What is a rights-based approach?

A conceptual framework for the process of human development that is normatively based on international human rights standards, and operationally directed to promoting and protecting human rights.

Integrates the norms, standards and principles of the international human rights system into the plans, policies and processes of development.

WHO is helping governments to RESPECT, PROTECT and FULFILL their human rights obligations related to health.

Respect: Governments have the duty to take steps to promote maternal and newborn health and rights.  Governments can respect rights to maternal and newborn health by, for example, changing policies that obstruct access to care, such as those requiring husband's permissions to use services.

Protect: Governments can protect rights by taking action to prevent violations of rights by others, such as enforcing equitable marriage laws or birth registration laws, and developing gender and rights training for health providers to address gender-based inequities

Fulfill: Governments can fulfill rights by taking necessary measures, including allocating sufficient resources, which would evidence the highest level of commitment, to ensure that women and newborns can realize their rights to care.

Barbara Barnett

In an effort to improve the reproductive health of adolescents and young adults, many organizations that work with youth are incorporating a gender perspective into sex education, service delivery and provider training programs.

"Gender" is a term that can be used to categorize the different roles of men and women, as determined by the society in which they live. While a person's sex -- the biological distinction of being male or female -- determines reproductive health status and reproductive health needs, gender perspectives also play a role. Sociocultural factors that influence adolescents' views on sexuality, their access to information, and their access to health services affect reproductive health and well-being, including teenagers' ability to protect themselves from unplanned pregnancy or STDs.

"A child's sex is determined before birth, but gender is learned," says Dr. Karen Hardee, an FHI principal research scientist. "Throughout childhood, boys and girls receive different messages about behaviors that are expected of them -- messages from parents, society, peers, the media -- messages that some behaviors are acceptable for boys but not for girls, and vice versa. Health workers must be sensitive to how gender norms affect adolescents' decision-making about reproductive health behaviors and how these norms affect access to health services."

"Providers must see reproductive health not only in terms of services but in terms of attitudes and quality of care," says Naana Otoo-Oyortey, an International Planned Parenthood Federation technical officer. "Both boys and girls have a right to basic information and access to resources that will enable them to live a satisfying reproductive and sexual life. Providers must recognize that boys have responsibilities that must not be neglected. They must acknowledge that women's decisions on reproductive matters are directly influenced by their partners, husbands, fathers, etc., and address the need for women to be empowered to make informed decisions."

Many societies place a higher value on males than females. From infancy, girls may receive less food than boys and less medical attention when sick. For adolescent girls, an unplanned pregnancy can mean expulsion from school and, consequently, limited job opportunities. In at least nine sub-Saharan African countries, girls are temporarily or permanently expelled from school if they become pregnant, but no punitive action is taken against boys who become fathers. In Kenya, some 10,000 girls leave school annually due to an unplanned pregnancy.

Gender norms can place girls at risk of sexual violence, including rape or domestic violence. A recent Demographic and Health Survey in Egypt showed that 86 percent of the more than 2,300 women interviewed believed beatings by husbands are justified under some circumstances; for example, if the woman refuses to have sex or "talks back." Nearly 31 percent of women reported being beaten during pregnancy. The percentage who believed beatings were justified was higher among women ages 15 to 19 than for other age groups.

For some young women, sexual intercourse is not a matter of choice. A study based on interviews with 128 adolescents in Peru and 108 in Colombia found that 60 percent had been sexually abused within the previous year. Thirty-nine of the women were pregnant as a result.³ Studies in Botswana and Kenya found that for many adolescent women, first sexual intercourse was forced or coerced.⁴ In rural Malawi, 55 percent of 120 adolescents surveyed reported they were often forced to have sex.⁵ A study by the Alan Guttmacher Institute found that 60 percent of U.S. adolescent girls who had sex before age 15 did so involuntarily.⁶ Boys also may experience forced or coerced sex. In Mwanza, Tanzania, one study among street children found that boys, as well as girls, performed "survival sex" -- sex used as a means of bargaining for money, food, or protection from violence.⁷

Female circumcision is another cultural practice based on gender that can jeopardize reproductive health. According to the World Health Organization (WHO), some 2 million girls annually undergo the procedure, which involves partial or total amputation of the clitoris, and in some cases, removal of the labia minora. In some forms of circumcision, the clitoris and labia minora are removed and the labia majora are cut, then stitched together to cover the urethra and the entrance to the vagina. The immediate health risks include infection, pain, and bleeding, which can lead to shock and possibly death. Long-term complications can include prolonged and obstructed labor. There are no health benefits.

Different views

Several studies have shown differences in the way girls and boys view their gender roles and the effects on reproductive health.

