SUPPORTING HEALTH COORDINATION ASSESSMENTS PLANNING ACCESS TO HEALTH

SUPPORTING HEALTH COORDINATION, ASSESSMENTS, PLANNING, ACCESS TO HEALTH CARE AND CAPACITY BUILDING IN MEMBER STATES UNDER PARTICULAR MIGRATORY PRESSURE — 717275/SH CAPAC MODULE 5: Specific health concerns Unit 3: Sexual and reproductive health Prepared by: Lotte De Schrijver & Ines Keygnaert – Ghent University – ICRH

Outline of the session • Introduction • Learning objectives • Learning Activities • • Sexual development & lifeline Definition of sexual & reproductive health (SRH) Definition of sexual and reproductive rights SRH & migration risk factors & guidelines for services • Recommended readings • Evaluation questions

Learning objectives: Introduction This Unit will focus on sexual and reproductive health [SRH]. SRH is not a typical health domain, since it cannot be described in a pure physical or biomedical way only. SRH is largely influenced by psychological, sociological and cultural mechanisms. Socially constructed norms and values guide our way of defining what SRH consists of. Since sexuality is/has been a taboo subject in many cultures for a very long time, people have often stereotypical ideas about what human sexuality is or should be. This challenges health professionals working in the field of sexual health. IOM 2014.

In M 3. U 4. we already provided you with communication skills guiding you in discussing sensitive issues such as sexuality in a multicultural context. The content of this unit is more theoretical. The main questions we address in this unit is: • which sexual and reproductive rights do migrants, refugees and asylum seekers have? • what should be done to provide sexual and reproductive health care in the European migration context?

Objectives The learning objectives of this part of the unit are: v. To understand that people have different needs according to their sexual development stage v. To be able to identify important supportive/hindering factors of sexual development v. To understand the elements of the definition of sexual and reproductive health v. To understand the concept of sexual and reproductive rights (history, purpose, meaning). v. To know which guidelines to apply to provide a minimal sexual and reproductive health care service v. To be aware of risk factors for poor sexual and reproductive health in the context of migration

Learning activities

1. Sexual development & lifeline Compulsory activity: Sexual development & lifeline Step 1: Draw a timeline on a piece of paper and write “sexual timeline” as a title. Draw a line from the top of the page until the bottom. The top will represent the moment you were born, whereas the bottom of the line will represent the present. Construct a sexual timeline from your personal experiences. (first kiss, fondling, physical changes, first time in love, first orgasm, divorce, …) For an example: Frans E, Keygnaert I. Make it Work! Prevention of SGBV in the European Reception and Asylum Sector. Ghent: Academia Press; 2010: p 27. Available from: http: //icrh. org/publication/sgbv senperforto make it work training manual

v. Step 2: Look at your sexual timeline: What were the needs you felt at certain stages of your sexual development? v For example: Maybe you felt the need to talk about contraceptives with an adult when you first became sexually active? Maybe your first sexual experience came too early and you felt the need to slow things down? v. Step 3: Discuss on the forum what the needs are at different stages of one’s sexual life to make these experiences positive ones or to reduce the negative impact of painful experiences. v Step 4: Reflect and discuss the following questions on the forum: v. What is the situation for refugees? v. Which problems are they facing? Which aspects of sexual and reproductive health are being limited due to the situations refugees are in? And which are not? v. What can and should be done to address the needs of refugees in that area?

2. Definition of sexual & reproductive health Compulsory activity: Defining sexual and reproductive health Step 1: Forum: v. In your opinion, when is somebody in good sexual health? v. In your opinion, when is somebody in good reproductive health? > Check whether you have identified elements related to the 5 sexual health core components: general well being and development, a safe and satisfying sex life, sexual relationships and sexuality, Family planning and fertility, access to Information & Care Keygnaert I, Vettenburg N, Roelens K, Temmerman M. Sexual health is dead in my body: participatory assessment of sexual health determinants in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. BMC PUBLIC HEALTH.

