who become sexually active tend to stop communicating on all levels," is the first sentence of this chapter in the Reasonable Reasons to Wait program. I can chew on a sentence like this for hours. What does this mean? That walking down the aisle provides you with communication skills? That all married couples are communicating? And, I always assumed that sex is, among other things, communication. A workbook for Choosing the Best Path includes this question: "Circle the item(s) that can be totally eliminated through the use of a condom? Infertility, isolation, jealousy, poverty, heartbreak, substance abuse, AIDS, pregnancy, cervical cancer, genital herpes, unstable long-term commitments, depression, embarrassment, meaningless wedding, sexual violence, personal disappointment, suicide, feelings of being used, loss of honesty, loneliness, loss of personal goals, distrust of others, pelvic inflammatory disease, loss of reputation, fear of pregnancy, disappointed parents, loss of self-esteem, leaving high school before graduation."

The answer, according to the teachers guide, is "None."

Then students are instructed to "cross out the item(s) that can be eliminated by being abstinent until marriage. According to the teachers guide, the correct answer is "All."
Sometimes I am very happy that we know that teenagers tend not to take messages on sexuality from parents and teachers too seriously. Also parents have a role to play. Since every parent remembers that sex is likely to happen in relation to dating, dating guidelines are provided:

· You may car date or single date after high school
· You may date a boy or a girl after they have spent an evening with us
· You may date a boy or girl if he or she is a Christian
· You must tell us what you have scheduled prior to each date and call us if your plans change.

Apart from the fact that this to me sounds as growing up in a prison camp, none of these guidelines are of any help to young people in dealing with feelings and relationships.

The abstinence only approach is being exported to developing countries in different ways. The US is still the biggest donor of family planning programs in the world. Under the current government funds have been shifted towards so-called faith based organisations. Faith based organisations tend to implement abstinence only programs where many others choose a more modest ABC approach (abstinence, be faithful and use condoms).

Official USAID money can still be used for a ABC approach but there is a strong emphasis on the A. The ABC approach has its own problems, being faithful does not protect you from getting infected with HIV. We know from statistics on rape and domestic violence all over the world that marriage is far from a safe place for women and children. In a country like India marriage is, in fact, the major risk factor with regards to contract HIV/Aids.

It is in developing countries where the abstinence only approach has its most devastating consequences. First and foremost of course because information on safe sex, contraceptives and condoms are not provided within these programs. In the light of HIV/Aids rates in many African countries, I cannot even see a shadow of a justification to withholding condoms from sexually active people. Every service provider in his or her right mind feels the same way which leads to a rather strange situation: in many programs the message is abstinence but the box with free condoms is on the table. Abstinence only approaches do not change reality, but they do change the way we talk about reality. And that is a problem in itself. Abstinence only is a highly ideological concept that today lays as a suffocating blanket over the reality of people's sexual activity. In order to develop effective HIV/Aids prevention programs, we need to know what sexuality looks like, what people's perspective on sexuality is, what the practices are, how the practices are viewed. Abstinence only tells people what sexuality should be, no questions asked, no conditions taken into consideration, no realities involved. Abstinence only approaches are blinding us and teach young people to lie about sex. Uganda is a good example of that. When the HIV/Aids rate went down in Uganda, the success was quickly claimed by the abstinence only advocates while others argued that Uganda always combined abstinence messages with condom information and provision. The truth is: we do not know what really happened in Uganda; we never asked, busy as we were telling people what to do. Open minded individuals come with their own observations that I do recognize. It looks like there is a tendency in Uganda towards serial monogamy instead of having several sex partners. If this is true it could explain that the infection rate is going down. If HIV gets transmitted from one person to one partner instead of to many partners, that would have a huge cumulative effect on the numbers. And if this is true: what triggers this change in sexual behaviour? That knowledge could be invaluable in developing new strategies to fight the HIV/Aids tragedy.

Abstinence only produces a culture of hypocrisy around sexuality: there is no relation between what we do and what we say. But if the reality does not change the discourse or the story, the story will eventually change reality. In a twisted way and with fierce consequences that are hard to foresee.

Two examples: Ghana has been the subject of a massive religious offensive from US conservative protestant churches, starting in the Reagan years and orchestrated by Nancy Reagan. With the second hand clothes and the bibles came a for Ghana new sexual moral, now called abstinence only. The university of Accra has a good reputation, on the campus are thousands of students living in dozens of buildings. In ten years the campus has changed from a place where girls and boys could study, live together, and yes, party and have sex, to a place where sex is as forbidden as violence. Free condoms are gone, and so is the sex education program that used to be attended by all students in their first year. Students caught in a sexual act are expelled. Pregnant students have to leave. In that same ten years a slum grew next to the campus where hundreds of poor Ghanaian women sell their bodies. To male students. Female students are believed to provide sexual services for their teachers, for money and high grades. That is what progress looks like in abstinence only logic.