A survey of more than 100 factory workers in Thailand, ages 15 to 24, found that the majority of men said premarital intercourse was accepted and expected for them, that their first sexual intercourse was with a prostitute, and that boys who had not yet had intercourse were ridiculed by their peers. Young women said premarital intercourse was unacceptable for "respectable" women and could damage the family's reputation. Young men viewed contraception as a woman's responsibility, but young women said they would not consider seeking or requesting contraception because of the fear of being thought of as sexually active.⁸

In Jamaica, a study conducted by FHI's Women's Studies Project among 945 youth, ages 11 to 14, examined sexual knowledge, attitudes and behaviors. More than 63 percent of the boys reported having had sexual intercourse, while 6 percent of girls reported having intercourse. However, the differences between the boys' and girls' sexual activity may be less than reported. Boys may have exaggerated their sexual experiences, while girls may have been hesitant to report they had sex, given sociocultural normsThe study also revealed other differences in attitudes between boys and girls. While nearly 70 percent of boys said "if you really love someone, you should have sex with them," only 33 percent of the girls agreed. Approximately 57 percent of boys agreed that if a boy spends money on a girl, she should have sex with him, while only 31 percent of the girls agreed.

In Brazil, researchers at the Universidade de São Paulo interviewed more than 5,000 adolescents, ages 14 to 20, about gender roles as part of a research project to develop AIDS prevention strategies. When girls were asked, "What does being a woman mean to you?" their answers were that women were dedicated to love and home life, they cried easily, and they did not have sex until they met the "right" man. When boys were asked what it meant to be a man, they replied that men were physically strong, were sexually attracted to women and often thought about sex. Boys also said it was important to be married, to work hard, and to show tenderness toward their wives. Boys divided women into two categories: those they would want to marry and those who were promiscuous and could infect them with STDs.

Involving men

Because women often lack the ability to control when they have sex and with whom, many programs that incorporate gender have begun projects that empower girls. These projects, such as Better Life Options administered by the Center for Development and Population Activities (CEDPA), provide information about sexuality, reproductive health, family planning and communications skills. Some also sponsor education or employment programs designed to give girls options to early marriage. Yet, to be successful, gender programs must include boys, too.

"One of the key things we have learned is that you cannot work with girls alone," says Seema Chauhan of the Better Life Options project, which began by educating girls, then expanded to include boys. "Either you do it jointly or in parallel, but boys have to be addressed as much as girls so that gender aspects of sexuality, reproductive health and male-female relationships can be challenged."

Incorporating gender into reproductive health programs for teens can be an opportunity to develop programs and services for men and boys.

"Men often have been left out of family planning programs," says Dr. Patricia Bailey of FHI, who is coordinating research in Brazil on adolescent pregnancy. "Unfortunately, men's own active involvement in reproductive health programs has been limited to treatment of STDs."

Educating boys that reproductive health is not for women only is one of the goals of the Young Men's Clinic in the United States. Located in an urban neighborhood of New York, the clinic is part of a health facility that provides other services, including pediatric and obstetrical care. Dr. Bruce Armstrong of the clinic says family planning services were rarely being used by men. When health workers asked adolescents why they did not use these services, boys said they were embarrassed, and that it made them "feel not like a man" to visit a clinic that was primarily for women.

The solution was to develop a clinic for men but to provide a variety of health services, including physical exams necessary for work or school and screenings for disease, such as sickle-cell anemia. That way, men could come to the clinic without the fear that friends or neighbors might think they were seeking contraceptives. The clinic also sponsored sports events for men to encourage them to use services.

On average, 30 to 35 men each week visit the men's clinic, which is administered by Columbia Presbyterian Hospital and Columbia University's School of Public Health. Regardless of the reason for a visit, providers try to educate men about their reproductive health, Dr. Armstrong says. For example, if a man comes in for tuberculosis screening, health workers might ask him about his contraceptive needs and STD risks.

"There are indicators of success of male involvement in reproductive health," Dr. Armstrong says. "One would be using condoms. Others would be talking to your partner, initiating the conversation with your girlfriend, bringing home information from our women's clinic, bringing home contraceptive foam, or learning about women's methods."

In another effort to involve men in ways that may lead to better reproductive health, Centro de Educação Sexual (CEDUS) in Rio de Janeiro, Brazil, conducted workshops that challenged gender stereotypes. In one activity, called "Hot Potato," adolescent boys each receive a card with a word associated with either a male or female stereotypical trait, such as "playboy," "faithful," "nurturing."