Step 2: v. Reflect on how this relates to your own sexual timeline? v. Which elements would you use to describe your own SRH? Step 3: Read the WHO definitions of sexual health, sexuality and reproductive health on the following slides.

Definitions Everyone has the right, at any given time in his or her life, to the highest possible standards of reproductive and sexual health since these are recognized as basic human rights. Sexual health The World Health Organisation (WHO, 2010) defines sexual health as …a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. ” WHO. Measuring sexual Health: conceptual and practical considerations and related indicators, WHO/RHR/10. 12 edn. 2010.

According to the WHO, sexual health cannot be defined, understood or made operational without considering sexuality in a broader sense. Sexuality is defined as “a central aspect of being human throughout life encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors” (WHO, 2006). WHO. Defining sexual health: report of a technical consultation on sexual health, 28 -31 January 2002. Geneva: WHO; 2006.

Reproductive health addresses at all stages of life, the reproductive processes, functions and systems. Therefore, reproductive health implies “that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this are the right of men and women to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant”. WHO. Health topics. Reproductive Health. Accessed on August 26, 2016 through http: //www. who. int/topics/reproductive_health/en/

v. Discuss the similarities and differences between what you indicated in the previous activity as being elements of good sexual and reproductive health and the given definitions. v. How do sexual and reproductive health relate to each other according to you? Which one is the more narrow and which one the more broader term? v. Discuss how SRH can be influenced by the process of migration. Try to identify aspects influencing SRH in arrival, transit and destination countries. v. How are reception centres in your country dealing with sexual and reproductive health? Do you have suggestions for improvement?

Optional activity: Sexual health indicators In 2007, a meeting was held by the joint WHO/UNFPA in order to elaborate and refine indicators of sexual health to monitor on national level the achievement of universal access to sexual and reproductive health. Step 1: read the following document: WHO & UNFPA (2010). Measuring sexual health: conceptual and practical considerations and related indicators. World Health Organization, Geneva. Step 2: apply the proposed indicators (Annex 3. Proposed indicators of sexual health) on the situation in your own country.

3. Definition of sexual and reproductive rights Sexual health and sexual rights are closely linked to each other. Ø In the context of sexual relationships under coercion for example, the result will most probably be sexual ill health. Ø In the definitions of sexual and reproductive health, one can identify a certain human rights. These human rights are recognized in national laws, international human rights documents and other relevant UN consensus documents. WHO & UNFPA (2010). Measuring sexual health: conceptual and practical considerations and related indicators. World Health Organization, Geneva.

Sexual and reproductive Health rights: include the right of all persons, free of coercion, discrimination and violence, to: vthe highest attainable standard of sexual health, including access to sexual and reproductive health care services; vseek, receive and impart information related to sexuality; veducation on sexuality; vrespect for bodily integrity; v choose their partner; v decide to be sexually active or not; v consensual sexual relations; v consensual marriage; v decide whether or not, and when, to have children; and v pursue a satisfying, safe and pleasurable sexual life.

The responsible exercise of human rights requires that all persons respect the rights of others. To this end the International Planned Parenthood Federation (IPPF) developed in 2008 a Declaration on Sexual Rights which complements and integrates the former IPPF Charter on Sexual and Reproductive Rights and stems from a more global integration of Human rights. WHO & UNFPA (2010). Measuring sexual health: conceptual and practical considerations and related indicators. World Health Organization, Geneva.

• 7 guiding principles for SRH: 1. Sexuality is an important part of being human 2. People under eighteen are also rights holders 3. The basic of human rights is non discrimination 4. People should be able to enjoy their sexuality and be free to choose whether or not they want to reproduce 5. Everyone has the right to be protected from harm 6. Sexual rights can only be limited by law if it is to protect others’ rights and freedoms, to ensure the general public welfare and to protect public health 7. States have the obligation to respect, protect and fulfil sexual rights for all

• 10 articles • The right to equality, equal protection of the law and freedom from all forms of discrimination based on sex, sexuality or gender • The right to participation for all persons, regardless of sex, sexuality or gender • The rights to life, liberty, security of the person and bodily integrity • The right to privacy • The right to personal autonomy and recognition before the law • The right to freedom of thought, opinion and expression; the right to association • The right to health and to the benefits of scientific progress • The right to education and information • The right to choose whether or not to marry and to found and plan a family, and to decide whether or not, how and when to have children • The right to accountability and redress. • More information can be found on www. ippfen. org.

