Susanna Rance

Ipas-Bolivia

I am contributing to this meeting as researcher and activist with the women's health movement in Bolivia. Laws, policies and their application are key to the exercise of women's rights in all fields, including sexual and reproductive life. Advocacy in these areas and others involves working collaboratively with decision-makers such as parliamentarians who se activities influence national legislation and policy.

This paper is based on the recent experience of coordinating with Dr. Javier Torres-Goitia, Vicepresident of the International Medical Parliamentarians Organization (IMPO), the Interamerican Symposium on Legislation in Sexual and Reproductive Health. Representatives of six countries participated in the event held in La Paz on 7 and 8 September 1998. Presentations from experienced legislators were followed by group work sessions and plenaries. Insights were shared from national advocacy initiatives on legal, health and gender issues affecting the exercise of sexual and reproductive rights.

Negotiating spaces for advocacy

Building alliances means declaring and recognising different identities and agendas. Our work as women's health advocates is based on principles of gender equity and an end to all kinds of social discrimination, racism and violence. The fundamental components of reproductive and sexual rights are bodily integrity, personhood, equality and respect for diversity. Defence of these rights implies a critique of patriarchy and its expression in institutions such as government, congress and the medical profession. Advocacy in these areas involves promoting gender-equal opportunities for participation in health policies and programmes as decision-makers, providers and users of services. It means access to quality, gender-sensitive health care for woman and men, with voluntary informed consent for all procedures.

In approaching parliamentarians on these issues, we need to acknowledge that dominant values and priorities in congress often contrast with our own. Gender and rights issues are seen as "difficult" and "polemical" precisely because they challenge the established social order. The supposedly neutral language of constitutions and laws is androcentric, reinforcing and condoning sexist practices. Parliamentarians tend to keep apace with patriarchally defined agendas, seeking maximum political impact nationally and with their constituencies. The minority of congresspeople already sensitive to gender and rights issues cannot always negotiate session time for their discussion. When they do raise them, they may be countered with ridicule, hostility and silencing tactics.

Nevertheless, there are shared spaces which allow for negotiation. The very functioning of congress in a democratic system is something we do not take for granted. In Latin American countries such as Bolivia, decades of military dictatorships meant imprisonment, torture, "disappearance", exile and assassination, particularly of those who were most active in the political opposition. There is a shared history of struggle among a certain generation of legislators and women's rights activists. These alliances can be built upon to raise awareness about the importance of parliamentary action in matters of sexuality, gender and health.

Challenges for parliamentarians

The women's health movement has some strong advocates and allies within legislative circles. Senator Piedad Castro de Córdoba is a key spokesperson for women's rights in the Colombian parliament. She points out that reproductive life is not just a matter for medicalised health interventions. Decisions and actions linked with sexuality, fertility, childbearing and raising are personal but at the same time social, involving particular constructions of women's and men's identities. In this dimension, reproduction becomes an issue for state intervention. Political, economic and religious interests determine the promotion of pronatalist or antinatalist policies.

Keeping sexual and reproductive rights on the agenda means taking action to sustain legislative ground already gained and campaign for new, gender-sensitive policies. IMPO Vicepresident Dr. Roger Guerra García pointed out a series of difficulties in this process. He attributes blocking procedures in Congress to lack of up-to-date information on the relevant issues, and to party, governmental and church pressures. He also notes the passion with which parliamentarians relatively unfamiliar with these topics, launch into the debates with an authority fired by their religious and ideological convictions.

"How could this be changed?" asks Guerra García. "I see it as very difficult because we're talking about educating or persuading men and women who are mature, ambitious in the political terrain and who seek to stand out by any means because they know they must make news if they want to be politically viable."

Case studies: dealing with real issues

The maturity which comes with long professional and political experience can sometimes lead parliamentarians to adopt attitudes of scepticism regarding possibilities for change. We found in the Symposium that a powerful antidote to pessimism is provided by work on case studies which sharply remind us of the real-life issues which legislation is about. Dealing with current medico-legal dilemmas and hearing experiences of successful (and unsuccessful) litigation from other contexts, brought a mood of indignation and will to act into the discussions.

Into the Symposium came detailed information regarding an unprecedented event in Bolivia, the subject of ongoing public debate: the first abortion to be performed under legislation dating twenty years back which allows interruption of pregnancy in situations of risk to the woman's life, rape and incest.

Since Article 266 was introduced in the Penal Code, religious and political pressures combined with the lack of procedural law meant that no women had had access to legal abortion. Indeed, in 1994 two teenage sisters simultaneously impregnated by their father had been denied the right to abortions, as a result of the judge's delaying tactics motivated by his religious convictions.

The first case which came to concern the Symposium involved a 14-year-old girl, raped and made pregnant by her father. With legal support from a women's organisation, a judicial order was presented for termination of the pregnancy. Then began the odyssey which lasted ten days. Although authorisation was obtained from the regional Medical College, Gynaecologists' Society and state hospital director, four successive doctors refused to carry out the abortion. Their arguments varied from accusations of foetal murder, the case not being an emergency, a novice's fear and inexperience, and declining to "dirty their hands" with the matter. The girl was subject to hostile treatment on the ward from hospital staff, with comments such as "We're angry with you because you're very hard". Finally, a magistrate demanded fulfilment of the judicial order and the abortion was performed.

Participants in the Symposium decided to dedicate time in work sessions and plenaries to analysing this case and defining appropriate action. In a plenary session, they drafted a letter of support which was sent to the hospital director, the object of harrassment during and after the case. The letter said: "We wish to express to you our support and respect for your determination in concordance with legal resolutions which allow the termination of pregnancy (Article 266 of the Penal Code on Non-punishable Abortion) of the citizen seeking to exercise the right which corresponds to her by law."