Another example is Sri Lanka, a country that did not need the policy of this US government to rely on an abstinence only discourse. This discourse is rooted in a colonial Victorian past and survived all changes in reality. For instance the average age of marriage, now being as high as 29 for men and 27 for women. In this extremely puritan society, being a virgin at your arranged marriage is a social rule that cannot be challenged. It is easy to imagine that this means hardship for young people but the facts are nevertheless shocking. In this beautiful country, a lot of things are well organized: education, access to healthcare, the status of women. Yet it has the highest suicide rate among adolescents in the world. Research over a five year period showed that 99% of these suicides are related to a sexual relationship being exposed. Every high school has its victims, every student can tell you stories about fellow students that killed her or himself after a teacher, parent or other adult found out that they were sexually active. I am afraid that this is what success looks like in the abstinence only logic.

It is far from sure that abstinence only will a remain a temporary bad dream if the current president is not re-elected. Abstinence only is older than this government but this president is and wants to be the ally of the fundamentalist Christian movement that produces abstinence only approaches. In the international arena, the Netherlands and many others need to support comprehensive health approaches towards sexuality. First of all because they work, as they worked for us. I think I share with many of you the experience that my own sexual behaviour as a teenager was not even close to what my parents would have liked to see. But I did take the pill that my mother got for me the moment she found out that I was sexually active.

Are there no moral values involved if we talk about sexuality? Yes there are, many of them. Mine can be easily summarized in three words, rights, respect, responsibility. Yours might be different. We can discuss them in the churches we attend, among friends, in our families, in the media. But we cannot play games with the lives of young people because of our convictions.

Main outcomes of the Debate

Paul Brest
The domestic scene is linking economic growth and alleviation of poverty to family planning and reproductive health. This is not mentioned in the Cairo+10. Family Planning is not included in the millennium development goals (MDGs), however do mention poverty alleviation. One has to be open minded on what the connections are.

Dr Sara Seims
The position of the US government on abstinence only would not have worked successfully without falling in a receptive climate (read: culture) which exists independently of the US governance. People agree more on the programs of the Bush Administration than for instance the programmes implemented by the Netherlands. This is the challenge for development workers. What can we do about it? We should (like Hewett) help communities to produce the evidence which documents what people need and what the effect of poverty is. Without this evidence we can do little.

Bert Koenders
Reproductive health; family planning; sexual rights; rights of women; and responsibilities of men are complex problems and is still not adequate on the political agenda. A clear strategy on how to keep the Cairo + 10 on the agenda is lacking within the EU. Therefore, these issues should not only be addressed to the Bush Administration but also to the EU. It should be put on the EU agenda during the Dutch Presidency. Moreover, there is no factual check and balance system on how much money has been spend on implementation of the Cairo Agenda. We should put these issues forward in very strong way and we should be more debate in the parliament with local NGO's and religious leaders on what is really going on. For example with our Dutch embassies. There should not be a difference in what is preached in and outside.

Regarding the abstinence policy it influences the reality of many people and assumes that abstinence and morality are the same. The global gag rule does an tremendous harm. What is happening in the US has a lot to do with cultural wars.

Many programmes on HIV/AIDS lead to a lesser spending on family planning. Why is this happening? That should be on top of the agenda. We should analyse if programmes that we set up are actually counterproductive. Parliamentarians should speak out to other colleagues, go in to the field to have a realistic picture what 'reproductive rights' means.

Reaction of Joke van Kampen
Cairo +10 has mainly been used for development countries and never been seen as a global programme of action. However, it also applies to our national situation. Reproductive right are always singled out and it should trigger an reaction in the EU.

Ans Zwerver invites the panel to react on what role the Netherlands government can they play during the EU presidency regarding sexual reproductive health issues?

Dr. Sara Seims and Paul Brest advice is to challenge the NGO's and WHO policies which are emphasising treatment instead of prevention. This emphasis benefits the richest countries more than the poorest.

Bert Koenders argues that we should be credible by doing ourselves what we preach to others. There should also be a reproductive rights agenda (not so much for the development minister but for our health and emancipation ministry). We should take risks in these country where the reproductive rights agenda's become rigid and bureaucratised systems.

Joke Kampen is afraid that the Cairo + 10 programme of action will drown in the millennium development goals. Cairo + 10 is more concrete and states how it should be financed. Thus, government should keep the Cairo + 10 alive!

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