Justice in sexual and reproductive health

The 9th Asia-Pacific Conference on Reproductive and Sexual Health and Rights (APCRSHR) held between 27 and 30 November 2017 in Halong Bay, Vietnam, which had the theme ‘Leave No One Behind! Justice in Sexual and Reproductive Health’, served as a stimulus for this special issue of Culture, Health & Sexuality. The chosen papers from academics and practitioners within the region engage with the main conference themes but are of enduring interest as they signal crucial issues demanding greater attention.

The conference examined what the Sustainable Development Goals’ (SDG) promises of raising inclusivity, reducing inequalities, and leaving ‘nobody’ behind might mean for the realisation of justice in sexual and reproductive health and rights (SRHR) in the Asia-Pacific region. Bringing about universal access to SRHR services and rights does not depend only on health system reforms but is also linked to gender equality, inclusive education, environmental sustainability and economic development.

However, the SDGs are, as Rosalia Sciortino writes in this issue, ‘much lauded, yet elusive’, and SDG statements and tools fall short of questioning and addressing the root causes and underpinning structures that keep uneven development in place. As she argues, in Southeast Asia disadvantaged groups and countries still face limited SRH choices and constrained rights within a context of rising authoritarianism, patriarchy and persisting income and health gaps. Real change requires greater awareness of these contextual drivers of inequity and substantial shifts in the current development paradigm – to redress them and ensure the ideals of inclusiveness and equity as promised by the SDGs are be attained in and through SRHR.

The other authors also recognise the structural social-economic and political determinants of SRHR, the need to transform patriarchal heteronormative assumptions, and the importance of lived experiences to understanding what change is taking place. The cutting-edge research findings from Cambodia, the Philippines, Thailand, Vietnam and Papua New Guinea reveal the diversity of approaches to how these inequities can be, or have been, transformed.

Changing gender norms require an intersectional approach that includes men and boys, transgender people, and individuals with non-heteronormative, fluid sexual desires. Yet policies still mainly focus on assumed homogeneous categories of ‘women and girls’. Suchada Thaweesit and Rosalia Sciortino’s analysis of Thailand’s response to HIV shows how programmes have neglected gender power dynamics and the ‘interconnected systems’ that disadvantage women and girls. Obvious differences between and within diverse groups of women (based on class, age, sexual orientation or ethnicity) are often overlooked in monolithic policy responses. Women’s empowerment needs to be unpacked, as it does its many interpretations. In a similarly de-constructionist vein, Siow Li Lai and Nai-Peng Tey find, in their study of women’s empowerment and contraceptive use in Cambodia, that age, educational level, work status, wealth and number of living children are all significant in predicting women’s contraceptive use. Women’s ability to make decisions, surprisingly, turned out to be of comparatively little importance.

Bui Huong’s study of the role of mothers in communication about sexuality shows that women’s perceived superior communication skills end up burdening them with the task of educating their daughters about sex. Although Vietnam has scored high on many development indicators in recent decades, economic growth co-exists with old Confucian patriarchal and heterosexual norms. In this study, mother-daughter communication instilled expectations about women’s sexual submission to their male partners, ignoring young women’s sexual rights including their right to sexual pleasure. But it is not only women and girls who are disadvantaged by patriarchal social norms concerning gender and sexuality. Gender non-conformity, too, can have serious mental health consequences. Doug Cheung and colleagues work in Thailand found a high burden of depressive symptoms among gender non-conforming female adolescents, as well as among gender conforming male and female young people who had experienced sexual and social victimisation.

Cultural norms can be central to the ways in which inequalities are (re)produced, but they can also enable equity and gender justice in politically and legally hostile settings. Angela Kelly-Hanku, Peter Aggleton and Ruthy Neo-Boli’s work in Papua New Guinea (PNG) provides insight into how culture can be deployed in response to inequalities faced by gender and sexually diverse people. Many studies have focused on the assumed negative influences of tradition on the prevalence of sexual and gender-based violence in PNG. Using the concept of practical justice, the authors present an alternative view via four case studies. The concept implies that there is no magic bullet or quick fix to deep-seated social inequalities and human rights violations. However, by examining lived realities in ‘traditional’ local settings, evidence of more supportive interactions and relationships can be found.

Other authors have also used the observation of lived experience to examine how power is dispersed, embodied, enacted and changes over time, rather than being located in a centralised, easily located structure. Gideon Lasco and Anita Hardon’s research on skin-lightening among young men in the Philippines shows how this longstanding and increasingly popular practice in many Asian countries relates to shifting trends in urbanisation, gender and socio-economic change. Men whiten their skin to keep up with other men, to enhance their beauty, and to conform to the expectation that white or light-skinned people are more modern and employable. Cultivating an aura of modern cosmopolitan sophistication is a way to obtain or protect one’s job. Examining how beauty practices relate to fluid quotidian social performances helps to, as Gideon Lasco and Anita Hardon put it, ‘bring nuance into the often-totalising debates about skin and skin colour’.

Taken together, the papers in this special issue contribute to a growing body of knowledge that questions current societal arrangements and power structures and signals lived and diverse experiences in realising gender justice and inclusive SRHR. The authors emphasise that states do have responsibilities, that radical paradigm shifts are necessary, and that there is a need to understand how agency and empowerment operate in realising SRHR in within specific contexts. However, within political and socio-economically constrained contexts and communities, individuals and communities creatively find ways to live their lives with freedom and to resist. It may take effort to notice and value some of these practices, as many require an in-depth knowledge of the local context. But along with other actions, they offer a way forwards to realising elusive sustainable development goals.

We thank all those who shared their experiences and knowledge both at the conference and here in this special issue. We also thank Dinh Phuong Nga for her help in developing the collection.

Pauline Oosterhoff
Institute for Development Studies, Falmer, UK
[email protected]

Rosalia Sciortino
Institute for Population and Social Research, Mahidol University, Nakhon Pathom, Thailand

Tu Anh Hoang
Center for Creative Initiatives in Health and Population, Ha Noi, Viet Nam

Peter Aggleton
Centre for Gender and Global Health, UCL, London, UK