The boys pass the cards among themselves during a timed interval. When the clock stops, each boy keeps the card he has, then tapes it to his shirt. Then the boys discuss the trait on their card and how they feel about this characteristic. "Values about gender roles -- planted in childhood and reinforced in adolescence -- should not be seen as something that we can change after brief participation in two or three short educational activities," a CEDUS report says. "Nonetheless, we believe that ... youth can use activities like these to stimulate discussion, reflection, and someday, we hope, attitude and behavior change."

When planning reproductive health programs for adolescent boys, experts say programs should offer information on men's health, including the risk of STDs; information about women's bodies and their reproductive health concerns; access to contraceptives and STD services (or referrals); and education to help boys improve their communication skills. Health programs can make reproductive health services more "male-friendly" by offering services in a separate room or at different hours from those offered for women.

"Building a separate infrastructure to deliver male services is unnecessary," says one report from the United Nations Population Fund (UNFPA). "Men's services can be provided by special hours or minor adaptations to existing facilities, such as establishing a separate waiting area."

In addition to improving their own health, involvement of men in reproductive health programs can indirectly improve the health of women, whose access to health services is often controlled by fathers, husbands or sexual partners. "The term gender can serve as a significant reminder that men play important roles in women's reproductive health," says FHI's Dr. Bailey.

Incorporating gender into programs

Several health projects have incorporated gender into their education and services. Others are examining ways in which gender affects adolescents' health.

In Argentina, the Foundation for Study and Research on Women in Buenos Aires offers education sessions on family planning and STDs to secondary school students. Some 50 to 100 students attend each program, then break into small groups to discuss a variety of reproductive health topics, including gender roles.

"We try to make them think about the roles men and women have in society," says Dr. Laura Pagani, an obstetrician-gynecologist, who is working at the Foundation for Study and Research on Women to develop a plan for incorporating gender into reproductive health programs. "We ask, 'How would you feel if you were pregnant? Who would you consult for advice?' We ask the girls, but we also ask the boys, 'How would you feel if this were happening to you?' "

In Gujarat, India, the Centre for Health Education, Training and Nutrition Awareness (CHETNA) incorporates gender into its melas, health education workshops for young people ages 11 to 18. Held in schools or other large facilities, the three-day melas feature information booths containing health materials and education sessions on different aspects of reproductive health, including menstruation, STDs and contraception. The melas also include a component that examines gender roles. Dramatic skits are held to illustrate gender stereotypes, and there are discussions among participants about different expectations for boys and girls. For instance, rural participants said when girls come home from school; they are expected to help with the cooking, while boys are allowed to play. To reinforce the message that gender roles can change over time and vary among cultures, workshop facilitators try to take on roles not typically associated with their gender. For example, women use video cameras to tape the sessions, and men sweep the floors.¹³

One checklist for incorporation of gender issues into health programs asks providers to consider these questions: How are girls treated differently from boys within the health care project? What constraints are there on women or girls' time that might prevent them from seeking health services? Does the project place the responsibility for improved health solely on women, or are men involved too? What impact does the project have on the relationships between men and women?

A draft paper prepared by the Population Council lists several steps health workers can take to incorporate gender into reproductive health programs. They include: developing sex education programs that address the specific needs of girls; educating young women about their bodies and fertility cycles; encouraging males of all ages to become involved in reproductive health education programs and services; and providing boys with information about male and female sexuality and opportunities to discuss sexuality.

Training is important. Health workers must be aware of their own views of gender relationships and how that may affect the services they provide. "Reproductive health is not just providing technical information," says Seema Chauhan of CEDPA. "It's understanding the dynamics between young girls and boys. Often service providers aren't trained to deal with their own biases."

In developing reproductive health programs for adolescents, providers should take into account both practical and strategic needs, explains Susan Pfannenschmidt, an FHI research analyst and one of the authors of a report on incorporating gender into development programs. A practical need might be teaching young adults about condom use and communications skills. A strategic element might seek to bring about more equality in gender roles in future; for example, a program that would offer young boys classes in childcare. "Ideally, a program should do both," Pfannenschmidt says.

Providers who consider gender relations and the reasons for behavior when they develop adolescent services may find that, in the long-term, programs are more effective, says Martine de Schutter, program advisor on women's health and development at the Pan American Health Organization.

"Becoming pregnant isn't always from a lack of information," de Schutter says. "It can be determined by what the expectations are for girls and boys."

"Think of gender like putting on new glasses," she says. "You see the same reality, but you focus on it differently. Be sensitive that men and women have different needs and you can make a difference in responding to their needs ... by improving dialogue between men and women, by improving negotiating skills. There is not a quick recipe to add gender. The main thing is to be sensitive that not only biology impacts on health, there are social issues as well."