The news from America is not unexpected, but it’s nonetheless devastating. The decision of the US Supreme Court to overturn Roe v Wade means that millions of women and people who can get pregnant will be unable to make decisions about their own bodies, lives and futures. Young women today will have less access to abortion care than their mothers and grandmothers did 50 years ago.
Those who can afford to will be forced to travel to neighbouring states to access abortion care. But it’s the poorest, most marginalised women and girls, particularly women of colour, who will be hardest hit.
The US joins a handful of countries that have imposed stricter abortion laws since 1994, along with Poland, Nicaragua and El Salvador. And yet, restrictive laws don't reduce the need for abortion – they just make it unsafe and increase preventable maternal deaths and disability.
Restrictive laws also fuel stigma against people who seek, provide and support abortion care, shrouding it in secrecy and shame. However, abortion is not rare: globally, three out of ten pregnancies end in abortion. Safe abortion care is an integral part of healthcare.
And they won’t stop here. The conservative groups, Christian nationalists and populist forces in the US who pushed for this decision are likely to challenge other basic human rights such as LGBTQI+ rights, including same-sex marriage, and access to contraception.
This isn’t about ‘life’. It’s about power and control over women.
We also know that what happens in the US has a far-reaching impact globally. Eroding human rights anywhere in the world threatens all of us. The expanded Global Gag Rule severely limited access not only to abortion care but also lifesaving sexual and reproductive healthcare, including HIV services for marginalised communities. The Supreme Court ruling will have a ripple effect, sending a signal to anti-choice groups who will seek to tighten abortion laws around the world and pursue an ‘anti-gender’ ideology.
Since the decision, many posts online have shared tragic stories of women who sought an abortion after being raped or experiencing an ectopic pregnancy or sepsis, for example. The suggestion is that in these dire, extreme situations, abortion is acceptable. But what about other circumstances? Nobody should be forced to stay pregnant if they don't want to. And this kind of diffident messaging does not further our cause: it's part of the ‘safe, legal and rare’ framing that stigmatises abortion and people who have an abortion. We need to stand up for the right of all women, girls and people who can get pregnant to make decisions about their own bodies. This is about protecting bodily autonomy.
As Michelle Obama said, “This horrifying decision will have devastating consequences, and it must be a wake-up call, especially to the young people who will bear its burden.” In response, feminist grassroots movements, reproductive rights organisations and activists are joining forces to fight for reproductive justice, as the Marea Verde did in Latin America.
Together, we stand in solidarity with women in the States and globally. We must safeguard the human right to abortion and ensure that quality abortion care is accessible to everyone who needs it.
The elephant in the room
Do you ever feel there's something missing in debates about sexual health and sexual rights?
Open conversations about sex, particularly sexual pleasure, aren’t easy – especially not between clients and sexual and reproductive health service providers. In public health circles, when we do talk about sex, it’s nearly always about the negative consequences of sex: risks, diseases, illnesses, infections and death.
Within the risk-based approach, sexual pleasure is often the elephant in the room.
But it doesn’t make sense to talk about safer sex without discussing pleasure. If we leave pleasure out of the equation we may fail to get to the root of why people are making sexually risky decisions, such as failing to use condoms correctly and consistently.
Some studies suggest that denying the possibility of sexual pleasure, particularly for women and girls, has a negative impact on their negotiation of safer sex. If a young woman can tell her partner what she likes or dislikes, and negotiate the quality of sexual relationships, she’s more likely to be able to discuss contraception and condom use. The benefits of frank communication and an approach that avoids fear, shame and stigma are clear.
That’s why I enjoyed working with the Global Advisory Board for Sexual Health and Wellbeing on an exciting project: a training toolkit and online resources on Sexual pleasure: the forgotten link in sexual and reproductive health and rights. Written by Doortje Braeken and Antón Castellanos Usigli, and supported by Durex, these practical materials are aimed at training health professionals and medical students around the world in providing sex-positive counselling, information and support. My role was to strengthen and edit the toolkit and resources.
This global initiative seeks to reframe the way in which service providers look at sexual and reproductive health and rights by putting sexual pleasure at the centre. The toolkit increases understanding of the benefits of talking about sexual pleasure – within the framework of sexual health and sexual rights – for individual wellbeing and empowerment. This broad vision is fully in line with the Guttmacher-Lancet Commission's comprehensive definition of sexual and reproductive health and rights. The toolkit examines how pleasure is linked to the freedom and right to express one’s sexuality; and how values, norms, culture, religion and stigma all shape the ways in which people experience sexual pleasure. The complex relationships between gender, sexuality and pleasure, agency, autonomy and power are analysed.
Equipping health professionals with the skills and confidence to talk openly to their clients about sex, sexuality and sexual pleasure – and to encourage clients to follow suit in their own relationships – is so important. It can empower people to make informed decisions about their own sexual and reproductive health, and help all individuals, regardless of age, sexual orientation, gender identity or disability, to enjoy a safe, fulfilling and pleasurable sex life.
Access or use?
Research by the Guttmacher Institute, Adding It Up (2020) shows that 218 million women of reproductive age in developing regions want to avoid pregnancy but aren't using modern contraception. They are not seeing the many benefits of contraception for their health and wellbeing as well as for their families and societies.
The language we use to describe unmet need is vital. Here, unmet need isn't framed as the number of women who want to avoid pregnancy but 'cannot access' contraception, or are 'denied access' to contraception. Instead, it’s simply the number of women who aren't using contraception. And that's for a range of reasons.
Understanding the reasons for unmet demand
Why does it matter how we talk about unmet need? To satisfy unmet demand, we need to understand why women aren't using contraception even though they don’t want to become pregnant.
The reality is complex. When asked, women rarely cite limited access to family planning as the reason why. The top reasons women give are:
Capturing this complexity isn't easy in a short, punchy message.
Meeting women's and girls’ needs
Access to rights-based contraception is essential. This means ensuring the availability of contraceptives; strengthening supply chains to avoid stock-outs; and delivering affordable services to marginalised, hard-to-reach groups, including adolescents, and in humanitarian settings.
But programmes must also ensure acceptability and quality of care. Dissatisfaction among family planning users – leading to discontinuation – is a major challenge. A study in 34 countries found that more than a third of women (38%) who were using a family planning method discontinued within 12 months.
To ensure family planning programmes are effective, evidence-informed, and meet women's and girls’ needs, we must listen to what women are saying. This means that programmes must:
To accelerate progress in meeting unmet demand for contraception and helping women and girls to exercise control over their own bodies, we need to make sure that our messaging is accurate and programmes are evidence-informed.