Compulsory activity: Defining sexual and reproductive rights Step 1: Discuss on the forum: v. Do you consider sexual and reproductive rights to be universal? v. Which rights are easily/not easily fulfilled as an asylum seeker in Europe? Do they have suggestions for improvement? v. What barriers do they see regarding the sexual rights of asylum seekers?

Both the Millennium Development Goals and more recently the Strategic Sustainable Goals call upon states to ensure universal access to SRH including maternal health care, to improve maternal health and to reduce maternal mortality, specifically addressing the vulnerability of migrants. WHO. Health in 2015: from MDGs, Millennium Development Goals to SDGs, Sustainable Development Goals. Geneva: WHO; 2015.

Millennium development goals

Sustainable development goals

4. Identification of risk factors for poor sexual and reproductive health in migrants Step 1: Read the HEN report nr 5 on reduction of inequalities in accessibility and quality of maternal health care delivery for migrants in Europe. http: //www. euro. who. int/__data/assets/pdf_file/0003/317109/HEN synthesis report 45. pdf Step 2: Look at table presented on the next slide. Step 3: Reflect on the following: Ø Do you recognize these risk factors in your country? Ø What could be done to prevent this? Ø Is anything missing according to you?

SH-CAPAC Project. Guide for assessment of health needs and health protection resources. 2016. Available from: http: //www. easp. es/sh-capac/

5. Guidelines on SRH & Migration The relationship between conflict, crisis and vulnerability to sexual health is a complex one. Ø Migrants, refugees and asylum seekers in crisis situations are especially vulnerable to STI’s and HIV since access to means of prevention, treatment and care often limited under crisis conditions and in migratory contexts. Ø In order to provide a set of minimum multi sectoral interventions to prevent and respond to HIV in emergency situations, one can consult the Inter agency Standing Committee Guidelines for HIV/AIDS Interventions in Emergency Setting: www. unfpa. org/upload/lib_pub_file/249_filename_guidelines hiv emer. pdf.

Another useful source in crisis situations can be the Minimum Initial Service Package MISP for Reproductive Health (RH) (http: //misp. iawg. net/), a coordinated set of priority activities designed to: Ø prevent and manage the consequences of sexual violence; Ø reduce HIV transmission; Ø prevent excess maternal and neonatal mortality and morbidity; and Ø plan for comprehensive RH services in the early days and weeks of an emergency. This distance learning module can be used to increase humanitarian actors’ knowledge of these priority reproductive health services to initiate at the onset of a crisis situation. Ø After completion of the online modules, you receive a certificate.

The objective of the MISP RH Module is to: v define and understand each component of the MISP; v grasp the importance of implementing the MISP in emergency settings; v understand the role and functions of the RH Coordinator/Focal Point; v be able to order MISP supplies internationally or obtain them locally; v know the most important things to do in the immediate days and weeks of a new emergency to prevent and respond to sexual violence; v know the priority interventions for reducing HIV transmission in the earliest phase of crisis situations; v understand the best ways to reduce maternal and neonatal death and disability at the onset of an emergency; v be able to plan for comprehensive RH programming once the crisis has stabilized.