The second matter which motivated discussion and reflection in the Symposium was presented by Pedro Morales of GIRE, Mexico. This institution had recently processed two demands concerning hospital insertion of IUDs in women without their knowledge or consent.

The first involved a woman medically deemed "elderly" for reproduction, who was systematically accused by hospital staff of being "irresponsible" for having yet another pregnancy. She was pressured to accept surgical contraception or an IUD, and refused both. On returning home she discovered the IUD threads. She presented a complaint to the National Commission for Human Rights. The hospital claimed she had signed an authorisation, which she denied. It was found that the signature had been falsified, but the hospital disclaimed responsibility on the grounds that it was "not a penal matter" and that there were no elements to determine who had done it. On following up the matter, other obstacles emerged: the woman's medical history file became "confidential" and the exclusive property of the institution; and the signed document disappeared, having being replaced by a photocopy.

The second case investigated by GIRE involved another IUD insertion without the woman's knowledge or consent. The woman had stated before giving birth that she did not want postpartum contraception. On being accused of inserting the method against the woman's will, hospital staff claimed she had "cried out for it" during labour. The woman was submitted to psychological tests to assess the reliability of her statements.

Problems identified

Consideration of these cases motivated intense discussion in the Symposium about diverse obstacles to the exercise of sexual and reproductive rights in the six countries represented. Participants recognised the cases discussed, in all their specificity, as examples of systematic barriers to the application of existing legislation.

Policies setting numerical targets for contraceptive distribution were highlighted as conducive to abusive practices. Participants agreed that many violations came under the heading of withholding access to some needed services, and imposing others without women's knowledge or consent.

Damage to women's health associated with pregnancy, abortion and perinatal emergencies remains a grave problem in the region. Political reluctance to address the reality and consequences of unsafe abortion is a major obstacle to improving women's quality of life and preventing needless deaths.

Another problem raised was the scant funding and attention given to promoting male participation and responsibility in sexual and reproductive health. Stereotyped models persist within health policies and programmes of women as mothers and reproducers, and men as (absent) providers. Governments and development agencies must assume their responsibility for perpetuating rigid gender roles which limit men's human development and have damaging or fatal consequences for women.

The struggle for public opinion - and legislative opinion - was emphasised many times by parliamentarians in the Symposium. As Dr. Javier Torres-Goitia said, "We have avanced from family planning, through sexual and reproductive health, to sexual and reproductive rights. But Parliament is still talking about all this as demographic control. Education is needed at a high level."

Symposium recommendations

The Symposium declaration posits "an integrated approach to sexual and reproductive health as a complex phenomenon with multiple determinants. This vision takes us away from the traditional, stereotyped view of masculine and femenine roles in sexuality and reproduction. It transcends merely demographic or medical treatment of the issues, and sets these firmly in the field of human rights, citizenship, democracy and the political agenda."

Parliamentarians in the Symposium acknowledged their role not just in making laws but in approving national budgets, monitoring dissemination and execution of policies, and following-up international agreements. On these points, Dr. Guerra García of Peru cited the presentation given by PAHO Director George Alleyne to IMPO's first Panamerican Conference.

Legislators benefit from well-presented informative materials which keep them up to date with rights, health and gender issues. Parliamentary commissions on human rights can be involved in monitoring the application of policies and dealing with reports of abuses.

A vital principle to be defended and promoted in health care is "offer but don't force". The Symposium declaration recommended that appropriate services for adolescents and adults of both sexes "guarantee the exercise of sexual and reproductive rights, including informed consent and postabortion care and counselling with an integrated and humane approach".

Dr. Javier Torres-Goitia of Bolivia, IMPO Vicepresident for the Latin American Region, announced that for the II Panamerican Conference to be held in Canada in 1999, GPI and IMPO are considering the theme of parliamentary defence of human rights. Actions will be focussed on combatting inequities affecting women, children, adolescents and socially discriminated groups.

Human rights constitute a shared framework for parliamentarians and women's rights advocates. Far from being restricted to technical problems with technical solutions, gendered issues of health and quality of life must be dealt with on all fronts. This involves challenging established power relations and questioning deep-rooted assumptions about men's and women's identities and roles in society.

References

Aliaga Bruch, S 1994. "Violó a sus hijas y las dejó embarazadas. ¿Qué dice la ley Sr. Juez?", Equidad de Hoy, 18/5/94

Centro Juana Azurduy, Defensoría de la Mujer 1998. "Caso de Interrupción Judicial del Embarazo". Unpublished case history. Sucre, 1/9/98

Córdoba, P 1998. "Un nuevo marco para la salud sexual y reproductiva", presentation to the Interamerican Symposium on Legislation in Sexual and Reproductive Health, La Paz, Bolivia 7-8 September

Correa, S and Petchesky, R 1994. "Reproductive and Sexual Rights: A Feminist Perspective", pp.107-108 in Sen, G, Germain, A and Chen, LC (eds.) Population Policies Reconsidered: Health, Empowerment and Rights, pp.107-123. Boston, Mass.: Harvard School of Public Health/IWHC

Guerra García, R 1998. "Responsabilidad Parliamentaria en el ejercicio de los derechos sexuales y reproductivos", presentation to the Interamerican Symposium on Legislation in Sexual and Reproductive Health, La Paz, Bolivia 7-8 September

Morales, P 1998. "Conceptos de Género en la Legislación sobre Salud y Población", presentation to the Interamerican Symposium on Legislation in Sexual and Reproductive Health, La Paz, Bolivia 7-8 September

Torres-Goitia, J 1998. "Legislación y derechos humanos". Presentation to the Interamerican Symposium on Legislation in Sexual and Reproductive Health, La Paz, Bolivia 7-8 September