Summary of MISP-RH Chapter 4 Reduce transmission of HIV: Ø make condoms freely available Ø enforce universal precautions against HIV (including sufficient supplies, safe waste disposal) Ø ensure blood transfusion is safe

Summary of MISP-RH Chapter 5 Prevent excess neonatal and maternal morbidity and mortality: Ø provide clean delivery kits to all pregnant women and birth attendants Ø provide health facilities and midwives with midwifery delivery kits. Ø initiate the establishment of a referral system to manage obstetrics emergencies

Summary of MISP-RH Chapter 6 Plan for the provision of comprehensive RH services, integrated into primary health care, as soon as the situation permits Ø collect background information on RH mortality, STD/HIV prevalence and contraceptive prevalence. Ø identify suitable sites for the future delivery of comprehensive reproductive health services Ø assess the capacity of staff and plan training/retraining Ø order equipment and supplies for comprehensive reproductive health services.

Compulsatory activity: MISP-RH Step 1: Read the MISP: http: //gbvaor. net/wp content/uploads/sites/3/2012/10/Minimum Initial Service Package MISP for Reproductive Health in Crisis Situations A Distance Learning Module. pdf Ø chapters 1, 2, 4, 5 and 6 are compulsory Ø chapters 3, 7 & 8 are optional Optional Step 2: take the tests Optional Step 3: Discuss on the forum how minimum initial service for reproductive health in crisis situations can be improved.

Additionally to the MISP, the WHO has also identified two other activities, which can be important to include in the core package of reproductive health interventions in emergency settings: • Meet pre existing family planning needs Ø provide basic family planning services in order to meet spontaneous demand. • Meet needs for menstrual protection Ø assess the need for menstrual protection and identify methods to meet this need.

Recommended readings • Inter Agency Task Team on HIV and Young People. Guidance brief. HIV Interventions for Young People in Humanitarian Emergencies. Geneva: UNFPA. Available from: www. unfpa. org/upload/lib_pub_file/249_filename_guidelines hiv emer. pdf • Women’s refugee commission. Minimum Initial Service Package (MISP) for Reproductive Health in Crisis Situations: a distance learning module. 2011. Available from: http: //misp. iawg. net/ • Keygnaert I, Ivanova O, Guieu A, Van Parys A, Leye E, Roelens K (2016): What is the evidence on the reduction of inequalities in accessibility and quality of maternal health care delivery for migrants? A review of existing evidence in the WHO European Region. HEN Report nr 45, WHO Europe, Copenhagen. http: //www. euro. who. int/__data/assets/pdf_file/0003/317109/HEN synthesis report 45. pdf • Keygnaert I, Guieu A, Ooms G, Vettenburg N, Roelens K, Temmerman M. Sexual and reproductive health of migrants: does the EU care? Health Policy, 2014; 114: 215 225. • Keygnaert I, Vettenburg N, Roelens K, Temmerman M. Sexual health is dead in my body: participatory assessment of sexual health determinants in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. BMC PUBLIC HEALTH. 2014; 14: 416.

• Frans, E, Keygnaert, I. Make it Work! Prevention of SGBV in the European Reception and Asylum Sector. 2010. Academia Press, Ghent. http: //icrh. org/publication/sgbv senperforto make it work training manual • Keygnaert I, Vangenechten J, Devillé W, Frans E, Temmerman M. Senper forto. Frame of Reference for Prevention of SGBV in the European Reception and Asylum Sector. 2010. Ghent: Magelaan cvba. ISBN 978 9078128 205 • SH CAPAC Project. Guide for assessment of health needs and health protection resources. 2016. Available from: http: //www. easp. es/sh capac/ • WHO & UNFPA. Measuring sexual health: conceptual and practical considerations and related indicators. 2010. World Health Organization, Geneva. http: //www. who. int/reproductivehealth/publications/monitoring/who_rhr_10. 12/en/ • WHO Regional Office for Europe & BZg. A. Standards for sexuality education in Europe. A framework for policy makers, educational and health authorities and specialists. 2010. Cologne: BZg. A. Available from: http: //www. bzga whocc. de/? uid=20 c 71 afcb 419 f 260 c 6 afd 10 b 684768 f 5&id=home

Evaluation questions Question 1: What might be hindering factors in one’s sexual development? Question 2: Explain the difference between sexual and reproductive health. Question 3: Name three measures to reduce HIV transmission. Question 4: Describe 3 risk factors concerning SRH in a migratory context.